Abstract
This article provides a case narrative and analysis linking system architectures to the complexity of a dynamic hospital system identifying potential system failures or failed functions within the system related to healthcare workplace violence. System dynamics analyzed included people, processes, and the environment and how these dynamics were impacted by communications, information, feedback, and outcomes. Referenced articles were selected based on publication dates between 2000 and 2020 and concentrate on Type II violence between patients and healthcare providers. Additionally, the research referenced utilized qualitative studies and surveys addressing employee perception of healthcare workplace violence. Each study reported limitations and potential reporting bias due to limited response rates and minimal control groups.
Keywords: healthcare, hospitals, workplace violence, systems approach, dynamic systems, complex systems
Organizations succeed or fail based on their ability to use people, process, and environment effectively. Organizational leaders familiar with system dynamics and the inter-connectedness between sub-systems create robust, sustainable cultures. Hospitals utilize vertical mechanical systems and horizontal dynamic social systems that interact throughout the day. They have numerous departments (emergency, behavioral health, medical, and security) and people (patients, visitors, clinicians, and security) that interact with each other. The following section will investigate the interconnections between hospital systems and potential causes of hospital workplace violence. This paper highlights general system architectures as they evolved over the past fifty years. A case narrative will be presented linking system architectures to the complexity of a dynamic hospital system identifying potential system failures or failed functions within the system related to healthcare workplace violence. System dynamics analyzed included people, processes, and the environment and how these dynamics were impacted by communications, information, feedback, and outcomes.
Systems Theory
In the 1940's Ludwig von Bertalanffy was an Austrian biologist researching organisms and coined General Systems Theory (GST). He reflected those organisms could break down into parts, breaking down into sub-parts, creating a system. Bertalanffy was one of several scientists that began discovering patterns within science. Bertalanffy coined the phrase open systems, explaining that inter-connections and relationships are created based on communication, feedback, and information. Other scientists believed that GST could apply to other disciplines like engineering, business, and sociology. Systems theory sets a precedent to further discoveries in transformational system dynamics and complex systems across multiple disciplines (Cain et al., 2019; Nadim & Singh, 2019; Richmond, 1993; Wright & Meadows, 2012).
System dynamics look at the changes in the system over time. Richmond's (1993) research at the Massachusetts Institute of Technology (MIT) views system dynamics by looking at the whole system from a 10,000-meter view (e.g., forest), understanding that the sub-systems (e.g., trees) impact the whole. Changes to individual trees could impact the forest, causing deforestation, animal environmental changes, and even weather changes. Along with Bertalanffy, Richmond concluded that one 'system' change could impact other systems or sub-systems over time.
Taking this philosophy further, Cain et al. (2019) explore organizational dynamics that change over time due to cause-and-effect relationships or inter-connections. The effect of one sub-system changing can impact the larger sub-system or other systems, making a chain effect that occurs over time. The dynamics may be positive in one sub-system yet negative in another.
Debashis, Chatterjee, and Peter Senge (1998) describe positive and negative cause-and-effect relationships as vertical and horizontal, where vertical is more linear and horizontal is dynamic. Due to the cause and effect and dynamics involved, organizations should "think globally, act locally" (p.89). Open, dynamic systems have horizontal relationships and are considered complex systems. Regardless of positive or negative, vertical or horizontal, researchers argue system dynamics change as situations evolve, whether biological, cognitive, social, ecological, political, or spiritual.
To draw on the forest example, we can assume that hundreds if not thousands of trees, plants, animals, animal types, and insects live in the ecosystem. Within this ecosystem, there is air, water, and earth. Scientists research all of the inner workings of these systems. In some situations, scientists found systems resist other systems for their sustainability. Nadim and Singh's (2019) research describes the resistance to change in complex systems. They assert that the equity and equality systems appear to have less resistance, support change, and have more extended stability. Reflecting on the example, because air temperatures could increase or decrease in temperature, water may rise or fall based on seasons or patterns, sub-systems learn these patterns and adapt to support change for longer sustainability.
Based on the above research, we will argue that Hospitals are complex dynamic systems, and workplace violence results from contributory factors within the sub-systems functions. Hospitals utilize vertical mechanical systems and horizontal dynamic social systems that interact throughout the day. They have numerous departments (emergency, behavioral health, medical, and security) and people (patients, visitors, clinicians, and security) that interact with each other. The following section will investigate the interconnections between hospital systems and potential causes of hospital workplace violence.
