As Nurses Grieve, The Nation Watches

Being a healthcare worker is my superpower, something that I am good at and advocate tirelessly for my nursing profession, and for those that help us with our jobs. With the overpowering emotions that I was feeling from the words being announced that “COVID-19 is here in the States” many emotions began, starting with denial, anger, bargaining, depression, and then acceptance.  Then it came quickly came to me, these are the stages of grief, and the thoughts of massive loss that we will encounter over the next few months wasn’t the nightmare on TV in another land, it was coming right for us.

For me, the denial was thinking the virus was only staying in China. Though it was terrible, people were probably making this out to be a big-nothing deal as usual. Something we do so well as a healthcare worker, we can handle anything, especially with our protective equipment!  As the viral wave hit Europe, it was inevitable. It was coming right for us. Living in Orlando, Florida, we have tourists coming here from all over and knew that was spreading right to us. Calmly preparing, getting my “hurricane” supplies at the beginning of March, the news hit a couple of days later…it was here.

Taking it all in, seeing my fellow healthcare workers and first responders on a typical day, knowing how what was about to happen was going to change our country forever. Independence running fiercely through our veins, Americans will not back down. This can either impede an effort or cripple us. It was becoming more noticeable, the influx of people rushing into the ED for minimal reasons, the panic was starting to set in, for some, not so much as the younger folks as infallible as they are.  It was almost like time was standing still and seeing the future, trying to bargain it to be okay, that is was all hype. Just wash our hands, everything will be okay, and don’t forget to buy some toilet paper.

Not being a huge TV person, especially the news, I tuned into credible avenues of information and let that guide my decisions. Deeply depressed by knowing that nurses, all health professionals, and first responders are heading into the lion’s den without the protection that we all have seen staff wear in China, that we were about to have massive casualties alone just with frontline caregivers. How our pleas are loud yet not heard. Healthcare workers and first responders put their work clothes on and went after the fear that was ahead, knowing that this could be the last month of their life. Not having proper protection to care for patients was not what we signed up for, as a soldier would not be sent into battle without a weapon. This was not what they taught us in nursing school, as this is just a bad dream.

As we embark on this mission of selflessness, resulting in isolation to aid our communities, we must accept and not forget those that we have already lost and what is to come. Many of you reading this may or may not be nurses or even in the medical field, but know that the stages of grief, are necessary and we are not immune. It is okay, even for the bravest and stoic to grieve, that crying is not a weakness but a way to help release the emotional pain one is feeling. The next few months are going to be rough on all of us, that will change our mental well-being and even cause trauma to a varying degree. Whatever you do, know that these stages are natural and healthy, you must experience them to be resilient and grow.

You are not alone. Please check in with your healthcare worker friend or family member, even neighbor. They may need that friendly conversation. If they are a danger to themselves, please take them to the ED or call 911. If you or know a healthcare worker that is afraid, isolating, or needs to talk, please ask them to join our group for support, Nurses Against Violence Unite, we are open to all healthcare workers. Together we can make the difference. Nobody should feel left behind.

BDD53515-B90D-4103-83A6-03BB2C177263_4_5005_c

Identifying the Violence Within

facebookWe need to 1st talk about how much violence is occurring on the floor, whether it be working in a skilled nursing facility, an assisted living facility, or a hospital setting. The American Nurses Association stated in 2018 that out of 14,000 nurses that answered an anonymous surveying system, 62% stated that they were verbally and physically abused. As a backup to this report in 2019 Bolvin, wrote an article with the American Nurses Association revealing one in five nurses have been physically attacked. These were the only statistics that I could find when working on my doctoral project, with a radius of 30 years trying to find theories, recommendations, and work that pointed to a solution. The biggest problem that was identified as the great depth of how nurses and nursing staff felt how it was not in their best interest to report or that the patient didn’t mean to hurt them.

The most widely spread statement was violence was a part of the job. How could this even be?  I was taking a real long look at my career starting over 29 years ago, as a nurses aide assistant climbing the chain to a certified nurse assistant to an ER tech working 15 years knee-deep in bedpans, juggling priorities and the most frontline of all of the health care workers in a health care facility. The expectations of the nurses assistant to have 20 to 30 patients to clean, feed, walk, or even Help the nurse with extra tasks would be almost impossible. When we started in these various positions, we were told this is the way it is. That our jobs were not that important, and a dime a dozen; at $4.25/hour in 1992, I would beg to differ!  Most of the time, my whole team, nurses included wouldn’t be able to take a break to attend to the basic human needs because we did not want to feel like we were neglecting our patients or disappoint our employers. At times, I couldn’t get out of my car from the pain I had lifting and turning patients in cranking beds.

