Individual, relationship, workplace, and societal recommendations for addressing healthcare workplace violence.

BACKGROUND: Workplace violence from coworkers, patients, and visitors is a problem affecting every occupational group in the health and social service sector [1-3]. Workplace violence is demonstrated by coworkers through bullying behaviors and by patients and visitors through physical threats and assaults. OBJECTIVE: The purpose of this article is to highlight the special issue authors' and guest editors' recommendations for protecting healthcare workers from being victimized and incurring the negative consequences of having experienced workplace violence. METHODS: Recommendations from the special issue were categorized and discussed in relation to the Social-Ecological Model and the prevention efforts targeting individuals, relationships, communities, and society. RESULTS: Individual-level recommendations focused on the personal risk reduction for healthcare workers. Relationship-level recommendations addressed the problem of bullying between coworkers and physical violence derived from patients and visitors. Workplace-level recommendations discussed a multi-faceted systems approach to violence management. Societal-level recommendations centered on a universal health policy approach. CONCLUSIONS: The use of a model such as the Social-Ecological Model can be helpful in planning violence prevention efforts in the healthcare setting.

A workplace violence educational program: a repeated measures study.

Violence against healthcare employees is a profound problem in the emergency department worldwide. One strategy to reduce the risk of violence is prevention focused education. The purpose of this paper was to report the learning outcomes of a workplace violence educational prevention program tailored to the needs of emergency department employees. A quasi-experimental design was used to determine the knowledge retention of program content following a hybrid (online and classroom) educational intervention. One hundred twenty emergency department employees that completed the workplace violence prevention program participated in the study. A repeated-measures analysis of variance was conducted to determine if individual test scores increased significantly between baseline, posttest, and six month posttest periods. The results indicated a significant time effect, Wilk's Λ = .390, F (2, 118) = 26.554, p < .001, η2 = .310. Follow-up polynomial contrasts indicated a significant linear effect with means increasing over time, F (1, 119) = 53.454, p < .001, η2 = .310, while individual test scores became significantly higher over time. It was concluded that the use of a hybrid modality increases the probability that significant learning outcomes and retention will be achieved.

Single-session motivational intervention to decrease alcohol use during pregnancy.

This randomized clinical trial tested the effectiveness of a single-session of motivational interviewing (MI) to decrease alcohol use during pregnancy, while examining theory-based mechanisms of the intervention. Eligible pregnant women who drank any amount of alcohol in the previous year (n=122) were randomized to an intervention or comparison group. Drinking behaviors, basic psychological need satisfaction, and autonomous motivation to decrease prenatal alcohol use were measured at baseline, 30 day postbaseline, and 30 day postpartum follow-ups. Poisson and linear regression with generalized estimating equations were used to evaluate treatment effects over time. Although MI was not found effective in decreasing alcohol use, low levels of reported alcohol use by the women at baseline left little room for improvement due to the intervention. To prevent fetal alcohol spectrum disorders, future studies will use self-report and biomarkers to more accurately identify women in need of interventions to reduce their risk of alcohol-exposed pregnancies.

Implementation of a comprehensive intervention to reduce physical assaults and threats in the emergency department.

INTRODUCTION: The purpose of this study was to test the effectiveness of a comprehensive program to reduce the incidence of workplace violence (WPV) against ED providers by patients and visitors. METHODS: An intervention study was conducted with 3 intervention and 3 comparison emergency departments. Participants completed monthly surveys during an 18-month period to measure violent event rates before and after the WPV intervention implementation. Descriptive statistics were used to describe violent events. Analysis of variance was used to assess if the emergency departments participating in the WPV intervention experienced a significant reduction in violence rates compared with nonintervention emergency departments. RESULTS: On average, participants experienced more than 6 incidents of violence during the 18-month study period. Although the study hypothesis was not supported, 2 intervention sites had a significant decrease in violence. DISCUSSION: This study emphasizes the risk of WPV to ED workers and highlights the need for prevention programs. Future research needs to be conducted to test additional comprehensive WPV prevention interventions.

Posttraumatic stress symptomatology among emergency department workers following workplace aggression.

Workplace aggression has the potential to adversely affect the psychological health of emergency department (ED) workers. The purpose of this study was to compare posttraumatic stress symptomatology based on verbal and verbal plus physical aggression. A descriptive cross-sectional design was used with a convenience sample (n = 208) of ED workers who completed a three-component survey. Descriptive statistics were computed to compare traumatic stress scores based on type of aggression. Two-way analysis of variance statistics were computed to determine if scores differed on the demographic variables. Fewer than half of the ED workers reported traumatic stress symptomatology; however, workplace aggression has the potential to adversely affect the mental health of ED workers. Occupational health nurses can establish or maintain a nurturing and protective environment open to discussing the personal thoughts, feelings, and behaviors of ED workers related to their experiences of workplace aggression. This open and more positive work environment may aid in reducing the negative impact of posttraumatic stress symptoms among those ED workers who have been victimized.

