September 8, 2021

Episode 57: The insidious role of organizational violence in nursing

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Podcast

Description

Workplace violence against nurses has been a longstanding issue, particularly in the ED. A landmark study published by the Emergency Nurses Association in 2011 found that more than half of emergency nurses had been the victim of workplace violence in the preceding seven days, and a third had considered leaving the profession as a direct result. 

Our guest for today's episode is a 20-year veteran of the ED and the Director of the Institute of Emergency Nursing Research who brings her training as an anthropologist to the study of nursing culture and how it contributes to the various forms of workplace violence.

In this conversation, Dan and Dr. Lisa Wolf  discuss her definition of workplace violence, which includes not just violence perpetrated by patients, but also organizational violence and the role that it plays in creating a culture of aggression and withholding.

Dr. Wolf shares insights from her significant research on this topic, as well as strategies for nurse leaders to address it within their organizations. 

Links to recommended reading: 

Podcast

Transcript

Dan:
I'm excited to have you welcome to the show, Lisa.

Lisa:
Thanks so much.

Dan:
All right, so tell me a little bit about your background. Would love to hear kind of your career path and how you got to the ENA and what you're working on now.

Lisa:
Okay. Short but twisty path. So I have training as an anthropologist, that was my undergraduate degree. And of course they throw all the anthropologists out of New Guinea so I had to find something else to do. So I was a playwright for a while and then I went to nursing school because it seemed ... Like I was working in reproductive health and the nurses were like the coolest. And so I went to a diploma school, diploma program. So very like clinically oriented, and started getting interested in, I did clinical research for a while. I got bored with that and did ICU, moved to the ED, and that was probably around 1998. So it's been 20 something years, 23 years in the ED. And I never really gave up my practice. So I went into education, I got my PhD, I started doing more formal research, and went to the ENA almost immediately after getting my doctorate.

Lisa:
I had done some, a lot of work with them prior, did a lot of speaking at conferences and being involved in committees and stuff. And so they asked me to take over the research division and that was about 10 years ago. So what all of that kind of falls into is this ability to look at nursing environments with an anthropological lens, like a real understanding of what the sociopolitical dynamics of that environment are. And I think that gives a lot of really important and rich information on things like violence and bullying, and why those things happen in this environment, and what some of the things we can do about them are.

Dan:
Yeah. And really the anthropologist dives into the culture of what's happening. I think we tend to miss that in nursing and in healthcare. We don't look at the culture. We talk about just culture, but blah, blah, blah. But we don't actually dive into like, what are the artifacts, values, deep assumptions of a culture that are driving this behavior for the longterm? We tend to throw things on it, like certifications in safety or whatever, but we don't actually address the underlying cultural issues. Do you find yourself kind of diving into that a little bit more with your background?

Lisa:
Yeah. Well, I think it's really important because we're people, right? And we work in a social environment. And our patients come and go, but our colleagues are the people we actually need to negotiate with. And so the way in which the environment pressures us to do that really informs much more clearly how we respond to these kinds of stressors.

Dan:
Yeah. And you've been in the field for a long time and it's a high stress, even in the research side, you're still dealing with all the stressors and the secondary trauma that happens in talking through these stories and things. How have you kind of coped across your career, and how have you kind of built up that ability to deal with these high stress situations?

Lisa:
Yeah, it's a really good question because I almost have secondary traumatic stress from talking to people about their secondary traumatic stress. So I continue to practice, I maintain a clinical practice, so it's once a week or so, but it still keeps me really grounded in what the environment is like. And so over the last 20, some odd years, I've done what I thought. All right, this is an interesting question. So I thought I had everything kind of under control. Like I'm very good at compartmentalizing, like we all are, so that we can do our jobs without crying all the time.

Lisa:
I run, I'm a fencer. Like I have all these ways of getting stress out, right? But in doing our study about PTSD in emergency nurses, we're listening to people talk about what they do, and I'm sitting there with my colleague, Paul Clark, and we're listening to this person and they're talking about like how they never turn their back. Like they always face the door. They never get, there's always an escape route, or whatever. And we're kind of like, doesn't everybody do that? Like, I guess not. So recognizing, I think, that some of those coping mechanisms are not super healthy, was an important thing that came out of some of the research that I've done. So I'm trying to be a little better about that.

