The outcome of a rapid training program on nurses’ attitudes regarding the prevention of aggression in emergency departments: A multi-site evaluation

Abstract

Background

Patient aggression is a common source of occupational violence in emergency departments. Staff attitudes regarding the causes for aggression influence the way they manage it. The Management of Clinical Aggression – Rapid Emergency Department Intervention is a 45 min educational program that aims to promote the use of de-escalation techniques and effective communication skills to prevent patient aggression.

Objective

We sought to evaluate the impact of the program on staff attitudes regarding the prevention and early management of patient aggression.

Design

A mixed methods approach was used including a pre-test post-test survey of training participants and individual interviews with key stakeholders.

Setting and sample

The setting was public sector hospital emergency departments located in metropolitan and regional Victoria, Australia. A convenience sample of eighteen emergency departments was recruited via the Victorian Department of Health.

Participants

Survey participants were nurses and midwives who were employed at the study sites. Interview participants were a purposive sample of nurse unit managers and trainers.

Methods

The Management of Aggression and Violence Attitude Scale was administered to training participants immediately before and 6–8 weeks after training. Semi-structured telephone interviews with trainers and managers occurred 8–10 weeks after the intervention.

Results

Four hundred and seventy one participants completed the pre-test and post-test. Statistically significant shifts were observed in 5/23 items (Wilcoxon Signed Ranks Test: p ≤ 0.01). Despite training, participants were undecided if it was possible to prevent patient aggression, and continued to be unsure about the use of physical restraint. Twenty-eight (82.3%) of managers’ and trainers’ eligible to be interviewed provided their perceptions of the impact of the program. Overall, these perceptions were consistent with the significant shifts observed in the survey items.

Conclusion

There was limited evidence to demonstrate that the program significantly modified staff attitudes towards the prevention of patient aggression using the Management of Aggression and Violence Attitude Scale. Additional survey items that specifically measure staff attitudes about the use of restraint in emergency settings are needed to better understand decision making about restraining practices. Further work is indicated to quantify the impact of training in practice.

Introduction

Patient aggression is recognised as the most prevalent source of occupational violence in hospital emergency departments (EDs) worldwide, and in this context, threatens the delivery of safe high quality healthcare (Taylor and Rew, 2010). Interventions undertaken to manage episodes of patient aggression may involve the application of physical and mechanical restraint as well as the administration of medications to manage acute agitation (Holloman and Zeller, 2012). For patient's there are serious health risks associated with restraining practices including physical injury and death, re-traumatisation of people with a history of trauma, loss of dignity and psychological harm (Huckshorn, 2005, Knox and Hollman, 2012).

In an evaluation of staff and patient views on strategies to manage aggression, Duxbury (2002) described the distinctly different perspectives between groups regarding the causes and management of aggression. She found that patients tended to view staff approaches as unnecessarily ‘controlling’ and felt environmental and poor communication factors triggered the development of aggression. Staff, on the other hand, mostly attributed aggressive patient behaviour to internal factors (patient related/biomedical).

Staff attitudes regarding the causes for patient aggression are known to influence the way they manage it (Calabro et al., 2002, Duxbury, 2002). In psychiatric in-patient settings, staff who attribute aggression to patient-related factors alone have been found to favour the use of traditional interventions (restraint and seclusion) while, those who consider the role of the environment and the quality of inter-personal interactions that occur within it, more likely to utilise a broader set of management strategies (Duxbury, 2002).

Although staff training programs have long been considered central to preventing patient aggression, a limited number of studies have evaluated the effect of training on learning or organisational outcomes (Beech and Leather, 2006, Farrell and Cubit, 2005, Hahn et al., 2006, Kontio et al., 2011, Kynoch et al., 2009). For example, Beech and Leather (2006) conducted a critical review of published training programs and evaluation models for preventing workplace violence in healthcare settings. These authors found that while training courses were generally available to staff, few were evaluated in terms of observable behavioural change or the relative costs and benefits to organisations. Similarly, Australian authors Farrell and Cubit (2005) evaluated 28 published aggression management training programs against 13 pre-determined criteria derived from the recommendations of a number of leading professional and industrial organisations worldwide, including the International Labour Office and the International Council of Nurses (International Labour Office et al., 2002). They found that few programs were based on a systematic evaluation of organisational outcomes.

