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Just over three weeks ago I wrote about a renewed calls by the Health Services Union (Vic.) to arm hospital security staff. My focus was on why I thought adding guns to an already volatile situation was a bad idea – though I touched on some of the occupational violence I and some of my colleagues have experienced, I concentrated on the impact of deregulating the Vocational Education sector.

Since then I’ve begun Health and Safety Representative training – and learned that nurses have the second highest risk of occupational violence: higher than police officers and prison staff. Lower, in fact, only than paramedics. And this week, four articles (see links, below) have been brought to my attention that make it clear I failed to write about an aspect of occupational violence in health care that is at least equally significant, and a current risk rather than the hypothetical issue of armed staff.

In one incident at the Royal Children’s Hospital, inappropriate placement of an aggressive adolescent on a low security psych unit resulted in two nurses being significantly assaulted last month – one was punched in the face, while another was partially scalped, sustaining nerve damage. I can’t speak to, nor imagine, what psychological impact this has had on the nurses involved, nor on their colleagues, but they are not the first significant incidents there just this year. A spokeswoman for RCH says hospital management is reviewing staff safety – somehow that wasn’t done until the fourth incident in under four months.

Were this one incident it would be troubling. Were it a problem at one hospital it would be a cause for concern. But this escalation in violence, coupled by inadequate support structures, appears to be widespread. At the Monash Medical Centre three psych nurses were sexually assaulted in a matter of weeks, when an impromptu psychiatric ward was created to deal with increased demand for beds – an audit by ANF (Vic.) has revealed Victoria has 24 fewer mental health beds now that when the Coalition government won office in 2010.

A mental health nurse at MMC who declined to be identified, and who reports daily threats and assaults (as well as being punched in the throat) is quoted in The Age as saying:

We help society’s most vulnerable and downtrodden during the most difficult time of their life. When people are unwell they can act really badly but the system is unwilling to deal with this because it is expensive.

He also pointed out that the focus of current health is throughput – true in every aspect of clinical management.

You could be forgiven for thinking that this escalation in occupational violence is isolated to mental health. That’s certainly a hot spot, along with the Emergency Department – and, as I noted in my last entry, that’s why security are often housed in or near the ED. It’s also why most psych units equip their staff with duress buttons.

I’ve mentioned Code Grey previously – a standardised emergency alert that there’s threatened violence triggers, at my hospital, an immediate team response: at least two members of our security staff, a registrar and nurse on clinical liaison from the psych unit, and a senior member of nursing staff (the unit manager in hours, co-ordinator after hours, and often the manager in charge of behaviours of concern) – ideally accompanied by medical staff from the treating team.

Before Code Grey I had no idea how widespread occupational violence in my hospital was – on an average shift I hear an average of three calls a shift, sometimes far more. Hearing them called not only alerts staff to stay away and avoid escalating a situation (and to give the ward some space because they’re busy), if reinforces that I don’t have to tolerate aggression at work. I don’t know how long ago the policy was instituted where I work, but certainly it’s several years old, and the difference has been enormous – I can call a Code Grey if I’m threatened, I can tell patients and family members who are becoming abusive that their behaviour won’t be tolerated, and I know that my management prioritises the safety of their staff and their patients.

That’s clearly not the case at Dandenong. They, and Monash, somehow have no Code Grey policy in place. At all.

That’s despite a working party implemented in 2011, following the release of recommendations by the Inquiry into Violence and Security Arrangements in Victorian Hospitals, a follow-up to the 2005 Victorian Taskforce on Violence in Nursing.

The 2005 report’s recommendations included a policy that “there is not a culture of tolerance of violence in the workplace” (recommendation two) – kind of hard to do if there’s no way to respond to violence as it’s happening. Recommendation 8, “the message that violence against nurses is unacceptable” is pretty words without enforcement; and clearly Dandenong has implemented neither recommendation 10: “That the Department of Human Services introduces into Victorian health services, standardised Code Grey (violence and aggression emergency) and Code Black response (armed threat)” nor recommendation 11, which reads in part that: “All health organisations will:
• establish an aggression management reference group which will be responsible for developing policies and procedures around the management of aggressive incidents, primarily through a clinically led aggression management team [and]
• establish, in all high-risk departments, security measures that include a response by staff who are trained in the prevention and management of violence and aggression during hours of operation”

That these recommendations weren’t implemented across the state is clearly not wholly the fault of the current government, who weren’t in power in 2005. The current government was, however, elected on a platform promising $21 million specifically directed to improving health care staff safety – since attaining government that’s translated, almost 30 months into their term, to $5.8 million for training and the installation of duress alarms in some areas. Not that duress alarms are particularly useful without staff to respond…

Perhaps Dandenong has no need for an occupational violence policy? Well, no – a nurse there recently required plastic surgery after a patient bit flesh out of her breast. I don’t swear here, but that news? Has brought me closer than former Premier Baillieu ever did. And that’s not an isolated incident – only two weeks ago another nurse was threatened at knife point.

But for me the absolute icing on Dandenong’s indigestible cake is that one of their nurses is currently in the Fair Work Commission after being disciplined and demoted for intervening when an unauthorised visitor was discovered in a supposedly secure area and became threatening and aggressive. Observers and the hospital’s own internal review found he’d acted reasonably during the incident, which included tackling the man to the ground, with the aid of a nearby doctor – the nurse and the visitor sustained injuries as a result, and at some point the visitor spat blood in the face of the nurse.

I can not better articulate my outrage than to quote ANF (Vic. branch) Assistant Secretary Paul Gilbert:

The nurse has been made a scapegoat. The hospital has criticised him for not following a Code Grey policy that doesn’t exist. He shouldn’t be criticised; the hospital should be ensuring a safe workplace.

A meeting of members at Dandenong has called for the hospital to reverse their decision and instead focus on measures to improve staff safety and hospital security, foreshadowing the possibility of industrial action – a move I wholeheartedly support.

Next time I’ll discuss the issue of security in smaller, sub-acute and stand-alone facilities, and the fact that in Queensland security staff are being withdrawn from some services altogether, despite high risks of occupational violence. Queensland Health itself, of course, has enough material to form a three-part series…

The Age: Hair ripped out, breast flesh bitten off: hospital violence triggers nurse safety demand – Julia Medew, April 24 2013
The Age: Nurses call for help after attacks – Henrietta Cook April 25 2013
The Age: Fix safety or we’ll strike, warn nurses – Julia Medew April 26 2013
The Queensland Times: Health staff defenceless after security guards axed – Kieran Banks April 24 2013
The Monash Weekly: Dandenong Hospital nurses may take action – Cameron Lucadou-Wells April 26 2013
ANF: Dandenong Hospital disciplines and demotes emergency nurse after incident with aggressive visitor – April 23 2013