Violence against physicians and nurses in a hospital: How does it happen? A mixed-methods study.

BACKGROUND: Violence against medical personnel is unexpected in hospitals which are devoted to healing, and yet, it is frequent and of concern in the health system. Little is known about the factors that lead to hospital violence, and even less is known about the interactions among these factors. The aim of the study was to identify and describe the perceptions of staff and patients regarding the factors that lead to violence on the part of patients and those accompanying them. METHODS: A mixed-methods study in a large, general, university tertiary hospital. A self-administered survey yielding 678 completed questionnaires, comprising 34% nurses and 66% physicians (93% response rate). Eighteen in-depth interviews were conducted separately with both victims and perpetrators of violent episodes, and four focus-groups (N = 20) were undertaken separately with physicians, staff nurses, head-nurses, and security personnel. RESULTS: Violence erupts as a result of interacting factors encompassing staff behavior, patient behavior, hospital setting, professional roles, and waiting times. Patients and staff reported similar perceptions and emotions regarding the episodes of violence in which they were involved. Of 4,047 statements elicited in the staff survey regarding the eruption of violence, 39% referred to staff behavior; 26 % to patient/visitor behavior; 17% to organizational conditions, and 10% to waiting times. In addition, 35% of the staff respondents reported that their own behavior contributed to the creation of the most severe violent episode in which they were involved, and 48% stated that staff behavior contributed to violent episodes. Half of the reasons stated by physicians and nurses for violence eruption were related to patient dissatisfaction with the quality of service, the degree of staff professionalism, or an unacceptable comment of a staff member. In addition, data from the focus groups pointed to lack of understanding of the hospital system on the part of patients, together with poor communication between patients and providers and expectations gaps. CONCLUSIONS: Our various and triangulated data sources show that staff and patients share conditions of overload, pressure, fatigue, and frustration. Staff also expressed lack of coping tools to prevent violence. Self-conscious awareness regarding potential interacting factors can be used to develop interventions aimed at prevention of and better coping with hospital violence for both health systems' users and providers.

Workplace violence in a tertiary care Israeli hospital - a systematic analysis of the types of violence, the perpetrators and hospital departments.

BACKGROUND: Worldwide, there is a widespread and disturbing pattern of violence towards healthcare workers. However, violent occurrences in Israeli hospitals have often been unrecognized and underreported. Moreover, most studies have not sufficiently differentiated among the different types of violence. To examine the different types of violence experienced by nurses and physicians, the types of perpetrators and the specialty fields involved. METHODS: A quantitative questionnaire was used to assess the incidence of a "basket" of violent behaviors, divided into eight types of violent manifestations. The study population consisted of 729 physicians and nurses in a variety of hospital divisions and departments (surgery, oncology, intensive care, ambulatory services including day care, and emergency room) in a large general hospital. Six hundred seventy-eight of them responded to the survey for a response rate of 93%; about two thirds of respondents (446) were nurses and about one third (232) were physicians. The questionnaires were completed during staff meetings and through subsequent follow-up efforts. RESULTS: In the 6 months preceding the survey, the respondents experienced about 700 incidents of passive aggressive behavior, 680 of verbal violence and 81 of sexual harassment. Types of violence differed between patients and companions; for example, the latter exhibited more verbal, threatening and passive aggressive behaviors. Violence was reported in all departments (ranging from 52-96%), with the departments most exposed to violence being the emergency room and outpatient clinics. Nurses in the emergency room were 5.5 times at a higher risk of being exposed to violence than nurses in the internal medicine department. Nurses were exposed to violence almost twice as much as physicians. There was a positive association between the physician's rank and his/her exposure to violence. A multiple regression model found that being older reduced the risk of being exposed to violence, for both physicians and nurses. CONCLUSIONS: These findings suggest that uniform definitions of a range of different violent behaviors and assessments of their prevalence are important to creating an improved discourse about hospital violence in both research and operational settings. The study findings could assist policy makers in the Israeli healthcare system in implementing interventions on a national level and can promote leaders' commitment to violence prevention and management. This is an important contribution, as executive commitment is necessary and critical for the necessary organizational changes to occur.

