- Email: [email protected]
Workplace Violence; Discharge Voiding
PRACTICE CORNER
Workplace Violence; Discharge Voiding Theresa Clifford, MSN, RN, CPAN QUESTION: I am a manager of a busy perianesthesia service, and I am interested in information related to workplace and horizontal violence. Education regarding this issue is an institutional and unit-based goal. Response: This is such a great question! Authors have written about the concept of horizontal violence in nursing since the 1970s. Unfortunately, the increased incidence of workplace violence noted throughout the country has brought the topic back to the surface. In general terms, horizontal violence is believed to be a symptom of oppression and the experience of powerlessness related to the historic dynamics of nursing and medical traditions. Horizontal violence is common in nursing because of the inherent differences between the primarily female culture of nursing and the predominantly male culture of medicine.1-3 The end result is a toxic atmosphere of those who oppress and those who have been oppressed.
Behaviors Defining Horizontal Violence A number of verbal and nonverbal actions (or inactions), overt or covert, constitute behaviors associated with this phenomenon. Nonverbal behaviors commonly observed include raising the eyebrows, rolling the eyes, or making faces in reaction to interactions. Some of the less subtle actions include the following: backstabbing, rudeness, disrespect, failure to respect privacy, gossiping, relentless criticism, withholding of information, blaming, complaining to others about a person
Theresa Clifford, MSN, RN, CPAN, is a Clinical Resource Nurse, PACU, Mercy Hospital, ME. Conflict of interest: None to report. Address correspondence to Theresa Clifford, PACU, Mercy Hospital, 144 State Street, Portland, ME 04101; e-mail address: [email protected]. Ó 2011 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 doi:10.1016/j.jopan.2011.04.067
294
without speaking directly to that person, excluding, and failure to respect privacy, to name a few.
Consequences of Horizontal Violence In terms of the outcomes associated with the experience of horizontal violence, effects can be evidenced in both the environment where the behaviors are occurring and in the target population. The adverse effects in the workplace include poor teamwork, which adversely affects patient care and safety, unreported errors, excessive use of sick time, and other nurse retention– related issues. The individual who is subject to persistent horizontal violence may demonstrate common stress-related physical manifestations, including weight gain or loss, hypertension, cardiac irregularities, and irritable bowel syndrome. The emotional toll to the victim of horizontal violence includes a propensity for depression, anxiety, feeling worthless or humiliated, and isolation.
Recommendations for Managing Workplace and Horizontal Violence There are currently a number of legitimate resources for helping to manage this issue. The Joint Commission recommendations include education for all members of the health care team, conflict management training for leadership, and the support for a just culture.4 The Center for American Nurses has published a position statement on ‘‘Lateral Violence and Bullying in the Workplace,’’ available from its Web site, which includes a sample policy for zero tolerance.5 The American Society of PeriAnesthesia Nurses (ASPAN) also published a position statement on ‘‘Workplace Violence in the Perianesthesia Settings’’ which encourages and supports the creation of a just culture with improved communications and improved access to conflict management resources.6 Management of horizontal violence will take commitment and teamwork to proactively address maladaptive
Journal of PeriAnesthesia Nursing, Vol 26, No 4 (August), 2011: pp 294-295
PRACTICE CORNER
295
work behaviors and create a workplace of trust, respect, and safety. Question: Must outpatients with a spinal anesthetic void before discharge? If the outpatient has had a spinal anesthetic, when should a scan of the bladder occur? At what volume should a catheter be inserted? Response: In part, the answer definitely depends on the type of surgery that the patient had and the reason for the voiding requirement. No established clinical guidelines are available that relate to this voiding requirement; however, several works have been published on postspinal voiding.7-10 Although traditionally patients having same-day surgeries were all required to void before discharge, evidence suggests that select patients can be safely discharged without voiding, whereas those at risk for postoperative urinary retention (POUR) should be more carefully observed. Normal bladder capacity ranges between 400 and 600 mL. Most individuals will experience the need to void with 150 mL urine in the bladder and the urge to void when the volume reaches 300 mL. POUR is defined as the inability to void with a bladder volume greater than 600 mL as
detected by portable bladder ultrasound scanners. At a volume of 600 mL after a minimum of 2 hours, catheterization is recommended. Patients considered to be high risk for POUR include those having hernia, anal, or urologic surgery, those older than 70 years, and those with a history of urinary retention. Also considered to be at higher risk are patients undergoing spinal, epidural, or combination neuraxial anesthesia. Other factors to be considered include the volume of infused intravenous fluids and length of surgery/anesthesia. Low-risk patients generally include those having nonpelvic procedures, such as those of an orthopedic nature. Literature also suggests that the risk of urinary retention in low-risk patients undergoing spinal or epidural anesthesia with short-acting agents may also be sufficiently minimal and can likely be discharged before voiding. To enhance patient safety, these patients should be instructed at discharge to return to the facility if unable to void within 6 to 8 hours of discharge. This column provides readers with an opportunity to submit perianesthesia practice questions. What is your practice concern? Are you interested in exploring ways to enhance your practice and explore perianesthesia resources? Send your question to [email protected].
