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Risk prevention policy in practice
The proposed study looks at lateral violence in U.S. healthcare institutions, through the scope of policy formation as it pertains to medical malpractice and organizational behavior in healthcare institutions. In recent years, investigations into lateral violence (LV) in the practice setting have become increasingly important as professional liability to 'duty' in patient care has been put under the microscope.
In Tarasoff v. The Regents of the University of California [S.F. No. 23042, Supreme Court of California, July 1, 1976], a wrongful death action filed against Regents of the University of California, charged that psychotherapists at a university hospital and campus policemen, had failed to respond adequately to information of patient, Prosenjit Poddar's intention to murder Tatiana Tarasoff in October of 1969. Charges against the Regents of University of California, alleged that Poddar confided homicidal ideation toward the victim Tatiana to Dr. Lawrence Moore, a psychologist employed by the Cowell Memorial Hospital at the University of California at Berkeley. At Moore's request, the campus police had briefly detained Poddar, but released him in brief assessment. The plaintiff's charged that Dr. Harvey Powelson, Moore's superior, also took no further action to follow upon the on the threat.
In the initial trial court decision, the defendants' demurrers to the complaint went without leave to amend, with judgment entered in favor of defendants. Upon appeal, the State of California Supreme Court affirmed the judgment in favor of the police officers; yet reversing the earlier decision in favor of the therapists and the regents. The reversed decision held that plaintiffs could amend their complaints to state a 'cause of action' against the defendants based on threat of imminent danger to the victim whom had put into serious peril. The court maintained that pursuant to the standards of professional 'duty to a standard of reasonable care' should have interpreted liability, and had nevertheless failed to exercise reasonable response toward protections of a third party threatened with intentional harm
In the landmark negligence ruling, the court held that when a therapist determines, or is forced to put an ethical dilemma to the test of professional expectations where a patient expressly states intent to cause harm or serious danger of violence to another, he/she incurs an obligation to exercise fair warning in part to the scope of 'duty' defined by reasonable care. The case was instrumental in further defining obligation to warn, stating that it was not a discretionary act within the immunity provisions of Gov. Code, § 820.2. Judicial reinterpretation which reversed the original decision cited breach to duty in the failure to communicate danger, yet held that they were insulated from substantial liability (Gov. Code, § 856). Nondisclosure (§ 5328), was redefined by the decision, however, as a measure for ensuring greater safety where healthcare organizations are involved. The policy definition of the case is articulated in the Healing Arts and Institutions § 30, 'Medical Practitioners and Duty of Therapist to Dangerous Patient's Intended Victim,' in provision of standards to profession conduct, including points of appropriate disclosure where serious danger of violence to another might be sustained.
The research proposal advances this topic, and looks at the general field of 'duty' to disclosure where healthcare practitioners are concerned. Of key importance to outcomes of the 1976 matter, is the recent trend in best practices policy recommendations directed at risk mitigation of violence in healthcare settings. If Tarasoff v. The Regents of the University of California set the pace for future decision on patient consent, and disclosure where imminent danger may be present, the expansion of the topic in the last thirty years or so now permeates the clinical practice setting. In keeping with contemporary interest on violence as a pronounced aspect of healthcare policy, the current study turns the disclosure issue toward questions of ethical obligation where peer-to-peer or lateral violence (LT) is present, and the formidable job that healthcare administrators, policy makers and practitioners are doing to ensure that 'duty' is adequately addressed.
According to the Center for American Nurses (CAN) (2008), the prevalence of lateral violence in healthcare organizations has increased exponentially in the last several decades. Nearly half of all nonfatal injuries in the workplace result from violent acts conducted by co-workers in the healthcare sector. U.S. Federal Bureau of Labor and Statistics reports that many if not in most states, the healthcare sector ranks amongst the top five sectors in workplace violence. Nurses, nurse's aides and orderlies are reported as victims of those injuries most consistently (OSHA, 2004). Incidences of disruptive and other anti-social behaviors experienced by staff in the high demand healthcare institution are indexed as 'serious' in the U.S.; with negative behavior, and misconduct issues cited as the norm rather than exception.
