Tools such as screening, visual alerts can reduce violence in health care

Identifying potentially aggressive patients through a variety of tools proves to be effective in reducing violence against health-care workers, according to a recent case study by Mount Sinai Hospital in Toronto.

An aggressive behaviour screening tool, visual alerts, care plans and communications to the team, patient and family were effective in reducing the health-care workers’ experiences of aggression on the job. Before the experiment, about one-third of both the intervention group and the control group reported experiencing physical aggression in their last 10 shifts. After three months of the program, 13 per cent of the intervention group reported experiencing physical aggression from patients, compared to 30 per cent of the control group. At the six-month followup, 17 per cent of the intervention group said they experienced aggression, compared to 26 per cent of the control group.

“This is the type of result we were very excited about because this was what we were trying to shift more than anything else,” said Carla Loftus, a clinical nurse specialist at Mount Sinai Hospital, who presented the findings at an Institute for Work and Health event in Toronto on Nov. 19.

Across Canada, the health-care sector has one of the highest levels of workplace violence with patients being the most common source. According to Statistics Canada, 34 per cent of nurses report experiencing physical assault from a patient within a given year, and the Ontario Nurses Association says that 54 per cent of its members have experienced physical violence or abuse on the job. The effects of aggression on health-care staff can include physical injuries, psychological trauma, increased sick leave and development of post-traumatic stress disorder and substance abuse disorders, various studies have found.

“We had nurses saying, ‘I got kicked and scratched for no reason. I am just trying to do my job,’” said Lesley Wiesenfeld, a geriatric psychiatrist at Mount Sinai, who was presenting with Loftus. “And people saying, ‘Do you know how many times I’ve gone in to give care and been hit out of nowhere?’”

The researchers conducted a case study where those in the experimental group followed a specific protocol, called the Behavioural Universal Precautions Program, and those in the control group did not. When a patient was first admitted, they underwent a screening tool that identified whether or not they were at risk of aggressive behaviour. If they were screened as positive, a series of visual alerts were used, including signage on the door to their room, signage above their bed, a sticker on their chart and on the nursing binder and a pink arm band was worn by the patient.

Next, a care plan was provided to effectively care for the patient, and this was communicated to the medical team, family and patient.

In addition to the reported decrease in physical aggression, confidence in dealing with aggressive patients increased for those workers who participated in the experiment.

According to the participants, some of the reasons why the program worked well were the following: the task was integrated into their existing work routines; the visual alerts were similar to those used for other programs; the training and reminders were effective; the program was a perceived benefit to them; and the screening tool was simple.

Participants also identified the following barriers: lack of knowledge of the patient at the time of developing the care plan; resource limitations for implementing the care plan; competing alerts and signage within the hospital; worried about the patient and family perception; multiple steps in the process; the care plans being too generic; and time and workflow constraints.

Although screening was the most adhered to tool in the program, just 75 per cent of participants were using it. And while 75 per cent were also using at least one visual alert, it was difficult to get them to use more than that.

“We knew they wanted help around these problems — we had a burning platform in that sense — and yet still when we added relatively low-time screening, it was still hard for people in a busy workplace with lots of things to do to implement it,” said Wiesenfeld.

When putting such programs in place to address workplace violence, Wiesenfeld recommends the occupational health and safety professionals within a hospital work together with the psychiatry department to ensure the issue is addressed at both the patient and worker levels.

“I think if it lives entirely in the safety realm without also being supported collaboratively in the clinical realm then you’ve got an ‘us vs. them.’”