Warning: today I will take the risk of being ridiculed for over-sharing and being melodramatic (it’s a grand tradition amongst bloggers).
Recently at work I spent a bit of time wondering whether I, one of my nursing colleagues, or one of the hospital patients or visitors was going to sustain a life-threatening brain injury at the hands of a man brandishing a fire extinguisher as if it were a weapon. Fire extinguishers are generally thought of as potentially life-saving devices. However, when a fire extinguisher is being held at shoulder height by a tall, fit, powerful young man on a violent rampage in a medical ward they don’t look like life-savers.
Fire extinguishers weigh 9kg and are made of steel. The fire extinguisher this man was holding looked a lot like a skull-cracking device to me. It was the most frightening workplace incident I have experienced.
I have been a nurse for 25 years. Like many nurses I have been struck while at work (39% of nurses have experienced physical violence according to this recent Australian survey, 36% worldwide says this quantitative review). I am lucky: I have only been hit by frail people with delirium or dementia, so have never been hurt – just surprised and amused. To illustrate: once, an elderly lady forgot I was the nurse making her bed, and suddenly started punching me (with the strength of a wet kitten) saying, “Stop it Malcolm! Don’t take my money from under the mattress and go to the pub again! You’re such a bastard Malcolm!” It was pretty funny – always wondered whether Malcolm was a memory from her past or a distortion of the present (probably a bit of both).
Zero Tolerance is Unrealistic and Unfair
I am not a fan of being abused or hit, but think that the “Zero Tolerance” campaigns that have popped-up in health services in Australia over the last 5-10 years are unrealistic and unfair.
Unrealistic because it is inevitable that health services, hospitals especially, will have a large percentage of patients who have cognitive and perceptual deficits due to the very medical condition that has them bought them to the health facility in the first place. More than half of older persons admitted to hospital will experience delirium, and about 9% of the over-65s (a significant component of health service users) have dementia. Often these people will not have the cognitive capacity to discriminate between friend and foe, and will, at times, lash out to defend themselves against a perceived threat. We can look out for the warning signs and be proactive in protecting ourselves, but we can not expect to transfer responsibility for our safety onto someone who does not have the cognitive capacity to even keep themselves safe.
In the health system it is very common to be spending time with people who are having the most traumatic, frightening and disempowering day(s) of their life. It would be lovely for staff if everyone experiencing acute emotional distress expressed their emotions in a clear, calm and composed manner, but is it realistic?
The “zero tolerance” concept is unfair because it is not reciprocated. We (that’s “we” as in “we the health system”) require patients and their loved-ones to be incredibly tolerant of us. Think waiting lists, physical discomfort, unplanned delays, unclear communication, unmet expectations, cancelled procedures, lack of privacy, lack of dignity, lack of control, lack of compassion, lack of progress… the list could go on. Can you find me a health facility where no patient has ever experienced these things? Our health system relies on people being tolerant – this “zero tolerance” malarkey doesn’t allow for a bit of crap.
Care and CrapInstead of zero tolerance, it is more realistic to expect that patients will occasionally need to vent their emotions. Not just the pleasant emotions like love, joy, gratitude and kindness, but also the less comfortable human emotions like grief, anger, sadness, worry, despair, frustration, fear, pain and hate. For these emotions swear words are adjectives, a raised voice is empowering, tears are cathartic.
In “Nursing Ring Theory” (more info here: impactednurse.com) when someone is in a ring that is smaller than the ring you are in you offer support, compassion, care and skilful expertise. When someone is in a ring that is larger than yours you are allowed to ventilate your emotions with them. It is pure client centred care: everyone sends care going towards the direction of the patient and accepts that there will be crap coming out at times.
This acknowledgement of crap coming out is not an offer to hold out nurses and other health care workers as targets for abuse. That’s not OK. However, let’s shelf the zero tolerance crap: of course we’re tolerant of people ventilating their emotions. All we ask is that nobody is put at risk and those closest to direct patient care also have an avenue to safely ventilate their crap.
In ring theory care goes towards the patient and crap moves away from the patient. Proximity to the centre of the ring will be a fair predictor of the intensity of both care and crap.
Fire Extinguisher Guy*
Fire extinguisher guy is admitted to a medical ward for investigation of possible neurological disorder, but it might be something mental health related. So the Consultation Liaison CNC (me) spent a lot of time talking to fire extinguisher guy before the violent outburst, and again afterwards.
Fire extinguisher guy works hard, is creative, can be warm and funny at times; sadness, anger and tears bubble-up during our conversation then settle quickly. Talking to someone is both distressing and helpful, says fire extinguisher guy. He wants to get these strong, bouncing-all-over-the-place emotions under better control. Fire extinguisher guy’s experience of terrible abuse in childhood and his recent over-the-top cannabis and alcohol use wouldn’t be helping his labile hypomanic symptoms.