Resident physicians' clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature.

Resident physicians' clinical training poses unique challenges for the delivery of safe patient care. Residents face special risks of involvement in medical errors since they have tremendous responsibility for patient care, yet they are novice practitioners in the process of learning and mastering their profession. The present study explores the relationships between residents' error rates and three clinical training methods (1) progressive independence or level of autonomy, (2) consulting the physician on call, and (3) familiarity with up-to-date medical literature, and whether these relationships vary among the specialties of surgery and internal medicine and between novice and experienced residents. 142 Residents in 22 medical departments from two hospitals participated in the study. Results of hierarchical linear model analysis indicated that lower levels of autonomy, higher levels of consultation with the physician on call, and higher levels of familiarity with up-to-date medical literature were associated with lower levels of resident's error rates. The associations varied between internal and surgery specializations and novice and experienced residents. In conclusion, the study results suggested that the implicit curriculum that residents should be afforded autonomy and progressive independence with nominal supervision in accordance with their relevant skills and experience must be applied cautiously depending on specialization and experience. In addition, it is necessary to create a supportive and judgment free climate within the department that may reduce a resident's hesitation to consult the attending physician.

The influence of age on the management of patients with diabetes in the Israeli population.

The authors' aim was to study the association between age and the quality of community health care of diabetes mellitus (DM). This was a cross-sectional study of patients with DM in the setting of a large health maintenance organization (HMO) in Israel. The population included DM patients aged 40-84 years who were identified at emergency rooms or through the HMO's computerized database. A set of quality care indicators were determined. Logistic regressions were used to estimate the odds ratios (OR) for diabetes care indicators, controlling for age and other potential confounders. Older patients were more likely to be in the target range of glycemic control and to be vaccinated against influenza. Patients older than age 70 years received fewer recommendations for physical activity (OR 0.41, P<0.01) and self-foot examination (OR 0.57, P=0.024). The authors found decreased performance of recommendations for physical activity and self-foot examination, and a higher performance of annual blood tests and immunizations among elderly patients with diabetes.

[Are you being served? The inter-organizational status and job perception of those responsible for patient rights in general hospitals in Israel].

BACKGROUND: Paragraph 25 of the Patient's Rights Law in Israel requires that every medical facility director in Israel appoint an Ombudsman who will be responsible for patients' rights, receive patient complaints and resolve them. The law aims to strengthen the patient's position vis-à-vis service providers. Therefore, it is desirable that the Ombudsman shall function independently without apprehension or bias. OBJECTIVES: Eleven years after the law was legislated, the authors researched the following: Were individuals responsible for patient rights appointed in all general hospitals? Who are the position holders? What issues do they deal with? What is the weight of their various responsibilities concerning patient rights, as defined by the law, relative to their other tasks? Do they benefit from organizational mechanisms that assure their independence within the service provider's organization? How do they perceive their job--as "Patient Representatives" (as defined by law), or as representatives of their hospitals? METHODS: Hence, the authors personally interviewed each of the 26 General Hospital Directors in Israel as well as the Ombudsmen in each of their facilities. RESULTS: In each of Israel's general hospitals, an Ombudsman responsible for patient rights was appointed. In the majority of cases (82.6%) the Ombudsman was also engaged in an additional managerial or staff position within the organization. As a result, the Ombudsmen are almost entirely dependent on hospital management. The necessary means, by which to fulfill their positions and responsibilities as defined by the law, such as instructing and guiding medical staff regarding the protection of patient rights, have yet to be put at their disposal. The majority of the Ombudsmen view themselves as management representatives. These perceptions do not agree with the spirit of the Patient's Rights Law which is meant to strengthen the patient's position vis-à-vis medical services providers. The authors found a correlation between these views and the fact that Ombudsmen simultaneously hold additional managerial positions and some see themselves as part of their hospitals senior organizational hierarchy. In addition, we found a correlation between their seniority within the organization and their identification with the organization. CONCLUSIONS: It is recommended that the independence of those responsible for patient rights be strengthened by adding specific stipulations to the law on this matter and that the necessary means needed to fulfill their responsibilities as legislated, be put at their disposal. The authors recommend promoting the independent status of Ombudsmen by not imposing upon them responsibilities other than those for patient rights.