How do we know when we have reached our limit?  A nurse and the staff caring for the injured, addicted, or those suffering mental illness, the passion runs deep and has invested not only a significant portion of our lives to fulfilling our nursing mission, role, but it is a personal investment as well.  We have been forced-fed beliefs of “deal with it”, over a long period of time, along with lack of resources such as supplies, care for patients, and forced to have to care for your patients by yourself, whether they are combative or a total care patient or not. Regardless of the level of care, is a significant safety concern for the patient and the staff caring for them.  Is it really staffing or is it conditioning the mind to think that this is OK and the new reality of what you should be expecting throughout your career?  Dollars over adequate care.  When will we say enough is enough, we are advocates.

Recognizing our limit is when either it’s too far gone and hopeless that we accept what is happening. Learned helplessness has not been explored in nursing as psychology and nursing have been regarded as two different subjects for so long, yet the great nursing theorists have tried to disclose issues, but mental health is not regarded as a priority in the nursing education system. They are two totally different professions?  This problem has been conditioning nurses from the very beginning before even starting nursing school that lab values and transactional nursing have more priority, while holistic methods with person-centered care are disappearing. How can we identify the violence within if we have no clue what it is or acts like?  The closest thing out there and worded backwards is that de-escalation is the key to a safe work environment, no preventing the problem is!

These are some of the things that we are changing every day with the organization Nurses Against Violence Unite, Inc.™ As our mission is to change the culture in nursing and all health care facilities through bringing awareness, educating, empowering, and eliminating violence in the workplace. Changing the face of health care and nursing is not going to change overnight, as we have to align and be the change.  Change within the system is a process that requires a significant focus on building relationships, have healthy coping mechanisms, such as; laughing, activities, social groups that are positive, healthy eating, and identifying when we need to take a break.

These can be beneficial to break the stress level that the healthcare professional is experiencing.  Every day, the nursing staff comes forward to discuss issues that they are facing, which includes collective statements of learned helplessness, how the team is stretched, and given high expectations from there employers while being told that they are not doing a good enough job. De-valuing the ones that are making the difference is a wrong business move as the nursing staff is the backbone of healthcare. To identify the problem of violence is one thing, but now is the time to break the cycle of violence, starting from within. Please help me help our healthcare community to heal for not only our patients but also for ourselves and our families.

If you are looking for more support, please visit us at https://www.facebook.com/groups/NAVUnite/

 

Nursing Assignment Danger.

The medical-surgical nurse gets the report on a 49 y.o. man, that fell into a thorn-bush and a foreign body is embedded into his arm. Nurse Allen, who is a seasoned nurse has 4 patients and is receiving a report on Mr. Smith. Allen’s current assignment is an ORIF (hip surgery) completed 2 days prior, MI rule-out, a pain management client that has been requesting PRN pain meds on a scheduled basis since last shift, and a patient that was unresponsive under a bridge yesterday that tested positive for opioids, THC, and alcohol, with a BAL 378, that in the ED was rebounding with IV fluids. Mr. Smith was admitted yesterday and being held in the overflow ED area until some unit beds were discharged. Allen is having a very eventful day as usual and extremely busy, so are the other nurses.

The patient finally comes to the floor, IV is halfway out of the patient’s arm, the site was now edematous and told that it must have just happened enroute. Nurse Allen asks for assistance for the vitals and he would be right in to say hi to the patient and start their head to toe assessment. Allen stops the fluid, assesses the area and starts another IV site then starts working on the skin assessment. Nurse Allen immediately sees multiple dots/lines in a row that are healed over but the area on his forearm is red, angry, swollen and painful to touch. Mr. Smith was diagnosed with cellulitis and is ordered to start IV antibiotics with an OR consult. Nurse Allen starts the antibiotic therapy, antipyretics, and the patient had a visitor. This was a particularly normal person, a female that holds some resemblance to Mr. Smith and introduced her as his sister visiting out of concern for his well-being. Nurse Allen attempts to take a break, notifies his colleagues and is so excited that he can get to the coffee shop for a little pick-me-up. The charge nurse Maggie walks in to adjust Mr. Smith’s IV pump, it is beeping and annoying the patient in the same room. When Maggie walked in, she saw Mr. Smith actively using a needle to inject a brown liquid into his IV line, this is why the pump was beeping. A code blue was activated as the patient was slumped over and leaning against the bathroom wall, a needle hanging out of his IV tubing.