Using proactive coping to manage the stress of trauma patient care.

Some emergency nurses are resilient following trauma patient care, while others report severe traumatic stress. The purpose of this study was to determine proactive coping behaviors used by emergency nurses to prevent traumatic stress. A cross-sectional research design was used with a national sample of emergency nurses. Participants completed a 5-component Web-based survey. Data analyses included 1-tailed partial correlations. The correlation of proactive coping score to traumatic stress was significant. Proactive coping strategies that focus on the planning and preparation to provide care for traumatically injured patients may be effective at preventing traumatic stress.

Stressful incidents of physical violence against emergency nurses.

Physical violence against nurses has become an endemic problem affecting nurses in all settings. The purpose of this study was to describe acts of physical violence against emergency nurses perceived as stressful using a qualitative descriptive design with a national sample of emergency nurses. The guiding conceptual model for the study was the Ecological Occupational Health Model of Workplace Assault. Narrative accounts of physical violence were analyzed using a constant comparative analysis method. Key findings included risks related to employee, workplace, and aggressor factors, and descriptions of physical violence. Discussion of the study findings suggests that efforts to prevent violence and promote workplace safety need to focus on designing work environments that allow for the quick egress of employees, establishing and consistently enforcing policies aimed at violence prevention, and maintaining positive working relationships with security officers. While patients with mental health or substance use complaints are deemed most likely to commit physical violence, they are not the only patients to become violent. Risk reduction efforts should target all patients and visitors.

Adolescents' experience with workplace aggression: school health implications.

Aggression exposure is a critical health issue facing adolescents in the United States. Exposure occurs in various settings including home, school, and the community. An emerging context for aggression exposure is in the workplace. Thirty adolescent employees age 16-18 participated in a qualitative study exploring proposed responses to future workplace aggression. Semistructured interviews were used to gather participants' proposed responses to a series of hypothetical aggressive incidents in the workplace. Conventional content analysis identified patterns and themes among the participants' responses. Results indicated adolescent employees' proposed responses to workplace aggression are similar to other forms of aggression such as peer-bullying and teen dating violence. Education and training are needed within the school setting to promote appropriate responses to various forms of aggression encountered by adolescents. Implications for school health professionals' involvement in addressing responses to such aggression and further research opportunities are explored.

Prospective study of violence against ED workers.

BACKGROUND: Health care support occupations have an assault-injury rate nearly 10 times the general sector. Emergency departments (EDs) are at greatest risk of such events. OBJECTIVE: The objective was to describe the incidence of violence in ED health care workers (HCWs) over 9 months. Specific aims were to (1) identify demographic, occupational, and perpetrator factors related to violent events (VEs) and (2) identify predictors of acute stress in victims and predictors of loss of productivity. METHODS: A longitudinal, repeated-methods design was used to collect monthly survey data from ED HCWs at 6 hospitals. Surveys assessed number and type of VEs, and feelings of safety and confidence. Victims also completed specific VE surveys. Descriptive statistics and a repeated-measure linear regression model were used. RESULTS: Two hundred thirteen ED HCWs completed 1795 monthly surveys and 827 VEs were reported. Average VE rate per person per 9 months was 4.15. Six hundred one events were physical threats (PTs) (3.01 per person). Two hundred twenty six events were assaults (1.13 per person). Five hundred one VE surveys were completed, describing 341 PTs and 160 assaults. Men perpetrated 63% of PTs and 52% of assaults. Significant differences in VEs were reported between registered nurses (RNs) and medical doctors (MDs) (P = .0017) and patient care assistants (P < .05). The RNs felt less safe than the MDs (P = .0041). The MDs felt more confident than the RNs in dealing with violent patients (P = .013). The RNs were more likely to experience acute stress than the MDs (P < .001). Acute stress reduced productivity (P < .001). CONCLUSION: Emergency department HCWs are frequent victims of violence perpetrated by visitors and patients. This results in injuries, acute stress, and lost productivity. Acute stress has negative consequences on workers' ability to perform their duties.

The Qualitative Learning Experience of Healthcare Workers Completing a Hybrid Workplace Violence Educational Program.

