Winter 1999, Vol. 8, No. 2.

Book Reviews

The One Best Way and Violence in the Workplace

By Marcia Scott, M.D.,
Boston, MA

The One Best Way, Frederick Winslow Taylor and the Enigma of Efficiency, Robert Kanigel, Viking, New York, 1997. 676 pp., cloth $34.95

This is a paean to Taylor's life but well written. It will start you thinking about the organization of the medical workplace today. People have struggled, since the Industrial Revolution, with the unsympathetic and often dysfunctional organization of various kinds of work. Taylor, the icon of modern factory methods promoted the assembly line as a way of decreasing the variability of tasks because decreasing variability is a way of dealing with uneducated workers and increasing profit. Despite the fact that technology and education have enabled most industries to find new ways to organize work, managed medical care is, in fact, modeled on Taylor's principle – reducing product variability to increase profit. It has clearly not been 'the one best way'.

Violence in the Workplace, Raymond B. Flannery, Jr. Ph.D., Crossroad Publishing Co., New York, NY 1995, 188 pp., cloth

Many times, after reading this book, I tried to put on paper why it's so important. Finally, I was motivated by the discordance between self-congratulatory front page headlines - 'Significant Drop in Urban Murder Rate' - and the back page follow ups that show, not a reduction in the epidemic of violence but only less dying from violence because of more and better trauma centers for the victims. So after you congratulate the trauma surgeons read this book.

The author is director of training for the Massachusetts Department of Mental Health and an associate clinical professor of psychology at the Harvard Medical School. While he doesn't write quite as well as Scott Turow, I believe, that given a different venue, he could. Dr. Flannery confronts all aspects of the public health epidemic that has subtly changed our lives. We have always known people who work in high risk situations, we have always worried about our naive, incautious children, but now we worry about ourselves. What's most chilling is the belief that exposure to violence is simply 'the luck of the draw' - unpredictable - something everyone has to live with. Dr Flannery takes exception to that belief and his book is dedicated to dealing with violence as something we need to and often can prevent. 'Workplace violence is not simply an incident in a poorly managed workplace or a violent act in a dark parking lot. Everyplace is someone's workplace and violence is a 'possibility' that exists in the places we all go every day - clinics, schools, offices, public buildings and health care settings…. The mayhem caused by (these) criminal, violent acts is not pleasant to consider, but if we understand the nature of violence at work, there are specific strategies we can take to reduce the risk of undue harm for our colleagues and ourselves.'

The first four chapters contain compelling descriptions of the victim, the workplace, the assailant, and the relationship between work and the disgruntled employee. The stories are gripping and clearly the product of experience. He conveys his reasoning and recommendations in gentle, almost literary prose. He is a consummate translator of complex social and psychological material. You will find his explanations of how people react to trauma and of the nature of PTSD useful when you need words to describe them to the naive or the disbelieving - 'During the crisis, reasonable mastery, attachments to others, and the ability to make meaningful sense of the crisis are all temporarily disrupted.......These are normal reactions to terrifying events, and gradually, with time, the fear and anger pass. The psychological trauma passes, and the employee victim moves on in life. But not always.'

In Chapter 3 he outlines the mind of the assailant, translating again - this time complex theories of biology, anatomy, chemistry, medical problems, TLE, substance abuse - the role of personality and culture, attachment, narcissism, entitlement, poverty, and guns - all with directness, humility, good prose, and without significant offense to the complex science he summarizes. He speaks movingly of spousal violence - how it follows the victim from home to shelter and finally into the street and the courthouse. He reaches into history to illustrate a cultural aspect of American violence. In English legal doctrine the 'duty to retreat until literally backed against the wall' was the basis of a civil society. In the early American West, this aspect of Common Law was gradually defined as cowardice and by the late 1800s court rulings, based on the fact that 'the tendency of the American mind to be strongly against any rule which requires a person to flee when assailed - even to save a human life'…has 'resulted in violence in cases that might have been otherwise settled more peaceably'. Chapter 4 covers unwritten contracts and investments at work that increase vulnerability - work ethic, the focus on achievement, hierarchical helplessness. 'The employee may have never mastered the skills to develop caring attachments…. Without attachments and constructive meanings, the disgruntled employee is left with only mastery, and thus, job mastery becomes everything. Add to this psychological state some demeaning management practice, alcohol or drugs for self-medication,...pervasive life stress or some form of severe debt, and the easy availability of guns, and we have violence waiting to happen.'

What becomes clear in this first half of the book is that solutions reside in our responses. The profiles of potential violence are obvious, he explains 'but is that kind of assessment useful, are teachers ever likely to become astute in that regard - or should they?' The second half of the book covers programmatic and ad hoc interventions. He opens by again dealing with the necessary denial we all use. 'Most of us have not been trained to deal with any form of workplace violence, yet we face this potential for violent behavior with each new working day.' His chilling description of the Royal Oaks Post Office massacre lifts our denial and is a prelude to the section on training. 'As the time for the grievance session approached, the Royal Oaks postal supervisors asked the Postal Inspection Service, and armed security force, to protect the facility. The Inspection Service reported that they could not do anything until something happened. On Thursday morning, November 14, at 8:35 AM, something happened.'

Chapters 5 - 7 cover preparation and prevention. 'While the published literature has clearly documented the problem of violence in the workplace, it has equally suggested some strategies that organizations can employ to reduce risk and to contain the aftermath when violence does occur. These strategies appear effective, and can be learned and implemented by others. In each of the four areas we have focused on (industry, policing, education, and healthcare), a common three fold approach to violence at work is emerging. This approach includes pre-incident training, stress management interventions, and employee victim debriefing.' Chapter 6, on Stress management, contains suggestions for ways of enhancing stress resistance in both the individual and the organization. What is covered in this chapter might be called good management training or simply better management - except here, it's about life and death, not simply about productivity. I found it refreshing that he clarifies the difference between EAP functions and threat assessment highlighting the fact that violence in the workplace is an organizational, not a therapeutic issue. No complete prevention program outlined but principles and suggestions included in Violence in the Workplace make it possible to do that.

The book is deceptively brief, elegantly written, balanced in its analysis, clear in its recommendations. It is dedicated to Alan Shields, MD, Employee Victim, and to Employee Victims Everywhere. Read it, heed it, teach it. It could save a life.

 
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