Educación y formación para prevenir y minimizar las agresiones dirigidas al personal sanitario en el lugar de trabajo / Education and training for preventing and minimizing workplace aggression directed toward healthcare workers

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Education and training for preventing and minimizing workplace aggression directed toward healthcare workers.

BACKGROUND: Workplace aggression constitutes a serious issue for healthcare workers and organizations. Aggression is tied to physical and mental health issues at an individual level, as well as to absenteeism, decreased productivity or quality of work, and high employee turnover rates at an organizational level. To counteract these negative impacts, organizations have used a variety of interventions, including education and training, to provide workers with the knowledge and skills needed to prevent aggression.  OBJECTIVES: To assess the effectiveness of education and training interventions that aim to prevent and minimize workplace aggression directed toward healthcare workers by patients and patient advocates. SEARCH METHODS: CENTRAL, MEDLINE, Embase, six other databases and five trial registers were searched from their inception to June 2020 together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: Randomized controlled trials (RCTs), cluster-randomized controlled trials (CRCTs), and controlled before and after studies (CBAs) that investigated the effectiveness of education and training interventions targeting aggression prevention for healthcare workers. DATA COLLECTION AND ANALYSIS: Four review authors evaluated and selected the studies resulting from the search. We used standard methodological procedures expected by Cochrane. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS: We included nine studies-four CRCTs, three RCTs, and two CBAs-with a total of 1688 participants. Five studies reported episodes of aggression, and six studies reported secondary outcomes. Seven studies were conducted among nurses or nurse aides, and two studies among healthcare workers in general. Three studies took place in long-term care, two in the psychiatric ward, and four in hospitals or health centers. Studies were reported from the United States, Switzerland, the United Kingdom, Taiwan, and Sweden. All included studies reported on education combined with training interventions. Four studies evaluated online programs, and five evaluated face-to-face programs. Five studies were of long duration (up to 52 weeks), and four studies were of short duration. Eight studies had short-term follow-up (< 3 months), and one study long-term follow-up (> 1 year). Seven studies were rated as being at "high" risk of bias in multiple domains, and all had "unclear" risk of bias in a single domain or in multiple domains. Effects on aggression Short-term follow-up The evidence is very uncertain about effects of education and training on aggression at short-term follow-up compared to no intervention (standardized mean difference [SMD] -0.33, 95% confidence interval [CI] -1.27 to 0.61, 2 CRCTs; risk ratio [RR] 2.30, 95% CI 0.97 to 5.42, 1 CBA; SMD -1.24, 95% CI -2.16 to -0.33, 1 CBA; very low-certainty evidence). Long-term follow-up Education may not reduce aggression compared to no intervention in the long term (RR 1.14, 95% CI 0.95 to 1.37, 1 CRCT; low-certainty evidence). Effects on knowledge, attitudes, skills, and adverse outcomes Education may increase personal knowledge about workplace aggression at short-term follow-up (SMD 0.86, 95% CI 0.34 to 1.38, 1 RCT; low-certainty evidence). The evidence is very uncertain about effects of education on personal knowledge in the long term (RR 1.26, 95% CI 0.90 to 1.75, 1 RCT; very low-certainty evidence). Education may improve attitudes among healthcare workers at short-term follow-up, but the evidence is very uncertain (SMD 0.59, 95% CI 0.24 to 0.94, 2 CRCTs and 3 RCTs; very low-certainty evidence). The type and duration of interventions resulted in different sizes of effects. Education may not have an effect on skills related to workplace aggression (SMD 0.21, 95% CI -0.07 to 0.49, 1 RCT and 1 CRCT; very low-certainty evidence) nor on adverse personal outcomes, but the evidence is very uncertain (SMD -0.31, 95% CI -1.02 to 0.40, 1 RCT; very low-certainty evidence). Measurements of these concepts showed high heterogeneity. AUTHORS' CONCLUSIONS: Education combined with training may not have an effect on workplace aggression directed toward healthcare workers, even though education and training may increase personal knowledge and positive attitudes. Better quality studies that focus on specific settings of healthcare work where exposure to patient aggression is high are needed. Moreover, as most studies have assessed episodes of aggression toward nurses, future studies should include other types of healthcare workers who are also victims of aggression in the same settings, such as orderlies (healthcare assistants). Studies should especially use reports of aggression at an institutional level and should rely on multi-source data while relying on validated measures. Studies should also include days lost to sick leave and employee turnover and should measure outcomes at one-year follow-up. Studies should specify the duration and type of delivery of education and should use an active comparison to prevent raising awareness and reporting in the intervention group only.

