Our Dirty Little Secret: Lateral Violence

I wish I could give credit to this artist...

Two years ago, I retired from bedside nursing. My initial anxieties of "what next.?", were soon relieved by sleeping late every day, volunteerism, crafting and oil painting. Ahhhh, Nirvana. A two-year nursing honeymoon period, for sure.

Last week, in an effort to maintain licensure, I attended the American Association of Critical Care Nurses' National Teaching Institute (AACN-NTI) where over 8,000 Critical Care Nurses converged on New Orleans, La.

I chose this conference because I could knock out over 20 CE's in 4 days. 

Coming to terms with recognizing my interests no longer lay in "Advance Concepts in Ventilator Management" or "Cardiomyopathies: Understanding the Complexities of Diverse Diagnosis", I chose to attend classes on topics that are rarely discussed outside of nursing circles... "Workplace Violence: Do You Have A Plan?", "Impact of Moral Distress on Perceptions of Work Environment and Patients Safety", " Bullying: An Unhealthy Intrusion in the Work Environment", "Silence: A Never Event" were just a few.

And I grieved. 

I grieved for the thousands of nurses broken by workplace violence, bullying, lateral (aka Horizontal) violence and workplace violence delivered at the hands of patients. 

I grieved for my oppressed and subjugated peers. I know it sounds bad - really bad - and for so many, it really is - but it's time to talk about it and delve into why it occurs so frequently in a profession that is consistently ranked as the most honest and ethical by the public.

In my twenties, a manager taught me a valuable life lesson ..."Don't come to me with a problem unless you have a solution." So I'm writing about 'our dirty little secret'. Not to 'slam' nurses - but to share what I have learned, if only to begin the uncomfortable conversation and possibly support those who are experiencing the phenomenon and to prevent future pain to those who are on the frontlines of healthcare delivery. 

Incidentally, ER Nurses are subject to this form of violence at a much higher rate than any other specialty.

_________________________________________________

25 years ago, Meissner coined the expression... "Nurses Eat Their Young". I disagree. In my experience, many of my peers have a less discriminatory palate and will "eat" anything that has let their guard down (ie: the nurse who has been on their feet for the past 12 hours and too tired to fight) .

I was 50 years old. An ER nurse for 25 years, it was the lateral violence I experienced at the hands of several young ER nurses that helped cement my decision to leave ER Nursing permanently and try my hand in the ICU. Usually, it was non-verbal, eye-rolling and sarcasm during patient-report at the end of my shift that really got to me. Giving "report" became dreaded. Miffed, badgering and nit-picking nurses who would get their egos massaged by trying to prove just how much more knowlegeable they were. It wasn't just one nasty nurse or one isolated incident. It was repeated several times a week. And it got old.

Wisdom told me that the confrontational report had very little to do with me. It had everything to do with them and their perception of themselves and their personal power. But I was getting to old for this shit and recognized that staying in the ER was not a healthy personal choice for me any longer. I transferred to ICU full-time.

Lateral Violence: Definition.

A consistent pattern of behavior designed to control, diminish or devalue a peer (or group) which creates a risk to health or safety (Farrell, 2005).

Some specific examples are:

• Overt. Name calling, bickering, fault finding, criticism, intimidation, gossip, shouting, blaming, put-downs, raised eye brows
• Covert. Unfair assignments, refusing to help someone, ignoring, making faces behind someone's back, refusing to only work with certain people or not work with others, whining, sabotage, exclusion, fabrication.  See more at: Break the Spell and End Lateral Violence

My experience was minimal compared to many, and I admittedly did not have the skill set (nor the inclination) that was necessary to deal with the problem. I was fortunate enough to have an 'out'. 

Several years earlier, our hospital offered a 6-week program in ICU Nursing. Although I loved being an ER Nurse, I knew the frenetic pace and physical requirements of the job could possibly be impacted as I aged. Attending those classes and gaining some part-time work in ICU nursing was one of my best career decisions made. My personal ICU nurse-nurse experience was by and large, welcoming, supportive and nurturing. It worked for me. 

