OSHA did not respond to calls or e-mail requests for an interview.

Any workplace safety regulations fall under OSHA's broad general duty clause, which states that employees have the right to work in a safe and healthy environment, says McPhaul. She says that workers have gone to OSHA to file complaints under this clause, stating that their work place is not safe or healthy.

"When you make a complaint, there's a high burden of proof [for the person filing the complaint]," she says. "People have done it, but it's very, very difficult."

Incidents that are reported, explains ANA's Hughes, can be filed as workers' compensation claims, though that's often not the case.

"A lot of times nurses don't report the incident and think they're too minor to report," she says.

Despite Casey's advice for nurses to be proactive and report violent events in an effort to seek help, she has never reported an incident, nor does she know of any colleagues who have reported events.

"Why haven't I? I don't know," she says. "It's such an everyday occurrence; it's not anything new. It's not shocking, not alarming. It's the same old drunk or addict peeing on the floor. Just when you think you've seen everything and nothing shocks you, you see something that shocks you and then that [becomes] the norm."

"There is a fear of repercussions from management," Casey says. "[Management] may interpret [an incident] as 'I must have done something wrong.'"

The battle over restraints

If nurses are the subject of so much violence in the workplace, isn't it their right to defend themselves?

That's where everything gets gray.

Because nurses are dealing with patients, many who are mentally ill or under the influence of either street or medical drugs, some feel it's not ethical to fight back as one would under normal circumstances.

"In the past, we were able to get more support dealing with dementia and delirium [patients] through restraints," says MNA's Pontus. "Nurses are trying to follow restraint orders. New regulations are talking about restraining - when you can and cannot restrain."

While the Substance Abuse and Mental Health Services Administration (SAMSHA) - a sector of the Department of Health and Human Services - advocates health professionals move away from all types of restraints, the group doesn't expect a nurse to subject herself or himself to assault.

"Our focus is to prevent the use of restraints, only using them when the safety of staff, the patient or another patient is at risk," says Larke Huang, a SAMSHA senior adviser.

Restraints, Huang points out, can be harmful to both patients and staff members; physical restraints kill between 50 and 150 psychiatric patients a year, according to a SAMSHA report. And studies have found that staff can suffer more injuries when attempting to use restraints than workers in high-risk industries such as lumber, construction and mining suffer carrying out their tasks.

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