Differences in risk and protective factors for workplace aggression between male and female clinical medical practitioners in Australia.

Objectives The aim of the present study was to investigate differences in prevalence, as well as risk and protective factors, for exposure to workplace aggression between male and female clinicians in Australian medical practice settings. Methods In a cross-sectional, self-report study in the third wave of the Medicine in Australia: Balancing Employment and Life survey (2010-11), 16327 medical practitioners were sampled, with 9449 (57.9%) respondents working in clinical practice. Using backward stepwise elimination, parsimonious logistic regression models were developed for exposure to aggression from external (patients, patients' relatives or carers and others) and internal (co-workers) sources in the previous 12 months. Results Overall, greater proportions of female than male clinicians experienced aggression from external (P<0.001) and internal (P<0.01) sources in the previous 12 months. However, when stratified by doctor type, greater proportions of male than female general practitioners (GPs) and GP registrars experienced external aggression (P<0.05), whereas greater proportions of female than male specialists experienced external (P<0.01) and internal (P<0.01) aggression. In logistic regression models, differences were identified in relation to age for males and experience working in medicine for females with external and internal aggression; working in New South Wales (vs Victoria) and internal aggression for females; a poor medical support network and external aggression, and perceived unrealistic patient expectations with internal aggression for males; warning signs in reception and waiting areas with external aggression for males; and optimised patient waiting conditions with external and internal aggression for females. Conclusions Differences in risk and protective factors for exposure to workplace aggression between male and female clinicians, including in relation to state and rural location, need to be considered in the development and implementation of efforts to prevent and minimise workplace aggression in medical practice settings. What is known about the topic? Workplace aggression is prevalent in clinical medical settings, but there are conflicting reports about sex-based differences in the extent of exposure, and little evidence on differences in risk and protective factors for exposure to workplace aggression. What does this paper add? Differences in workplace aggression exposure rates between male and female clinicians are highlighted, including when stratified by doctor type. New evidence is reported on differences and similarities in key personal, professional and work-related factors associated with exposure to external and internal aggression. What are the implications for practitioners? In developing strategies for the prevention and minimisation of workplace aggression, consideration must be given to differences between male and female clinicians, including with regard to personality, age and professional experience, as well as work locations, conditions and settings, as risk or protective factors for exposure to aggression in medical work.

Embedding continuous quality improvement processes in multidisciplinary teams in cancer care: exploring the boundaries between quality and implementation science.

Objective The aim of the present study was to identify key enabling factors for engaging multidisciplinary teams (MDTs) in cancer care across the spectrum of translational research and quality improvement (QI) projects. Methods The study was conducted in two large Sydney metropolitan hospitals. Qualitative methods, including structured observations of MDT meetings and semi-structured interviews with MDT leaders and champions, were used to identify how teams interact with and generate research and implementation initiatives. Enabling factors for and barriers to the engagement of MDTs in translational research and QI were identified. Results Four key enabling factors emerged from the analysis of data generated from observing 43 MDT meetings and 18 semi-structured interviews: (1) access to high-quality data around individual and team performance; (2) research-active team leaders; (3) having experts, such as implementation scientists, embedded into teams; and (4) having dedicated research or QI-focused meetings. Barriers included a lack of time, administrative support, research expertise and access to real-time data. Conclusions The identification of enabling factors for and barriers to translational research and QI provides evidence for how multidisciplinary cancer care teams may best be engaged in research and QI that aims to improve service and care outcomes. What is known about the topic? MDTs are key to the delivery of cancer care in Australia, but there is scant research into how teams can best be engaged in translating research from basic science through to implementation science and QI. What does this paper add? This paper provides new evidence from an immersive study of cancer care MDTs in two large metropolitan hospitals in Sydney (NSW, Australia), regarding the key enabling factors for and barriers to successful engagement in translational research and QI in cancer care. What are the implications for practitioners? Cancer care professionals in MDTs are presented with an opportunity to embed translational research and QI into cancer care. MDTs can operate as an ideal vehicle to look beyond individual patient outcomes to broader trends and population health outcomes.

