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Violence in hospitals: recommended interventions

A key finding is that there is no simple solution.
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Violence in hospitals: recommended interventions

Violence in hospitals: recommended interventions

19 March 2021

By Gaby Grammeno

A project aiming to understand and prevent work-related violence in hospital settings has highlighted the complex nature of the problem - involving many drivers and contributing factors - and created a roadmap that may be adapted to help tackle violence in other types of workplaces.
A key finding is that there is no simple solution – a multi-pronged response is the most effective way to manage the risk.

The problem

Work-related violence is a complex and growing issue that has significant personal, societal and economic costs in a wide range of occupations and industries. Healthcare and the hospital system in particular is notorious for the risk of violent incidents affecting staff.
Work-related violence includes any form of assault, such as biting, spitting, scratching, hitting, kicking, punching, pushing, shoving, tripping, grabbing or throwing objects; any form of indecent physical contact; and intimidating behaviour that creates a fear of violence, such as stalking or threatening to do any of the above.
The report notes that while estimates vary, indications are that up to 98% of emergency department staff experience physical or verbal forms of occupational violence. The World Health Organisation’s data suggested in 2020 that between 8% and 38% of all healthcare workers will suffer physical violence during their careers.

This scale of violence has been confirmed locally, with a 2019 survey of nurses and midwives in NSW finding that close to half had experienced an episode of violence in the past week.
Action is clearly required, but to date, efforts to control the risk have demonstrated that the complexity of the issue in hospital settings is such that it is very difficult to understand and manage.

The study

In a major research project funded by SafeWork NSW, the University of the Sunshine Coast's Centre for Human Factors and Sociotechnical Systems applied a ‘systems thinking’ approach to workplace violence in hospital settings, with the intention of developing a set of interventions to prevent it.

The research involved a series of workshops with stakeholders who either currently share the responsibility for designing and implementing violence prevention strategies in the healthcare sector, or are experienced in human factors and systems thinking.
The three phases of the study aimed to reveal the stakeholders (‘actors’) who share the responsibility for work-related violence in NSW hospital settings, the factors that interact to create the violence, and networks of potential interventions that could enhance the prevention and management of the violence.
The findings demonstrate that the scope for work-related violence can be influenced by a large and diverse set of ‘actors’ (as distinct from perpetrators) spanning multiple levels of the hospital system. It is not a problem relating solely to patients, healthcare workers and security staff.
Similarly, the study revealed that work-related violence incidents in hospital settings are caused by multiple contributory factors from across the hospital system and involve many different causal pathways. For example, aspects of staffing that can affect the likelihood of violence include recruitment processes, salary levels, training and education, rostering and planning, staff shortages, and healthcare workers’ levels of knowledge, skill and experience.
Improved prevention and management of work-related violence can therefore only be achieved through system reform.
To facilitate the identification of specific ‘leverage points’ where interventions could potentially have widespread effects on multiple contributory factors, a series of key themes were identified, including:
  • risk management
  • the provision of sufficient and capable staffing
  • timely and effective incident response
  • promoting the safety and dignity of patients and healthcare workers
  • incident reporting and learning systems
  • managing the risk of patients with a high propensity of violence
  • the design of hospital environments
  • collaboration, consultation and coordination across the hospital settings system, and
  • public attitudes and behaviours towards healthcare workers.

The study’s authors recommended that these themes be the immediate focus of future efforts to improve work-related violence prevention and management in hospital settings.
The final phase of the research focused on potential interventions that could be explored in response to each of the key themes. These include a range of interlinked interventions spanning all levels of the hospital setting system.
A synthesis of the preventive strategies revealed a core set of nine interventions which could have multiple positive impacts throughout the hospital system. It is recommended that stakeholders further investigate these nine interventions with a view to further development and implementation in the short term.
In particular, the establishment of an independent multi-agency collaboration group is recommended as an important first step towards improved prevention and management of work-related violence in hospital settings in NSW.
Understanding and preventing work-related violence in hospital settings: A systems thinking approach, Final Report, Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, February 2021

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