References 1. Lally RM. Bullies aren’t only on the playground: A look at nurse-on-nurse violence. ONS Connect. 2009;24:17. 2. Embree JL, White AH. Concept analysis: Nurse-to-nurse lateral violence. Nurs Forum. 2010;45:166-173. 3. Brown L, Middaugh D. Nurse hazing: A costly reality. MedSurg Nurs. 2009;18:305-307. 4. Joint Commission. Behaviors that undermine a culture of safety. 2008. Available at: http://www.jointcommission.org/ assets/1/18/SEA_40.PDF. Accessed April 18, 2011. 5. Center for American Nurses. Lateral violence and bullying in the workplace. 2008. Available at: http://www.mc.vanderbilt .edu/root/pdfs/nursing/center_lateral_violence_and_bullying_ position_statement_from_center_for_american_nurses.pdf. Accessed April 18, 2011. 6. Aspan A. Position statement on workplace violence in the perianesthesia settings. 2009. Available at: http://www.aspan
.org/Portals/6/docs/ClinicalPractice/PositionStatement/1012/ Pos_Stmt_13_Workplace_Violence.pdf. Accessed April 20, 2011. 7. Darrah DM, Greibling TL, Silverstein JH. Postoperative urinary retention. Anesthesiol Clin. 2009;27:465-484. 8. Feliciano T, Montero J, McCarthy M, Priester M. A retrospective, descriptive, exploratory study evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect on PACU discharge. J Perianesth Nurs. 2008;23: 394-400. 9. Mulroy MF, Salinas FV, Larkin KL, Polissar NL. Ambulatory surgery patients may be discharged before voiding after shortacting spinal and epidural anesthesia. Anesthesiology. 2002; 97:315-319. 10. Baldini G, Bagry H, Aprikian A, Carli F, Phil M. Postoperative urinary retention. Anesthesiology. 2009;110:1139-1157.
Workplace Violence; Discharge Voiding Theresa Clifford, MSN, RN, CPAN QUESTION: I am a manager of a busy perianesthesia service, and I am interested in information related to workplace and horizontal violence. Education regarding this issue is an institutional and unit-based goal. Response: This is such a great question! Authors have written about the concept of horizontal violence in nursing since the 1970s. Unfortunately, the increased incidence of workplace violence noted throughout the country has brought the topic back to the surface. In general terms, horizontal violence is believed to be a symptom of oppression and the experience of powerlessness related to the historic dynamics of nursing and medical traditions. Horizontal violence is common in nursing because of the inherent differences between the primarily female culture of nursing and the predominantly male culture of medicine.1-3 The end result is a toxic atmosphere of those who oppress and those who have been oppressed.
Behaviors Defining Horizontal Violence A number of verbal and nonverbal actions (or inactions), overt or covert, constitute behaviors associated with this phenomenon. Nonverbal behaviors commonly observed include raising the eyebrows, rolling the eyes, or making faces in reaction to interactions. Some of the less subtle actions include the following: backstabbing, rudeness, disrespect, failure to respect privacy, gossiping, relentless criticism, withholding of information, blaming, complaining to others about a person
Theresa Clifford, MSN, RN, CPAN, is a Clinical Resource Nurse, PACU, Mercy Hospital, ME. Conflict of interest: None to report. Address correspondence to Theresa Clifford, PACU, Mercy Hospital, 144 State Street, Portland, ME 04101; e-mail address: [email protected]. Ó 2011 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 doi:10.1016/j.jopan.2011.04.067
294
without speaking directly to that person, excluding, and failure to respect privacy, to name a few.
Consequences of Horizontal Violence In terms of the outcomes associated with the experience of horizontal violence, effects can be evidenced in both the environment where the behaviors are occurring and in the target population. The adverse effects in the workplace include poor teamwork, which adversely affects patient care and safety, unreported errors, excessive use of sick time, and other nurse retention– related issues. The individual who is subject to persistent horizontal violence may demonstrate common stress-related physical manifestations, including weight gain or loss, hypertension, cardiac irregularities, and irritable bowel syndrome. The emotional toll to the victim of horizontal violence includes a propensity for depression, anxiety, feeling worthless or humiliated, and isolation.
