A MULTIDISCIPLINARY APPROACH
Addressing violence and aggression requires an integrated, multidisciplinary approach. A common link among the three cases that we presented is the failure to recognize the systemic causes of frustration and the resulting vulnerability of the physician who seemed responsible, as an individual, to deal with the aggression. Violence prevention and control is a systemic problem that requires the input of administrators, educators, security personnel, and legal staff.
Although hospitals are not required to establish violence prevention programs, recognition of the increasing prevalence of fatal and nonfatal assaults in the health care setting prompted the Occupational Safety and Health Administration (OSHA) to publish guidelines that specifically focus on the problem of violence inflicted by patients against staff. Published in 1996, these guidelines outline the essential elements of a violence prevention program in the health care setting and provide sample incident reporting forms and surveillance surveys. Although it is beyond the scope of this article to review all of these strategies in detail, we highlight the key components to a successful violence prevention program and provide physician-specific discussion of each:
- A commitment from health care administrators and physician educators to acknowledge the reality of violence and to allocate resources for the development of training, crisis management, debriefing, and surveillance programs.
Administrative support not only legitimizes violence toward physicians as an important problem, but also provides the impetus for systemwide involvement. Many institutions have established detailed intervention procedures for handling dangerous situations; at a minimum, security officers should be actively involved whenever personal safety is felt to be at risk. After a violent incident, a debriefing session is recommended. This provides the opportunity for injury assessment and supportive counseling. To evaluate the success of a program and ensure accurate surveillance of ongoing violence, prompt reporting of all threats and assaults is necessary and is the responsibility of the individual involved.
Legal counseling is an important part of the debriefing process for both the individual and the hospital. Health care employees who are injured by violence during the course of their work are usually eligible for workers’ compensation, but generally cannot sue their employer for negligence. Although the General Duty Clause of the Occupational Safety and Health Act does require employers to provide a workplace “free from recognizable hazards,” whether or not a legally defined duty exists to warn health care workers of patients known to be dangerous is not firmly established. Administrators can, however, be cited by OSHA for failing to prevent or abate a recognized hazard of workplace violence.
- The development of training and educational programs for employees, supervisors, managers, and security personnel.
Educational programs for physicians should include the practical skills necessary for recognizing and responding to violence. It is important to be able to differentiate between angry, frustrated, or “difficult” patients and those who may actually cause physical or emotional harm. This requires observation for specific behavioral cues and discussion between doctor and patient. For example, a person who is sitting tensely on the edge of his seat, using loud, pressured, or threatening speech, or who is agitated and pacing should be viewed as potentially violent by the physician. When working with potentially violent individuals, physicians should be direct, nonargumentative, and honest. Experts recommend asking straightforward questions, such as “Do you plan to harm me?”, and clearly conveying that violence is unacceptable.
Behavioral cues were present in all three of the cases presented. Mr. A was increasingly agitated and began yelling prior to throwing a chair, Mr. B was argumentative and angry with the nursing staff prior to throwing a pitcher, and Mr. C’s family had been making direct threats and intimidating gestures for 5 months. Unfortunately, only in case B was this behavior recognized and addressed appropriately. In this case, after Mr. B threw the pitcher, the medical student left the room and returned with her senior resident. The resident calmly told Mr. B that no further acts of aggression or destruction would be tolerated.
Physicians also need to trust their “gut instincts” and feelings. A useful rule of thumb is to heighten one’s suspicion when dealing with any individual who makes one uneasy and to take action when one feels threatened or frightened. As internists, we are trained to collect and analyze data. A displaced PMI, a rising creatinine level, and a blood pressure of 80/40 are all data with familiar meanings that we know how to interpret because we have been trained to do so; we should recognize that our feelings and instincts are reliable data as well.
In a dangerous situation, there are numerous personal precautions that physicians can take to ensure their safety. Simple to implement, these strategies include maintaining physical distance, never turning one’s back on a potentially violent person, always staying between the door and the potentially violent person, to be certain of a safe exit, and removing dangling items that can be used as weapons, such as stethoscopes, neckties, or jewelry.