Associations between Australian clinical medical practitioner exposure to workplace aggression and workforce participation intentions.

OBJECTIVE: The aim of the present study was to determine the association between clinician exposure to workplace aggression from any source in the previous 12 months and workforce participation intentions. METHODS: A cross-sectional survey, in the third wave of the Medicine in Australia: Balancing Employment and Life (MABEL) study, was conducted between March 2010 and June 2011. Respondents were a representative sample of 9449 Australian general practitioners (GPs) and GP registrars (n = 3515), specialists (n = 3875), hospital non-specialists (n = 1171) and specialists in training (n = 888). Associations between aggression exposure and workforce participation intentions were determined using logistic regression modelling. RESULTS: In adjusted models, aggression exposure was positively associated with a greater likelihood of intending to reduce clinical workload in the next 5 years (odds ratio (OR) = 1.15, 95% confidence interval (CI) 1.02-1.29) and intending to leave patient care within 5 years (OR = 1.20, 95% CI 1.07-1.35). When also accounting for well being factors, aggression exposure remained positively associated with intending to leave patient care within 5 years (OR = 1.13, 95% CI 1.00-1.27). CONCLUSIONS: Exposure to workplace aggression presents a risk to the retention of medical practitioners in clinical practice and a potential risk to community access to quality medical care. More concerted efforts in preventing and minimising workplace aggression in clinical medical practice are required.

Workplace aggression prevention and minimisation in Australian clinical medical practice settings - a national study.

INTRODUCTION: This report describes the extent to which 12 workplace aggression prevention and minimisation actions have been implemented in Australian clinical medical practice settings. METHODS: Using a cross-sectional, self-report survey conducted as part of a national longitudinal study of the Australian medical workforce, differences in the proportions of medical clinicians reporting the implementation of 12 aggression prevention and minimisation actions in their main workplace were determined. RESULTS: Only one-third of aggression prevention and minimisation actions achieved point-prevalence rates of greater than 60%, including aggression policies and protocols (65.7%) and incident reporting systems (68.2%). Overall, lower point-prevalence rates were detected for general practitioners and specialists compared with hospital non-specialists and specialists in training, largely reflecting those for doctors mainly working in private rooms compared with public hospitals. Key environmental interventions had relatively low point-prevalence overall, including duress alarms and optimised clinician escape in consulting and treatment areas, and after-hours and off-site safety strategies. CONCLUSIONS: More widespread adoption of aggression prevention and minimisation measures in medical practice settings is required. Specific legislative and accreditation provisions and funding support may provide the necessary impetus for reform. Further studies can enhance the evidence base on the most effective approaches to the prevention and minimisation of workplace aggression in medical practice settings.

Personal, professional, and work factors associated with Australian clinical medical practitioners' experiences of workplace aggression.