This patient was sent to the ICU, nurse Allen was written up for not adequately performing a skin assessment, as the needle casing imprint was on the patient’s leg, where the TED hose was pushed down. A blood test was performed, the patient tested positive for opioids and meth that was injected into his arm. Should Allen be liable if the needle was not there during the skin assessment and was possibly brought in from the visitor? Some say absolutely and others may not see it that way. Security is minimal in all healthcare facilities, so much that nurses and CNA’s are unable to keep up with their own assignments and tasks than to be in the room observing contact between a patient and their loved one. Syringes, along with many other objects are being “pocketed” in rectums or flesh folds, not to mention the female genitalia or even brought in by friends and family. This article is not to condemn those who are addicted but to bring awareness about addiction and how it is straining healthcare workers, who are not adequately trained with nursing education or from their facility. Furthermore, a set up for failure. It is not fair or right that nurses should feel that standing up for what is going wrong in healthcare that it is pointless to report. Many lives that we work with depend on healthy nursing staff, we cannot remain healthy if not protected from harm or have resources to become a stronger and a happier workforce.

If you or someone you know that needs a voice, please join us on Facebook at: Nurses Against Violence Unite (click the business name) and join our community today, feel the difference and supported.

What is Nurses Against Violence Unite?

Freshly graduated from my Master’s program, with a project focused on de-escalation techniques, I decided to bring to light a sensitive subject among nurses.  Before deciding which way that I was going to go with Nurses Against Violence Unite, Inc, NAVUnite for short, the one thing that came up was staffing shortages.  But WHY were the floors always short?!  Growing up in the nursing field since a kid, 16 years old, I have seen many issues with violence against nursing staff.  It wasn’t until I became a nursing instructor is when the dots were connecting.  Between lateral and patient on nurse violence, who would want to come to work and deal with that every day?  Unless you enjoy the constant negativity, I would have to say this was a direct correlation of why the turnover and injuries are high and job satisfaction scores are so low.  My fellow advocate groups shooting for more staffing are marvelous and respect their cause as it indirectly relates to mine.  Partnered with a couple of my closest friends that are connected but respect my vision, have supported me through this venture and grateful to them for believing in me.  To be honest, I am sure they thought by now I would have given up on this cause but there is no way.

My vision for Nurses Against Violence Unite, Inc, a non-profit 501 (c) (3) is to create an education plan, as it is coming along nicely, to fill the gap of acute mental health and addiction that is a missing piece in the nursing curriculum.  There is also roughly 25 hours of mental health training in the nursing frameworks that equates to minimal chronic mental health training and awareness.  With the opioid epidemic combined with other substances, nurses are learning from an ancient curriculum.  It needs to be modern and reflects the current trends in healthcare.  October 2, 2017 was our first free event and plan to continue to them as education is number one along with therapeutic interventions for nursing staff that are on the front line in healthcare.

The events will continue to be free and donations will start to be accepted.  With donated funds, we will continue the events, build scholarships for nursing students, build a community online and in-person to help nurses be heard without retaliation or bullying, and resources for nurses to receive free to discounted private therapeutic services that are separate from their employer.  Nursing is about caring about others and have been in the field for over 27 years, yes dating myself, we are a family that argues and can still love each other equally, as this is what we do.  A team of professionals that have your back and laugh with often because we are a silly and resilient profession that need to stick together to make the change we need in nursing.

If you hate what is happening in nursing, help us change it!

Dr. Sandra Risoldi

Nurses Against Violence Unite: Stop the Bleeding of Frontline Nursing Staff

Nurses and healthcare staff feel unsupported and leaving the field altogether due to unsafe work environments and lack of organizational support.