Recommendations for Managing Workplace and Horizontal Violence There are currently a number of legitimate resources for helping to manage this issue. The Joint Commission recommendations include education for all members of the health care team, conflict management training for leadership, and the support for a just culture.4 The Center for American Nurses has published a position statement on ‘‘Lateral Violence and Bullying in the Workplace,’’ available from its Web site, which includes a sample policy for zero tolerance.5 The American Society of PeriAnesthesia Nurses (ASPAN) also published a position statement on ‘‘Workplace Violence in the Perianesthesia Settings’’ which encourages and supports the creation of a just culture with improved communications and improved access to conflict management resources.6 Management of horizontal violence will take commitment and teamwork to proactively address maladaptive
Journal of PeriAnesthesia Nursing, Vol 26, No 4 (August), 2011: pp 294-295
PRACTICE CORNER
295
work behaviors and create a workplace of trust, respect, and safety. Question: Must outpatients with a spinal anesthetic void before discharge? If the outpatient has had a spinal anesthetic, when should a scan of the bladder occur? At what volume should a catheter be inserted? Response: In part, the answer definitely depends on the type of surgery that the patient had and the reason for the voiding requirement. No established clinical guidelines are available that relate to this voiding requirement; however, several works have been published on postspinal voiding.7-10 Although traditionally patients having same-day surgeries were all required to void before discharge, evidence suggests that select patients can be safely discharged without voiding, whereas those at risk for postoperative urinary retention (POUR) should be more carefully observed. Normal bladder capacity ranges between 400 and 600 mL. Most individuals will experience the need to void with 150 mL urine in the bladder and the urge to void when the volume reaches 300 mL. POUR is defined as the inability to void with a bladder volume greater than 600 mL as
detected by portable bladder ultrasound scanners. At a volume of 600 mL after a minimum of 2 hours, catheterization is recommended. Patients considered to be high risk for POUR include those having hernia, anal, or urologic surgery, those older than 70 years, and those with a history of urinary retention. Also considered to be at higher risk are patients undergoing spinal, epidural, or combination neuraxial anesthesia. Other factors to be considered include the volume of infused intravenous fluids and length of surgery/anesthesia. Low-risk patients generally include those having nonpelvic procedures, such as those of an orthopedic nature. Literature also suggests that the risk of urinary retention in low-risk patients undergoing spinal or epidural anesthesia with short-acting agents may also be sufficiently minimal and can likely be discharged before voiding. To enhance patient safety, these patients should be instructed at discharge to return to the facility if unable to void within 6 to 8 hours of discharge. This column provides readers with an opportunity to submit perianesthesia practice questions. What is your practice concern? Are you interested in exploring ways to enhance your practice and explore perianesthesia resources? Send your question to [email protected].
References 1. Lally RM. Bullies aren’t only on the playground: A look at nurse-on-nurse violence. ONS Connect. 2009;24:17. 2. Embree JL, White AH. Concept analysis: Nurse-to-nurse lateral violence. Nurs Forum. 2010;45:166-173. 3. Brown L, Middaugh D. Nurse hazing: A costly reality. MedSurg Nurs. 2009;18:305-307. 4. Joint Commission. Behaviors that undermine a culture of safety. 2008. Available at: http://www.jointcommission.org/ assets/1/18/SEA_40.PDF. Accessed April 18, 2011. 5. Center for American Nurses. Lateral violence and bullying in the workplace. 2008. Available at: http://www.mc.vanderbilt .edu/root/pdfs/nursing/center_lateral_violence_and_bullying_ position_statement_from_center_for_american_nurses.pdf. Accessed April 18, 2011. 6. Aspan A. Position statement on workplace violence in the perianesthesia settings. 2009. Available at: http://www.aspan
.org/Portals/6/docs/ClinicalPractice/PositionStatement/1012/ Pos_Stmt_13_Workplace_Violence.pdf. Accessed April 20, 2011. 7. Darrah DM, Greibling TL, Silverstein JH. Postoperative urinary retention. Anesthesiol Clin. 2009;27:465-484. 8. Feliciano T, Montero J, McCarthy M, Priester M. A retrospective, descriptive, exploratory study evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect on PACU discharge. J Perianesth Nurs. 2008;23: 394-400. 9. Mulroy MF, Salinas FV, Larkin KL, Polissar NL. Ambulatory surgery patients may be discharged before voiding after shortacting spinal and epidural anesthesia. Anesthesiology. 2002; 97:315-319. 10. Baldini G, Bagry H, Aprikian A, Carli F, Phil M. Postoperative urinary retention. Anesthesiology. 2009;110:1139-1157.