The Impact and effect of vulnerability on staff

Dr. Yafa Haron, Dror Tran

Mazra Mental Health Medical Center, Israel

Vulnerability: The state of being subjected to injury (physical or emotional), unprotected from danger. Susceptible to attack; insufficiently defended. (The American Heritage Dictionary)

Ironically, one of the most hazardous work settings for an employee of mental a health institution is his own department. (Caldwell M.F., Hospital Community Psychiatry, 1992)

Unfortunately, Workplace violence is a virtually normative experience for the psychiatric staff, rather than a rare occurrence. (Lanza M.L., Zeiss R., Rierdan J. Mental Health Nursing, 2008)

Moreover, the media contributes to the notion that mental health nursing occupies an aberrant, secret and dangerous world and that its role remains one of custodial companionship. (De Carlo K., et al., Int. J. Mental Health Nursing, 2007)

Staff working in psychiatric departments were shown to experience severe psychological impact when exposed to violence or verbal abuse. (Makoto I. et al., Psychiatry and Clinical Neurosciences. 2006)

Family BehaviorPatient Behavior

Beliefs andAttitudes of the General Public

Staff Vulnerability

Factors from the legal System

Research ModelResearch Model

Factors from the Ministry of Health/

hospital management

To estimate the level of staff vulnerability that is related to the above mentioned various factors.

To evaluate to what degree does the level of vulnerability affect the process of clinical decision making, during various situations?

Cross - sectional study

Questionnaire - 26 situations indicating daily life in the

departments - 4 point scale.

Sample - personal from 9 departments; doctors, nurses,

social workers, psychologists, and occupational

therapists. A total of 150 (83%) respondents from a total

staff of 180.

Was based on a scale designed to measure staff perceptions regarding difficult psychiatric situations.

Palmer G.A. et al., The Internet Journal of Mental Health, 2006.

The Questionnaire:

Situation Not at all

Slightly A lot Greatly Not at all

Slightly A lot Greatly Not at all

Slightly A lot Greatly

1 2 3 4 1 2 3 4 1 2 3 4

1 Patient who smokes in the department

2 Physical threat

3 Lack of supervisor support

4 Lack of cooperation

5 Problematic compoition of staff in a shift

Discomfort Threat Feeling of continuous vulnerability

Grade the following situations and your feelings of:

A questionnaire evaluating discomfort, threat and continuous vulnerability

Situations Provide acceptable treatment and extra attentive

Provide acceptable treatment

Attempt to be not involved in treatment

Refrain from being involved in treatment

Not relevant

1 Patient who is verbally abusive towards me during treatment

2 Lack of cooperation among various staff members

3 Patient who threatens to hurt me

4 Fear of lack of supervisory support

5 Patient who previously verbally attacked me

A questionnaire evaluating how do certain situations influence the therapeutic treatment processPlease grade the following situations:

Sample distribution (n=150)

Results

Patient who threatens to harm me 3.18 Patient who previously physically threatened me 3.0 Patient family members who verbally threaten the staff 3.1 Fear of lack of necessary senior staff support 3.06 Lack of collaboration among various staff sectors 3.06 Unfavorable/criticizing articles and media reports 2.9

Situations Causing Least Discomfort (or not at all)

Presence of Students in the ward 1.3Patient knowledgeable about illness 1.3

Patient who threatens to hurt me 3.2 Patient who previously physically hurt me 3.0

Least Threatening Situations (or not at all)• Presence of family during treatment 1.5• Presence of a Lawyer 1.4• Presence of Immediate supervisor and directors of

other departments 1.4• Present of a well informed patient 1.3• Presence of students 1.26

Presence of a patient who threatens to hurt me 2.7

Presence of a patient who previously physically harmed me

2.7

Insufficient support from supervisor 2.7

Racial insults of patients

Unfavorable/criticizing media reports or T.V. programs

Presence of a police investigator

Overly involved or verbally abusive family members who

are present during treatment

Treating patient with a history of drug abuse

NursesNurses presented the highest vulnerability feelings as compared to other sectors in the fallowing situations:

At the presence of a restrained patient

Patient who physically threatens them

Patient with delusional thoughts

Patient who physically attacked in the past

An over involved family

Family that threatens to file a complaint

Presence of a police investigator

DoctorsDoctors exhibited lower vulnerability feelings as compared to other sectors in the fallowing situations:

Patient who smokes in the ward

Presence of direct and indirect superiors

Presence of police investigators

Patient with delusional thoughts

Social workers had the highest discomfort as compared to other sectors in the following situations

Psychologists had the highest average score as compared to other sectors in the following circumstances:

Discomfort

A restrained Patient

Unsuitable or lack of suitable physical-setting

ThreatPatient who threatens to harm me

Patient who previously physically attacked me

racial insults of a patientVulnerabilityPatient who verbally abuses

Presence of a lawyer in the department

Various media articles Presence of a police

investigator Present of a family during

treatment

Men Women

A patient has delusional thoughts about me

A patient has previouslyphysically attacked me

Problematic composition of staff during shifts (doctors and nurses)

Staff fear they do not have supervisor support (30% of nurses)

Lack of cooperation among various staff sectors (30% of doctors)

Unsuitable or lack of suitable physical-setting in the department (30% of nurses) Criticizing articles and media reports (25% of staff)

Situations that influence the staff to pay more attention during Treatment

Patient who threatens to harm me Patient who has previously attacked me physically Patient with delusions about me Patient who racially insults me Family members who express aggressive attitude

towards the staff (especially nurses) Family members who are over involved or threaten to

file a complaint (especially nurses)

Organizational factors such as physical setting, lack of supervisory support and lack of collaboration among different staff sectors, lead to over-attention during treatment

Patient and family verbal violence leads to over-attention while physical violence encourages staff to avoid treatment

Verbal abuse leads to feelings of being threatened and to a feeling of continuous vulnerability

There is a difference among sectors in the way they respond in various situations

Fear of lack of supervisory support leads to feelings of discomfort, threat, continuous vulnerability, and causes over-treatment of patient

Presence of an over-involved family leads to continuous feeling of vulnerability and avoidance of providing treatment

Men are more effected by the presence of representatives of the law, family and media. While Women are more effected by patient’s thoughts and violence.

Implementations of research Implementations of research findingsfindings In order to reduce the feeling of vulnerability, It is necessary to create workshops that include staff from all sectors, to emphasize the need for collaboration among allContinues supportive-supervision from the management, will contribute to reduce the feelings of threat, discomfort and staff vulnerability

To educate staff to handle patients and family violence

To market the psychiatric staff and treatment procedures in a positive manner

Dr. Yafa Haron, Staff Chairperson Dror Tran Yaron Nachmias Orit Ben Naftali Svetlana Kazkor Libi Mor Ofer Grossan Christina Yogev Suliman Abbas Geula Fenoloven