Tufts Medical Center

Tufts Medical Center, Boston, MA

TEAM: Inpatient Psychiatric Nursing Staff

ENTRY SUBMITTED BY: Jasper Tolarba, DNP, RN, NEA-BC, clinical nursing director

In psychiatry, the inherent nature of the patient population we serve makes one think that patient violence against staff is just “normal and part of the job.” In fact, violence against nursing staff in this unit comes in various forms-verbal assaults, insults, threats, and even physical attacks. Just a few months ago, staff morale at Tufts Medical Center was very low because, on an almost daily basis, a nurse was being hurt in a patient assault.

As one of the few hospitals in the city offering electroconvulsive therapy (ECT) treatment, this 20-bed adult inpatient psychiatric facility is considered the destination for patients with the most acute psychological problems. We admit patients whose illnesses warrant intensive psychiatric treatment-people suffering from catatonia, schizophrenia, bipolar disorder, and severe depression with suicidal and/or homicidal thoughts, just to name a few. Thus, the nature of our patient population and the resulting assaultive behaviors made the nursing staff feel weary and helpless.

All this changed after an incident last year. A patient, responding to internal stimuli, badly beat a nurse who just happened to be walking nearby. After that, nursing staff gathered and came to an agreement: this culture of violence needed to end. They refused to accept the long-embraced notion that patient assaults in the psychiatric setting are merely part of the job; and they vowed to do something to change their situation as soon as possible. In collaboration with various disciplines and departments of the hospital, the nurses spearheaded different initiatives with the ultimate goal of ending workplace violence.

The first initiative that was piloted was the implementation of the Assaulted Staff Action Program (ASAP). This program is a voluntary, system-wide, peer-to-peer crisis-intervention program designed to address the psychological aftermath of acute traumatic violence (Flannery, 2012).

The implementation of this program forced every nurse to be cognizant of incidents of assault, no matter how small. We logged all types of patient assaults (e.g. verbal, physical, sexual) and made sure to provide support to the staff victim, rather than just ignoring or downplaying the incident. ASAP gave us the opportunity to debrief every incident, so that all staff could learn from it and be equipped with the right knowledge if faced with a similar situation. It also provided useful data that served as guide in making policy and practice changes.

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Another morale-boosting initiative was the implementation of a monthly, interdisciplinary debriefing session (attended by social workers, physicians, nurses, mental health counselors, occupational therapists, and other interested staff). In this debriefing, anyone can freely share their worries, fears and experiences related to working in the unit. This provided everyone the opportunity to vent their emotions in a “psychologically safe” environment. The staff came to realize they are not alone and isolated in their experiences, giving them a sense of support.

One other change we implemented was to improve communication between our inpatient unit and the ED. It used to be that the ED would just send patients to the inpatient psychiatric unit without calling to make sure we had a room and bed ready-which often led to unsafe situations. Now, the process has been improved to ensure that the patient’s room is prepped, a nursing report has been given, and all of our staff’s questions have been answered. Patient transfer is now safe and seamless.

As a result of these initiatives, this team has come a long way from where it was before. The incidence of staff assaults has dwindled significantly. All it took was teamwork, determination, and sense of support for each other. Our team is living proof that caring for our patients and our fellow staff members can go hand-in-hand. Remember: workplace violence is NOT part of the job by any means-even in a psychiatric setting!

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