Active learning: when is more better? The case of resident physicians' medical errors.

An active learning climate facilitates new knowledge acquisition by encouraging employees to ask questions, seek feedback, reflect on potential results, explore, and experiment. These activities, however, also increase a learner's chances of erring. In high-reliability organizations, any error is unacceptable and may well be life threatening. The authors use the example of resident physicians to suggest that by adjusting the conditions of priority of safety and managerial safety practices, organizations can balance these potentially conflicting activities. Participants in the study were 123 residents from 25 medical wards. Results demonstrated that the positive linear relationship between priority of safety and safety performance, demonstrated in earlier studies, existed only when the active learning climate was low. When the active learning climate was high, results demonstrated a U-shaped curvilinear relationship between priority of safety and number of errors. In addition, high managerial safety practices mitigated the number of errors as a result of the active learning climate.

Hand hygiene compliance by physicians: marked heterogeneity due to local culture?

BACKGROUND: Physician compliance with hand hygiene guidelines often has been reported as insufficient. METHODS: The study was conducted in 2 hospitals (Hadassah Ein Kerem [EK] and Mt Scopus [MS]) in Jerusalem, Israel. Covert observations were conducted during morning rounds by trained observers. The data were recorded as the percentage of times that hand hygiene was applied out of the total contacts with patients. After the observational step, an intervention-providing an alcohol gel and encouraging its use-was instituted in several wards. RESULTS: Physicians' compliance with hand hygiene averaged 77% at MS and 33% at EK (P < .001), and was characterized by a marked additional heterogeneity among wards. Rates of adherence ranged from as low as 4% in a gynecology ward to as high as 96% in a neonatal unit. Availability of a handwashing basin in the room and seniority status of the physician were associated with higher compliance rates but explained only a small part of the variation. Compliance improved significantly in 2 wards exposed to the intervention. CONCLUSION: The remarkable heterogeneity in physicians' hand hygiene compliance among sites within the same institution is consistent with an important role of the local ward culture.

Differences in quality of diabetes care between Jews and Arabs in Jerusalem.

AIMS: To evaluate whether differences exist in the quality of diabetes care delivered to the Arab and Jewish populations in Jerusalem. METHODS: A cross-sectional study was conducted in West Jerusalem's 4 major hospitals. Participants were patients with type 2 diabetes mellitus, 45 to 75 years of age, who were insured by Israel's largest health maintenance organization (HMO) and admitted to an emergency room (ER) between May and June 2004 for any medical cause. Hospital files were reviewed, patients were interviewed, and computerized data were retrieved from the HMO's database. RESULTS: Arab patients received less nutritional counseling (odds ratio [OR] = 0.46; 95% CI = 0.24-0.85; P = .013), fewer recommendations about and less support in performing physical activities (OR = 0.42; 95% CI = 0.24-0.74; P = .003), and less guidance in performing self foot examinations (OR = 0.55; 95% CI = 0.32-0.96; P = .035). CONCLUSIONS: Arab patients in Jerusalem receive lower quality diabetes care compared with Jewish residents.

Safety self-efficacy and safety performance: potential antecedents and the moderation effect of standardization.