Fire extinguisher guy isn’t an unlikable person – he has a job, a car, a girlfriend, workmates, footy mates, other friends and a family. Fire extinguisher guy and the people who love him are all normal people. Fire extinguisher guy is one of the 20% of Australians who will experience problems with their mental health this year.
I am really grateful that fire extinguisher guy made the choice to direct his violence at property and not people. He had the capacity to make a very bad decision to hurt somebody; he chose not to. The only person physically harmed during this violent outburst was fire extinguisher guy himself: cuts from punching glass, bruises from punching and kicking windows, doors and walls of the medical ward.
I can’t figure out how long fire extinguisher guy’s violent outburst lasted. Replaying the scene in my mind I guess it was less than 2 minutes, but it’s like time measured in dog years… even though everything happened very quickly it somehow felt like slow motion too.
The fire extinguisher had been hurled into a storeroom doorway (THUD! CRACK!), the outburst was tentatively over, and fire extinguisher guy’s mum and i were lightly holding him and talking to him quietly when security arrived. Fire extinguisher guy allowed us to lead to him to an empty room and was cooperative with all of our suggestions and interventions. He apologised first to me, then to each of the other clinicians who provided care in those first couple of hours after the event. His apologies were heartfelt. He let the nurses, the doctor and the cleaner go about their business uninterrupted: his wounds were dressed, he accepted oral medications to dampen the intensity of his emotions, the blood and broken glass were cleaned-up, the other patients and visitors were reassured, detailed file entries were made, incident reports were filled-in, and negotiations between various members of the hospital’s multidisciplinary team were underway. The request for transfer off the medical ward could not be accommodated, but the insistence on two security guards overnight for staff and patient safety was.
Those of us up-close-and-personal to the incident took a couple of moments to exchange thoughts, but we tried not to get too bogged down in feelings at the time – it’s the beginning of the shift and fire extinguisher guy is just one of many patients on this busy medical ward.
There is a hole in the wall that fire extinguisher guy created by punching it. One of the senior nurses on the medical ward covers the hole in with an anti-violence poster. We all laugh at the delicious irony and get on with our jobs.
As with the poster covering the hole, we crudely paper-over the cracks… it’s not fixing a problem, just covering it over… that’s good enough for now.
In the days that follow I find myself a bit preoccupied at times thinking about the event. Get teary every now and then when I think of what could have happened: those skull-cracking thoughts are the worst bit… acquired brain injury anyone?
Skull-cracking thoughts are from my fear and imagination not from what actually happened.
That’s a good reminder. Keep saying that.
I’m OK: no flashbacks, no vivid dreams, no avoidance, no hyperarousal. I was back at work the next day (left a few hours early because I stayed back a few hours with fire extinguisher guy the night before). I’m seeing patients in the same medical and surgical wards, spending time with my very supportive colleagues.
I’m OK: I’m resisting the urge to quietly whisper to every fire extinguisher in the hospital, “Stay where you are my little red friend. Stay gently hooked on the wall. Do not allow yourself to be raised higher than my head. Please don’t go violently leaping about medical wards – people don’t like that THUD! CRACK! sound you make. Stay exactly where you are my little red friend.”
I’m OK: I’ve told the story a few times now – it’s losing its potency. The funny bit about the poster is good – every story needs a punchline (you’re welcome). The scary bit about the fire extinguisher is getting less vivid – it feels more like a story from the past now. It’s turning into a half-joke about fire extinguishers staying on walls exactly where they belong.
I’m OK: the only thing I’ve noticed is a bit of kummerspeck (great word, eh?). Kummerspeck is a German word that literally translates as “grief-bacon” – it refers to the weight gained through emotional over-eating. I’ve had to let my belt out a notch, and my favourite shirt feels too tight. Still going to the gym, so it must be the eating, Better keep an eye on that.
Yeah yeah yeah. If you’re so OK why are you blogging about it?
Part of the motivation is catharsis. Very self-indulgent, I know.
More importantly, senior clinicians should offer information and support that will empower and protect junior clinicians. Just a few days after the most frightening workplace incident I have experienced these two tweets popped-up on Twitter:
I do not know either of these people IRL (In Real Life), but I do feel a tremendous responsibility towards Emily, Dani and any other nearly-nurse who is as enthusiastic and passionate as these two. But what to say to Emily and Dani? How do we nurture them safely into our profession and keep their enthusiasm intact?
Nursing – mental health nursing especially – needs people like Emily and Dani.
Sharing a battle story is not enough.
Referring to a patient as “fire extinguisher guy” is not a good example to set (more about that later – look for the red asterisk*).
As a senior nurse I should be supportive and encouraging to Dani, Emily and other enthusiastic nearly-nurses, and also be providing safety-tips and useful hints. I have two:
One: Make Like a Boy Scout
Be prepared for some fantastic days at work where you’ll glide home feeling like you’re doing the most important and rewarding work that any one human can do. Those will be the days where you will use your knowledge-base, your skill-set and (most importantly) yourself to make a profoundly positive difference in somebody’s life. That person might never forget you.
