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A seemingly innocuous incident

Haaretz on research by Israeli nurse about causes of hospital violence

News conference Shafran-Tikva 
March 13, 2012 --  Today Haaretz (Tel Aviv) reported on a new study in which nurse Sigal Shafran-Tikva examined the factors that lead to violence by Israeli hospital patients, most notably the role of health care staff themselves. Dan Even's article gives a fair account of the main findings of this research, which is of particular importance to nurses and does reflect their perspectives. And the piece includes some good quotes from Shafran-Tikva. Unfortunately, the report does not mention that Shafran-Tikva is a nurse, greatly reducing the piece's potential to improve understanding of nursing. We don't know whether someone publicizing the study downplayed the nursing element, perhaps so the research would be taken more seriously. But the net effect is to bury nursing expertise. And it seems likely that many readers will assume that Shafran-Tikva is some other kind of health professional--particularly since the piece itself does nothing to convey nurses' skill or authority, and instead subtly suggests that nurses are less important than physicians in hospital care. We hope those responsible for this piece will credit nurses for their research in the future.

Israeli ERThe main headline of the article is "Medical staff partly to blame for patients' violence, Israeli study finds," and the subhead explains that the research was conducted at Hadassah University Hospital. The main hook seems to be the role that the conduct of "medical personnel" themselves plays in "patient violence against doctors and nurses in hospitals." We suppose that nurses are fortunate to get that mention, since the caption of the accompanying hospital photo--which shows two males in light blue scrubs, two females in darker blue scrubs, and two apparent emergency response personnel--simply describes the personnel shown as "doctors and staff."

Haaretz quoteThe piece focuses mainly on the scope and findings of Shafran-Tikva's study, noting that she carried out the research "for her Ph.D." but failing to say what Ph.D. she was seeking or what her profession is. In fact, she is a nurse and the Ph.D. is a public health doctorate from the Hebrew University in Jerusalem. The research was to be presented at a conference hosted by the Institute for the Study of Health Services and Health Policy, which funded it. In a quote getting at the larger context, Shafran-Tikva observes that "violence in the health-care system is different from violence in the street or on the soccer field because it appears in a place that symbolizes compassion and saving lives like an emergency or trauma room, turning it into a battlefield."

The study was reportedly based on questionnaires completed by 705 "doctors and nurses." Apparently researchers collected 4,047 "statements about violence," and 39 percent said that the conduct of the reporting staff themselves "contributed to the violent incident in question," while in general, "48 percent of those questioned said the behavior of hospital staff contributed to violent incidents." In addition, 29 percent of the reports linked the violence to patients, 16 percent to "organizational aspects," and 10 percent to "prolonged waiting time." The "organizational" factors appear to include "the architectural structure of the department, a lack of personnel and overcrowding." The study found that an ED nurse is 5.5 times more likely to be violently attacked than a nurse in an "internal medicine ward." The piece does not say if the study determined how much more likely a nurse is to be attacked than a physician is.

Haaretz quoteThe piece does note that the research indicated that most violent situations start with a "seemingly innocuous incident that escalates," such as "a relative sitting next to a patient on a clean bed angering the staff, or relatives who want to visit a patient outside of visiting hours." Shafran-Tikva says that in these cases "hurt feelings were prominent and went both ways between attacker and victim and each side blamed the other." But her report stresses that--contrary to the headline of the article--"medical personnel who are violently attacked are not to blame for it, and there is no justification for violence . . . But the medical team can act responsibly and avoid contributing to escalation of violence, and they should be given the tools to do so."

The article includes a few of the study's ideas about those tools. Shafran-Tikva says that (in the piece's words) "explanations, conversations, respect and empathy" were found to "delay the outbreak of violent incidents" (and we assume might also prevent them altogether), whereas "factors precipitating violence included lack of respect, lack of awareness of service and a disrespectful tone of voice on the part of medical personnel." Haaretz quoteThe piece also includes a curious prescription directed only at "doctors," who "can help prevent violence by creating a more confident environment for patients and families to ask questions and giving detailed explanations if asked." Don't nurses have at least as much to do with patients' "environment"? Can't they provide "detailed explanations"? In any case, the piece also notes that the study recommends that a "national task force" be established to help reduce violence in health institutions.

And the article concludes with some data on recent trends in hospital violence in Israel. Health Ministry statistics show that violent incidents peaked in 2008, but have been declining since. The piece notes that "about one-fifth of the violent incidents were physical and the rest verbal"--readers might have assumed that "violence" meant physical. The piece also notes that few incidents of hospital violence result in police complaints (only 22% in 2010). Of course, if the 22% figure is based on a group of incidents that includes purely "verbal" ones, that might mean that most or all incidents involving physical violence actually do result in police complaints. And to the extent the "violence" is solely verbal, it's not clear what role the police would play. But if only 22% of incidents involving physical violence resulted in police complaints, it might suggest that the wellbeing of staff is not always taken as seriously as it should be, as other research has also suggested.

The Haaretz article addresses a subject of great importance to nurses. It does include nurses in a couple references, showing that they are one important group of hospital workers affected by violence by patients. And the very fact that the piece is publicizing nursing research has some value, since the study inevitably reflects nursing perspectives. This is just the kind of research that nurses often do, focusing on how the care environment itself affects patients. The research confirms findings elsewhere that nurses face high levels of violence in the workplace, though this article does not really distinguish that violence from violence against other health workers. And the piece includes several quotes by Shafran-Tikva. For the few readers who know that she is a nurse, the report may well signal the importance of nursing scholarship.

Unfortunately, we doubt that will be the case for many readers. Instead, given the stereotypes that continue to dominate the public image of nursing, it's likely most will assume that Shafran-Tikva is some other kind of health professional, perhaps a physician. That means that a golden opportunity to highlight nursing scholarship--including the facts that nurses get advanced degrees and add to the body of scientific knowledge affecting public health--has been lost. The piece also include a couple minor elements that reinforce the idea that health care revolves around physicians, while nurses and others merely help them; these are the suggestion that "doctors" can reduce violence by explaining things better and the photo caption indicating that health care is provided by "doctors and staff." We know that some might take Shafran-Tikva and her research less seriously if the word "nursing" were attached, and we have seen some nurses downplay their own status as nurses, apparently for that reason. But that is not helpful to the profession.

We congratulation Sigal Shafran-Tikva on her study and on getting mainstream media attention for it, and we thank Haaretz for at least publicizing her work. But we hope that next time the public can learn of the role that nursing played in that research.

See the article "Medical staff partly to blame for patients' violence, Israeli study finds," by Dan Even, posted on March 13, 2012 in Haaretz (Tel Aviv).