Dan:
I think any nurse is good at compartmentalizing, ER nurses, we both know, are very good at it. And I remember coming home and like never talking about work with family, ever. Like they're like, what's the, until you go to dinner one day and they're like, what's the worst thing you've seen in the ER? And you're like [crosstalk 00:05:37].

Dan:
Yeah, don't ever tell me again. But then like I find reflecting on certain patients or situations pop up in like the weirdest spaces. And you're right, there is a PTSD in it and I don't think we acknowledge it enough. And we're seeing it more come out now with COVID and the continual pressures and things that are happening with nurses.

Lisa:
But it becomes really, really important because it affects the idea of violence in a huge way.

Dan:
So tell me that. Now, let's go into that. So let's talk about your definition of workplace violence. I think a lot of people think, well, the patient hits somebody or the angry physician throws a book at you, or whatever. But there's a broader piece to this. So I'd love to hear you explain your definition.

Lisa:
Yeah. So I use the typology of violence that is put forward by a guy called Von Bowie, he's out of Australia. And I met him randomly at a conference when I was presenting on workplace violence in Melbourne. And so we got to talk and he said, "You might want to take a look at this." And I was like, "Okay." So I went and looked at it and I was like, "Okay, this makes a lot of sense to me." And what he posits is that there are four types of violence. The first is called, what he calls, intruder violence. So violence is sort of a random, unrelated person who comes in. We normally think of these as kind of like your active shooters, or the people who drive their cars into the ED, but that's not always the case, but it can be, right? So somebody has no connection to anybody else in the department.

Lisa:
The second is the consumer violence. So that's what we think of when we think of ED violence, right? Patients or visitors attacking nurses or physicians. The third type of violence, he calls relational violence, and this covers lateral and hierarchical violence, right? So there's sort of bullying, but also the physician throwing a book at you and that kind of stuff. It's sort of like relational. And what it also covers are incidents of interpersonal violence that follow into the ER.

Lisa:
So the active shooter who comes in looking for his estranged wife or girlfriend, who's an ED doctor or an ED nurse, and then kind of taking out the department. That's actually relational violence, that's not an outsider. And the fourth time, which I think is very under-discussed, but I think the most important, is what he calls organizational violence. And that is where the structure itself keeps people, not just like kind of brutalized, but also like very off guard. Right? So let's say you've got a problem in your department and you all get together and you work together and you figure out you've got a solution, and then all of a sudden, all the managers leave. And now you have to start over again, right? Like it's a way of depriving people of power and autonomy that comes from the organizational level.

Dan:
I resonate with all of those, especially that last one, which I think isn't talked about enough. I ended up writing a book chapter in our last book on leadership about what we call toxic leadership. And it was exactly that. It was the removal of decision-making power, keeping people off guard, in and out groups that constantly switch, really keeping a group of people from being able to evolve, solve problems, all with the guise of a leader who needs to have the power of it. And that's very traumatic. I remember being an ER nurse and our director came in one day, she was like, we have budget problems that you guys need to use less four by fours because you're using too many four by fours on your patients. And we're looking at them like, are you kidding me?

Lisa:
That's going to solve it.

Dan:
Yeah, we use more four by fours.

Lisa:
That's going to solve the budget problem, absolutely.

Dan:
No, and it's like, and you know, that's a simple, silly example. But those are the kinds of the things where this disconnect happens. And I think leaders and organizations don't understand the impact that has on people, and it has psychological effects at its worst as well.

Lisa:
Sure. Well, I mean, we see this really played out very clearly in the last 18 months with this pandemic where the violence from the feds on down. Right. You know, I mean, imagine at this point being an ER nurse in Florida or Texas and like, what do you even do with that? Right?

Dan:
Yeah. I mean, you're like literally told not to wear PPE.

Lisa:
Right. You can't. I'm hoping most of them are vaccinated, but still. I mean, watching the flood of humanity that are basically being prevented. There's a deliberate attempt to prevent any mitigation of spread and then, oh, let's bring in the morgue trucks because, freedom, I don't know. Right? But that is a form of violence because it does not allow people to act in their own best interest.