Discussion
Hospital inter-connectedness functions with one primary goal
Hospitals are very complex dynamic organizations due to the numerous interconnections between service lines and department functions that have one purpose: to treat patients safely. GST can be applied to hospitals and the functions within the hospitals. Similar to Richmond's (1993) example of the forest and tree ecosystem, hospitals have numerous service lines that interact and can create positive or negative effects with each other. The most visible hospital service line is clinical services. Clinical services consist of physicians, nurses, technicians, and advanced practitioners. Support services include registration, billing, case management, housekeeping, and food services. A third service line consists of engineering, information technology, biomedical, supply chain, and security. In addition, service lines and departments can have sub-systems of other systems which provide support functions to patient care or the environment. (See Appendix, Figure 1). A fracture or break in one service line or department (e.g., x-ray machine failure) can have a trickling effect on others resulting in multi-system delays (e.g., diagnostic results) or complete failures (e.g., death).
Department Sub-systems and Inter-connectedness
Breaks or fractures in complex and dynamic sub-systems can cause catastrophic effects throughout the hospital due to their inter-connectedness. Specifically, the ER utilizes laboratory, imaging, therapy, intensive care, supply chain, and security services often on an hourly basis. When individuals seek medical care, they are often first greeted by an Emergency Room (ER) Triage Nurse. The nurse quickly gathers vital information, including chief complaints and vital signs. The individual then became admitted as a patient and handed off to a physician and ER nurse.
One of the primary goals for this team is to diagnose and initiate medical treatment to stabilize the patient to either be admitted into the hospital or discharged home. Often, physicians create an order for laboratory or imaging tests to diagnose the patient. There may be another handoff to other department technicians who will complete the test procedure when this occurs. Another physician will read the test results, interpret the findings and create a report, then handed to the ER physician. The ER physician will diagnose the patient and order medical treatment, which the ER nurse implements. When the physician deems the patient stable, the patient may be admitted into the hospital, in which this system continues, or discharged home. The patient flow through the ER and hospital may not specifically cause workplace violence; however, a deeper dive into how systems affect other systems or sub-systems (processes, people, and environment) will show how these interconnections contribute to or have the ability to prevent healthcare workplace violence.
Deep Dive into Systems That Affect Subsystems Resulting in Workplace Violence
National Institute for Occupational Safety and Health (NIOSH) researchers conducted studies identifying patterns in healthcare workplace violence and published their findings in 1996. NIOSH identified patterns within their study, presented to the Occupational Safety and Health Administration (OSHA). As a result of the recommendations, OSHA developed the Guidelines for Preventing Workplace Violence for Health Care and Social Services ("Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers," 2016). These guidelines recommend five building blocks to develop a violence prevention program. Processes such as management commitment and employee participation, worksite analysis, training, and hazard prevention and control address how they are interdependent and rely on a holistic view (hazards assessment) overall yet specific to certain situations and individuals.
Process design focuses on linear steps and includes cause-and-effect patterns to determine practical corrective actions. Examples of cause-and-effect processes include communication and feedback expectations, de-escalation training, hazards assessment, and the development of workplace violence response teams. Several studies conclude healthcare employees feel safer when they report incidents and actions to their supervisor, management, or security to support the victim (Cain et al., 2019; Schmidt et al., 2019). Adversely, victims become disengaged when the facility does not take action and experience physical and psychological trauma symptoms. Blando et al. (2013) raise awareness of this as productivity, staff turnover, and customer satisfaction will be impacted.
Systems Approach and Impact on Healthcare Organizations
As mentioned at the beginning of this paper, healthcare organizations succeed or fail using people, processes, and the environment effectively. Organizational leaders familiar with system dynamics and the inter-connectedness between sub-systems create robust, sustainable cultures. OSHA reports that healthcare Type II workplace violence is only second to law enforcement, and the trend of violence continues to rise in both fields. In addition, Blando et al. (2013), Lipscomb et al. (2007), McPhaul et al. (2013), Phillips (2016), and Schmidt et al. (2019) argue hospitals will have severe financial impacts due to higher turnover rates, workers compensation claims, lost work time, productivity, and customer satisfaction. Suppose workplace violence programs are not managed effectively. In that case, productivity and staffing resources could be perceived as a non-value-added waste of resources managing the chaos of response and recovery from incidents.
