Managing workplace violence against health care workers: education alone is not enough

Health care workers are constantly faced with the possibility of occupational violence from patients, visitors, and others. Occupational violence encompasses any physical or verbal aggressive behavior, including abuse, threats, or assault, occurring in the workplace.1 Within acute hospital settings, reports of verbal, physical, sexual, psychological, and emotional violence are increasingly reported, with the outcomes affecting workers physically and psychosocially.2 Exposure to and subsequent trauma from such incidents can affect individuals in numerous ways, such as reduced work performance; increased cynicism; burnout; and feelings of isolation, depression, fear, negativity, and anxiety. Organizational outcomes of occupational violence include increased absenteeism, high staff turnover, and poor recruitment and retention.2,3 Given the risks to staff and organizational productivity, many health care institutions are turning their attention toward implementation of strategies to equip staff with the skills and required knowledge to assess the risk of occupational violence and, where appropriate, de-escalate the situation to ensure their safety. This issue of JBI Evidence Synthesis includes our systematic review synthesizing the available evidence on the impact of educational programs and interventions for health care staff to prevent and manage aggressive behaviors in acute hospitals.4 Education programs aim to prepare health care workers to recognize and respond appropriately to potentially violent situations. However, due to low-level study designs and inconsistent reporting across the studies included in our review, certainty regarding the most effective education intervention to prevent and manage aggressive behaviors is unclear.4 Furthermore, self-reported outcome measures, such as levels of confidence, attitudes, or knowledge, may not be indicative of a person's ability to diffuse or manage violent situations. Some authors suggest that programs focusing on skill mastery may be more effective for de-escalation strategies5; however, appropriate and consistent measures are needed to ascertain the most effective modality and intensity of educational interventions for preventing violence. Nevertheless, our systematic review provides valuable insights into how educators could strengthen the design of educational interventions related to the topic.4 More specifically: Although the educational content was variable, common components included risk assessment, communication, and de-escalation. Most interventions were delivered using a multi-modal approach, with both theoretical and practical components. When measuring occupational violence incidents, investigators should consider issues of under-reporting. Self-reported measures are convenient but also prone to detection bias that could inflate outcomes. Scales do exist for objectively assessing the effect of education in skill or competency.6 Many studies were prone to information bias because measures (self-reported) were taken immediately after the intervention. Longer-term follow-up with repeated measures will assist in identifying the sustainability of programs. Validated tools also exist for measuring attitudes and confidence, and these should be considered for use prior to researchers developing new tools. When using validated tools, investigators should conform to scoring conventions set by the tool developers. Variations make it more difficult to synthesize evidence and impede generalizability of results. The results of the review identified that, in certain contexts, such as emergency departments or mental health settings, staff are at higher risk of exposure to violent behaviors from patients and/or visitors.4,7 Additionally, staff at rural and remote facilities report higher exposure to occupational violence due to unique factors, such as geographical distance from back-up teams; limited access to resources; and other limitations, including poor telecommunication support.8 Due to the potential for the adverse outcomes we have described, some organizations mandate that workers undertake training in programs designed to recognize and de-escalate potentially aggressive situations. A multifaceted approach is suggested, whereby health care workers are educated on how to assess patient behaviors and risk for violence,9 as well as how to safely respond to situations. As mentioned, under-reporting of violent incidents is another important consideration. Under-reporting may lead to misrepresentation of the extent and severity of the issue, and also affects the ability of organizations to develop preventive strategies, as not all issues surrounding the incident may be reported. Staff may under-report for several reasons, including fear of reprisal, perception of the incident, embarrassment, or as a reflection of the culture of the organization.10 Feeling psychologically safe to report such incidents requires leadership and organizational support to develop a safety culture. It is imperative to cultivate an understanding of the underlying causes of under-reporting and formulate precise and credible mechanisms tailored for this purpose. There is value in simplifying the reporting process for health care professionals by devising user-friendly tools. The devastating impact of violent workplace attacks on health care workers across all disciplines is too serious to ignore. Global instability, war, the COVID-19 pandemic, and other international concerns have had horrific consequences on health care workers. Organizations such as the World Health Organization, World Medical Association, and the International Council of Nurses are working on responses to these events.11,12 While legislation is one suggested strategy, health care policies, procedures, and processes for preventing and managing workplace violence are essential at local levels also, and should be informed by robust evidence, supporting the need for additional resources and funding for further multidisciplinary research. Reviewing the available evidence clearly indicates that there is no one-size-fits-all solution to the problem. Our review highlights that education programs require careful consideration, and that a combination of approaches are needed to equip health care workers with the knowledge, skills, and confidence to manage aggressive situations.4