Dan:
Right. And it goes directly against the value set of nurses and frontline nurses, especially. You're constantly in this ethical conflict with yourself and your community. And obviously that's not healthy either. Well talk to me about some of the research you've done. What's some of the latest research you've done? What are some of the findings that might help inform nurses and nurse leaders on how to be, how do we fix this stuff?

Lisa:
We started off like the ENA I think before I got there, did a fairly comprehensive study of violence in emergency nursing. And that's probably the most, one of the most cited articles that have ever been published in JONA. And it, I want to just think of the numbers. It was like some overwhelming, 78% of nurses reported weekly violence. Like regular physical and verbal violence in their emergency departments and that's kind of the benchmark that we go by, right? Like this is a huge problem. So in 2012 or 2013, when I first took the job over at ENA, the way that we got a lot of research ideas was members would come up to me at conferences and be like, you have to do a study on this. You have to do this. So people were really talking about like, they really wanted to just get up in meetings and talk about what had happened to them.

Lisa:
And so we thought to ourselves, like let's collect all these stories and see if we can do a narrative analysis and see like, what are the commonalities? Right? So we published a paper called, Nothing Changes, Nobody Cares. And the gen would publish, was a little horrified at the title. They're like, can you explain to us why you picked the title? And we're like here, in 36 of 42 narrative this shows up. So that really, that was a qualitative analysis. It was one of very few at the time, qualitative analysis of the experience of being assaulted at work, and while providing care. And what we really found was that there were some very important factors, some very important barriers to mitigating the situation. And one was that nurses honestly saw this as part of the job.

Lisa:
Like this is part of my job, right? I'm going to go to work, somebody's going to hit me, right? Which is horrifying to start with like, oh yeah, that's my job is to get hit. The second was that feeling of it being endemic to the work went from the bedside all the way up to the judicial bench, right? Like nobody, at the time, people were making a lot of noise about like, we need to make this a felony and we need to ... But it doesn't matter if nobody prosecutes.

Dan:
Right.

Lisa:
Right? Like, who cares if the law is there if nobody invokes it? And so because institutions are very reactive, and they tend to be very risk averse in terms of their catchment area, the pressure was for nurses to not file charges, to not bring any kind of complaint. There was no punishment for anyone who did this.

Lisa:
And so that's kind of how that was operationalized, really, is that nobody saw this as a problem worth getting teeth into a solution. So we developed. From there, we got an OSHA grant to develop a, sort of an educational offering to sort of talk about those things and talk about like the etiology and what kind of patients were risky, and how to set up your staffing. So I mean like the big thing is, and this falls into like the CPI and the Moab and those, all these deescalation programs. You have to actually notice escalation.

Dan:
Right.

Lisa:
Right? Before the patient is like on your back. So you have to have enough staff to do that. Right? So we were like, okay, so staffing is a big chunk of this, right? You need to have like enough bodies to notice things in order to mitigate the violence. That work kind of got extended. We did a study on fatigue, right? So this is one of those weird things that led to this big thing on violence. We did a two arm study on the effects of like repeated shifts and effects of fatigue really on cognition.

Lisa:
And so that was a quantitative piece, we published it in JONA. The second though, was a qualitative analysis of the experience of working fatigue. And we thought we'd have people be like, oh, it's terrifying to be so tired and not be sharp, and whatever. But what they actually told us that was important about violence was that mean people are tired and tired people are mean. And so fatigue was this both cause and effect of workplace aggression. We were like, whoa, that's kind of interesting. So then we did a theoretical, we built a grounded theory of violence, of bullying in emergency nursing environments.

Lisa:
And what we found was that you had to have kind of a narrative of like toughening up, like this dominant narrative of like, you have to have a tough skin, or we have to toughen you up or don't be a wuss or whatever. Right? Like those kind of prove yourself type of narratives. We eat our young here, type of narratives. If you didn't have that, you didn't have a lot of bullying. But if you did have that, then what happened was that you get these two flavors. Like one is these dynamics of aggression, right? So these are where people actively yell at you in front of your colleagues, or whatever. But more insidious, more common and more difficult to do anything about is the dynamics of withholding. So this is where, and this is also where this falls into violence, right? Is not telling people important pieces of information.

