Zero Tolerance Policies Make Zero Sense

Schools are responsible for educating millions of children across the United States. One element of that responsibility is to maintain the safety of children while they are at school. Restricting the presence of weapons at schools is a good policy, it's hard to learn when you know that several of your classmates have knives, guns, or other lethal weapons in their backpacks. Unfortunately, some school districts and administrators have gone overboard in the application of laws designed to restrict the presence of weapons in schools and have involved the criminal justice system inappropriately in the punishment of these children. This is usually accomplished through the creation of a "zero tolerance" policy for the district.

A zero tolerance policy provides a mandated minimum penalty to ANY student who brings anything that can be construed as a weapon into a school. This may be suspension, expulsion, or referral to the police depending on the district.

For one incident last year, a 6 year old boy was suspended for bringing a camping utensil to school to use for lunch. The school district claimed that it had no discretion in the matter because the code of conduct of their district mandated a suspension for any type of knife regardless of possessor's intent. No flexibility allowed.


Apparently the face of a potential murderer

For another example,

In Denton County, Texas, a 13-year-old was asked to write a "scary" Halloween story for a class assignment. When the child wrote a story that talked about shooting up a school, he both received a passing grade by his teacher and was referred to the school principal's office. The school officials called the police, and the child spent six days in jail before the courts confirmed that no crime had been committed.

Spending time in jail for writing a fictional story is certainly an example of appropriate punishment for a thirteen year old!

There are at least a few dozen of these types of stories that draw media attention every year, as students are suspended, expelled, or even jailed because school administrators don't apply common sense to these cases. There are certainly many more that go unrecognized.

A bit of background on the origin of many of these district policies:

In reaction to a series of school shootings, Senators Dianne Feinstein and Byron Dorgan introduced the Gun Free Schools Act. The law's actual wording:

(1) In general.--Except as provided in paragraph (3), each State receiving Federal funds under this Act shall have in effect a State law requiring local educational agencies to expel from school for a period of not less than one year a student who is determined to have brought a weapon to a school under the jurisdiction of local educational agencies in that State, except that such State law shall allow the chief administering officer of such local educational agency to modify such expulsion requirement for a student on a case-by-case basis.

Feinstein after the bill passed

The federal law itself stipulates that local educators are supposed to regulate penalties for students on a case by case basis. Thus, common sense is written into the law. I don't think it was the intent for students to be expelled for bringing butter knives or plastic knives into school for the purposes of cutting food.

However, the event that greatly accelerated the spread of zero tolerance policies was the shooting at Columbine High School. Parents demanded that their school districts keep their children safe. Unfortunately, the route that many schools took to do this was to adopt these policies, thinking that a harsh penalty would deter violence.

This goes against recommendations made by the secret service based on an investigation of 37 school shootings. The investigation showed that kids do not go on a killing rampage on a whim, there is a pattern of behavior beforehand. In most cases, they had told multiple people and made plans before the incident. Instead of banning anyone who brings weapons to school, it is better to focus on educating students to tell teachers or administrators when someone has made plans to attack. Additionally, these reports must be taken seriously and investigated appropriately.

The real effect of zero tolerance policies is shown in increasing rates of suspensions and also expulsions:

While students are reporting school crime at the same level as in the 1970s, the number of youth suspensions has nearly doubled from 3.7% of students in 1974 (1.7 million students suspended) to 6.8% of students in 1998 (3.2 million students suspended). In Michigan schools, 3,500 students were expelled during academic year 1999-2000.

All of those suspensions and expulsions are not related to zero tolerance policies, but they are certainly part of the reason behind the dramatic increase in a few decades.

The goal of school is to provide an education for our youth. Numerous studies have shown that suspensions lead to increased dropout rates.


As suspensions increase, so do dropout rates

Children who leave school early do not get an effective education and are more likely to be involved in crime. It is in the best interests of our children and the country to provide children with every opportunity to get the best education possible. The decision to suspend or expel a child from school needs to be made very carefully and ideally provide the child with a chance to correct their behavior.

It makes no sense to remove a child from school entirely simply because they made the error in judgment of bringing a butter knife, aspirin, ibuprofen, or other innocuous object to school only to discover that it is considered a "weapon." This is especially true when the federal law itself indicates that these policies should be considered on a case by case basis-indicating that common sense needs to be applied to punishing children for violations.

As the American Bar Association puts it:

Zero tolerance policies for students adopt a theory of mandatory punishment that has been rejected by the adult criminal justice system because it is too harsh! Rather than having a variety of sanctions available for a range of school-based offenses, state laws and school district policies apply the same expulsion rules to the six-year-old as to the 17-year-old; to the first time offender as to the chronic troublemaker; to the child with a gun as to the child with a Swiss Army knife.

Adults - especially those who teach children - are expected to have the skills and knowledge to teach behavior in age-appropriate ways. Unfortunately, zero tolerance as practiced today is not rooted in theories of pedagogy or child or adolescent development. It teaches children nothing about fairness, and often creates injustice.