But for those of you who can't bear the thought of leaving the specialty of where you work, I have a few suggestions...

• Consider creating (or joining) a multidisciplinary departmental committee on Healthy Work Practices.
• Develop a departmental"Safe" word or phrase when you are feeling oppressed or bullied by someone ("Peace").
• Develop a departmental "Safe" word or phrase when you recognize someone is failing to complete job requirements or slacking (ie: "Dude")
• Develop or tweak the current "Code of Conduct"
• Violations in Code of Conduct should include clearly defined disciplinary actions
• Prepare now for an 'out'. 

Now, take a long, hard look in the mirror. Could you be the problem? Maybe it's time to reflect and regroup.

My own, personal 'Year-of-the-bitch" was 1995. It wasn't pretty. And then I gave myself an attitude adjustment. Why was I such a bitch? Just like the experts say... I was feeling oppressed. powerless and silenced. Simple as that. Fortunately, I (hopefully) made amends to those nurses I may have hurt.If not, I am truly sorry. 

_________________________________

In an effort to promote healthy work practices, I plan on writing about the ways I have learned that we, as nurses can care for ourselves. 

Who knew?

Some of this info I gleaned from the NTI - some I just made up. I hope it helps. I look forward to hearing from you and your experiences in this area as I have learned that "getting your cards on the table" is generally a good place to start when the topic causes discomfort.

ER Nurses: The Cycle of Violence

Lateral Violence and Bullying in the Workplace

A Career in Nursing: The Middle

 

It took me a while to get my groove on in nursing but when I finally caught on, I learned that working in healthcare can be extreme, aggravating, thought-provoking and heart-breaking - all in the same shift.

I learned to differentiate the sounds of a cry of mourning, the cry of pain and the cry of attention.

I learned to have fun at work.

One night, while having a smoke (yup) in the medication room of the Telemetry unit where I worked, one of the docs suggested I work in the ER.

Me? An ER Nurse? Why not? 

ER Nursing was my life for about 20 years. I loved it and I loved my fellow 'Adrenalin Junkies', 'Trauma Mamas' and  the like. Ours was a club like no other. The ER requires physical stamina, quick reaction times and integrity.

In anticipation of the changes that were bound to occur in ER Nursing - I chose to participate in an ICU Training Program and when the time came, I left ER Nursing behind me. It was a painful decision but I felt it was important to step away from the ER while I was still on top of my game and had a decent attitude. As I've always said, "ER Nursing can suck the life out of you...if you let it."

And then I became an ICU Nurse.

Have You Hugged Your ER Nurse Today?

A few years ago I packed up my trauma shears, kelly clamps and community acquired antibodies to leave ER Nursing behind me. The separation was quick and clean and one of the toughest career decisions that I have ever made but knew it was healthiest for me to quit while I was still on top of my game and while I remained patient, competent and caring.

To me, the intrinsic beauty of ER Nursing was in the capacity to choose to be someone’s hero every day but believe me when I say that ER Nursing can suck the life out of you. If you let it.

So there you have it. A love/hate relationship if ever there was one.

During my twenty-odd years in ER Nursing I recall the token gifts of appreciation that were given to us by our nurse managers during Emergency Nurses Week…

• an “ER Nurse’s Call The Shots” t-shirt
• a  tote bag with matching pen
• a battery-operated alarm clock 

Although I was thankful for the gesture, I couldn’t help but think that Emergency Nurses Week always fell a little flat.

Why? I think I get it now.

How do you thank someone for…

• Allowing themselves to be exposed to God-knows-what-kind of viruses, bacteria, air-borne and blood-borne pathogens on a daily basis?
• Caring enough to incorporate extraordinary measures - just to make sure a patient can get a ride home?
• Working for several hours without so much as a drink of water?
• Bathing a homeless person - just because they needed it – all the while hoping you are adequately protected from the transmission of scabies and/or lice?
• Participating in the life-saving efforts of a critically ill child..immediately followed by de-escalating someone who is angry because they "are waiting too long to be seen" by the doctor for their rash?
• Reaching into their own pocket to help a patient or family member down on their luck?
• Choosing to "rise above" and continue to care for someone who just verbally, physically and/or emotionally assaulted you?
• Risking personal injury by having to restrain someone who may hurt him or herself?
• Rarely receiving a simple thank-you?