Background: Hybrid educational methodologies which include online and classroom-based learning experiences increase learning. However, the course delivery preferences of learners need to be evaluated so that the design and delivery of future programs will maximize learning outcomes. The aim of this study was to describe how the delivery of a hybrid program contributes to learning outcomes. Methods: A qualitative descriptive design was used. Participants were recruited from two large emergency departments that completed a hybrid workplace violence educational program. Four focus group sessions were held with a convenience sample of 17 participants to discuss their learning experience with the hybrid educational program. Sessions were audiotaped and transcribed verbatim. Data were analyzed using a constant comparative analysis method. Results: Three themes emerged from the data. The first theme was "Implementation of the Intervention" and represented the opportunity for learning, the environment of learning, and the need for uniform training. The second theme was "Experience of the Intervention" and represented the conditions of learning, interdisciplinary learning, facilitated engagement, and realism of the learning content. The third theme was "Translation of the Intervention" which represented the transferability and retention of the program content. Conclusion: An active learning classroom-based component was perceived to yield greater knowledge attainment and retention than online learning for the participants in this study. Consideration of the learning styles and needs of learners should be taken into consideration when developing content for the online delivery or hybrid approach for educational programs.

An educational program to prevent, manage, and recover from workplace violence.

There exists a gap in the preparation of emergency department (ED) employees to prevent, manage, and recover from workplace violence (WPV). Thus, the purpose of this article is to evaluate learning outcomes following a 4-unit WPV educational program. A quasi-experimental study was used to evaluate learning outcomes with 315 employees from 3 EDs. Units 1-3 were web-based and included a pretest-posttest. Unit 4 was classroom-based and allowed employees to apply the knowledge learned during the web-based program. A paired samples t tests reflected a significant increase in knowledge attainment (p < 0.001). There was no significant difference in knowledge attainment between employees who completed the web-based learning only and employees who completed the hybrid web-based/classroom-based education (p = 0.136). A well-developed WPV educational program can achieve significant learning outcomes in ED employees. Web-based learning may be an effective alternative yielding learning outcomes equal to that of a hybrid educational program.

Workplace violence in emergency medicine: current knowledge and future directions.

BACKGROUND: Workplace violence (WPV) has increasingly become commonplace in the United States (US), and particularly in the health care setting. Assaults are the third leading cause of occupational injury-related deaths for all US workers. Among all health care settings, Emergency Departments (EDs) have been identified specifically as high-risk settings for WPV. OBJECTIVE: This article reviews recent epidemiology and research on ED WPV and prevention; discusses practical actions and resources that ED providers and management can utilize to reduce WPV in their ED; and identifies areas for future research. A list of resources for the prevention of WPV is also provided. DISCUSSION: ED staff faces substantially elevated risks of physical assaults compared to other health care settings. As with other forms of violence including elder abuse, child abuse, and domestic violence, WPV in the ED is a preventable public health problem that needs urgent and comprehensive attention. ED clinicians and ED leadership can: 1) obtain hospital commitment to reduce ED WPV; 2) obtain a work-site-specific analysis of their ED; 3) employ site-specific violence prevention interventions at the individual and institutional level; and 4) advocate for policies and programs that reduce risk for ED WPV. CONCLUSION: Violence against ED health care workers is a real problem with significant implications to the victims, patients, and departments/institutions. ED WPV needs to be addressed urgently by stakeholders through continued research on effective interventions specific to Emergency Medicine. Coordination, cooperation, and active commitment to the development of such interventions are critical.

Emergency department workers' perceptions of security officers' effectiveness during violent events.

OBJECTIVE: The emergency department (ED) is among the most at-risk settings for violence by patients and visitors against ED workers. A first response to potential or actual events of workplace violence is often contacting hospital security officers for assistance. The purpose of this study is to describe ED workers' views of security officers' effectiveness during actual events of verbal and/or physical violence. PARTICIPANTS: Healthcare workers (n=31) from an urban pediatric ED in the Midwest United States. METHODS: Participants were interviewed regarding their experiences with workplace violence. Verbatim transcripts were qualitatively analyzed. RESULTS: Six themes were identified: (1) a need for security officers, (2) security officers' availability and response, (3) security officers' presence or involvement, (4) security officers' ability to handle violent situations, (5) security officers' role with restraints, and (6) security officers' role with access. CONCLUSIONS: It is important that early communication between security officers and ED workers takes place before violent events occur. A uniform understanding of the roles and responsibilities of security officers should be clearly communicated to ED workers. Future research needs to be conducted with hospital-based security officers to describe their perceptions about their role in the prevention and management of workplace violence.

