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Expertise in Clinical Aggression: Knowledge Transfer, from Research to Best Practice Prof. Sabine Hahn, PhD, MNSc, CNS
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Expertise in Clinical Aggression:Knowledge Transfer, from Research to Best Practice
Prof. Sabine Hahn, PhD, MNSc, CNS
BERN
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Content
- Definition
- What we know
- Prevalence,
- Influencing factors.
- Best practice transfer: SAVEinH
- Professional organisations,
- Health professionals,
- Education,
- Research,
- Politics. 3
Definition
Patient and visitor violence/aggression is any verbal, non-
verbal, or physical behaviour that is threatening to others
or to property, or physical behaviour that actually does
harm to others or to property (Morrison, 1990).
- Violent/aggressive behaviour is exhibited in different
forms (McKenna, 2004)• Verbal violence • Threats• Physical assault
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BACKGROUND: WATH WE KNOW
Violence & Aggression (V&A) in the Health Sector- 25% of all workplace violence- Mental health care and emergency settings- Nursing profession- Patient and visitor- Underestimated
General Hospitals, elderly care, community setting- No comprehensive description- Existing results are conflicting- No specific prevention and intervention strategies- No best practice
(Chapell & Di Martino 2006, Fernandes et al. 1999, Hahn et al. 2008, Hahn et al. 2012, Hegeny et al. 2010, Wells &
Bowers, 2002, Winstaley & Whittington 2004)5
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PREVALENCE AND CONSEQUENCES IN THE GENERAL HOSPITAL SETTING
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Prevalence of violence & aggression
%
In the past 12 months1 51
VerbalPhysicalThreats
461716
In the week prior to data collection1
11
VerbalPhysicalThreats
67207
3 multiple responses possible
Consequences of violence & aggression
%
In the past 12 months1
Emotionally upsetting 90
Physical 15
Participants: 2495 health care staff, nursing staff, medical doctors, physical therapists, occupational therapists, nutritionists, medical assistants, radiology assistants ward secretaries etc. (response = 52%)(Hahn et al. 2012a, 2012b)
Workplace/Organisational Context• Architectural work environment• Organisational work environment • Regulations• Information strategies• ....
Staff• Profession• Gender• Age• Experience• Attitude and perception • Closeness of patient and
visitor contact• Consequences • Training in aggression
management• ...
Interaction• Intervention or treatment• Information management• ....
Patient/Visitor• Gender• Age• Health condition:
Physical illness, Mental state
• Emotional condition• Knowledge
(situational)• …
INTERACTION
InteractionViolence - Aggression
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INFLUENCE OR RISK FACTORSIN GENERAL HOSPITALS
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Workplace/ Organisational context- Geriatric wards, intensive care units, recovery rooms, anesthesia,
intermediate care, step-down units, emergency rooms, outpatient units- Processes of long waiting times, multiple examinations and tests,
institutional bans or coercion- Low personnel level- No official position or formal process in the sense of a verbal or written
report after PVV (no standards)- Confusing and disturbing environment
Interaction- Close patient contact- Painful examinations or tests- Not at the same eye level- Counselling
(Hahn et al. 2009; Hahn & Metzenthin, 2010; Afzali et al. 2010; Hahn et al. 2012a, 2012b, 2013)
RESULTS: EXAMPLE 1 - INTENSIVE CARE
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INFLUENCE OR RISK FACTORS
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Higher risk Lower risk
Profession Medical doctors
Professional level Students
Attitude Aggression is emotionally letting off steamPreventive measures against violence is important
Age Younger staff up to age 30
Patients’ age Over 65 years
Visitor contact Husbands, wives, partners, siblings
Training in aggression management
Yes (only 16% have a training in aggression management) (Participants: 2495 health care staff,
in Hahn et al. 2012b)
INFLUENCE OR RISK FACTORS IN GENERAL HOSPITALS
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Patient Characteristics
Health cognitive impairment, pain, substance intoxication, withdrawal, mental or behavioural disorders, disorders of the blood and immune system
Emotions frustration, dissatisfaction, anxiety and stress
Orientation deficits in comprehending the situation, low level of information provided
Age over 65 years (geriatric wards for patients between 71 and 80 years, surgery for patients between 18 and 24 years)
Gender results inconsistent
Visitor Characteristics
Emotions anxious, having excessive demands, insecure in the situation, dissatisfied with therapy
Orientation low level of information (Hahn et al. 2012a, 2012b)
INFLUENCE OR RISK FACTORS IN GENERAL HOSPITALS
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INTERACTIONS AND INTERVENTION
- Strategies are numerous, imaginative and individually effective.