Lisa:
Like, oh, let's see how little Susie does as we send her in the back to deal with Larry, the drunk, who will try to grope her, hit her, or whatever. And let's just see what happens. Right? Nobody's done anything like overt, but they have put their colleague in a position of danger and violence.

Dan:
Yeah.

Lisa:
And that's what we see. Like we see people set up to fail in that dynamic. And so we see people leaving, we see levels of PTSD, which are really incredible. So we get that like arc. Right? So now we get it, right? We see the charge nurse is really pivotal to this role of bullying because they can give appropriate assignments, or they can make people drown. Right? Kind of depending on what's going on and how they feel.

Dan:
Yeah, the interpersonal dynamics.

Lisa:
Right. So we're in the middle of that, writing up that study on charge nurses right now, which is fascinating. More on that later. So in order to test the theory, right? So you build a theory and you think like, okay, this all fits together we think, but now you have to test it. So we tested it using a whole bunch of valid instruments last year, and published it this year in 2021. So it's a valid theory, you can use it like for implementation stuff at this point. Like it works. But what we needed to find out was just how important the concept of secondary traumatic stress was to this. And like, was it actually a direct result of bullying? So we do this study about PTSD in nurses. And we find like, yes, people related that a big part of their secondary traumatic stress came directly from like their preceptors and their charge nurses, and people more dismissing their feelings, like more dismissing their distress.

Lisa:
Like imagine the first time you have a patient die on you and you go to your preceptor and you're like all freaked out. And they're like, yeah, yeah, don't worry about it. It's like, just go wash your face, you'll be fine. Sort of making it this, no big deal, piece. And so people feel like they've got to stuff it down, they've got to compartmentalize. So in order to get through your day, that idea of like numbing yourself down so that you're just totally focused on the task, that also prevents you from noticing patients who are escalating. Right? So there's all these different pieces that all come to the same end, which is you can't pay attention to changing dynamics fast enough to protect yourself.

Dan:
Yeah. You're completely distracted by all the pieces of the culture that you're trying to figure out and mitigate because there's so much uncertainty.

Lisa:
And try to shut out. Right.

Dan:
Right. Meanwhile, you miss the certain things like the observable factors of escalation, and all these other things.

Lisa:
And patient decompensation too. Like this is why there's more failure to rescue.

Dan:
Right. Yeah. I think that's fascinating, all of those factors. And I think we always try to just push it off onto, well that nurse doesn't have the competency to do this, or they're not good enough, but even the seasoned nurses that have compartmentalized it are still affected by this. I'm curious, from like a stratification of experience, did you see any differences between the newer nurses or the seasoned ER nurse?

Lisa:
Not really. It didn't seem to play out by experience level. You know, there are some studies that seem to suggest that people with a lot of experience carry around less secondary traumatic stress. And that would make sense because if you're still in the ER, 30 years later you've figured something out.

Dan:
You've figured it out, yeah.

Lisa:
So it's really like those beginning and mid-career people who are just like doggy paddling furiously to just stay at work. That seemed to have more of it. But that's not what we found, but other studies have found that.

Dan:
And then the correlation across units, are there similar pieces that happen in the ICU and across other inpatient and even outpatient settings?

Lisa:
I think the bullying stuff, the lateral violence stuff can be pretty broadly extrapolated. Actually a couple of friends of mine were like, this goes everywhere. This is like, this is office culture right here. You know? But the stakes are a little bit higher than they are in the office in an ER. So the lateral violence stuff really resonates a lot with most nurses I've spoken to, regardless of practice area.

Dan:
So now we have a theory, we have some data on what's causing this, what adds to it, the result of it and the impact to, not only nurses but patients and systems as well. So if I'm a nurse manager of an ER, what do I do about it? Like, what's my first step to start addressing this?

Lisa:
Understanding that kind of the fallout of a bullying culture is turnover, right? So a nurse in our theory validation study, a nurse who reported frequent bullying behaviors was 10 times more likely to leave, to report intent to leave.

Dan:
Wow.