PURPOSE: The purpose of this paper is to suggest a new safety self-efficacy construct and to explore its antecedents and interaction with standardization to influence in-patient safety. DESIGN/METHODOLOGY/APPROACH: The paper used a survey of 161 nurses using a self-administered questionnaire over a 14-day period in two large Israeli general hospitals. Nurses answered questions relating to four safety self-efficacy antecedents: enactive mastery experiences; managers as safety role models; verbal persuasion; and safety priority, that relate to the perceived level of standardization and safety self-efficacy. Confirmatory factor analysis was used to assess the scale's construct validity. Regression models were used to test hypotheses regarding the antecedents and influence of safety self-efficacy. FINDINGS: Results indicate that: managers as safety role models; distributing safety information; and priority given to safety, contributed to safety self-efficacy. Additionally, standardization moderated the effects of safety self-efficacy and patient safety such that safety self-efficacy was positively associated with patient safety when standardization was low rather than high. Hospital managers should be aware of individual motivations as safety self-efficacy when evaluating the potential influence of standardization on patient safety. ORIGINALITY/VALUE: Theoretically, the study introduces a new safety self-efficacy concept, and captures its antecedents and influence on safety performance. Also, the study suggests safety self-efficacy as a boundary condition for the influence of standardization on safety performance. Implementing standardization in healthcare is problematic because not all processes can be standardized. In this case, self-efficacy plays an important role in securing patient safety. Hence, safety self-efficacy may serve as a "substitute-for-standardization," by promoting staff behaviors that affect patient safety.

The moderate success of quality of care improvement efforts: three observations on the situation.

Why is the health care system still unable to achieve a breakthrough in its quality performance? This commentary offers three observations on the problem of the moderate success of quality of care improvement efforts. We based our discussion on theoretical models from management theory and research. We conclude that health care organizations invest efforts in quality improvement initiatives; however, there is a potential in improving the fit between these efforts and the specific problems these organizations face.

Readiness to report medical treatment errors: the effects of safety procedures, safety information, and priority of safety.

BACKGROUND: Medical error reporting is an essential component of patient safety enhancement. However, increasingly, the literature points to a problem of underreporting of treatment errors, mainly as a result of the fear of malpractice lawsuits and limited formal data collection systems. Few studies, if any, have examined the influence of informal aspects of the organization, such as safety climate, on employees' willingness to report errors. OBJECTIVES: This study investigated the relationship between safety climate aspects and personnel readiness to report treatment errors in different hospital departments. METHOD: The model was tested in 3 hospitals (n = 632 in 44 medical departments of 3 types; internal medicine, surgery, and intensive care). Three safety climate aspects were measured using questionnaires: the way employees perceive the safety procedures, the safety information flow within their department, and the relative priorities given to safety in the department. Readiness to report was measured by tallying each department's annual number of treatment errors reported to the hospitals' risk management systems. RESULTS: Negative binomial regression analysis indicated that the more personnel perceive procedures as suitable and safety information as available, the higher was their willingness to report treatment errors. These relationships significantly differed depending on the department type. CONCLUSIONS: Hospitals should take into account the perceptions of personnel regarding safety procedures and information and understand that these perceptions operate differently in different department types in their effect on the staff's willingness to report treatment errors.

[The quality of medication orders--can it be improved?].

Medication errors are a common cause of morbidity and mortality among patients. Medication administration in hospitals is a complicated procedure with the possibility of error at each step. Errors are most commonly found at the prescription and transcription stages, although it is known that most errors can easily be avoided through strict adherence to standardized procedure guidelines. In examination of medication errors reported in the hospital in the year 2000, we found that 38% reported to have resulted from transcription errors. In the year 2001, the hospital initiated a program designed to identify faulty process of orders in an effort to improve the quality and effectiveness of the medication administration process. As part of this program, it was decided to check and evaluate the quality of the written doctor's orders and the transcription of those orders to the nursing cadre, in various hospital units. The study was conducted using a questionnaire which checked compliance to hospital standards with regard to the medication administration process, as applied to 6 units over the course of 8 weeks. Results of the survey showed poor compliance to guidelines on the part of doctors and nurses. Only 18% of doctors' orders in the study and 37% of the nurses' transcriptions were written according to standards. The Emergency Department showed an even lower compliance with only 3% of doctors' orders and 25% of nurses' transcriptions complying to standards. As a result of this study, it was decided to initiate an intensive in-service teaching course to refresh the staff's knowledge of medication administration guidelines. In the future it is recommended that hand-written orders be replaced by computerized orders in an effort to limit the chance of error.