Monitoring Health Care Worker Aggression Exposure
Monitoring Health Care Worker Aggression Exposure
Two interlocking areas must be addressed to improve understanding of patient aggression and worker aggression exposure. First, monitoring or surveillance of aggressive events in health care systems should be routine. This will positively impact efforts to prevent patient aggression and its many important consequences, including worker health and safety. Second, common measures must be developed and used to identify events, their characteristics, interventions, related exposures and patient and worker outcomes or sequelae from events.
For many years, researchers and clinicians have identified the need to monitor aggression in hospitals. However, monitoring is not yet comprehensive or standardized. This hinders efforts to evaluate change due to interventions and to monitor worker safety, even in psychiatric settings where rates and safety risks tend to be highest (Arnetz, Aranyos, Ager, & Upfal, 2011; Hahn et al., 2008; Lanza, 1988; Lanza, 1991; Lion, Snyder, Merrill, 1981; Nijman, Bowers, Oud, & Jansen, 2005a). The full range of aggression is not routinely monitored. Ignoring lower level aggressive events is detrimental to measurement, intervention, and improving patient and worker safety. Without routine comprehensive measurement of aggressive events, one cannot determine the probability of a particular type of aggressive event or a positive or negative event outcome. Monitoring to acquire the baseline incidence and prevalence of all types of aggressive events across the entire continuum of aggression (e.g., verbal, physical) would be useful to evaluate the effectiveness of preventive intervention.
National standards require hospitals to monitor events of injury or illness to workers and patient restraint (OSHA, 2001; The Joint Commission, 2010; 2011); however due to the challenges discussed above, these often identify only a fraction of aggressive events. They typically represent serious events, higher on the aggression continuum, which have had a negative or untoward outcome in terms of worker or patient safety and liability (Arnetz, 1998; Ross, Bowers, & Stewart, 2012). Rate differences between standard and scale measures demonstrate that the majority of events are successfully resolved short of restraint or injury and do not have negative outcomes. Thus efforts to better understand successful resolution of aggression via monitoring and evaluation may be of low priority. However, due to likely under-reporting; the possibility of multiple negative outcomes; and many events that are 'near misses' of sentinel events (e.g., restraint, injury), interventions to support a successful resolution to an aggressive event should be better understood. We also know that psychological effects after non-physical events are greater than after physical events; overlooking this aspect limits our understanding of how to reduce worker risk (Gerberich et al., 2004).
If an aggressive event results in seclusion and restraint, there is often debriefing of staff involved. Debriefing offers a chance for reflection on the episode, learning from the experience, and planning for future prevention and intervention. Events where interventions were less successful are carefully examined. However, successfully resolved events are not typically examined to learn what worked and thus insight from the majority of aggressive events and the interventions that resolved them is not systematically evaluated. To change this, measures need to identify patient aggression and worker exposure as well as antecedents, interventions, and outcomes for patients and workers. Identification of the trajectory of behavior and intervention(s) across all levels of aggressive events can provide insight to improve intervention. Current measures tend to either identify only patient aggression or worker exposure; without providing a comprehensive understanding.
Improvement of the measurement of aggression may help eliminate undercounting of aggressive events in health care settings. Required debriefings after sentinel events aid in understanding root causes and planning effective intervention. This process should also be studied, if possible, using an experimental design to examine other events across the aggression continuum and potential interventions. Comprehensive data collected from both the patient and worker safety perspective may improve approaches to patient aggression management and workplace safety and health.
An appropriate first goal is to use a measure that will help researchers quantify, as accurately as possible, the number and characteristics of aggressive events that health care providers are exposed to in the workplace. Counters to measure patient aggression have been introduced (Lanza, 2009; Ridenour, 2009), although reliability and validity have not been described. For these reasons, a pilot study was conducted by the authors to consider the feasibility of this relatively new exposure measure, handheld counters.
The Need for Monitoring and Improved Measurement of Aggression in Health Care
Two interlocking areas must be addressed to improve understanding of patient aggression and worker aggression exposure. First, monitoring or surveillance of aggressive events in health care systems should be routine. This will positively impact efforts to prevent patient aggression and its many important consequences, including worker health and safety. Second, common measures must be developed and used to identify events, their characteristics, interventions, related exposures and patient and worker outcomes or sequelae from events.
Monitoring
For many years, researchers and clinicians have identified the need to monitor aggression in hospitals. However, monitoring is not yet comprehensive or standardized. This hinders efforts to evaluate change due to interventions and to monitor worker safety, even in psychiatric settings where rates and safety risks tend to be highest (Arnetz, Aranyos, Ager, & Upfal, 2011; Hahn et al., 2008; Lanza, 1988; Lanza, 1991; Lion, Snyder, Merrill, 1981; Nijman, Bowers, Oud, & Jansen, 2005a). The full range of aggression is not routinely monitored. Ignoring lower level aggressive events is detrimental to measurement, intervention, and improving patient and worker safety. Without routine comprehensive measurement of aggressive events, one cannot determine the probability of a particular type of aggressive event or a positive or negative event outcome. Monitoring to acquire the baseline incidence and prevalence of all types of aggressive events across the entire continuum of aggression (e.g., verbal, physical) would be useful to evaluate the effectiveness of preventive intervention.
National standards require hospitals to monitor events of injury or illness to workers and patient restraint (OSHA, 2001; The Joint Commission, 2010; 2011); however due to the challenges discussed above, these often identify only a fraction of aggressive events. They typically represent serious events, higher on the aggression continuum, which have had a negative or untoward outcome in terms of worker or patient safety and liability (Arnetz, 1998; Ross, Bowers, & Stewart, 2012). Rate differences between standard and scale measures demonstrate that the majority of events are successfully resolved short of restraint or injury and do not have negative outcomes. Thus efforts to better understand successful resolution of aggression via monitoring and evaluation may be of low priority. However, due to likely under-reporting; the possibility of multiple negative outcomes; and many events that are 'near misses' of sentinel events (e.g., restraint, injury), interventions to support a successful resolution to an aggressive event should be better understood. We also know that psychological effects after non-physical events are greater than after physical events; overlooking this aspect limits our understanding of how to reduce worker risk (Gerberich et al., 2004).
Measurement
If an aggressive event results in seclusion and restraint, there is often debriefing of staff involved. Debriefing offers a chance for reflection on the episode, learning from the experience, and planning for future prevention and intervention. Events where interventions were less successful are carefully examined. However, successfully resolved events are not typically examined to learn what worked and thus insight from the majority of aggressive events and the interventions that resolved them is not systematically evaluated. To change this, measures need to identify patient aggression and worker exposure as well as antecedents, interventions, and outcomes for patients and workers. Identification of the trajectory of behavior and intervention(s) across all levels of aggressive events can provide insight to improve intervention. Current measures tend to either identify only patient aggression or worker exposure; without providing a comprehensive understanding.
Improvement of the measurement of aggression may help eliminate undercounting of aggressive events in health care settings. Required debriefings after sentinel events aid in understanding root causes and planning effective intervention. This process should also be studied, if possible, using an experimental design to examine other events across the aggression continuum and potential interventions. Comprehensive data collected from both the patient and worker safety perspective may improve approaches to patient aggression management and workplace safety and health.
An appropriate first goal is to use a measure that will help researchers quantify, as accurately as possible, the number and characteristics of aggressive events that health care providers are exposed to in the workplace. Counters to measure patient aggression have been introduced (Lanza, 2009; Ridenour, 2009), although reliability and validity have not been described. For these reasons, a pilot study was conducted by the authors to consider the feasibility of this relatively new exposure measure, handheld counters.
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