Lisa:
So it really does make a difference. Right? And so the problem is that people, and the problem for managers of course, is that the reason that they are managers a lot of the time is that they've left the bedside due to traumatic stress and they bring it to their new job. So that's the huge problem. It's like, you got to unpack your own stuff first and really get a good therapist and spend a couple of weeks kind of parsing this stuff out, and then get a sense of, okay, what are the behaviors that I'm seeing in my department? What am I hearing? What are my charge nurses doing? Do they have adequate training?

Lisa:
So step-by-step, one, unpack your own stuff. Two, get a sense of the sociopolitical dynamic in your department and the turnover, right? So your goal really is to reduce your turnover. Start with your charge nurses and your clinical managers. Those are the people who are making decisions that can make or break people's days. Are they adequately trained in what they're doing? Do they have support? Do they have information? And what we find in our charge nurse study, just very preliminarily, is that the common theme is that the charge nurse sets the tone. So when I was a charge nurse, the mantra in my ER was, nobody has a good day, unless everybody has a good day. Nobody has a bad day, unless everybody has a bad day. So there has to be like this teamwork approach. And you need to give people a lot of support in order to be able to do that.

Dan:
We also need to be developing out our leadership of capacity for these managers as well. A lot of times they're really good ER nurses that, like you said, either step away, because they don't want to do bedside anymore, or they are, for whatever reason, but we never give them the skills of leadership. We think they're good clinicians so let's pop them in the leadership role that's totally different.

Lisa:
That doesn't make them good leaders. Right? Exactly. That's making an ICU nurse say, you're a really good nurse for critical patients, here's five of them.

Dan:
Right.

Lisa:
Right? So, exactly. Like leadership training is so appallingly deficient for nursing. Our charge nurses report, like literally no training, nothing. I shadowed another nurse for three shifts, and I was in charge.

Dan:
Right.

Lisa:
Right? And that happens also, like a previous ER that I worked in, it was like how to set people up to fail. Like, oh, the manager left, oh, you have a BSN, you seem pretty reasonable, how would you like to be our manager? No, don't worry, someone will mentor you. That mentor leaves. So now you've got someone with no experience in charge of everything. Of course they're going to fail. Of course they're going to screw it up. But it's not because they're bad. Like if they had the right training, they could be very good at it.

Dan:
Yeah. And they're not incented to change things either they're incented to staff and like maintain the status quo. And then we throw in, well, you also got to fix your turnover and your violence and ...

Lisa:
Right. And I have no idea how to do that because I only know how to do is put patients in beds because I'm a charge nurse. Now I'm just in charge of my department though.

Dan:
For sure, I think there's a leadership aspect there. I think exactly what you said. And this follows along with the research on innovation and change in cultures as well, which is, you have to find the opinion leaders, you have to understand what's driving the culture, those underlying assumptions, and you have to systematically address those and change the behaviors to change those.

Dan:
And we don't teach enough in leadership school, in healthcare, about change and how cultures evolve and how people like interpret environments.

Lisa:
Why do people do what they do?

Dan:
Exactly. It's the whole, I mean, it's your whole anthropologists piece. Like we all, leaders are anthropologists. That's their number one job is to navigate and hopefully influence people in a population. So this is sort of all depressing. And COVID has like doubled down on all of this stuff so it's 10X what was happening beforehand. In your opinion, what are some of the bright spots that show there's a way out of all the types of violence you mentioned? Are there places that have really nailed it and have created amazing programs and ways for nurses to be supported and feel supported? Or are we all kind of at like this learning stage?

Lisa:
Nope. I wish I could do, because people call me up and they're like, reporters and stuff they're like, can you give me the name of somebody who's doing this really well? And I'm like, no.

Dan:
No.

Lisa:
No, I can't. Because everybody's really like got their head down, focused on like, we just got to get through what's happening right now. But I think that perversely, the break spot is that the whole thing is going to collapse. This is unsustainable. Like we can't continue providing health care in this system in this way. And so there's an opportunity, which I really hope that we can seize in nursing, to reimagine like what nursing is, what the role of nursing is, which is really to coordinate public health. We are the people who are the, like the canary in the coal mine, especially in the ED, right? Like we're the people who see where community deficits are in terms of care and access, and all those things.

