IAHSS Foundation

The International Association for Healthcare Security and Safety (IAHSS) Foundation was established to foster and promote the welfare of the public through education and research and the development of a healthcare security and safety body of knowledge. The IAHSS Foundation promotes and develops research to further the maintenance and improvement of healthcare security and safety management, and it develops and conducts educational programs for the public. For more information, please visit www.iahssf.org.

The IAHSS Foundation is completely dependent on the charitable donations of individuals, corporations and organizations. Please help us continue our mission and our support of the healthcare industry and the security and safety professionals who serve institutions, staff and, most importantly, patients. To donate or to learn more about the IAHSS Foundation, please visit the website or contact Nancy Felesena at (888) 353-0990.

Thank you for your continued support.

Ronald Hawkins
Research Committee Chair
IAHSS Foundation

IAHSS Foundation Board of Directors

Bill Navejar
President

Ashley Ditta, CHPA
Treasurer

Bonnie Michelman, CHPA, CPP
Massachusetts General Hospital

Steve Nibbelink, CHPA, CA-AM
Secure Care Products

Brigid Roberson, Ed.D., CHPA
Texas Medical Center

Chad Rioux, CHPA, CPP
Motorola Solutions

Paul Greenwood, CHPA
Unity Health Toronto

Scott Hill, Ed.D., CHPA, CPP
King’s Daughters Health System

Marilyn Hollier, CHPA, CPP
Security Risk Management Consultants

Ronald Hawkins
Security Industry Association

Roy Williams III, CHPA

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ABSTRACT

Purpose

The integrative review is designed to determine the effectiveness of implementing workplace violence (WPV) prevention programs in hospital settings. The WPV prevention programs will include various training and education, focusing on WPV from patient to staff. Healthcare workers are at an increased risk for encountering WPV due to various factors. The purpose is to inform best practice by evaluating and synthesizing findings from studies about the impact of WPV de-escalation programs in the hospital setting.

Introduction

Healthcare leaders must identify successful de-escalation strategies to incorporate to reduce WPV. Currently, very little is known relating to WPV in healthcare. This includes precursors to violent events, departments with higher rates of violence, effectiveness of de-escalation training, healthcare workers perceptions to WPV, confidence levels post de-escalation training, and methods to reduce WPV in healthcare. The aim will be to determine the effectiveness of de-escalation training in hospital settings and staff confidence in managing violent events.

Methodology

The integrative review will utilize the Whittemore and Knafl (2005) approach and design. An integrative review method of design was chosen for this project due to the acceptance of a variety of methodologies. These steps include problem identification, literature search, data evaluation, data analysis, and finally, presentation (Whittemore & Knafl, 2005). Each article will be apprised for a level and quality of literature utilizing the Johns Hopkins Nursing Evidence based Practice Research Appraisal Tool. The Johns Hopkins Nursing Evidence Based Practice Research Appraisal tool categorized articles first by level of evidence then by quality (Johns Hopkins University, n.d.). Finally, a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach will be utilized to show the steps leading to the final included articles and studies. The PRISMA will guide readers in understanding how the final included articles are selected (Moher, Liberati, Tetzlaff, & Altman, 2009).

Results

A total of 10 articles were synthesized for the integrative review, three articles are qualitative, four are quantitative, and three are mixed method studies. Three of the articles discuss the effectiveness of various training and education programs to reduce WPV. Only two articles reduced the rates of WPV. The second aim was to determine staff’s confidence level in managing WPV and the perception of WPV in healthcare. Nine articles address confidence and/or perception of WPV. Six articles showed evidence of improved confidence in managing and coping with WPV after an intervention. Four of these articles utilized a standardized coping scale developed by Michael Thackrey in 1987 (Thackrey, 1987). Three articles implemented aggression management training courses to determine staff’s perceptions to the effectiveness of aggression training. Overall, the aggression management courses indicated that staff attitudes did not improve with training, nor did staff’s ability to emotionally cope with aggression.

Conclusions/Recommendations

WPV in healthcare is a global pandemic that will affect the future of healthcare and care delivery. Leaders must focus on three key aspects relating to WPV; a standardized coping scale to improve confidence in managing aggressive patients, increased de-escalation training utilizing education and simulation training, and developing a better understanding of the prevalence of WPV in healthcare. A multidisciplinary approach, with high emphasis on utilizing public safety, to understanding and reducing WPV would benefit healthcare leaders. As healthcare continues to grow, the need for a safe work environment must become a high priority.

INTRODUCTION

Workplace Violence has a significant impact in the healthcare systems. Healthcare is growing at an exponential rate. While healthcare is expanding into various components, the needs for healthcare workers are growing at the same rate. One of the top impacts of workplace violence is retention. Unfortunately, the retention rate for healthcare workers is rapidly declining. One of the reasons for the decline in retention is directly correlated with the increase in workplace violence. Hospitals have had a workforce turnover rate of 87.8% since 2014 (NSI Nursing Solutions, Inc., 2019). Increased turnover rates could be directly correlated to a potential increase in serious safety events impacting not only the patient but also the healthcare worker. This could result in new inexperienced staff, long work hours due to staffing issues, unsafe nurse to patient ratio, decrease staff satisfaction and more.

