Violence perpetrated against nurses and other healthcare workers worldwide has gained increasing attention over the past several years and requires urgent organizational intervention. Exposure to violence perpetrated by patients and visitors creates moral and ethical distress among the frontline nursing staff and may impact the quality of care they are willing and able to provide.

Greater than one-third of workers experience physical violence during their careers in healthcare and are five times as likely to become injured due to workplace violence than other workers overall (U.S. Bureau of Labor Statistics, 2020; World Health Organization, 2023). Most physical and verbal assaults are perpetrated by patients and visitors. This type of exposure to violence in a hospital setting has negative impacts on the psychological and physical well-being of the staff and may contribute to a larger gap in the equity of healthcare (World Health Organization, 2023).

In an industry already struggling to staff its workforce, the added exposure to violence could result in compromised quality of care, increased lengths of stay, and nursing turnover creating additional financial losses as a direct result of injuries and traumatization (Naveen Kumar et al., 2020; World Health Organization, 2023).

The overall aim of this project was to implement training and education for medical-surgical nursing staff that would increase their perceived confidence in the management of aggressive behaviors. There were three measurable objectives of this project: (a) to increase nurses’ confidence in managing aggressive behaviors, (b) to increase the number of reported workplace violence incidents, and (c) to decrease the number of workplace injuries that occurred due to aggressive behaviors perpetrated by patients and visitors toward nurses.

The setting for the project was an academic safety-net hospital in the Midwest with a level-one trauma center servicing all patient demographics. Much of the patient population comes from lower socioeconomic demographics and are underserved in the larger community. Any type of patient may be found in the medical-surgical unit depending on the significance of the medical diagnosis, including developmentally delayed or cognitively impaired patients and those with mental health diagnoses.

Education and training were deployed to increase medical-surgical nurses’ confidence level in managing aggressive patients and visitors. Didactic and role-play simulations were executed in situ where staff could receive immediate feedback while applying the knowledge and training in a controlled, familiar environment. The implementation of de-escalation training for nursing staff in the medical-surgical unit was supported by the Occupational Safety and Health Administration (2016), the Joint Commission (2023), the American Nurses Association (2021), the Emergency Nurses Association (2022), and the National Institute for Occupational Safety and Health (2015).

Participants completed Thackrey’s Confidence in Coping with Patient Aggression (CCPA) evaluation tool (Abozaid et al., 2022; Ming et al., 2019; Story et al., 2020; Thackrey, 1987) to assess their perception of confidence before the intervention. The participants received online classroom and multi-media content including early recognition of escalating behaviors, verbal de-escalation strategies, response resources at the organization, documentation of patient behavior, reporting of incidents using the organization’s reporting system, and peer support resources (Abozaid et al., 2022; Buterakos et al., 2020; Chang et al., 2022; de la Fuente et al., 2019; Jones et al., 2023; Lamont & Brunero, 2018; Ming et al., 2019; Occupational Safety and Health Administration, 2016; Story et al., 2020; Thompson et al., 2022). They then participated in simulations with a volunteer actress posing as the escalated patient or visitor (Abozaid et al., 2020; Ming et al., 2019; Schwartz & Bjorklund, 2018; Story et al., 2020).

After the training, participants were asked to implement learned de-escalation strategies into their daily practice when faced with patients or visitors who displayed early signs of escalation or became aggressive. They were asked to report all incidents through the organization’s reporting system and all injuries sustained as a result of patient or visitor aggression. It was noted on several occasions during the intervention implementation period that staff intervened when patients were moderately anxious or mildly agitated, preventing a further escalation of aggressive behavior. Debriefing occurred allowing the staff to discuss thoughts and feelings regarding the interaction, actions that could be implemented differently, and receive feedback and suggestions. The participants were asked to complete the CCPA evaluation a second time after the implementation period (Abozaid et al., 2022; Ming et al., 2019; Story et al., 2020; Thackrey, 1987) to assess their perception of confidence after the intervention.

Conclusions

The findings of this project were consistent with previous literature regarding this topic and added to the body of evidence-based literature supporting robust workplace violence prevention programs in healthcare organizations across the globe. Although the sample size was statistically insignificant (n=6), the outcome of increasing nurses’ perception of their ability to manage aggressive behaviors in patients and visitors was achieved. In addition, quality insight into effective strategies to train and prepare staff for interactions with aggressive patients and visitors was obtained. Staff responded well to simulations performed in their normal work environment. This seemed to be the most valuable piece of the training and elicited the most participation. Maguire et al. (2022) support this approach as it allows staff to actively engage and practice skills unique to situations that may occur in their own unit.

When trained to identify early signs of escalation, workforce members were more successful in preventing an episode of extreme escalation thereby avoiding physical injury and emotional distress. Increased awareness of workplace violence, proactive measurements, and strong support from nursing leadership showed workforce members their concerns were heard and considered. The number of reported workplace violence incidents increased by 6 after the intervention implementation satisfying the second objective of this project.  The third objective was not satisfied as the number of reported injuries due to workplace violence increased, rather than decreased, by one post-intervention.  This may be due to the comfort level of the staff with reporting. Christensen et al. (2022) endorse creating a culture supportive of reporting encounters that threaten the safety and security of the healthcare staff.  

References

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