Lisa:
And if we were able to reimagine how we could link the ED with outpatient stuff and community stuff and getting people to the right places and resources, the whole system would transform. It's like revolution, right? So for me right now, resiliency is revolution. You have to change this in order to stay in it. This is just utterly unsustainable right now in terms of just sort of the general violence in our society right now, right? Like we have people punching other people for wearing masks. Like this is ridiculous. And so to be able to separate from that and create something that is a little more fact based perhaps, might be really helped.

Dan:
I agree. I think there's a huge opportunity to just re-imagine this and kind of put some stakes in the ground of expectations of systems leaders and nurses. I mean, nurses behaviors also contribute to this and I've done a fair amount of speaking over the last couple of years trying to push to say like, the way people act, the way nurses act in a group, especially if it's toxic, has direct impact on, not only your turnover in your staff satisfaction, but it kills patients, like we talked about. And we need to be treating these types of behaviors with the same rigor that we're treating collapses and falls and all the other joint commission related things. And our sense of indicators.

Dan:
This is a nurse sense of indicator and we have the most control over ourselves. So let's bring this up. And I don't know what the right answer to make that stick with people, but I think there's an opportunity for us to really hold people accountable for how they act and not just dismiss it to say, well, that's a cranky ER nurse. And that's the, that's just how they are, let them stick around forever. Like it seeds so much horrible culture within an organization and the cost associated and impact is just massive.

Lisa:
My dissertation study back in grad school was about the intersection of moral reasoning and clinical reasoning. So nurses who were morally invested in what they were doing, right. They had a social justice orientation, made better clinical decisions because they would ask the right questions. Whereas nurses who were functioning at much lower levels of moral reasoning, right, like your refrigerator nurse. Everybody knows the nurses just there to like, so I can go on vacation. For them, it's just a job. And those people do what's convenient for themselves, right?

Lisa:
Like they will ask as many questions as they feel like asking, and they will decide the rest are not important. And then there's this middle group who are very rules-based, which means that the environment has to be more moral than the nurses. Which means the leadership is critical in holding people to an ethical standard of practice. And I think in the ED, the tendency for a lot of things is to say, well, we don't have time for that. If you don't have time for that, then don't do it. Because the whole point is that we have to be really ethically focused on what we're doing because we're dealing with a huge amount of disparity in our ERs. To screen people for moral orientation would be my dream. Right? Take this instrument please and oh, okay, yep, you can come in. Right? Or, you know what? Why don't you go work somewhere else.

Dan:
I think that's right on. And we see that in our business too. We see nurses that are super engaged and we know they can handle anything across the board. And then others that are like, well, if you don't pay me more, I'm out of here. And I'm like, I don't know if I want to even work with you at this point. Like I know pay is a big piece of it, I'm not saying it shouldn't be. But if that's your motivation, nursing is really not the right spot to be in because there's so much other baggage that happens there.

Lisa:
Well right now this becomes a huge piece, right? Because ERs have like 30% vacancy rates all over the place. And part of it is because nurses are going to travel nursing, right? Like if I have to work under these untenable conditions, why should I not get paid a hundred dollars an hour for that? And frankly, can't blame them. But there's a better way to do that. And this is the organizational violence where an organization says, no, we will not pay you what you're worth. We will not give you the support you need. You will just need to suck it up and keep going. Like, why would you be surprised when they leave?

Dan:
Totally.

Lisa:
I'm not going to change anything else. Like we'll pay travelers a hundred bucks an hour, but we won't give our nurses a $5 an hour raise. Like, what is that? There's a big strike going on here in Massachusetts at St. Vincent's. And so the last I read about it, it was basically over staffing. It wasn't even over pay or benefits, it was over staffing. Because they were making them go like five to one when they needed to be four to one. And they've been striking for like eight months.

Dan:
Wow.

Lisa:
And so the last offer, I think, from the institution was, well, we'll give you a raise. And they're like, it's not about the raise. It's amazing, like nurses know what they need.

Dan:
Well, and there's a big disconnect between the supply and demand right now, too. There's not enough nurses, there's overwhelmingly too many jobs for various reasons.

Lisa:
Oh yeah. Texas has like, Parkland has 500 vacancies right now.

