What can we do about occupational violence in emergency departments? A survey of emergency staff

Effect of safety and security equipment on patient and visitor violence towards nurses in multiple public hospitals of China during the COVID-19 pandemic: a retrospective, difference-in-difference analysis

OBJECTIVES

This study aimed to analyse whether safety and security equipment decreased patient and visitor violence (PVV) towards nurses in the COVID-19 period and quantify to what extent safety and security equipment affects PVV.

DESIGN

Controlled before and after study and difference-in-difference (DID) analysis.

SETTING

A large hospital medical group, consisting of three public tertiary teaching hospitals, namely, Xinjiekou Branch, Huilongguan Branch and Xinlongze Branch of Beijing Jishuitan Hospital, located in the west and north parts of Beijing, China.

PARTICIPANTS

A panel of nine departments recruited using two-step sampling method, administered online surveys in 2021 and 2022. A total of 632 eligible nurses participated in the survey in 2021 and 725 eligible nurses in 2022.

MEASURES

We assessed impacts of the safety and security equipment on the PVV. The policy had been enacted in June 2020, and the corresponding measures were established after mid-December 2020, and therefore, we use a DID design to evaluate changes in nurses' PVV incidence. Departments are classified as either department installed or non installed, and nurses are classified based on their department.

RESULTS

Within the treatment group, the incidence of physical PVV significantly decreased from 13.8% in 2020 to 2.0% in 2021. In the control group, the incidence of physical PVV increased from 0.6% in 2020 to 2.7% in 2021. The application of the safety and security equipment decreased the incidence of physical PVV by 13.93% (95% CI: -23.52% to -4.34%). In contrast, no difference was observed between the treatment and control groups for the incidence of psychological PVV (6.23%, 95% CI: -11.56% to 24.02%) and overall PVV (0.88, 95% CI: -20.90% to 22.66%).

CONCLUSION

The safety and security equipment reduced the incidence of physical PVV towards nurses. For hospital managers in public hospitals, longer-term strategies roadmap for PVV prevention measures are needed to create a more supportive work environment in employees.

[Emergency care as a high-risk workplace-Measures to deal with violence against employees]

BACKGROUND

Many employees in the field of emergency care experience verbal and physical violence caused by patients or visitors. The aim of this project is to gain insights into which measures are available to deal with violence in emergency care and how employees subjectively evaluate them.

METHODS

A nationwide cross-sectional online survey was conducted in 2020. The questionnaire contained items on violence prevention, intervention, and follow-up measures. Quantitative data were analysed descriptively and free text data according to Mayring's qualitative content analysis.

RESULTS

A total of 349 respondents, including 115 supervisors participated in the survey. The availability of security staff and standardised reporting of incidents were considered important measures for dealing with violence. Of the managers, 67% reported not having a security service, while 56% claimed that reported incidents of violence were not dealt with in a structured way. A high workload in emergency care can impede the implementation of measures. Overall, the demand for increased support by supervisors and the hospital management became clear.

CONCLUSION

It is evident that employees consider certain measures to be effective; however, these measures are often not consistently implemented. There is a need for structured reporting of violent incidents against employees to facilitate a realistic recording of the prevalence. In addition to increasing the (nursing) staff, restricting access for visitors can decrease the conflict potential.

Introducing a Digital Occupational Violence Risk Assessment Tool Into an Emergency Department: A Pilot Implementation Study

INTRODUCTION

Occupational violence in emergency departments is prevalent and detrimental to staff and health services. There is an urgent call for solutions; accordingly, this study describes the implementation and early impacts of the digital Queensland Occupational Violence Patient Risk Assessment Tool (kwov-pro).

METHODS

Since December 7, 2021, emergency nurses have been using the Queensland Occupational Violence Patient Risk Assessment Tool to assess 3 occupational violence risk factors in patients: aggression history, behaviors, and clinical presentation. Violence risk then is categorized as low (0 risk factors), moderate (1 risk factor), or high (2-3 risk factors). An important feature of this digital innovation is the alert and flagging system for high-risk patients. Underpinned by the Implementation Strategies for Evidence-Based Practice Guide, from November 2021 to March 2022 we progressively mobilized a range of strategies, including e-learning, implementation drivers, and regular communications. Early impacts measured were the percentage of nurses who completed their e-learning, the proportion of patients assessed using the Queensland Occupational Violence Patient Risk Assessment Tool, and the number of reported violent incidents in the emergency department.

