Violence against health-care workers was rising. Then the pandemic hit, and made things worse.

The woman was clearly in crisis, threatening to hurt herself and staff at Einstein Medical Center’s emergency department.

Nurse Julia Kristan had a knack for calming down tense situations, though, and thought she had reached an understanding with the patient that would allow her to give the woman an antianxiety medication.

Kristan tried to administer the shot, and then reeled from a punch to her left eye.

“I was very upset by that, more emotionally than anything,” she said of the attack that happened last winter. “Typically, I’m very good at de-escalating people and trying to read the room.”

Kristan, 38, was unsettled, even questioning whether her decisions caused the episode. She called police, but officers said she would need to file a civil complaint to pursue legal action against the woman, and Kristan didn’t think it was worth the trouble.

“I kind of went running outside for a few minutes to get myself together and then, ultimately, back to work,” she said.

Violence against health-care workers in what are supposed to be places of healing has been a growing hazard of the profession in recent years, but the pandemic has worsened the situation. Nationally, health-care workers say they are under assault more than ever. Public health and medical workers have “experienced stigma, threats, and assaults” over the last year, the CDC noted.

Doctors and nurses in the region blamed overtaxed emergency departments, understaffing, and limited access to specialized care due to COVID-19 restrictions as contributing to a tense workplace where abuse is more likely to erupt.

A certified nursing assistant at Jefferson University Hospital faces murder charges in last Monday’s shooting death of a coworker at the Center City hospital — a dramatic reminder that violence is too often a part of the health-care workplace.

The situation has become so alarming that one of the state’s largest nurses’ unions, the Pennsylvania Association of Staff Nurses and Allied Professionals (PASNAP), plans to meet with Philadelphia District Attorney Larry Krasner in the coming week to address workplace violence in health-care facilities.

Doctors, nurses, and other staff face routine physical and verbal abuse from the people they’re trying to help. It’s so commonplace, in fact, that it is often accepted as part of the job. These episodes, piled atop the stress of a seemingly endless pandemic and the frustration of treating COVID-19 patients who could have avoided serious illness if they had not refused vaccination, have left many health-care workers feeling anxious, burned out, and even considering retirement.

“I have a couple more years, I‘m just counting it down,” said Angela Neopolitano, a 40-year nursing veteran in the emergency department of Delaware County Memorial Hospital. “Now, everybody’s just screaming at us.”

» READ MORE: A nursing assistant killed his coworker at Jefferson University Hospital, then shot two Philadelphia police officers, authorities say

Even before the pandemic, health care was seriously plagued by violence. Almost three-quarters of the nation’s workplace injuries due to violence occur in health-care settings, according to the Bureau of Labor Statistics. Jennifer Comerford, a risk management analyst with ECRI, a Plymouth Meeting-based nonprofit that advises hospitals on safety and quality, described the situation as “mind-boggling.”

That threat is no surprise to front-line health-care workers.

“I’ve been punched, kicked, called names, spit on,” Neopolitano said, “I can’t even tell you how many times.”

Within health care, workplace violence is most common at psychiatric and substance-abuse hospitals. In 2018, there were about 125 intentional injuries per 10,000 workers at these specialty hospitals, compared with a rate of about 10.4 episodes per 10,000 full-time workers in the health-care field and a rate of 2.1 among all workers, according to the Bureau of Labor Statistics.

“People are brought into the emergency room or the psych setting involuntarily, it’s hugely scary,” said Diane Allen, a retired psychiatric nurse who now trains hospital workers on how to reduce workplace violence and aggression. “There’s certainly a level of anxiety that rises above what we have in our everyday lives and I think that leads into a lot of the violence people who are being cared for will often exhibit toward their caregivers.”

At Eagleville Hospital, a Montgomery County facility specializing in behavioral health and addiction treatment, nurse Kendra Barkasi described a patient recently hitting her in the face with a container used to hold needles.

She also described a litany of vile names patients routinely hurl at her. “It’s mentally draining.”

“To have the patient use vulgarity and profanity at you does cause some low morale,” said Ronald Hall, a Jefferson University Hospital doctor and president of the Pennsylvania chapter of the College of Emergency Physicians. “You do really care about your job, you care about the patient’s well-being.”

Compounding the problem: The pandemic’s lockdowns and restrictions limited access to in-person medical care, Hall said.

“Doctors’ offices last year had a difficult time trying to meet the needs of their patients because of social distancing and because we didn’t want to spread COVID,” he said.

