PROTOCOLS LEAVE PATIENTS RUNNING THE ASYLUM?

A report made public this week reveals that the staff of Alaska Psychiatric Institute feel that protocols used to control violent patients are prioritizing the patients’ safety over the safety of staff. At times, they just avoid responding to “codes,” which are intercom announcements that extra hands are needed to control a violent patient.

In the 2017 Department of Health and Human Services Annual Report, however, there’s barely a mention of API. It doesn’t even show up as a division on the department’s organizational chart (Page 22).

Where it is mentioned, it’s one sentence about a remodeling project that was planned for 2018.

Some of the problems identified by the report prepared by attorney Bill Evans points to a cultural divide between those on API staff who want to more liberally use physical restraints on and seclusion of violent patients, and those who are trying to make the facility comply with regulations of the Centers for Medicare and Medicaid Services.

Staff said they feel the Quality Improvement workers are making their work harder and creating hesitancy in their decision-making, which leads to dangerous situations.

“A large segment of the staff believe that Quality Improvement [personnel] and the administration are being overly zealous in protecting patients and thereby reducing the staff’s ability to maintain safe control of the units. The divide between patient safety and staff safety is much broader than API. Many mental health professionals believe that a reduced use of restraints and seclusion results in less incidents of injuries to staff. A large section of the staff, however, are not convinced of this somewhat counterintuitive theory and believe that not intervening promptly and consistently increases the danger both to staff and to other patients,” Evans wrote.

That doesn’t mean staff who argue in favor of more aggressive use of restraints and seclusion are advocating for abuse of patients, he noted. They just have a very different philosophy about what works with the people that are being admitted to API.

“All appear to be committed to the safety and well-being of the patient,” he wrote.

The report came about because of complaints from the staff of API about an unsafe work environment, and a very public protest earlier this year, when workers picketed the facility. Evans tried to determine if safety is indeed a problem and if employees fear retaliation from supervisors for reporting unsafe conditions. The answer was yes and yes.

“The fundamental cultural divide existing at API cannot be overstated as it permeates nearly all aspects of the workplace,” Evans wrote. “At present the staff expresses tremendous anxiety about utilizing any force in any situation involving a patient as they are fearful that their interaction will be scrutinized by Ql based on video evidence and they will be disciplined or possibly terminated.

“This hesitancy and uncertainty, in and of itself, contributes to an actual safety concern as hesitation to act promptly could result in the escalation of a situation into a much graver and more violent situation. This also leads to an increased perception of danger because staff members are uncertain as to whether other staff members can be counted on to react in a crisis. The nature of this divide is further evidenced by the recent email messages sent by the Safety Officer to many public figures claiming that a culture of ‘patient abuse’ exists at API and that his calls to address it have gone unheeded.”

As an acute care psychiatric hospital, API is always going to have safety issues, Evans wrote. He said that inefficient scheduling of workers created periods when there were not enough staff to provide a safe facility, and other times when there was an overabundance of staff.

Changes to the patient population is also a factor. The staff reports they perceive that the overall patient violence seems to be on the rise, which Evans said is consistent with information nationwide.

Evans said a significant number of staff members he interviewed complained that patients who engage in physical assaults on staff are not punished either in the facility or by law enforcement.

Because the hospital attempts to protect its provider/patient relationship with patients, it does not assist employees who wish to pursue criminal charges against assaultive patients.

This hands-off policy is often interpreted by staff as being unsupportive of them as victims of assault.

Staff members also reported that the Anchorage Police Department is reluctant to arrest a patient at API, creating a sense among staff that the patients are allowed to assault them without consequence.

The facility uses a protocol called NAPPI, or Non-Abusive Psychological and Physical lntervention, for handling escalating situations. But many staff members Evans interviewed said that NAPPI is not adequate for calming violent patients. Yet, if a staff member is found to not be implementing the protocol correctly, they fear disciplinary action. NAPPI requires a significant amount of training to be implemented successfully.

“This increases the chilling effect whereby a number of staff are simply avoiding, if at all possible, responding to codes and similar situations,” Evans wrote.

After staff safety concerns, the next most relevant concern was a perception of favoritism shown by the nursing administration, including the widespread view by staff that some employees are “favored” by the nursing administration and are thus granted better treatment and more favorable assignments, while others are disfavored and are denied promotions, transfers, and other favorable treatment.

A number of employees told Evans that favoritism was a key reason why a number of employees have left their jobs at API and why a number of those who were interviewed are considering resigning.

The report was addressed to Attorney General Jahna Lindemuth. At a news conference on Wednesday, Commissioner Valerie Davidson of the Department of Health and Human Services, acknowledged that the work environment is unsafe at API, and that measures are underway to address the concerns.

“No employee should feel unsafe when they go to work, and clearly the report indicates we do have an unsafe work environment,” Davidson said.  “We want to know the truth even if it’s hard truth, and maybe it’s more important to hear the truth when it’s hard because we don’t have a baseline from which to begin.”

Read the entire report here:

API+Public+Report+FINAL