Join Our Facebook Support Group for Healthcare workers: #NursesAgainstViolenceUnite

Nurses and all those that help us with our jobs are at risk for our safety, have less than adequate training which should focus on prevention, not solely on the de-escalation of verbally aggressive patients and their families. We are losing nurses and healthcare staff every day and feel as if we do not have a voice, as our employers discourage us to report, make every effort to silence us while making vicious retaliation attacks, by also using micromanagement and attempts to ruin careers. When we do report an incident or injured on the job, we are frowned upon, made an example of and many have lost their jobs because of the injuries they received. There are many issues that still need to be addressed with the Workplace Violence Bill 1309, that was recently passed.

Workplace Violence Bill 1309

Other areas that need to be added for clarity:

1) Clear reporting on the computerized program for reporting incidents, to not be under the tabs labeled “miscellaneous” or “provision of care”. By having the titles unclear, the reports are not accessible to count.

2) Implement anonymous reporting for workers who are afraid to report, encrypted by a government system so the employer cannot detect the person to retaliate against.

3) Offer therapeutic services as a 3rd party vendor and no way connected to the partnered agency. This will enable the healthcare provider to feel safe and move onto recovery.

4) Overhaul OSHA’s system to have a healthcare sector that does not make recommendations but instead, OSHA will enforce investigation of retaliation within the organization.

5) Behavior Prevention programs designed with systemwide training that is not monopolized by a single company and have frameworks applied that target the problem. It should be mandatory for all healthcare agencies to build from the provided extensive frameworks without the healthcare worker being penalized by losing their job for making an error by hyperextending an inch farther due to fear of being injured or trying to shield and protect themselves.

6) Lateral violence of demeaning, hateful, targeted behavior to another staff member including turning pumps off without a rationale, not assisting with potentially violent or upset patients or family members, and not blending the acuity fairly with the patient assignments, should not be tolerated.

7) Implement acuity to patient ratios with algorithms to assist and color coding to mild to severity patient care, including mental health incorporated with medical.

8) Mental health/addiction in nursing education is subpar and schools are not preparing nurses for the reality of societal trends, resulting in the newly graduated nurse not being prepared. This includes behavior from other nurses or healthcare staff that have endured high levels of stress, burn-out, and PTSD. According to the recent ANA study, 1 in 4 nurses are suffering from workplace violence, and these represent those individuals that have reported.

9) Organizations to offer light-duty positions for all healthcare workers. Many nurses and healthcare staff would rather continue to work while injured and should have this option.

10) Organizations should not use personal time off that is accrued for injuries that occurred on the clock, and the employer’s obligation to keep the healthcare worker safe. Instead, organizations have been taking the earned time off to supplement the employee’s time off from work. This is a form of retaliation, as the recipient is a victim of violence.

11) Workers Compensation should cover mental health, including PTSD for employees that witness severe self-injurious behavior (suicide) of the patient or the person being attacked by a patient.

12) Penalties to employers with high turn-over and investigated for the root of the issue, such as employees being afraid to come forward, and offer a retraining program to assist in the retention of healthcare staff.

13) Increased security measures, cameras in all garages, hallways including patient rooms, drug and weapon dogs, police officers with tasers — more than 1–2 security personnel in the facility. Trained behavior techs, CNA’s and nurses should be on every unit in every facility, to have an enhanced violent code team that immediately intervenes without a delay of a code team to arrive.

14) Streamline police reports through the reporting system and the police to take the report on-site and not on the employee’s own time. The incident happened during working hours and should not be penalized to report it on their own time.

15) Have therapists round the clock who are in-house to assist with patients suffering from acute mental illness, or escalating to be called for assistance.

16) All patients that consciously threaten to cause bodily harm, stalk, harass, physically attack or cause the worker to fear for their own safety should be held accountable and punished to the fullest extent of the law. If the patient was incompetent, the employer should be held accountable.

Our Polls:

Do you feel safe at work?

9,510 participants reached, 547 votes 71% No 29% Yes

Have you suffered Lateral/Horizontal Violence from co-workers or administration?

5,971 participants reached, 279 votes 81% Yes 19% No

Please sign and share this petition as we are on the verge of making a huge impact in our profession. More things will be added along the way, but this is the data from doctoral project research, and from all valued members who participate in Nurses Against Violence Unite, Inc. Without your voice, we cannot get the protection we need to feel safe in our roles. This is the change that We have been asking years for…Our Time is NOW!!