Hospital Organization-Nursing

After working at two different major hospitals in the United States, I've seen a few things that should be applied to any health system to improve efficiency. Here's a few of them:

1. In all stockrooms have all the shelves labeled with a code and a list somewhere in the room saying what is on each shelf. This makes it so much easier to grab supplies that are not used all that often, you can just use the list to see exactly where it is and get back to work. This is even more essential in hospitals that have nurses float to different units, because every unit inevitably organizes their stockrooms differently.

2. Place commonly used supplies, such as caps for IVs, in the patient's room. This reduces the need for staff to walk back and forth to the supply room every few minutes when they need to complete a task, saving a considerable amount of time. Most units in both hospitals I worked at have a storage unit in the patient's room with several drawers filled with everything from blue pads to biohazard bags to gauze. This makes it much easier to get through a shift without feeling like you ran a marathon.

3. Simplify the computer system as much as possible-add functionality to existing programs rather than adding new programs. One hospital I've worked at does a great job with this-everything is available from just two programs-Careweb and Carelink-from lab results to physician orders to medication charting. For nursing purposes, Carelink alone is sufficient to discharge almost every task for the whole day. A new program is being added, Centricity, that allows nurses to chart on patients electronically instead of on paper. However, it is easy to use so it's not a big deal.

In comparison, the other hospital I worked at was a bit of a mess. You had to open Q-reads to look at X-rays, use two different programs for charting, and a fourth program, synthesis, to access all of the information from these various programs. The medication system was confusing as well-there were three different ways to view the medications for each patient, each way organizing them completely differently. In short, it was a bit of a clusterfuck and in many cases staff did not know how to perform the tasks that were not done on a daily basis, necessitating questions to colleagues.

In planning a computer system for a hospital, try and limit the number of programs needed for staff to perform their duties as much as possible, it will make everything more efficient and probably improve patient safety. Even better, do a test run where you have staff use the system to take care of imaginary patients so you can find stumbling blocks before a gigantic investment is made.

4. Keep commonly used educational materials on each unit. When all of the educational pamphlets are easily available for staff to grab and explain to patients it makes it a lot easier to provide patient education. If a patient came back with an Ivor-Lewis esophagectomy-all the pamphlets needed were on hand-one describing the surgery, one describing pain control, one describing how to control constipation caused by narcotic medications, etc.

In comparison, when patient educational materials have to be accessed through the online system and manually printed off it's much less likely that these necessary materials will get to the patients early in their stay. Instead, they will be thrown at the patient when they are being discharged in a big lump. This means that the patient will be less likely to understand their discharge instructions, and thus more likely to face complications from not properly following clinician directions.

5. Pain Teams-basically this is a multidisciplinary team with a M.D., nurse, and other staff who specialize in assessing patient's for pain and make recommendations about the medication regimen that they should be on to control their pain. They also assess epidurals, PCAs, and other devices that may be in use on the patient. Although obviously the general service and regular nurses should also be assessing all of these devices, the pain team is extremely helpful because they have more experience with pain and provide good recommendations to control it. Good pain control contributes to better patient outcomes so it's important to achieve.

6. Bedside Report. At the end of every shift, nurses are responsible for giving a status report on each patient they have to the nurse coming on. This allows for any problems such as changes in vital signs or an upcoming test to be described to the next nurse so they know what they need to do on their shift. This report is usually given at the nurse's station or some other private area.

Instead, this should be done at the patient's bedside. Sometimes the patient may have some information that the nurse coming off shift does not have, such as if a doctor came in while the nurse wasn't around or if a problem they're experiencing is getting worse. Additionally, physically seeing the patient helps bring about continuity in care. The nurse can note what is going on with the patient, such as IV infusions running and how the patient actually appears, which is frequently important to know for the purposes of comparison if they worsen later in the day. The patient also knows who is taking over for their last nurse, helping to reduce confusion.

There are a few systems in place at each institution that I have more reservations about, but may still be a good idea to consider for other hospitals.

1. IV teams-basically these are nurses who go around the hospital and do nothing but put in peripheral IVs, PICC lines, and other types of intravenous access devices. The advantage to this system is that you have very experienced nurses putting in your IVs, limiting complications and pain to patients from incompetent IV insertion techniques.

The disadvantage is that it makes the rest of the nursing staff basically unable to insert a regular IV-they've maybe done it in school once or twice or while working at a different facility that did not have an IV team. If an emergency arises where a patient needs IV access and there is not time to wait for the IV team, the regular nursing staff may be unable to gain access. At Saint Mary's, I don't believe that the equipment for starting IVs was even available on the floor, it was all with the IV teams.

2. Catheter teams-Similar to IV teams, these are urology techs who place all of the foley catheters and do all of the straight caths in a hospital. Once again, this leaves a lot of nurses with only a theoretical knowledge of how to insert a catheter, as the urology team ends up doing it for almost all patients. The advantage is that these guys do nothing but insert catheters so they know what they're doing, possibly reducing the incidence of UTIs from cath placement. Additionally, there is a female and male cath team, which may make many patients more comfortable. As catheter placement is a less frequent and less urgent occurrence than many other procedures, you don't need that many techs to cover the whole hospital either.

Any hospital should think about all of these methods and consider whether they are appropriate for their institution. They potentially can save a lot of staff time and improve patient outcomes, thereby improving staff and patient satisfaction.