Thread by @usnehal

Caused furor w/ this tweet that was not clear or complete by itself

Explanation:
What may be going on may BE abuse of staff

needs to be clear, rational, fair, transparent ways to define it & address it

plus, committed resources for toll of abuse on staff

system level solution

https://twitter.com/usnehal/status/1175424032390426624

Clearly, I chose poor wording that sounded a lot like common minimizing language to dismiss

As both a clinician & former administrator see HUGE gaps in a system that makes everything about “personal responsibility” while system lacks resources for outcomes expected & needed

Instead, need a system that is clear, consistent, with rational resource allocation

If ED RNs & docs are getting PTSD from the job itself, sometimes witnessing results of physical trauma, where are the mental health resources?
acepnow.com/article/we-mus…

Our EDs and hospitals are also giving patients PTSD symptoms as a result of care received

jwatch.org/na48976/2019/0…

The human interaction between clinicians and patients can reduce development of PTSD symptoms in patients who visit the ED

ncbi.nlm.nih.gov/m/pubmed/30911…

Instead of system resources to support humans in system

we see exploitation of good will and personal responsibility mindset of nurses and docs

with ongoing cuts to the system that put stress on both patients and staff to overcompensate for cuts

nytimes.com/2019/06/08/opi…

Whenever I lead clinicians

I have a *really* hard time getting them out of this mentality used to exploit.

When things happen do not react on personal level

turn the personal into data

to quantify & document gaps

to fix at a system level with dedicated, committed resources

From emergency psychiatry perspective, there are these guidelines

And if we want the right outcomes, for patients and staff

means committing resources

to the best practices described here

ncbi.nlm.nih.gov/pmc/articles/P…

From a more general perspective, there is this advice with a lot of overlap with the best practices from emergency psychiatry

What are hospitals & facilities doing to commit resources to early intervention, prevention

from a systems approach?

psqh.com/analysis/talk-…

This takes 💰💰💰

Are administrators willing to spend 💰 to keep everyone safe?

“It is money well-spent,” says Scott Zeller, MD, chief of psychiatric emergency services. “This is truly a situation where an ounce of prevention is worth a pound of cure.”

the-hospitalist.org/hospitalist/ar…

And not just training staff — again, that only puts responsibility on human in flawed system — but space considerations as well. What design & utilization of spaces is there for right outcomes on safety for patients and staff? Assess all factors, causes.

physiciansweekly.com/emergency-depa…

“Dr. Martin Reznek, UMass Memorial Medical Center's vice chair for emergency medicine and a panel member for the report, said overcrowding is at the root of many of the issues, with patient demand challenges worsening in the past five to 10 years.”

wbjournal.com/article/state-…

Adding to overcrowding in EDs is the opioid epidemic

with EDs as place of immediate care for problems created by the system itself

This is a population of patients at intersection of medical & behavioral health

That EDs unprepared/unequipped for

beckershospitalreview.com/patient-flow/e…

“Opioid misuse explodes in our face on nearly every shift, splattering the entire department with pain and suffering, and addiction and malingering and cursing and threats and hospital security, and miosis and apnea and naloxone and cardiac arrest.”

emergencymedicinecases.com/opioid-misuse-…

@ZDoggMD is spot on that it is NOT about empathy (=feeling other’s pain), or making everything personal — that leads to wrong decisions, short term thinking, and burnout

*To my knowledge, Zdogg is citing work by @paulbloomatyale on dangers of empathy

@paulbloomatyale talks of rational compassion as opposed empathy — latter infused with personal bias, increases tribalism, can be flat out immoral, in fact.

This explains benefits of compassion well — it frees up cognitive resources for better decisions

psychologytoday.com/us/blog/mindfu…

Everything else in healthcare, especially emergency medicine, has a protocol to improve safety, rather than personal variation, why not policies and protocols for how to address abuse in an ED setting?

acep.org/how-we-serve/s…

What is it about medical culture that promotes and excuses abuse overall, starting from within the system? This explores:

annfammed.org/content/10/2/1…

Why are nurses more at risk for abuse? (Answers: Hierarchical system, gender issues, amount of time at bedside)

I get many roll their eyes at stuff like this — “another useless policy”

Still, it *is* important to write down in black & white for all to see what definitions & boundaries are

Those least empowered often fight hard for things written down clearly, as policy

Keep in mind the “norm” of broader culture — NOT an excuse — as a way to estimate how much to expect, especially in certain healthcare settings and resources needed

Why clear definitions are key, because what is tolerated/norm in culture is abuse

ncadv.org/statistics

Why do we romanticize and celebrate this sexual assault, a drunk man grabbing a random woman in a nursing uniform, to kiss her because of emotions he felt in the moment, felt he could grab the nearest nurse?

cratesandribbons.com/2012/09/30/the…

Clarity & policy protects

“Nurses..not sure if what was happening to them was classified as violence”

“”NYSNA is working on educating nurses, as well as management, on how to proceed so that we are proactive, rather than reactive, in these situations,””
nurse.com/blog/2010/11/2…

Data needed

“I’d like to see hospitals be required to collect and report statistics regarding violence against their staff,”

Personal -> Aggregate data
Uncertain -> Defined
Reactive -> Prevention
Arbitrary -> Consistent
Self-policing -> Transparency

huffpost.com/entry/violence…

"The organization has to work with them to come up with a plan to mitigate those risks associated with those problems, and it really takes a comprehensive and systematic approach to that particular issue."

modernhealthcare.com/providers/heal…

We need there to be clear definitions understood by everyone
posted & enforced

"The thing is, healthcare workers, they put up with a lot of stuff..extremely resilient..oftentimes they don't even realize that this is probably something that we should probably report."

This is a growing problem, including gun violence withIN hospitals

“Within 48 hours we had 2 hospital shootings in South Carolina. Something like that happens once & everybody’s antenna goes up.”

Violent culture outside increasingly entering hospitals
ajmc.com/focus-of-the-w…

Yet, @WSJ & @JAMA_current tell us that gun violence not relevant topic for med school despite it appearing in our own healthcare facilities & killing our own while on the job

Young docs sent out in world w/out knowledge of reality
#goldfarbchallenge

nytimes.com/2015/01/22/us/…

A policy will not stop an irate patient with a gun intent on murder, of course. Is an extreme case.

Or is it really that extreme?

Given rates of violence in broader society, shouldn’t we expect violence in healthcare too?

Be prepared, proactive?

gunresponsibility.org/gun-violence-a…

Why are we talking about “empathy”

vs sensible, rational, measured, proactive policy & resource allocation at system level

for expected amount of abuse & violence, norm in culture, that will enter through doors of hospitals

and put all staff directly in harm’s way by default?

And beyond level matching levels in culture & country

there will be a higher level of abuse and violence

by nature of
1-reasons people seek care
2-biological & psychological mechanisms (incl stress)
3-failure of system to invest in safety,deescalation

in all healthcare, esp ED

Let’s get out of personal & siloed
Out of reactivity to individual incidents

->rational compassion

with clear definitions, policies, focus on prevention, support after incident, sensible resource allocation per data

Create a safer system for all within it, patients & staff