Novice nurse productivity following workplace bullying.

PURPOSE: To determine the prevalence and effects of workplace bullying (WPB) on the work productivity of novice nurses (NNs). DESIGN: Internet-based descriptive cross-sectional survey design. METHODS: One hundred ninety seven NNs (91.4% female, 8.6% male) in practice less than 2 years completed the Healthcare Productivity Survey, Negative Acts Questionnaire, and a demographic survey. FINDINGS: The majority (72.6%, n= 147) of NNs reported a WPB event within the previous month, with 57.9% (n= 114) the direct targets and another 14.7% (n= 29) witnesses of WPB behaviors. Using a weighted Negative Acts Questionnaire score, 21.3% (n= 43) of NNs were bullied daily over a 6-month period. When asked if bullied over the past 6 months, approximately 44.7% (n= 88) of NNs reported repeated, targeted WPB, with 55.3% (n= 109) reporting no WPB. WPB acts were primarily perpetrated by more experienced nursing colleagues (63%, n= 126). Further, work productivity regression modeling was significant and NN productivity was negatively impacted by workplace bullying (r=-.322, p= .045). CONCLUSIONS: WPB continues in the healthcare environment and negatively affects bullied NNs' productivity by affecting cognitive demands and ability to handle or manage their workload. CLINICAL RELEVANCE: Healthcare facilities should continue to measure WPB in the work environment after policy implementation as well as eliminate negative behaviors through root-cause analysis to correct environmental factors associated with WPB.

An internet training to reduce assaults in long-term care.

Physical and verbal assaults by residents on care staff are not uncommon in long-term residential care facilities (LTCs). This research evaluated an Internet training designed to teach nurse aides (NAs) strategies to work with aggressive resident behaviors. Six LTCs were randomized in an immediate treatment (IT) and delayed treatment (DT) design, and NAs were recruited in each (IT: n = 58; DT; n = 45). The treatment involved 2 weekly visits to the online training. Hard copy assessments collected participant responses at baseline (T1), 8 weeks (T2), and at 16 weeks (T3). The DT group viewed the program after T2. Hierarchical linear models showed significant group differences at T2 in knowledge, and these levels were maintained at T3. The number of aggressive incidents reported per day by the IT group were nonsignificant at T2 but decreased significantly from T1 to T3 with a large effect size. The program was well received by users. These results suggest that the Internet training was an effective tool to reduce assaults in LTCs, and training effects may improve over time as NAs gain experience using the techniques.

Internet training to respond to aggressive resident behaviors.

PURPOSE: This research evaluated an individualized Internet training designed to teach nurse aides (NAs) strategies to prevent or, if necessary, react to resident aggression in ways that are safe for the resident as well as the caregiver. DESIGN AND METHODS: A randomized treatment and control design was implemented, with baseline, 1-, and 2-month assessments for 158 NAs. The training involved 2 weekly visits. The Internet intervention was a behaviorally focused and video-based training that included content on skills for safely dealing with physical aggression. Measures included video situation testing and assessment of psychosocial constructs associated with behavior change. RESULTS: Analysis of covariance showed positive results for knowledge, attitudes, self-efficacy, and empathy, with medium-large effect sizes maintained after 2 months. The training was well received by participants. IMPLICATIONS: Internet training is a viable approach to shape appropriate NA reactions to aggressive resident behaviors. This format has future potential because it offers fidelity of presentation and automated documentation, with minimal supervision.

Occupational and demographic factors associated with violence in the emergency department.

Violence against health care workers is a serious and growing problem. The objectives of this cross-sectional study were to (a) describe the frequency of workplace violence (WPV) against emergency department (ED) workers; (b) identify demographic and occupational characteristics related to WPV; and (c) identify demographic and occupational characteristics related to feelings of safety and level of confidence when dealing with WPV. Survey data were collected from 213 workers at 6 hospital EDs. Verbal and physical violence was prevalent in all 6 EDs. There were no statistically significant differences in the frequency of violence for age, job title, patient population, and hospital location. Sexual harassment was the only category of violence affected by gender with females having a greater frequency. Feelings of safety were positively related to the frequency of WPV. Females were significantly more likely to feel unsafe and have less confidence in dealing with WPV. The study findings indicate that all ED workers are at risk of violence, regardless of personal and occupational characteristics. Feelings of safety are related to job satisfaction and turnover. Violence has serious consequences for the employers, employees, and patients. It is recommended that administration, managers, and employees collaborate to develop and implement prevention strategies to reduce and manage the violence.