As a result, much attention to bullying and sexual harassment stems from patient related stressors where malpractice litigation is already in process. Since the emergence of such reported occurrences has reached what are discussed as 'epidemic' proportions, policy makers have been put to the work of crafting adequate legislative responses to excessive risk and misconduct. This movement toward depth in policy regarding violence, and especially lateral violence (LV) is of real concern to healthcare organizations, as conflict resolution and protection from liability suits is fiscally impactful, as well endangering to comprehensive patient care. Staff shortages, long hours, and stressful circumstances in hospital environments implicate employees into duress with each other.
The pervasiveness of LV is substantiated in the number of legal complaints filed against healthcare institutions, as described in policy consideration of regulatory restrictions articulated by the Joint Commission, OSHA and NIOSH in 2001. In 2002, the Joint Commission extended recommendations to violent perpetration and threats of physical assaults as 'workplace terrorism' under the definition of the U.S. Federal MPC (Modern Penal Code). Policy incorporation of MPC statute really underscores the 'last straw' imperative promoted by advocacy specialists on behalf of healthcare professionals concerned with their own and patient safety. The American Association of Occupational Health Nurses (AAOHN) replicated this amendment in 2003, in public support of U.S. Federal Bureau of Investigation (FBI) wording that "any action that may threaten the safety of an employee, impact the employee's physical or psychological well-being, or cause damage to company property."
In an occupational study of the healthcare workforce, nursing was targeted for multidimensional analysis toward interpretation of the 'domino effect' that persists in clinical practice settings, that begins with triggered stress in individuals, but ultimately serves as a feedback loop; impacting safety in the environment in general. Proposed solutions to LV in healthcare organizations it is said must include the entire scope of considerations, including the nurse-patient journey. Patient related risk and intentional negligence by colleagues goes hand in hand. For instance, exhaustion on the job is a standard complaint within nursing. It is relevant, then to argue that LV's elements vitiate without control.
Violations may include an entire host of threats, including intentional humiliation, infighting, non-verbal innuendo, risk to safety, verbal affront, undermining activities, withholding job pertinent information, sabotage, scapegoating and efforts to make vulnerable (Griffith, 2004). Almost without exception, it is also suggested, that breach of privacy or failure to respect privacy of individuals is the core root to detrimental misconduct and subsequent risk. Lateral violence in nursing practice is defined in table 1.
Nonverbal cues (covert/overt)
Raising eyebrows, making faces
Verbal remarks (overt)
Snide, rude and demeaning comments. Interruption of discussion
Actions that undermine the Victim's ability to perform or to be recognized for performance
Withholding information (covert/overt)
Deliberately not disclosing critical information to job, or protection from risk
Purposefully sabotaging (overt)
Group infighting (overt)
Cliques, and exclusion
Blaming identified colleague irrespective of real responsibility
Passive aggressive behavior (overt)
Failure to respond directly to conflict (i.e. backstabbing)
Broken promises/disrespect of privacy (covert)
Sharing of information without consent
Table 1. Types of Lateral Violence (Griffin, 2004).
The proposed research looks at the new directives in policy dedicated to the management of lateral violence risk in the healthcare workplace. It also examines 'policy in practice' through change management strategies in combating the force of malpractice litigation related to LV, through institutional adherence to protocols, and attendant morale building and leadership within horizontal nursing teams. Finally, following the Stanley/Martin Applied Model of Oppressed Group Behavior to Explain Lateral Violence in Nursing (2007), the study examines how policy influences healthcare practice in group accountability to liability, and duty to a reasonable standard of care of patients, as illustrated in Figure 1.
igure 2: Stanley/Martin Applied Model of Oppressed Group Behavior to Explain Lateral Violence in Nursing (De Marco and Roberts, 2003).
Interpretation of the practice setting through the lens of policy on disclosure where violence may pose danger to colleagues and patients is in essence, the intention of the proposal. Review of research on LV encompasses a range of evidence-based practice cases. Six Sigma diagnostic assessments of institutional best practices recommendations and application, will serve to support the study, and advance…[continue]
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