Incorporating these clinical skills into medical school, residency, and continuing medical education classes is an essential step in the prevention and management of violence. Recognizing that societal violence is an important public health topic, physicians are being encouraged to include interpersonal violence assessment and intervention in their training and practices. Addressing violence directed toward physicians in this developing curriculum will help to broaden the focus of these discussions and provide useful information to students regardless of the specialty they choose. Case presentations, discussion groups, and didactic sessions with practical advice are all potential forums for education. There are publications that can assist as well, including the American Psychiatric Association’s Guide to Clinician Safety, a booklet from the Young Physician’s Section of the American Medical Association, entitled “Violence in the Medical Workplace,” and a recently published syllabus by Lion and Scaletta.
Educational programs for physicians also need to acknowledge and support the effect that aggression and violence can have on an individual. Examining the aftermath of the case of Mr. C demonstrates the range of emotions that can result. Subsequent to Mr. C’s death, an organized discussion was held with the housestaff and attending physicians who had cared for him during his prolonged hospitalization. There, more than 30 interns and residents recalled their experiences with this patient. Almost all were fearful of and felt intimidated by his family. Many residents felt abandoned, stating that the attending physicians were not supportive of their concerns, a problem attributed to lack of experience with such situations. Although many residents were uncomfortable interacting with this particular family, they felt that it was part of their job as physicians to deal with “difficult” individuals, be they patients or, in this case, family. Some expressed feelings of guilt, blaming themselves for not developing a stronger relationship with the family. Others had denied to themselves the possibility that physical violence could actually result. In addition, because the family had mentioned bringing legal suit against the hospital, residents felt that every effort should be made to accommodate their anger. The feelings of guilt, denial, fear (of litigation), and inadequacy generated by this case are common responses to aggression and violence. As in this case, these emotions can be important barriers to open, constructive discussion. Educational efforts should acknowledge these barriers and provide a supportive environment in which to understand and process them.
- Ongoing work site analysis to identify existing or potential hazards for violence and the implementation of measures to prevent or control such hazards.
Ensuring a safe practice environment in the health care setting is another component to a violence prevention program. Because long delays have been associated with frustration and violence, the waiting area should include diversions such as patient education materials, magazines, open space, and available telephones. Further measures such as panic buttons, flags on charts of high-risk patients, and metal detectors may be implemented in specific high-risk settings. There is evidence that such measures are effective and do not detract from patient care. It is not known, however, if these strategies are appropriate for internal medicine training and practice settings.
Of the three cases we presented, case A, that of the acutely psychotic patient in the acute care clinic, provides the most obvious example of a violence-prone work site: Mr. A was placed in an inappropriate environment, and cared for by internal medicine residents with little training or experience in the management of psychotic patients. Emergency departments or acute care clinics that serve a large population of psychiatric patients should be equipped, both in terms of personnel and space, to handle potentially aggressive or violent patients.
Physicians harmed by the people for whom they provide care experience a unique type of workplace violence. Because general internists have responsibilities in a wide range of clinical settings, the potential for aggression and violence is a realistic concern. The significant emotional, psychological, and financial costs of violence make this an important issue for us all. It is crucial for general internists to recognize the various forms of violent behavior, to address the clinical and institutional factors that both perpetuate and result from patient violence, and to be aware of the appropriate security measures to take in a dangerous situation. Guidelines published by OSHA, the Joint Commission on Accreditation of Health Care Organizations, and a number of professional organizations such as the American Medical Association and American Psychiatric Association are valuable resources for practicing clinicians and educators.
The three cases we have presented exemplify how aggression and violence can manifest in the internal medicine setting. Within internal medicine, it is likely that certain clinicians are at increased risk, such as those who care for patients in the emergency department, on psychiatric wards, in substance abuse programs, and in prisons. Regardless of where one trains or practices, however, the possibility of encountering an aggressive or violent individual will always exist. The belief that physicians are exempt from physical violence because of their status, power, prestige, or knowledge is a myth.
Efforts to address this problem should be aimed at better understanding the situations in which violence occurs and the unique way in which violence affects general internists. Future research is needed to describe the epidemiology of aggression and violence toward physicians and to evaluate the efficacy of educational programs and interventions designed to prevent its occurrence.
Link – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497004/