What the hell is happening out there…Man we are a freaking violent society. There is no easy way to put it and the worst part is we accept it, especially in the medical field. Front line medical staff (that includes first responders who really need to stop acting like they are the only people that take abuse as front line staff) raise your hands if you have been assaulted by a patient. See, over 80% of us have. Yeah you play it off as “part of the job” but face it guys, it is getting worse and I am not sure it is us or hospital administration that is fueling this. We are often goaded into “brushing it off” as “part of the job” but the reality is we have seen an up tick in the amount of violence.

This issue has several points to it. The first is a lack of adequate staff, especially on the night shift where some hospitals have forced a 1 nurse to 6 patient ratio on an acute post op unit and 4 patients per nurse on step-down care (this is another bull shit “cost saving” measure that lets the hospital not put the patient in the ICU, but yet provide critical care) and up to 15 to one ratio on psych units. You may be granted more CNA’s or psych techs but they lack the assessment ability of the nurse as well as the ability to accept delegation of a provider to write orders. In one ludicrous move a Nurse Administrator actually suggested that a unit’s Hospitalists (who are NP’s and PA’s) should help with Nursing duties. Yeah up hers, seriously. Nursie poo graduated from that a while ago and has another role that needs to be performed. Not that basic nursing is beneath me, but, I was hired to perform a different function.

This is at the crux of what I am talking about. Anything to cut costs and fail at responsible staffing. You don’t believe me? Fight me. Tell me how doing more with less is anything but a safety issue and a moral injury to staff. I know that Sen. Walsh in Washington thinks we play cards all night, but shadow one of us and you will see a different story.

Before I graduated, I started working on an awesome nursing unit. A manager that was a leader and the kind of guy that would come in early in the morning so that he could make sure the morning transition was smooth. He used mistakes and such as a teaching point to improve care and very rarely picked a pencil to do a “write up”. Morale, super high. Super productive unit. They hire an assistant to help with floor management and then the leader leaves on military orders. In 6 short months, the assistant manager who was no leader proceeded to unravel everything that the floor manager had built. Write ups went up 90% and morale tanked. Moral injury was everywhere. In a 6-month period nurses with 15 years, 10 of them on that unit, left either to other departments or the hospital entirely (which tanked their pension). Safety incidents including assaults, doubled. Med errors went up and basically the floor went to shit. Now that is not saying the nurses gave up when he left, but they did start to give up when there was no support. Seeing the trend yet? Managers who fail to regulate the floor work environment and to fight for a safe environment rapidly lose even the best of floors. The fact is that we have too many managers that are bogged in the numbers set by administration. You wanna know something fun? We received an email from the chief of nursing telling floor staff that incident reporting and staff write-ups are too low. Like more write ups will help. What it came down to is that it would make Joint Commission suspicious if the write ups were low. Wow, and we can’t have too many findings on Joint Commission or guess what? No bonuses.

If I am making hospital administrators sound like money grubbing bastards, well I am. Many of them make three times what I do in a year (or more) and hefty bonuses for meeting standards. Shaking my head since this level of shit makes it spin. I get it, I should be more focused on the money, but I am not. I have the safety of myself and my team in mind as well as that of the patients

Ok, enough bitching. How do we fix it. This is where the pain begins. Well this is painful (see what I did there?).

First the hospital needs to go back to being a place of recovery, a place of healing (yeah they aren’t, they are glorified hotels where patients are waited on hand and foot). We need to focus, like we used to, on care plans and treatment plans and enforce that standard. I have been in the field for 20 years and patients were not only not “waited on” unless they were incapable of movement, they were asked to and allowed to use the “patients galley” for water, coffee, snacks, etc. They were asked to be out of bed, they were made to get out of bed to the chair. They were mobile. They were still medicated and they were still carefully assessed, they also were encouraged to heal. Healing does not mean laying in a bed 24/7. Also the nurse needs to be a voice of authority. They need to push the patient without the fear of administration being upset that their 5 star hotel rating, Michelin Star is revoked, or a bad rating. Order and some level of patient direction indicates that this is not a place to “have it all done for you”. Most patients are fairly well before they have surgery, they are only there to recover from the procedure.

Violent patients need to be flagged in the chart or otherwise identified and that information passed down in report. All staff need to be aware that even though Mr. Jones may have dementia, he will strike anyone in arms length. Those patients should require more than one staff person (in certain occasions) to provide a safety net (oops more staffing since we often do this as a floor between the team on duty) Patients that are violent, do need to be confronted about their violence if they are cognitively able and reminded that even though they are healing that behavior will not be tolerated. Look, stop coddling people who hurt staff. They need to understand there are consequences even though there are mitigating circumstances. In 95% of all cases a report should be filed on violent behavior. If the patient is cognitively aware, there should be a formal investigation.

Continue with good violence prevention on all units and places in the hospital. Good customer care (which doesn’t mean the total ass kiss) is a key start and then good deescalation training, including theraputic listening is essential. Don’t believe me? When I was a younger nurse I worked in a facility that used a technique known as MANDT. This was basically a hold and throw class. Violence begets violence. No deescalation techniques, just let them flip out. Yeah, no.

Lastly, hospital administration as well as EMS, PD, and the Fire Service administrations need to be held to a standard that protects staff and enforces a managed approach to violence.

Will it solve it all? I don’t know, this is really a pipe dream since very little of this has more than lip service paid to it, if it even exists. Yes, this is bleak and needs to be hammered from the top down, instead of worrying about letting front line staff lose their ethics over magical thinking. Spirituality is nice, but it shouldn’t override your ethics and give you an excuse to not deal with a patient, because a magical being told you. Yes I am tough on any religion that uses its force to marginalize anyone.

Watch the back of the members of your team and be diligent about their safety. We all don’t make enough to be put in harms way alone.