Click Here — > http://chng.it/WWvXZxwfcX

Peacefully marching to fruition

Let’s face it…this march is happening and solidifying an end to one of the most difficult transitions into the most prestigious category both in education and career.  Why a march to #EndHealthCareViolence ?  Well, my question is, why not?!  Isn’t it about time? Aren’t the lives of my co-workers, those that work in the thick of things…aren’t their lives worth anything?

When determining the path of my DNP project, I could have easily picked something simple, easy-breezy, and complicated it with something unmeaningful with enough passion to graduate -or- focus on something that has affected myself and others personally, to create social change.  The culture of nursing, in particular, is one that I am very familiar with.  Not so much about patient on nurse violence personally, as I would ask to have the most volatile patients on the floor, but how nurses not only treat each other but how they are treated by administration and co-workers.

At the time, I was working as a nursing professor, working on the curriculum from the Department of Education, finding the connection with all the hard data that I could gather, interviews, past experiences, latest issues, and societal trends in nursing, there was something terribly wrong.  I had been on the floor for approximately 27 years until achieving my MSN Ed, I saw this but did not even realize how big the problem really was.  I was not imagining what was in front of me!  One day my former co-worker asked me about what my project was going to be.  I sat back in my chair, gave her a look in disbelief shaking my head, turning into a smile and said, “You know how you know something and no matter how kind and nice that you make it, it is going to be ugly? I’m going to get kicked out of my clinical setting, I just know it and feel it in my bones”.  She said “what?!”  I just nodded and at that moment, I made a decision that no matter how much backlash that I would get, that my nursing family needed to feel safe and protected, that the violence had to stop.

All these years I saw the abuse, heard the complaints of nothing being done, seen open wounds and bruises from patients on my co-workers over the years, something had to be done.  Some of you reading this might say “yeah no duh” but the fact of the matter was, nothing was truly being done and confirmed while working on my DNP.  I was blacklisted by my former employer, nobody would hire me and it proved even more challenging as the school said DNP or Ph.D. educators were not allowed to mentor me for my clinical rotations.  The clinical rotation was to be in a clinical setting, despite what the AACN Essentials state that it would be acceptable.  So I sold my house, moved 2 hours to the Orlando area to ensure that I had access to a DNP as the psychologist that I was with was approved, but not an assistant Dean of Nursing with their DNP that was 5 miles from where I was living prior to moving.  Sincerely Thankful for those that reached out to help, more than they will ever know.

Why am I saying this?  Did I stop because of a barrier, actually many?  No.  Healthcare violence has to be stopped.  If I picked pressure ulcers or something benign, would there be another nurse injured?  Yes.  Is there legislation being introduced?  Yes.  How many nurses will still be injured until legislation is enacted?  Many!  We need solutions and protection now and funding to make this happen.  The fact of the matter is, we do need legislation but by the time something is done, organizations will turn their head to Joint Commission sentinel events, OSHA recommendations, and the ANA will continue to be ignored.

The time is now to show the world that Nurses & Healthcare workers in the United States are Done with Healthcare Violence.  Our time is now to take back our professions!

Join Us: Peaceful Rally/March 8/2/19 starting at 10am Freedom Plaza, Washington DC then walk down Pennsylvania Avenue to the front of the Capitol.  Friends & Family are Welcome!

Reporting: Patient on Nurse Violence

          There is an influx of verbal and physical abuse that is affecting nurses throughout that United States and the world.  According to the American Nurses Association in the latest survey and response to the Joint Commission sentinel event, is that “62 percent of nurses had experienced verbal or physical abuse” (American Nurses Association [ANA], 2018, para. 4).  Working on the floor myself for 26 years, until last year taking a teaching position, verbal and physical abuse is a common occurrence no matter what unit that you worked on.  Experiencing first hand the morale of the staff when it came to the effectiveness of reporting incidents to the unit managers or administration, and nothing changes.  The rationale given by nurses is that they believe that their patients are not in their right mind when they lash out at the nurse and leaves them unsure of what constitutes as a violent act (The Joint Commission, 2018).  The nurses that do report the incident usually give a verbal report of the issue to the supervisor, and since it is not in writing, the incident may not be available to pass along for policy changes (Arnetz et al., 2015).