RESULTS

Overall, 149 of 195 (76%) of emergency nurses completed their e-learning. Further, adherence to Queensland Occupational Violence Patient Risk Assessment Tool was good, with 65% of patients assessed for risk of violence at least once. Since implementing the Queensland Occupational Violence Patient Risk Assessment Tool, there has been a progressive decrease in violent incidents reported in the emergency department.

DISCUSSION

Using a combination of strategies, the Queensland Occupational Violence Patient Risk Assessment Tool was successfully implemented in the emergency department with the indication that it could reduce the number of incidents of occupational violence. The work herein provides a foundation for future translation and robust evaluation of the Queensland Occupational Violence Patient Risk Assessment Tool in emergency departments.

A descriptive study on the use of restrictive interventions for potentially or actually violent patients in the emergency department

BACKGROUND

Restrictive interventions (chemical, physical, or mechanical restraints) to manage patients who are potentially or actually violent in the emergency department (ED) can be harmful and costly. Non-restrictive interventions are advocated; but this must be preceded with an understanding of patient characteristics that influence their use. A study was conducted to describe the use of restrictive interventions and ascribe it with patient characteristics in the ED.

METHODS

Records from October 2020 to March 2021 in the occupational violence database were used to analyse patient characteristics and restrictive interventions. Logistic regression was used to establish influencing factors of restrictive interventions adjusting for clinically relevant confounders.

RESULTS

Of the N = 1276 potentially or actually violent patients, 70 % received restrictive interventions. Chemical restraint was common, with 1 in 2 patients receiving either oral medication or intramuscular injection. Probability of restrictive interventions were higher in patients who were intoxicated [(adjusted odds ratio (aOR) 3.48, 95 % confidence interval (CI) 1.675-7.21)], had high triage score (aOR 2.084, 95 % CI 1.094-3.96), and were in the ED involuntarily (aOR 1.494, 95 % CI 1.105-2.020).

CONCLUSION

The results reveal the need for multifaceted approaches that limit the presentations of, and minimise restrictive interventions among, potentially or actually violent patients.

Inter-rater reliability of the occupational violence risk assessment tool for emergency departments

BACKGROUND

The three-item occupational violence (OV) risk assessment tool was developed and validated for use in emergency departments (EDs). It prompts review of each patient's aggression history, behaviours, and clinical presentation. However, confidence around representativeness and generalisability are needed before widescale adoption; hence we measured the inter-rater reliability of the tool among a large group of emergency nurses.

METHODS

A cross-sectional study was conducted between Sep 2021 and Jan 2022. Nurses were directed to a website that hosted an e-learning module about the tool. They were asked to apply the tool to two video scenarios of typical patient presentations. Demographic data, including years of emergency experience, were collected to contextualise their responses. Gwet's Agreement Coefficients (AC1) were calculated to determine inter-rater reliability.

RESULTS

There were 135 participants: typically female, under the age of 40 years, with more than 3 years of emergency nursing experience. Overall, there was excellent inter-rater agreement (AC1 =0.752, p = 0.001). This was consistent when years of ED experience was stratified: 0-2 years, AC1 = 0.764, p = 0.002; 3-5 years, AC1 = 0.826, p = 0.001; 6-10 years, AC1 = 0.751, p < 0.001; 11-15 years, AC1 = 0.659, p = 0.004; ≥ 16 years, AC1 = 0.799, p < 0.001.

CONCLUSION

The three-item OV risk assessment tool has excellent inter-rater reliability across a large sample of emergency nurses.

Validity and reliability of the novel three‐item occupational violence patient risk assessment tool

Aim

To develop and psychometrically test an occupational violence (OV) risk assessment tool in the emergency department (ED).

Design

Three studies were conducted in phases: content validity, predictive validity and inter‐rater reliability from June 2019 to March 2021.