Not every nurse gets exposed to violence or abuse, but you’ll see it up-close-and-personal through your patient’s eyes sometimes. Nurses do emotional labour: be prepared for the emotional aftershocks that come with the job. Find out about stress reactions and how to be pro-active in protecting yourself. I have an old, kind-of-dicky resource to share with you here, but you might find something better.
Two. Nurture the Nurturer
I’ve written about this before: meta4RN.com/nurturers
I am so angry that my nurse and midwife colleagues don’t have ready access to clinical supervision as a tool to reflect on practice and keep themselves (and their patients) safe. People say it would be too expensive to provide clinical supervision to every nurse who wants it, but there is huge cost already being paid. This cost (in terms of relationship stress, sleep disturbance, emotional trauma, anxiety, depression, substance use and kummerspeck) is being borne by individual nurses and the people who love them. Clinical supervision allows another way – through guided reflective practice many of these costs can be prevented.
I don’t see why looking after a nurse’s practice and emotional self through regular confidential support with a trusted colleague would be any less important than looking after a nurse’s back. Australian health facilities all have tools, time and training devoted to safe lifting, it is time to provide tools, time and training devoted to safe thinking.
Clinical supervision is available to mental health nurses, but not nurses in general hospital wards. In his epic novel Catch-22, Joseph Heller wrote:
People knew a lot more about dying inside the hospital, and made a much neater, more orderly job of it. They couldn’t dominate Death inside the hospital, but they certainly made her behave. They had taught her manners. They couldn’t keep death out, but while she was in she had to act like a lady. People gave up the ghost with delicacy and taste inside the hospital.
It is the nurses that make death and illness more neat, orderly and ladylike.
It is the nurses who paper-over the holes punched in the walls.
It is the nurses who stay on the ward to make sure that care keeps going in.
The nurses should be provided with an avenue to let crap out.
Guided reflective practice (aka clinical supervision) should be available for all nurses and midwives.
I would like to leave the story there because I have waffled-on for a long time already. However, it is necessary to address two tricky subjects raised in this blog post:  mental health and violence, and  my use of “fire extinguisher guy” when referring to a hospital patient.
Mental Health and Violence
Let’s get the facts straight:
- the overwhelming majority of people who experience mental health problems are not violent: never have been and never will be
- most violence is not perpetrated by people with a mental health problem
- people who experience mental health problems are more likely to be victims of violence than perpetrators
I started specialist education in mental health nursing in 1993 and have spent most (not all) of my career working in clinical mental health nurse positions since then. I have never been physically assaulted by a person experiencing mental health problems. Never. However, earlier in the week there was a newspaper article reporting that “half of the nurses working on hospital psychiatric wards are themselves suffering from mental illnesses such as post-traumatic stress disorder, depression and anxiety.” I know that I have been more fortunate than some of my colleagues.
There are lots of myths and misunderstandings about mental health and violence. Please scroll to the bottom of the post for evidence-based resources and references.
Explanatory Note re the use of “Fire Extinguisher Guy”*
Using the term “Fire Extinguisher Guy” protects confidentiality and is, obviously, an irreverent, playful way to refer to a person. I don’t think this is wise for somebody creating a professional social media portfolio – somebody might think I’m being disrespectful.
Yet, here i am doing it anyway. Why?
Irreverence, humour and playfulness can be useful defence mechanisms: used correctly they can trivialise the other/traumatic events and empower the self. During the event I did what I could (very little) to assist this man to regain control and to keep himself and others safe from physical harm. It would not be useful to dwell on how powerless and vulnerable we all were at that time. I spent many hours talking to the man both before and after the event and treated him with kindness, respect and dignity.
Care goes in. Crap goes out.
This blog post is some crap coming out.
As always, your comments and feedback are welcome (scroll down).
Paul McNamara, 11th August 2013
References and Resources re Mental Health and Violence
SANE Australia have a very readable resource, downloadable fact sheet and MP3 file here
The references below are via Australia’s Mindframe National Media Initiative:
New South Wales Health. (2003). Tracking tragedy: A systemic look at suicides and homicides amongst mental health inpatients. First report of the NSW Mental Health Sentinel Events Review Committee.
Walsh, E., Buchanan, A., & Fahy, T. (2002). Violence and schizophrenia: Examining the evidence. British Journal of Psychiatry, 180, 490-495.
Noffsinger, S. G., & Resnick, P. J. (1999). Violence and mental illness. Current Opinion in Psychiatry, 12, 683-687.
Brennan, P. A., Mednick, S. A., & Hodgins, S. (2000). Major mental disorders and criminal violence in a Danish birth cohort. Archives of General Psychiatry, 57, 494-500.