I could go on forever, but now I understand why the tote bag didn't cut it.

In my opinion, ER Nurses are not motivated by gratitude or money...but simply to the service of caring for human beings ...at their worst.

Emergency Nursing. It's a thank-less job - but somebody has to do it. And I'm proud to say that I've been fortunate enough to have worked along-side some of the best.

What can I say?

Keep your chin up, your eyes open and know that you are 'in the trenches' for a reason.

You are there not only for your patients and family members. You are there for the docs, cops, firemen and co-workers that need you to be.

So, for all you intelligent, skilled, compassionate and funny ER Nurses out there…Thank You. And know that you are sincerely appreciated.

If only by an ex-ER Nurse.

PS: I miss you.

UAB "ER Rap"...

Free Advice: On Death

 Death, the final frontier.

There you have it. There's not a whole-helluva-lot you can do about it though. As adults, we are acutely aware that death is a very real part of life - the finality of it all is incomparable to anything we will ever experience. There is no going back. No "do-overs". It is what it is.
 
I am no expert on death and dying but I do have a fair amount of 'hands-on' experience in this area that has come, in part, from being a Critical Care/ER Nurse but sadly, I've held more than one hand of a friend and family member at the moment of their last breath on earth. I've learned that death can be orchestrated into an intimate, beautiful and loving journey in life.

Yes, I've been a feverish participant during traumatic, no-holds-barred, heroic attempts of resuscitation. People who were too young to die and had so much to live for. Children, are most difficult. Enough about that for now. Today's post is not about them.

Today's post is about the countless whose lives came to an end despite the technology, medications, surgeries, complications and care we in health-care have provided to them. Today's post is about those who have lived a long healthy life and/or a short one of pain and suffering. Although, not at all scientific, this is what I've learned...

• The people who are closest to you right now will most likely be with you at the time of your death.Let them know how feel about end of life issues. Mr. Something wants to be told "Hey! Everything is looking good!" and as difficult as it may be for me, I will honor his request.
• If you find yourself to be assisting someone on their journey of illness, chances are they chose you to be there. 
• If you find yourself at the bedside of someone as they take their last breath, chances are they chose you to be there.
• If you are not around someone when they die, chances are they needed you not to be there.

• There are far worse things in life than death - but, that's a whole other list.

• Strangely, people may choose to die alone or when that certain someone who is having the most difficulty with their loss leaves the room. How many family members have said to me (upon hearing the news of their loved ones death) "But I just left to get a cup of coffee!".

• If you can, think about telling your loved one that you will miss them. Let them know that when it is time to go, you wish them peace and assure them that you will be strong and/or will help others through it.
• Thank your loved one for their impact on your life. I thanked my dad for helping to put me through nursing school. A sacred profession. I know how proud he was. Did he hear me? Who knows? It doesn't matter. The process of dying is a process for the living as well.

• Sometimes, people will wait to die until someone they have not seen in a long time arrives at their bedside.
• Grief is natural. Give yourself time to cry. Avoid drugs. They could delay the inevitable and you might just find your delayed grief rearing itself at a most inopportune time.Two months after my brother died. I couldn't stop crying. Was it the Ativan that "held me together" during and immediately after his death?
• "Wakes" are a good thing. Everyone gathers at the home of the departed family member following the service. They eat, drink, swap stories, cry and laugh. Royally pissed-off at the thought of having a party after the tragic death of Susan, (my 25 year old sister-in-law), my wise Aunt Marie said ”Joanie, I have wakes to help people get beyond their grief and this party gives everyone permission to laugh again. Life goes on and know that Susan will forever remain in your heart but it’s time to get back with the living.”
• Sometimes "ritual" can help with the journey. A few days before the death of my dear friend, Rob, I arranged to have his hair cut (he was all about looking good). I requested that locks of his hair be saved for me. Tying them with ribbon, and placing them in small photo note cards for his family and closest friends, my memento of Rob remains treasured today..

