Expertise in Clinical Aggression: Knowledge Transfer, from Research to Best Practice Prof. Sabine Hahn, PhD, MNSc, CNS BERN 2 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, nonverbal, 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 4 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 5 PREVALENCE AND CONSEQUENCES IN THE GENERAL HOSPITAL SETTING Prevalence of violence & aggression % Consequences of violence & aggression In the past 12 months1 51 In the past 12 months1 Verbal Physical Threats 46 17 16 Emotionally upsetting 90 Physical 15 In the week prior to data collection1 11 Verbal Physical Threats 67 20 7 3 multiple responses possible (Hahn et al. 2012a, 2012b) % Participants: 2495 health care staff, nursing staff, medical doctors, physical therapists, occupational therapists, nutritionists, medical assistants, radiology assistants ward secretaries etc. (response = 52%) 6 INTERACTION Staff • Profession • Gender • Age • Experience • Attitude and perception • Closeness of patient and visitor contact • Consequences • Training in aggression management • ... Workplace/Organisational Context • Architectural work environment • Organisational work environment • Regulations • Information strategies • .... Interaction Violence - Aggression Interaction • Intervention or treatment • Information management • .... Patient/Visitor • Gender • Age • Health condition: Physical illness, Mental state • Emotional condition • Knowledge (situational) • … 7 INFLUENCE OR RISK FACTORS IN GENERAL HOSPITALS 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) 8 INFLUENCE OR RISK FACTORS RESULTS: EXAMPLE 1 - INTENSIVE CARE Zur Anzeige wird der QuickTime™ Dekompressor „“ benötigt. Zur Anzeige wird der QuickTime™ Dekompressor „“ benötigt. Zur Anzeige wird der QuickTime™ Dekompressor „“ benötigt. 9 INFLUENCE OR RISK FACTORS IN GENERAL HOSPITALS Higher risk Lower risk Profession Medical doctors Professional level Students Attitude Aggression is emotionally letting off steam Preventive 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) 10 INFLUENCE OR RISK FACTORS IN GENERAL HOSPITALS 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) 11 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.). 12 (Hahn et al. 2009) THERE IS NO WORLD WITHOUT AGGRESSION OR VIOLENCE…. - 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. 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. 13 BEST PRACTICE SAVEinH A global Strategies Addressing ViolencE in Hospitals Advance notice Prevention Early warning signs Safe environment Information strategy Escalation Intervention De-escalation Medication Crisis Recovery Intervention Protection of self and others Security service Self-defense techniques Maybe Depression Reflexion Aftercare for workers, patients, relatives of patients Documentation Group reflexion Interdisciplinary support and collaboration Concept of advanced interdisciplinary training Security Service Aftercare and support Controlling Normal behaviour Clear Attitude & Definition Quality measures and Quality development programmes SAVEinH Guideline & Standards Clear and suitable public information Technical and structural means and conditions 14 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. 15 BEST PRACTICE EDUCATION AND TRAINING WITH SP’s 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 deescalation competences in a safe setting. Increased level of learning due to experiencing own emotions combined with the training situation. 16 BEST PRACTICE SAVEinH Strategies Addressing ViolencE in Hospitals 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. 17 17 THERE IS NO WORLD WITHOUT AGGRESSION OR VIOLENCE…. 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 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). 18 THANK YOU FOR YOUR ATTENTION For more information, please contact Sabine Hahn, sabine.hahn@bfh.ch 19