Friday, May 19, 2017

Luncheon Consensus - Management Continues To Do Nothing About Hospital Violence

I had lunch last weekend with staff from several psychiatric facilities in the Twin Cities.  The group included nurses, nurse practitioners, and health unit coordinators.  Many of them were at the retirement party that I described a couple of years ago.  At one point in time we all worked on the same inpatient unit and that was the common bond.  Over the several hour long lunch the discussion gravitated to one of our favorite topics - violence and aggression in hospitals against medical and nursing staff.  There was the usual litany of injuries - concussions, a stabbing, beatings, and musculoskeletal injuries.  At one point I heard how a staff nurse in her fifties with knee replacement surgery and back problems had to interject herself between a patient she was admitting and a violent and aggressive person who walked in off the street.  In that situation she had to hope that security got there in time to protect her.  I listened to another nurse tell me how the assault charges were determined after she was assaulted - first degree assault only because she had a concussion.  The other forms of being punched and kicked that she sustained that day were all lesser forms of assault.  I also heard how some members of the hospital administration minimized the incident and how her assailant eventually was not charged with anything.

This is one of many areas where the army of health care administrators really don't seem to be able to do anything productive.  Every hospital in the country has posted non-discrimination policies.  They discuss how every patient will be treated respectfully.  These same rules do not apply to their own staff.  When staff are assaulted there is a common belief that it is an occupational hazard.  It is all part of the job.  The other crucial part of the problem occurs at the committee level in higher levels of administration.  When ever there is a potential problem resulting in injury, a standard administrative strategy is to move it to a committee or Task Force.  That is where real problems occur because there is no expertise on the committee in assessing and resolving problems with violence in medical settings.  That lack of expertise is common.  A corollary is that administrators are in the position that they do not believe that they can defer to clinical staff with much more expertise because of the chain of command.  That is a recipe for inaction and manipulation.  If a staff person brings up a concern that the administrators can't solve - the issue is tabled or the person is not asked to come back.  Even more problematic, some administrators embark on their own ideas about how to solve the problem.  I have listed some instances of this happening on this blog that have resulted in more staff injuries.  A final strategy is to bring in consultants.  I have seen situations where expensive business consultants are brought in to either tell the staff that their patients are not any more aggressive than the patients seen in other hospitals in the state.  If that doesn't work - bring in a consultant who will try to demonstrate that he or she knows more than the current staff.  Both administrative strategies fall flat when the staff is dealing with some of the more significant problems with aggression in the state and they have the most experienced clinicians.

No - the violent outbreaks that are described in most hospitals are the result of administrative failures at several levels.  A failure to recognize the issue exists.  A failure to recognize that your staff has the expertise to deal with it.  A failure to recognize that aggression toward the staff is not the result of staff failing to treat people in a particular way or due to a deficiency of the staff person.  And most of all - a failure to facilitate a team approach among the staff in the hospital or clinic with the most expertise.  It is really that easy.

In our discussion, several instances of these manipulative responses to hospital violence were noted.  Even very basic requests for additional security staff and to prevent aggressive people from walking in off the street are ignored.  There is no shortage of meetings and I have participated in many.  One of the administrative strategies is blaming physicians for the problem.  There is nothing like having a dedicated and skilled staff with as much expertise as can be found anywhere - suddenly being blamed for the problem.  In some of these situations the administrators bring in "consultants" to tell senior clinics who have been treating the problem for 20 years.  I am speculating that is right out of "Power Plays 101" in administrator school.  It is not difficult to see how all of this administrative drama and expense fails to solve the problem.  In most cases it ends up looking like nobody is even trying.  A scapegoat has been found - let's leave it at that.

There has been a laudable effort by nurses.  In my home state, the Minnesota Nurses Association (MNA) has been very vocal in terms of the number of aggressive incidents toward nurses in Minnesota hospitals very year.  A 2004 study showed that that nurses were physically assaulted at a rate of 13.2 assaults per 100 persons per year.  17% of nurses were threatened and 34% were verbally abused in the preceding 12 months of the study.  The MNA has also been active to get legislation to legally protect nurses from aggression and assault.  This link to their proposal does not indicate whether either of their proposals have been successful.  

It appears that there are no comparable efforts by the state psychiatric association or medical association.  I am sure that if this luncheon group meets again, there will be reports of further injuries and a continued lack of response to the violence and aggression toward health care workers.

It probably makes sense in terms of the American inertia in dealing with violence and aggression in general.  But it also makes sense because health care administrators really don't do anything to support clinicians or improve the environment where they work.

Replacing all of those administrators is the best place to start.

George Dawson, MD, DFAPA              


1:  Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. Review. PubMed PMID: 27119238.

2: Nachreiner NM, Gerberich SG, McGovern PM, Church TR, Hansen HE, Geisser MS,Ryan AD. Relation between policies and work related assault: Minnesota Nurses' Study. Occup Environ Med. 2005 Oct;62(10):675-81. PubMed PMID: 16169912; PubMed Central PMCID: PMC1740877.

3: Gerberich SG, Church TR, McGovern PM, Hansen HE, Nachreiner NM, Geisser MS, Ryan AD, Mongin SJ, Watt GD. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study. Occup Environ Med. 2004 Jun;61(6):495-503. PubMed PMID: 15150388; PubMed Central PMCID: PMC1763639


Aggression and violence and their prevention is one of my interests on this blog.  A sampling of posts can be found at this link or by selecting any of the links from the right margin.

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