Parkland 1: The Introduction

"WHEN YOU THINK YOU'VE SEEN IT ALL, WE CAN MAKE YOU THINK AGAIN..."

This was the ad campaign for Parkland Memorial Hospital, Dallas Texas circa 1984-1985. The slogan was on T-shirts and ball caps and included the following text “…we think you can do more, learn more in one shift at Parkland, than you can in a month at a lot of other hospitals. The experience is that intense, that demanding. Nursing at Parkland isn’t for everybody. It’s hard work and there are no guarantees. The Parkland nurse knows that. Instinctively. It’s nursing that tests every skill you have. And some you haven’t.”

I was hooked.

With a year of ER Nursing experience embedded in my stethoscope and despite the fact that I was advised to have my head examined, I was willing to ‘suck it up’ and be a Parkland ER nurse. OO-RAH!

My formal orientation to Parkland’s ER included six weeks of combined didactic and hands-on instruction. My ‘preceptor’ a seasoned ER nurse named Cathy C. was tougher than nails. Once, I thought saw her smile, but soon learned it was just a little gas bubble. Ahem. We were joined at the hip for three long months.

In 1984, Parkland’s ER was divided into five separate ‘pits’ or specialties, all under one roof. Each 'Pit' had a doctor in charge - he or she was referred to as "The Pit Boss" and was a senior resident of that specialty.
Upon reporting for duty, I would be assigned to any of the following specialties on any given shift. Each specialty was unique and had their own set of challenges, but that was why I signed up to be a Parkland nurse in the first place.

Triage: 1 RN + 3 clerks Determine level of acuity of every person and ambulance that hit the door, based on chief complaint, vital signs, gut instinct and/or simply vision. The triage process was simple back then: Chief complaint, name, birthdate (which was optional) and level of acuity – emergent, urgent, non-urgent.

Surgery: 3-4 RN's + 2 clerks + 1 Patient Care Assistant (PCA)
All surgical (or potentially surgical) cases including trauma and burns – considered ‘clean’

Pediatrics: 2 RN's + 1 PCA
All children excluding pediatric trauma (they were triaged to surgery)

OB-Gyn: 2 RN's +1 clerk
All women of child-bearing age with complaint of low abdominal pain, gynecologic issues, pregnant women, and female sexual assaults.

Psychiatry: 1 RN + 1 MHMR (psychiatric intake) worker
Enough said.

Medicine: 3-4 RN's + 1 PCA + 1 clerk
Anything that didn’t fit into any of the other specialties – considered ‘dirty’

And so begins my Parkland Experience…and the nurse with the "gas bubble"? I could only aspire to be as good an ER Nurse as she was.

Parkland 2: The Times

"The Knife and Gun Club" - Part 1

Circa 1990, I was an ER Nurse at a hospital situated in a (less than) desirable neighborhood of Dallas, Texas across the street from an apartment complex referred to “The Projects” - a government assisted  apartment complex for the very poor where many occupants were armed to the teeth. See ER 101

Consequently, walk-in or dump-off trauma was commonplace. The ER Team was expert in managing 'penetrating' trauma as Gun Shot Wound's (GSW) and Stab Wounds (SW) were fairly routine.

The majority of our patients originated from The Projects but an additional source of blood and guts was from 'The It'll Do' nightclub located about three blocks away from the ER and notorious for late night stabbings.

The “Knife and Gun Club” would kick off on Thursday nights (payday) around ‘closing time’ (2 am) and continue until Sunday evening. Most of the victims were drunk or stoned, poor and under-educated.  I was told a long time ago that the ‘club’ name began by way of the differentiating members. The weapon of choice and modality of maiming and/or killing were determining factors on whether or not you were a member of the ‘knife club’ or the ‘gun club’. Divided by nationality, American citizens could legally purchase a gun to shoot one another. Undocumented aliens, were unable to legally purchase guns, so knives were the preferred mechanism of assault. Who knows?