- Suggestions for solutions are, however, not always realised
(problem of interdisciplinary communication).
- In very critical situations, many people are involved; this fact often
increases the aggression potential of the patients, thus preventing
a purposeful de-escalation strategy.
- Coercive measures
"Well, I did not feel good, somehow, it made me, somehow, if I may say so, ”pissed off“. In such a situation, one has much to do, and then been so long at the emergency, with the patient so out of control that one has to resort to a syringe injection. So, I was not in any way satisfied"(I2.1.2.).(Hahn et al. 2009)
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- It is important how health care staff
control their own aggression and how
they react to the aggression of
patients/visitors/relatives.
- It is a challenge to find constructive
solutions for a better interaction in
aggressive situations.
THERE IS NO WORLD WITHOUT AGGRESSION OR VIOLENCE….
To improve best practice in the prevention and management of patient and visitor violence, we need attention to this problem in general hospitals, nursing homes and community care.
BEST PRACTICE SAVEinH A global Strategies Addressing ViolencE in Hospitals
Security Service
Advance notice Escalation Crisis Recovery Maybe Depression
PreventionEarly warning signsSafe environmentInformation strategy
InterventionDe-escalationMedication
InterventionProtection of self and othersSecurity serviceSelf-defense techniques
ReflexionAftercare for workers, patients, relatives of patientsDocumentationGroup reflexion
Concept of advanced interdisciplinary training
Interdisciplinary support and collaboration
Aftercare and supportControlling
SAVEinH
Quality measures and Quality development programmes
Technical and structural means and conditions
Normal behaviour
Clear Attitude & Definition
Guideline & Standards
Clear and suitable public information
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BEST PRACTICE EDUCATION AND TRAINING
Theoretical input Verbalisation of experiences of clinical aggression Repetition and reflection of communication skills Training with professional actors with special
education in principals of communication, especially in feedback techniques.
2-6 students per training session: 1 is the nurse and others are observers.
Video observation and structured reflection Students alternate their roles; nurse or observer.
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BETTER AGGRESSION MANAGEMENT WITH “PATIENTS”
SP’s offer the best way to simulate realistic realistic interactions.
Experiences can be directly transferred to the work setting.
A more realistic method in contrast to role playing.
Provides possibilities to reflect on the communication and de-
escalation competences in a safe setting.
Increased level of learning due to experiencing own emotions
combined with the training situation.
BEST PRACTICE EDUCATION AND TRAINING WITH SP’s
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Professional organisations, Education, Research and
Politics:
- Advice and support for Hospitals, nursing homes and community
care how to address patient/visitor/relative aggression & violence.
- Providing adequate education and further education for all health
care staff and improving staff resilience.
- Providing information and information strategies for politics,
security law, community and professionals.
BEST PRACTICE SAVEinH Strategies Addressing ViolencE in Hospitals
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Staff experience less patient and
visitor violence
- If hospitals have a clear organisational
attitude and take patient and visitor
violence seriously
- If staff feels safe
THERE IS NO WORLD WITHOUT AGGRESSION OR VIOLENCE….
In a climate of reduced financial resources and efforts for patient safety, it is significant for clinical aggression now to be carefully explored and addressed (Gallant-Roman 2008, Hahn 2012).