Information, Communication, and Feedback
Sub-group communication and feedback are essential between clinicians. If a sub-system has a failure in the process, for example, the x-ray machine fails, this could extend the process. Suppose Radiology does not provide feedback to the ER clinical team. In that case, they are not aware of the delays to share with the patient. The ER physician and nurse may become a victim of violence due to the patient becoming agitated. Cain et al. (2019) assert that individuals who receive feedback and are engaged have less potential to resist and have higher levels of support. Communication and feedback between patients, diagnostic team, and ER clinical team creates a system loop that becomes inter-connected.
Patient communication and feedback are often limited while receiving care in the ER. Individuals receiving emergency care expect to receive treatment quickly. Hospitals implement processes that follow a typical pattern unfamiliar to patients. As mentioned earlier, a patient presents to a triage nurse and obtains the individual's chief complaint and vital signs to determine the criticality of being treated over other individuals. The patient is handed off to the ER physician and nurse, who may ask the same questions again along with additional questions to determine a care plan. Patients typically are not aware of the differences in asking similar questions. The physician may order laboratory or imaging tests to substantiate their diagnosis, followed by medical treatment. The time to order, take the test and receive results can take several hours. During this time, patients are usually waiting and not receiving treatment or information related to the timeliness of the results. The longer patients wait, the higher the potential they will become afraid of the pending results, agitated for not receiving treatment or being in an unfamiliar, noisy, crowded environment, or angry for not getting their needs met.
Other sub-systems that can impact workplace violence beyond processes are people. Patients seeking medical treatment are not feeling well, confused, or are in pain. Security personnel receives limited training on healthcare and patient management. Often, security has a background in military or law enforcement, so they revert back to their initial training when observing violence. Clinical staff have limited staffing resources and are usually measured on a patient-to-staff ratio. The severity or complexity of patients rarely is included in determining staffing ratios. When a complex patient needs clinical staff resources, other patients typically do not receive active communication about their treatment or medical care, such as pain medications. Lastly, external people also have an impact on internal systems. Suppose law enforcement is requested to respond to the hospital. Their response is delayed, or they fail to take action. In that case, bottlenecks can occur, and staff resources are reallocated to assist.
McPhaul et al. (2013) reviewed the facility's culture correlating higher culture of safety has less tolerance of low-level crime and higher leadership engagement. Other qualitative studies concluded that higher leadership engagement resulted in an increased feeling of safety and lower workplace violence incidents (McPhaul et al., 2013; Almost et al., 2016).
A NIOSH study conducted in 2002 assessed physical and social environment and contributing factors to healthcare workplace violence. The NIOSH study found higher incidents of violence due to understaffing, long wait times, limited training, and inadequate internal and external support. Findorff et al. (2005) study of healthcare workers aimed to identify individual and employment characteristics associated with reporting violent and non-violent incidents. Results show individuals are willing to report physical violence more often than non-physical violence. McPhaul et al. (2013) evaluated how to prevent violence towards healthcare workers. The study conducted a systems review identifying categories and patterns occurring during incidents. Their research reflected on the effectiveness of the Haddon Matrix framework looking at the type of victims, perpetrator, incident location, and contributing social, environmental factors to the event.
Contribution
Based upon a systems approach and referenced research, I hypothesize that the critical hour where most Type II WPV occurs between 30 minutes of the patient arrival and 60 minutes while patients wait to receive test results. During this time, patients' fear increases, agitation raises, and needs become unmet. I recommend hospitals:
Provide continuous communication/ feedback (treatment times) between patient and clinical staff (e.g., similar to food delivery apps provide status updates)
Decrease time from physician orders tests to results to treatment time
Limitations
Referenced articles were selected based on publication dates between 2000 and 2020 and concentrate on Type II violence between patients and healthcare providers. Additionally, the research referenced utilized qualitative studies and surveys addressing employee perception of healthcare workplace violence. Each study reported limitations and potential reporting bias due to limited response rates and minimal control groups.
Conclusion
This paper intended to highlight general system architectures as they evolved over the past fifty years. I provided a case narrative and analysis linking system architectures to the complexity of a dynamic hospital system related to healthcare workplace violence. System dynamics analyzed included people, processes, and the environment and how these dynamics were impacted by communications, information, feedback, and outcomes.
Organizations succeed or fail based on their ability to use people, processes, and environments effectively. Organizational leaders familiar with system dynamics and the inter-connectedness between sub-systems create robust, sustainable cultures. This paper identifies potential system failures or failed functions within these sub-systems, resulting in workplace violence.
References
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