A direct positive correlation has been identified between increased job contentment and improved nurse retention (Robbins & Davidhizar, 2007). By ensuring a healthy work environment that protects healthcare workers from violence, healthcare systems will increase retention, increase patient safety, increase the quality of work, increase staff satisfaction, and thus increase patient satisfaction. Patient care will be improved by preventing healthcare workplace violence. This integrative review will analyze the effectiveness of incorporating workplace violence prevention programs in hospital -based settings.

The United States nursing industry has an estimated over 4 million Registered Nurses, with increasing job shortages due to numerous issues, one major issue being workplace violence (American Nurses Association). Jackson, Clare, and Mannix (2002), linked workplace violence to the recruitment and retention of nursing in the workforce. Their journal, Who Would Want to be a Nurse? Violence in the Workplace – a Factor in Recruitment and Retention, gathered evidence from multiple countries to prove that workplace violence in healthcare is an international dilemma. The consequences of not addressing the problem of workplace violence can result in decrease retention rates, decrease recruitment rates, increase in staff anxiety, increase in extended length of absences due to injury, decrease in quality of care delivered, increase in burnout (Jackson, Clare, & Mannix, 2002).

Evidence shows that nurses are suffering from post-traumatic stress disorders as a result of workplace violence (Rippon, 2000). A lack of complete understanding of the true magnitude of workplace violence in healthcare is in part due to the topic being under researched and under reported. In a real-time observation study conducted by Erickson & Williams-Evans (2000), Attitudes of Emergency Nurses Regarding Patient Assaults, “seven incidents were reported out of 686 observed occasions of violence or aggression” (Jackson, Clare, & Mannix, 2002). Violence in healthcare and the controversy of reporting stems from a belief “that being assaulted ‘goes with the job” (Erickson & Williams-Evans, 2000) from the majority of nurses surveyed by Erickson and Williams-Evans. Due to the lack of reporting, officially or unofficially, workplace violence will continue to be under recognized as a leading cause of issues in healthcare. Healthcare leaders must formulate a systematic approach to address the prevention of workplace violence. Addressing workplace violence and implementing processes to create a safer work environment will directly correlate to an increase in retention. WPV training can decrease the incidence and severity of violent episodes through early intervention in potentially violent situations. Security staff and nursing personnel can partner on training and to support efforts to reduce WPV.

H.R. 1309 – Workplace Violence Prevention for Health Care and Social Service Workers Act was formed to mandate the Secretary of Labor to issue a standard that enforces healthcare and social service industry employers to develop and implement a workplace violence prevention plan (Courtney, 2019) Currently, there is no formal standard policy or process enforced to prevent nor deter workplace violence in the healthcare setting. State by State guidelines have previously been formed however few are enforced. For instance, Georgia’s law only covers violence in the Emergency Department setting. (American Nurses Association, “Workplace Violence”, 2019) Violence to healthcare workers occurs in all settings. While some units are at a higher frequency, we as a community cannot chose who to protect.

The Occupational Safety and Health Act of 1970 (OSH Act) is a guideline for states and hospitals to utilize to prevent workplace violence. This Act does not enforce states and hospitals to carry out the recommendations made. OSHA is a federal agency supported by the Department of Labor (DOL). However, the Occupational Safety and Health Administration (OSHA) is required to ensure that healthcare systems provide a safe environment for employees from serious hazards. (United States Government Accountability Office, 2016) Due to the increase in healthcare related violence, OSHA has increased its annual safety checks from 2010 to 2014 (United States Government Accountability Office, 2016). Healthcare related violence is not limited to fatalities, in fact, the majority of violence has resulted in non-fatal injuries. The Bureau of Labor Statistics (BLS) stated “between 2011 and 2013, workplace assaults ranged from 23,540 and 25,630 annually, with 70 to 74% occurring in healthcare and social service settings” (U.S. Department of Labor Occupational Safety and Health Administration, 2016). These statistics are only based on reporting individuals, there is a high potential that these are low numbers as violence in healthcare has historically been underreported. Workplace violence in healthcare is an underreported and minimized crisis that can greatly impact the future of healthcare.

BACKGROUND

Healthcare leaders must identify successful de-escalation strategies to incorporate into the workplace to reduce workplace violence. This integrative review will evaluate literature themes from various de-escalation programs implemented throughout the world and the success rate in reducing workplace violence events and/or the healthcare team’s confidence in handling violent situations. Currently there is very little knowledge relating to workplace violence in healthcare. This includes precursors to violent events, departments with higher rates of violence, effectiveness of de-escalation training, and healthcare workers perceptions to workplace violence, confidence levels post de-escalation training, and methods to reduce workplace violence in healthcare. Security leaders and other healthcare leaders can partner with nursing to develop and implement training to support workplace violence prevention efforts. There is a high significance to better understanding workplace violence in healthcare and the impact workplace violence has for the future of healthcare delivery. The aim of this integrative review will be to determine the effectiveness of de-escalation training in the hospital setting in relation to the reduction of workplace violent events and staff confidence in managing violent events.

OBJECTIVES

The objective of this integrative review is to determine the effectiveness of implementing workplace violence prevention programs in hospital settings. The workplace violence prevention programs will include various training and education to hospital-based staff with a primary focus on workplace violence from the patient to staff. Healthcare workers are at an increased risk for encountering workplace violence due to various factors. This integrative review will assess the effectiveness of workplace violence prevention programs from several key points. The purpose of this integrative review is to inform best practice by evaluating and synthesizing findings from studies about the impact of workplace violence de-escalation programs in the hospital setting.