It took me years to learn how to create strong boundaries between the patient and myself without losing my sense of compassion for them. After all, many of our ER clients were not the nicest of people.

The secret was to view their reality separately from mine and treat them as I would want my own brother or sister to be treated. It was the healthiest way for me to deal with some of the most horrific people and witness some of the most disfiguring trauma. But it took some time to get there as they don’t teach you this stuff in nursing school.

It was just after midnight on a Friday and “The Knife and Gun Club” was running full tilt. The ‘Bat Phone’ rang and we were told to prepare for an unconscious, hypotensive male with multiple GSW’s to chest and abdomen.

Within minutes, the patient arrived by DFD. An African American male, wearing a African print “doo-rag” and jeans, he was bloody and appeared lifeless. I could tell just by the look of him that he was a gangster.

Next:Knife & Gun Club - Part 2 

"The Knife and Gun Club" - Part 2

(See Knife & Gun Club - Part 1)

Trauma One was stocked with everything needed for a rapid trauma resuscitation … including a machine to transfuse massive amounts of blood and fluids within minutes, a chest ‘cracking’ tray (used for - just what you would think), an abundance of sterile tubes, needles and catheters used for placement in patient’s heads, hearts, chests and nether-regions. Trauma is brutal, no doubt about it and many times, invasive procedures are performed without anesthesia. The life-saving procedure itself trumps pain management. Thankfully, most trauma patients tend not to have memory of their ER experience and that I believe to be and example of God’s grace.

The trauma team converged on this guy. Multiple gunshot wounds to the chest, abdomen and legs. Doctors, nurses and techs all had, literally, a piece of him. Within sixteen minutes of his arrival to our ER, he was stripped, assessed, monitored, had two tubes that were as big around as some garden hoses inserted into each side of his chest with 'auto-transfusers' attached. Auto-transfusers collect blood coming out of his chest into special sterile, filtered containers so that when they fill, his own blood can be transfused back into him. A foley catheter, multiple IV’s, arterial blood, and other diagnostic blood and urine samples were sent, a quick chest xray and before I knew it, he was out the door (OTD) and en route to the O.R. Although central pulses (groin and neck) were present, at no time were we able to find a peripheral pulse (arms) or get a blood pressure.

What happened to me during those sixteen minutes were the strangest that I have ever experienced with any patient in this shape. It didn’t (and still doesn’t) make sense.

As I was preparing to start my gangsta’s IV, I looked at his face. It's a reflex to warn someone that you're about to shove something sharp into them. Normally, when a trauma patient is so profoundly in shock, they are unable to make eye contact with you but this trauma patient did. “What’s your name?” I asked, not expecting a response. His affect was serene and peaceful. His reply, calm and almost musical, “Michael” he said.

I looked up at a tech who shrugged his shoulders and raised an eyebrow as if to say “go figure”. I then recited a fairly standard statement that I would usually give to frightened, less critical, alert trauma patients…”Michael, I want you to know that we are here to help you, you're in the hospital and you will be feeling better soon. Don’t be afraid OK?”

Much to my surprise, Michael looked straight at me – all the while being poked and prodded (remember the chest tubes?) by strangers and said “What’s your name?” This was a first. I told him my name was Joan. “Joan.., Joan.., Joan” he said slowly. Then he actually smiled and said, “I know where I am and I know where I’m going. I’m OK. I’m not afraid.” I asked him if he was in pain and he said he was not. Knowing that he may not survive, I asked him if we could call anyone for him. He smiled again and said “Cameron, tell Cameron.” I asked for Cameron’s phone number and unbelievably he gave it to me. I had the ER tech write it down.

Michael made it to the OR but died 'on the table'. Should I call his family? Do I call Cameron? Do I really want to get involved with a 'gangster's paradise', so to speak?

Next: Knife & Gun Club - Part 3