Strategies for stakeholder participation

            Awareness of the problem and formulation of a plan is the first step in the process of creating a policy (Laureate Education, Inc. (Executive Producer), 2011).  One of the strategies for stakeholder participation is through implementing an education plan for nursing professionals and practitioners focusing on the barrier to reporting incidents.  When analyzing the structure of an organizational policy that is in place, the facility should have reported data in their system, if not then this would be the best place to start.  The goal should be finding out why there is no data that reflects patient on nurse injuries.  When nurses state that they obtained lasting injuries, then ask them if they reported it, many times they will tell you no due to “nothing being done to fix the problem.”  One reason for underreporting can include a “lack of reporting policy, lack of faith in the reporting system, and the fear of retaliation” from the organization (Occupational Safety and Health Administration [OSHA], n.d., p. 2).  Many places have a no tolerance policy when it comes to workplace violence.  However, the verbiage is mainly geared towards lateral violence and not upheld when the incidents happen.  When it comes down to be a patient safety issue, patient on nurse violence is huge.  The rationale is, if a nurse is injured, staffing is often reduced, leading to job dissatisfaction, and eventual nursing turnover.

References

American Nurses Association. (2018, April 18). ANA responds to the Joint Commission sentinel event alert on physical and verbal violence against healthcare workers. Nursing World.

Arnetz, J. E., Hamblin, L., Ager, J., Luborsky, M., Upfal, M. J., Russell, J., & Essenmacher, L. (2015, May). Underreporting of Workplace Violence. Workplace Health & Safety, 200-210. https://doi.org/10.1177/2165079915574684

Laureate Education, Inc. (Executive Producer). (2011). Healthcare policy and advocacy: Agenda setting and the policy process [Video file]. Retrieved from https://class.waldenu.edu/bbcswebdav/institution/USW1/201870_27/DR_NURS/NURS_8100_WC/USW1_NURS_8100_week03.html

Occupational Safety and Health Administration. (n.d.). Workplace violence in healthcare; Understanding the challenge. Retrieved from https://www.osha.gov/Publications/OSHA3826.pdf

The Joint Commission. (2018). Physical and verbal violence against health care workers. Retrieved from https://www.jointcommission.org/assets/1/18/SEA_59_Workplace_violence_4_13_18_FINAL.pdf

**You must ask for permission prior to duplicating data & blog post**

The Broken Path

With the increase of drug and alcohol abuse tagged with the large homeless population that we have in society today, the dynamic of a nurse’s assignment.  Some people do not understand or know the progression or living options for these individuals.  It can be a continuation of the same unless the patient chooses to change and has resources to take the necessary steps to get better.

Where do these people go?

Let’s examine the options:

  1. Home – The most ideal.  Usually at the beginning of the illness, prior to and the beginning of the addiction or the progression of the mental illness.  This patient still has a job and functional.
  2. Move in with friends – The addiction is growing to the substance of their choice to the point they need to downsize due to the cost of the lifestyle.  The reason is that the mental illness untreated or treated they had lost their job or need to work part-time due to decompensating.  If the patient is treated, will they continue their meds or self-medicate?  More times than not, they self-medicate.
  3. Homeless shelters/Tent cities – The issues (addiction & mental illness) are becoming great.  The patient may have exhausted their resources to the point that their friends and family cannot take them in any longer due to stealing, the mental illness progression, or other reasons relating to abuse and illness.
  4. The streets – Life has completely changed for this patient where they could be committing crimes to support their habit or they aren’t able to work due to the decompensation from their illness.
  5. Hospitals – In Florida, we have the Baker Act.  If you feel that you are a danger to yourself or others you or someone else can Baker Act you for a mandatory 72-hour psychiatric hold.  The psychiatric doctor can hold the patient or not and also depends on if the patient takes their medications, and cooperates with meetings or rules of the unit.  Often, the patients can refuse the medication so this delays treatment.  The other scenario is that the patient forgot to make their appointment due to their illness and ran out of medication.
  6. Jail – The patient is arrested in the community and they stay there for their sentence and released back into the community.  Some with lengthy records, including felonies.  When you have a lengthy record or receive a felony, it is difficult to find housing and a job.
  7. The cycle starts back at #3 unless they get housed in an Assistant Living Facility (ALF), group home, or Skilled Nursing Facility (SNF) as a Traumatic Brain Injury (TBI) staying across the hall from a fragile individual.  The patient may sign themselves out of the facility and go back to the streets due to having more freedom and options for continuing the same circle.