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To Change A Culture, Health Care Educators Say Best Practices Start With Students

Aug 28, 2018


  It’s probably obvious that hospitals can be high stress environments, and it’s not just patients who can get agitated and upset. Sometimes it’s also co-workers. Last week, we heard about how some see tolerating violence in health care as part of the job. In the latest installment in our series Part Of The Job, we look at how health care educators have been trying to change that culture of harassment and violence before their students reach the workforce.

This idea wasn’t always discussed in college courses, though.

Ray Purcell is a nurse practitioner, and spent three decades in private practice and hospitals in Kern County. In those settings, he says he saw his fair share of violence. He says one night when he was working in the urgent care facility, he upset a coworker.

“It was at the end of the shift, it was about midnight. Staff was just going home. They were kept over late, and, the physician chose to confront me in a dark parking lot, was very angry, and it’s terrifying,” Purcell says.

Purcell says the dispute was small -- he was moving patients into the physician’s department, and the physician thought it was unnecessary, and got mad.

Purcell says that the encounter was intimidating, but not life threatening, so he tried to move on.

“It was clear that even though I'd extended apology, it was not accepted, and it's a very strained peace with that particular physician.”

Eventually, Purcell moved jobs, but the incident still sticks in his mind.

He says health care workers deal with a lot of incivility, both from each other and patients, in part because it’s a stressful environment. He says violence wasn’t something he remembers discussing in college, but he acknowledges that his education was thirty years ago.

“Even as a student nurse a very long time ago, if a doctor came onto the floor, you'd be there working as a student and there would be times that established physicians in the community, doing rounds and seeing patients would expect nurses to stand, give their chairs, to interrupt their own work,” says Purcell.

Dr. Janine Spencer is a professor of nursing at Fresno State. She’s seen similar incivility in her career, and she tries to teach her students to be aware of what can happen.

“But we also tell them that we really should not tolerate bullying. We shouldn’t tolerate any kind of incivility,” says Spencer. “So it is our responsibility to report those things and to kind of rely on the chain of command to help deal with those very uncomfortable situations.”

 

Spencer says the curriculum also covers dealing with patients in various settings, like a psychiatric department, where there’s often a higher risk of violence from patients.

“In the psychiatric setting, actually, we do a lot of role-playing,” Spencer says. “We try to teach the students how to be therapeutic, we try to teach them how to teach them how to identify early on the signs and to take take significant measures to deescalate the situation.”

In general, Spencer says they try to prepare students for the real world.

“I think the best way we get to that is really, we have to be aware of our environment, but we also have to be proactive in speaking up for ourselves,” says Spencer.

It’s not just nurses who deal with the spectrum of peer to peer or patient to provider threats and violence.

Dr. Lori Weichenthal is an assistant dean at UCSF Fresno. She says that her graduate students also receive a lot of training about how to avoid an incident.

“Just also, common, practical things like, you don't wear something around your neck that somebody could you choke you with and just being aware of your own safety,” says Weichenthal.

She says that while safety isn’t new to the curriculum, she thinks they spend more time discussing it today. Part of it, she says, is because of their location and awareness of local gang violence.

“I think it certainly has escalated in the last 10 years, where it's not just that were worried about gangs, but we're worried about people with mental health issues that aren't getting appropriate care,” Weichenthal says. “We're worried about people who just are angry and upset because you know, they have long wait times and there's a lot of boarding of patients in the emergency department.”

Weichenthal adds that the burden to reduce violence shouldn’t just be on health care providers.

“There also needs to be a no-tolerance policy, and an understanding from the patients that there are certain types of behaviors that won't be accepted,” says Weichenthal.

She acknowledges that there are circumstances where a patient may be mentally ill and unaware of what they’re doing, but even then, she says civility should be expected.

Jonna Pagaduan is a recently certified nurse at Valley Children’s Hospital. She graduated from Fresno State in December. When she thinks about how her education prepared her to address violence, she says a lot of it was preventative.

“It's part of the fundamentals of nursing: how to communicate, and how to deal with behaviors that can escalate to being aggressive,” says Pagaduan.

At the same time, Pagaduan says, there are moments when she tolerates agitated families, because she wants to be sympathetic.

“I'm coming from the perspective that they're unhappy, they don't want to be in the hospital, they're sick,” says Pagaduan. “I give them that leeway as well, that if they do become angry and start yelling, that I’d be okay and calm about it. But now that you asked me about it, I don't think it should be part of the workplace.”

Pagaduan says, despite knowing how to handle people, she doesn’t think she’ll completely avoid aggressive behaviors in a hospital. So while she doesn’t think it should be, maybe violence is an unavoidable part of the job.

And the best that health care workers can do is to be prepared.

 

This story was produced in partnership with USC’s Center for Health Journalism California Fellowship.