Dan:
Yeah, it's ridiculous. And then other nurse leaders I'm talking to say they have to hire a thousand nurses in the next year. I'm like, it's not going to happen, you're not even getting half of that. And they'll all be brand new. And then meanwhile, we're not giving new grads jobs and we're not letting them go into the ER to kind of live out their passion. We force them into these holes of whatever they have to orient in until they can have that year of experience, or two years, and they can move down.

Lisa:
You know what? If you give them, I mean, I ran, that was my first thing doing, I ran orientation programs for new grads. And if you train them well, if you give them the support that they need, they will do fine. If you give them a three week orientation and throw them in, of course they're going to fail because they don't know anything. But if you give them a good, solid orientation, how to think from symptomatic presentation to diagnosis, they're fine.

Dan:
100%. I mean, I'm a product of that. I am the ER nurse, started at UCLA in the ER, I had eight months of orientation where they slowly moved you from acute care to critical care to trauma, and everything in between. And within my first year, I was able to get past the certified emergency nurse exam. I mean, so there's ways to do this really well. And what a great way from a culture change perspective is to bring that excitement of a new nurse into your culture, and create that learning cycle that they need to be supported that can permeate the rest of the team. And I don't think we think about those pieces enough.

Lisa:
Well also the trauma processing piece, right? So that's the thing that ENA has put into their residency program is in the preceptor piece we talk about. Like, you're the person who's going to help them learn to manage this. Like you don't tell them to go wash their face and come back. Right? You got to sit down and figure out how to manage this.

Dan:
The dream at the end of the rainbow, or the pot of gold at the end of the rainbow is, how do we embed these skillsets or these tools, these interventions in the day of the nurse? Not saying, hey great shift, five people died and you had a train wreck and now you're upset. Go figure that out at the bar or with your family. But like to embed after these really stressful events, coping, even if it's five minutes of deep breathing or a debrief, something that allows you to like do something to let this out and not just compartmentalize it and then figure out how to deal with it on your own.

Lisa:
Right. Absolutely.

Dan:
So can you talk a little bit about some of the resources that ENA has that nurse leaders and nurses might be able to tap into?

Lisa:
Yeah. We actually have a couple of good educational stuff. The Know Your Way Out module is really good for kind of understanding the precursors to violence, and how to do an assessment of your own department. Like do a review of your reports, right? Like where is violence taking place? Is it taking place in your triage area or in the back hallway where no one could hear you scream? Are there targeted places that you can act to make your ER more safe?

Lisa:
There's also a leadership toolkit piece that we did with AONL about the culture of nursing and leadership and how to, again, assess and evaluate like where your problems are. Is it consumer violence that you're worried about, or is it bullying? Is it a combination of both? Examine your own leadership practices and see if you're contributing to organizational violence. So there's definitely some stuff to look at there. The bottom line is that there is no magic bullet, right? Like each emergency department culture is a little bit different. And so I think the assessment things are the most useful because it shows you where you need to shine your light.

Dan:
Yeah. I love that. And we'll link to some of that stuff in the show notes as well. Lisa, the last thing we like to ask our guests is, what would you like to hand off to the audience? So that one nugget that you're like, I want them to walk away knowing this thing. What would you like to hand off?

Lisa:
Yeah, this is a system. Violence in emergency departments is part of a web of factors and it's really hard to untangle them. So know that there's not one single thing that you do to make your ER safer. But you have to look at people, you have to look at physical plant, and you have to look at leadership to really get a full picture of where you need to act.

Dan:
I love it. And I'm a huge systems, complex systems, guy. That was the theoretical foundation for my dissertation. So I'm all about that. Right? You got to look at the actors and all the interactions that happen. So, love that. Lisa, thanks so much for being on the show. Where can we find you and more information if listeners want to get in touch?

Lisa:
Sure. Well, I'm easy to find. You can find me at Lisa.wolf@ena.org. Or you can go to the ENA website.

Dan:
Awesome. Really appreciate you being on. This is such an important topic that I think is just 10X right now in our current situation. I think the insights you gave are amazing. So just really appreciate your time.

Lisa:
Sure, thanks for having me.

Dan:
Thank you so much for tuning into The Handoff. If you'd liked what you heard today, please consider leaving us a review and subscribing on Apple Podcasts, or wherever you listen to podcasts. And for more information about Trusted, please visit trustedhealth.com. This is Dr. Nurse Dan. See you next time.

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