Methods

For content validity, ED end users (mainly nurses) were recruited to rate items that would appropriately assess for OV risk. Subsequently, a risk assessment tool was developed and tested for its predictive validity and inter‐rater reliability. For predictive validity, triage notes of ED presentations in a month with the highest OV were assessed for presence of OV risk. Each presentation was then matched with events recorded in the OV incident register. Sensitivity and specificity values were calculated. For inter‐rater reliability, two assessors—trained and untrained—independently assessed the triage notes for presence of OV risk. Cohen's kappa was calculated.

Results

Two rounds of content validity with a total of N = 81 end users led to the development of a three‐domain tool that assesses for OV risk using aggression history, behavioural concerns (i.e., angry, clenched fist, demanding, threatening language or resisting care) and clinical presentation concerns (i.e., alcohol/drug intoxication and erratic cognition). Recommended risk ratings are low (score = 0 risk domain present), moderate (score = 1 risk domain present) and high (score = 2–3 risk domains present), with an area under the curve of 0.77 (95% confidence interval 0.7–0.81, p < .01). Moderate risk rating had a 61% sensitivity and 91% specificity, whereas high risk rating had 37% sensitivity and 97% specificity. Inter‐rater reliability ranged from 0.67 to 0.75 (p < .01), suggesting moderate agreement.

Conclusions

The novel three‐domain OV risk assessment tool was shown to be appropriate and relevant for application in EDs. The tool, developed through a rigorous content validity process, demonstrates acceptable predictive validity and inter‐rater reliability.

Impact

The developed tool is currently piloted in a single hospital ED, with a view to extend to inpatient settings and other hospitals.

Australian nurses' perceptions about workplace violence management, strategies and support services

AIMS

This study ascertained nurses' perceptions about workplace violence management, strategies and support services.

BACKGROUND

Nurses regularly encounter verbal and physical violence in their workplace. Workplace violence has long-term consequences on nurses' personal lives and professional work ability. However, more needs to be known about nurses' perceptions of violence management and interventions used.

METHODS

Ninety-eight nurses from a regional public hospital in Queensland, Australia, completed a survey about workplace violence. Nurses worked in the Emergency Department, Intensive Care Unit or Mental Health Department.

RESULTS

Ninety-five per cent of nurses stated that all violence should be reported, but 18% would take no action, and 22% would not complete an incident from. Perceptions and preferred responses differed for verbal and physical violence. Low-level interventions and aggression management training were preferred by nurses. Nearly all nurses felt that they should be involved in the development of workplace violence policies.

CONCLUSIONS

Nurses rate aggression management training highly, and they desire more input into violence policies. The under-reporting of violent incidents remains an issue for future management.

IMPLICATIONS FOR NURSING MANAGEMENT

Understanding nurses' perceptions of workplace violence management enables the identification of gaps when applying policy and adopting practical approaches to reduce the incidence and severity of workplace violence.

Interventions for Workplace Violence Prevention in Emergency Departments: A Systematic Review

Emergency departments (EDs) are high-risk settings for workplace violence, but interventions to prevent violent incidents and to prepare staff are not yet consistently implemented, and their effectiveness is often unclear. This study aims to summarise evidence on workplace violence prevention interventions that were implemented in EDs to reduce violent incidents caused by patients/relatives or to increase the knowledge, skills or feelings of safety of ED staff. A systematic review was conducted. The databases MEDLINE, Web of Science, Cochrane Library, CINAHL and PsycINFO were searched for studies dated between January 2010 and May 2021. Interventional and observational studies reporting on behavioural, organisational or environmental interventions among healthcare workers in hospital EDs were included. Studies were assessed for methodological quality using the Johanna Briggs Institute Tools. Key findings of studies were summarised narratively. Fifteen studies were included, of which eleven examined behavioural interventions (classroom, online or hybrid training programmes) on de-escalation skills, violent person management or self-defence techniques. Four studies included in addition, organisational and environmental interventions. Most studies showed that interventions had a positive effect in the form of a reduction of violent incidents or an improvement in how prepared staff were to deal with violent situations; however, evidence is still sparse. Further studies should consider in particular, environmental and organisational interventions and ensure a high methodological quality.