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Violence Prevention Education in Healthcare
Violence from patients and visitors towards healthcare workers is a serious international issue affecting the safety and health of workers, quality of care, and healthcare system sustainability. The main intervention is violence prevention (VP) education for healthcare workers. Both the healthcare environment and reasons for patient violence are complex, making it challenging to evaluate VP education using traditional methods. An alternative realist evaluation approach offers the ability to understand how, why and for whom VP education is effective to prevent violence and related injuries.
2. CMO Explanations 1–6: Decreasing Violent Incidents
2.1. CMO 1: VP Education Specific to Clinical Settings
“Participants in the workplace violence program were taught information that was directly applicable to their work environment. The tabletop exercise provided contextual meaning by using video case studies that were both realistic and applicable to the environment in which the acquired knowledge would be applied” (p. 471)
“…ward specific training may address these limitations by facilitating the transfer of knowledge to practice, developing skills identifying problems and implementing prevention strategies” (p. 7)
“Someone who teaches aggression management should be on the wards to get the feel of what actually happens’ (Ward security staff member). ‘Have the trainer experience the ward environment and apply the program to the situations on the ward’ (Nursing staff member)” (p. 237)
2.2. CMO 2: Content Focuses on Communication and De-Escalation
“Direct skills teaching [provides] knowledge of behavioural skills and strategies for emotional regulation [leading to] increased confidence/self-efficacy [and] enhanced interpersonal style when managing aggressive behaviour [and] emotional regulation when faced with aggressive behaviour” (p. 237)
“Crucially, training needs to help staff understand how problems, such as CB [challenging behaviour], can arise within and as a result of their routine interactions with clients” (p. 237)
“…training helped them control their temperament in a challenging environment and also enabled them to effectively practice active listening and empathy” (p. 297)
“…training interventions that enhance staff communication skills do decrease violent incident rates” (p. 2828)
2.3. CMO 3: Unit Level Mentoring and Modeling of VP
“It is recommended that early contact is made with clinical experts when high-risk patients are first identified, rather than following an incident, and that key ward staff are trained and mentored to develop confidence in managing patients with a risk for violence/aggression” (p. 13)
“Experienced workers can mentor and guide less experienced colleagues in communication and care delivery strategies that may calm patients and visitors, diffuse tense situations” (pp. 182–183)
“Because of the sometimes impromptu nature of violence, consequent debriefing and the sensitivities involved, a change agent from within the clinical team may have been more successful as an internal ‘implementer’ working with peers” (p. 12)
2.4. CMO 4: Team-Based Education and Discussions
“Wards adopting a whole-team approach are more likely to reduce the risk of assault than individual advances in knowledge and skills… Clinical managers should not only ensure that sufficient numbers of their staff are trained, but also that as many staff as possible are trained together at the same time, to foster such approaches and facilitate maximal gain” (p. 453)
“Interventions to support nurses and nursing teams in processing transgressive behaviour in care relationships should be implemented on a team level, incorporating the culture of the ward and the dynamics of teams” (p. 2381)
“Participants in the intervention group of a structured program for regular discussion of workplace violent incidents reported an improved awareness and management skills” (p. 21)
2.5. CMO 5: Workload Enabling the Use of VP Skills
“Most ED RNs thought that the classes they were forced to take were not effective or had little efficacy in successfully de-escalating patient behaviours. Most ED RNs cited a lack of time to implement the tools taught in these classes” (p. 549)
“Staff members also identified barriers that sometimes prevented their managing behaviour problems optimally. These included time pressure” (p. 38)
“Training alone is not enough and staff need to be enabled to learn with adequate support and resources e.g., … reasonable workload to apply skills and communicate with patients or residents” (p. 20)
2.6. CMO 6: Sufficient Physical/Emotional Energy
“Participants are more able to apply skills when they are fresh and have energy early in their shift but when they are tired and nerves are frayed they resort to previous behaviour” (p. 550)
“The high levels of physical, verbal and sexual violence combined with the structural violence of caring in an understaffed and under-resourced environment stretches workers to the limit. Personal support workers leave physically and mentally exhausted” (p. 21)
3. CMO Explanations 7–10: Decreasing Injuries from Violence
3.1. CMO 7: Physical Support during Violence
“’It feels great to have support at times like these. It helps me feel like I am not alone when these situations occur and that someone has my back’” (p. 125)
“A sense of abandonment underlay accounts where a physical absence of support staff and managers on the wards meant that staff ‘often felt totally alone in a difficult and dangerous situation’” (p. 5)
“The RN who steps in and either takes over for an RN who is experiencing a challenging patient or intervenes for another nurse who might be newer or more timid… ‘ We have a couple of nurses who just stand up, you know, for the weaker nurses who can get picked on by certain patients. They will just slip in and take over the assignment or whatever they can do to help, but in a positive way’” (p. 552)
3.2. CMO 8: Acknowledgement and Support after Violence
“More importantly nurses in the study felt most supported when the manager acknowledged the event as explained by this RN, ‘just having the event recognized as something that was critical and you know, it was traumatic and …they weren’t minimizing it and actually embracing it as something that was not acceptable’” (p. 7)
“The nature of the organisational response to the traumatised staff member can therefore play a pivotal role in the process of recovery and, where the organisational response fails to understand or consider the needs of the victim(s) can itself constitute a source of secondary injury or trauma” (p. 481)
“Participants actively looked toward their colleagues and managers for support and acknowledgment following client violence in the workplace, and indeed having supportive peers and supervisors can significantly improve a victim’s sense of coping and lessen their fear of further attacks” (p. 293)
“Many other nurses described feeling very angry, unsupported and blamed by their managers. Some RNs never heard from their managers following events of patient violence, while others described receiving a phone call or a brief conversation, which was felt to be thoughtful, but not sufficiently supportive” (p. 7)
3.3. CMO 9: Clear, Supported Policies and Consequences for Violence
“Organizational factors like clear expectations for patient behaviour and consequences empower management and staff members to feel less frustrated and more equipped to deal with violence” (p. 549)
“Zero tolerance policy enforcement is thought to be constructive in terms of supporting and empowering staff to have confidence in managing problematic patients and hostile situations” (p. 97)
“An organization that positively addresses violence through the themes of consistency, consequences, and collaboration potentially mitigates the development of cynicism and conflict as maladaptive reactions of staff” (p. 15)
3.4. CMO 10: Work Culture Free from Judgement
“Staff may feel less confident in taking the risk to apply new skills if they fear that their image may be harmed and they are seen as ignorant or incompetent” (p. 2)
“Nurses are reluctant to report violence in the workplace and may not seek support after incidents of violence because they think asking for help may be interpreted as personal weakness or professional failure” (p. 45)
“When admitting (or simply calling attention to) mistakes, asking for help, or accepting the high probability of failure that comes with experimenting, people risk being seen as incompetent, whether in a narrow, particular domain, or more broadly. Reluctance to take such interpersonal risks can create physical risks in high-risk industries” (p. 256)
4. CMO Explanation 11: Increasing Reporting
CMO 11: Follow up after Violence
“When staff do not see any result or change as a consequence of reporting violence when experience violence they feel hopeless and resigned that reporting is of no benefit and will not report” (p. 271)
“Registration of violent incidents without regularly scheduled, structured feedback discussions may have increased frustration in the control group, leading to less likelihood of reporting” (p. 674)
“Recordkeeping was rated as the second lowest subcomponent in terms of importance in reducing WPV. This finding may be related to employees not recognizing any benefit of recordkeeping as a form of WPV prevention” (p. 381)
This entry is adapted from 10.3390/healthcare9030339
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