The results were overwhelmed emergency departments facing more patients who were experiencing mental health crises, while other patients became infuriated by long waits and a triage system that meant quick treatment went to the most ill or injured.

“Everybody’s nerves are all frayed and they’re all screaming, because they’ve waited so long and their emotions get so out of control and they take it out at people trying to help them,” Neopolitano said.

There’s no easy way to quantify the pandemic’s impact on violence in health-care settings. The Philadelphia health department doesn’t collect data on violent episodes in health settings. The Pennsylvania Department of Health receives reports of episodes through the Patient Safety Reporting System, a spokesperson said, but it does not track the data. Complicating the issue is a tendency for these episodes to go unreported.

Kristan, the Einstein nurse, still struggles with her decision-making before she was punched. She prefers to avoid restraining people if possible, she said.

“People, they’re in a bad way,” she said. “They are stressed, they are angry, and hurt with all of the trauma the city has faced.”

Despite her efforts to de-escalate the situation, she still got hurt.

“In hindsight,” she thought, “maybe I should have restrained you.”

Her reaction, questioning her own choices, is common among health-care workers, said Maureen May, PASNAP’s president and a Temple University Hospital nurse.

“If it was an unintentional act from a cognitively impaired patient,” May said, “we did blame ourselves.”

» READ MORE: Jefferson Hospital officials admit staffers should have known sooner about active shooter on campus

That mind-set can lead to episodes not being reported, particularly if no serious injury results. PASNAP and the College of Emergency Physicians are among the groups supporting a bill in the Pennsylvania House that would require health-care facilities to start a violence prevention committee to handle risk assessments, develop a prevention plan, and provide training to workers.

“The stories that I have heard from nurses during COVID makes me believe that the need is greater than ever,” said State Rep. Leanne Krueger (D., Delaware County), one of the bill’s authors.

It would also require workers to report episodes of violence.

“Health care is populated with people who were born wanting to help others and who tend to put themselves in the backseat,” said ECRI’s Comerford. “But there is a critical need for health-care leaders at every organization to ask themselves the hard question: Have we done a comprehensive workplace violence assessment? You’re never going to mitigate a risk you never identified.”

As part of an assessment, hospitals should evaluate physical safety measures, she said, such as entryway security, panic buttons, and mirrors to see around corners. But administrators must also consider less obvious risks, such as whether staffers are routinely delivering bad news to families who could lash out, the dynamic within medical teams, and how well people work together.

A proposal to require health-care and social service providers to create violence prevention plans has been introduced in Congress as well.

Hospitals’ precautions to prevent worker abuse vary widely. Kristan credited Einstein with having security in the room with a volatile patient who stepped in the minute she was hit. And Barkasi was highly critical of Eagleville’s response to violence against staff. People often don’t file reports, she said, because there’s no expectation anything will come of it.

“Do you want to stay later on your shift and write an incident report where you know nothing is going to happen?” Barkasi said.

Concerns over a lack of protections for workers are among the issues that prompted that hospital’s nursing staff to vote to authorize a strike last week amid contract negotiations.

Eagleville Hospital did not return a call for comment.

Some employees may feel that nothing will change by reporting an episode, or think the process of filing a formal complaint is cumbersome.

When Allen was a nurse manager at New Hampshire Hospital, a psychiatric facility in Concord, N.H., she partnered with a state police lieutenant to develop a program to improve reporting and tracking of violence and aggression against nurses.

Under the Staying Safe Program, the hospital reduced staff injuries that resulted in lost time by 70% between 2008 and 2018, said Allen, who has also served as chair of the American Psychiatric Nurses Association’s council for safe environments.

Even if reporting of violence is mandated, hospital administrators need to take the lead in setting an expectation for staff that incidents -- physical or verbal -- will be reported, said ECRI’s Comerford.

“If people at every level of the organization don’t feel empowered to speak up, it’s very much a leadership, top-down imperative to make people feel safe at work,” she said.

Allen said there is a “widely held culture that staff believed getting hurt was just part of the job. Nurses talk about a culture of toughness where staff are expected to just shrug off anything bad that happens.”

Yet the feeling of being at risk of violence in the workplace can reverberate long after bruises and aches heal. Kristan has been an emergency department nurse for almost a decade, but anxiety plagued her after being hit.

During her first shifts back to work after the episode, she froze for moments and felt her heart race, she said. The fear that she might be unable to function at work led her to start seeing a therapist.

“I was very, very thrown off for weeks after that,” she said. “As a practitioner I never want to be sort of beholden to my fears.”