OBJECTIVES: This study examined the extent to which a range of personal, professional, and work factors are associated with workplace aggression experienced by medical practitioners in Australian clinical practice settings. METHODS: An exploratory, descriptive study of cross-sectional, self-report survey design was undertaken in the third wave of the Medicine in Australia: Balancing Employment and Life survey during 2010-2011. Of 16 327 medical practitioners sampled, 9951 (60.9%) responded and 9449 (57.9%) worked in clinical practice. Logistic regression was undertaken to detect statistically significant associations between a suite of personal, professional, and work variables and eight binary outcome variables measuring exposure to verbal or written and physical aggression from patients, patients' relatives or carers, co-workers and others external to the workplace during the previous year. RESULTS: Age was consistently negatively associated and external control orientation was consistently positively associated with workplace aggression exposure from each source. Key variables related to work conditions (total hours worked, unpredictable work hours, a poor support network of other doctors, patients with unrealistic expectations, patients with complex health and social problems) and the presence of workplace aggression prevention and minimization strategies (alerts to high risk of aggression, restricting or withdrawing access for aggressive persons and optimized patient waiting) were also associated with aggression exposure. CONCLUSIONS: A broader implementation of strategies to prevent and minimize the likelihood and consequences of workplace aggression is required and needs to take account of both the individual and sub-group profiles of medical practitioners. Strategies need to mitigate the more challenging aspects of medical work, including excessive work hours, inadequate access to professional support networks, and larger caseloads of patients with complex conditions.

A national study of workplace aggression in Australian clinical medical practice.

OBJECTIVE: To describe the 12-month prevalence of verbal or written and physical aggression from patients, patients' relatives or carers, coworkers and others in Australian clinical medical practice. DESIGN, SETTING AND PARTICIPANTS: An exploratory, descriptive study of cross-sectional survey design in the third wave (March 2010 to June 2011) of the Medicine in Australia: Balancing Employment and Life longitudinal survey. MAIN OUTCOME MEASURES: Proportions of clinicians reporting verbal or written and physical aggression from each aggression source and the significance of differences reported by doctor type, sex, international medical graduate status, age and postgraduate experience. RESULTS: Of 16,327 medical practitioners sampled, a response rate of 60.9% (9951) was achieved and 9449 (57.9%) were in Australian clinical practice. Participants comprised 3515 general practitioners and GP registrars, 3875 specialists, 1171 hospital non-specialists and 888 specialists in training. Overall, 70.6% of medical practitioners experienced verbal or written aggression and 32.3% experienced physical aggression from one or more sources in the previous 12 months. While patterns of exposure were complex, more female clinicians, international medical graduates (IMGs) and hospital-based clinicians experienced workplace aggression. Age and postgraduate experience were significantly negatively associated with aggression exposure. CONCLUSIONS: This is the first nationwide study of workplace aggression from all sources experienced by all subpopulations of Australian medical clinicians. The findings suggest particular risks for younger and more junior hospital-based clinicians, and for IMGs in general practice. A failure to address this important professional and public health concern may contribute to ongoing challenges in the recruitment and retention of medical practitioners in an era of increasing shortages internationally.

Prevalence and prevention of workplace aggression in Australian clinical medical practice.

OBJECTIVE: To determine the extent of aggression directed towards Australian doctors and the implementation of aggression prevention and minimisation strategies in medical workplaces. METHODS: Data were obtained from the pilot phase (n=321) of the Medicine in Australia: Balancing Employment and Life survey of the clinical medical workforce in 2010. Descriptive statistics were generated in relation to doctors' experiences of aggression at work in the previous 12 months, and the implementation of workplace aggression prevention and minimisation strategies. Distributions of the outcome variables were evaluated by doctor type and sex. RESULTS: More than 70% of doctors experienced verbal or written aggression and almost a third experienced physical aggression. Higher proportions of hospital non-specialists and specialists-in-training experienced aggression from patients, patient relatives or carers and co-workers. Higher proportions of female doctors experienced verbal or written aggression from patient relatives or carers and co-workers. Overall, the more basic aggression prevention and minimisation strategies had been implemented in approximately two-thirds of clinical settings, with lower rates for more extended strategies. CONCLUSIONS: Many Australian doctors experience workplace aggression. The more widespread adoption of measures that support the prevention and minimisation of aggression in medical practice settings appears necessary.