To establish best practice in the prevention and management of aggressive behaviours in patients admitted to acute hospital settings, Kynoch et al. (2009) went on to conduct a systematic review. Of the 13 studies that met review criterion, only three evaluated training outcomes. Of these studies, all demonstrated some improvements in the levels of knowledge, skills and attitudes of acute care staff in the management of aggressive behaviour.

The aim of the current study was to measure the outcome of an educational intervention (the Management of Clinical Aggression – Rapid Emergency Department Intervention, MOCA-REDI) on staff attitudes about the prevention and early management of patient aggression. In addition we sought to describe staff perceptions of the impact of the program from the perspective of Nurse Unit Managers (NUMS) and local trainers.

The MOCA-REDI program is based on a theoretical model that divides the causal factors for patient aggression into three categories: internal (patient/biomedical causes), external (environmental causes) and interactional (situational causes) (Duxbury, 1999). Accordingly, this evaluation is structured around the measurement of staff attitudes across three structural domains: the environment, the situation and the patient.

For the purpose of this study we defined patient aggression as: “any client [patient] – initiated incident in which an employee [nurse] is physically attacked or threatened in the workplace” (International Labour Office et al., 2002).

We sought to test two hypotheses.

• Exposure to the MOCA-REDI program will result in a change in staff attitudes about the causes of patient aggression by recognising the role environmental and inter-personal factors have on patient behaviour in the ED.

• Exposure to the MOCA-REDI program will result in a significant change in staff attitudes about the management of patient aggression by recognising use of least restrictive interventions to achieve patient and staff safety.

The MOCA-REDI program was initially developed and pilot tested by the authors in conjunction with a multi-disciplinary team including: a carer representative, a mental health consumer, members of the police force, medical and nursing staff. The consumer representative was employed as a mental health consultant in the health service where the program was originally developed. She was specifically engaged by the project team to review the program content, provide feedback on each of the scenarios, and to develop a section of the trainers program related to the consumer's perspective on the prevention and management of aggression.

In essence the program is a structured evidence-informed training course which is delivered over a 45 min staff in-service session. The program involves three key learning activities. First participants view a 3.5 min DVD simulation of an episode of patient aggression in the ED. Next participants are presented with and discuss the research evidence regarding the prevention of aggression in healthcare settings generally and with respect to the case depicted in the simulation. Here the risk factors for violence and early warning signs for aggression are reviewed. Finally through a process of facilitated reflection, participants review the current approaches used to manage episodes of aggression in their workplace and consider the ways in which practice may be improved. Fig. 1 shows a summary of core components of the MOCA-REDI course.

Dissemination of the MOCA-REDI program to other EDs within the jurisdiction was achieved using a train-the-trainer model. This was supported by the Victorian Department of Health Emergency Care Improvement and Innovation Clinical Network (ECIICN). Trainers were emergency nurses with an educational role who were selected by an executive sponsor at the participating sites based on the following key selection criteria.

• Qualifications in nursing: trainers were required to be a registered nurse working in a nominated ED.

• Specialist role: trainers were required to be employed as either a specialist emergency nurses/emergency nurse educator or a member of an emergency crisis assessment team or were psychiatric liaison service.

• Availability to teach the program: trainers were required to be available to attend a 3 h workshop prior to delivering the program.

Trainers were provided with a teaching manual, lesson plan, presentation slides, speaker notes and a set of four 3.5 min DVDs depicting simulated episodes of aggression in the ED. Two trainer education sessions were provided by Author 1 (a PhD qualified registered nurse with 12 years of specialist emergency nursing qualifications and experience and 10 years of university based teaching experience) and Author 2 (a Masters prepared registered nurse with specialist qualifications in psychiatric nursing and 12 years experience as a management of clinical aggression trainer). The two training sessions occurred at central location, which was away from the hospitals involved in the study. After taking part in one of these sessions, trainers were then supported by the ECIICN to implement the 45 min MOCA-REDI intervention.

In addition to receiving instructions on the program content and materials, trainers were educated about the pedagogical approach and observed a training demonstration. No incentives or payments were made to participating sites. All EDS who took part were provided with the training materials free of charge.