BERN

1. Expertise in Clinical Aggression:Knowledge Transfer, from Research to Best Practice Prof. Sabine Hahn, PhD, MNSc, CNS

2. BERN

3. Content • Definition • What we know • Prevalence, • Influencing factors. • Best practice transfer: SAVEinH • Professional organisations, • Health professionals, • Education, • Research, • Politics.

4. 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

5. 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)

6. PREVALENCE AND CONSEQUENCES IN THE GENERAL HOSPITAL SETTING • Participants: 2495 health care staff, nursing staff, medical doctors, physical therapists, occupational therapists, nutritionists, medical assistants, radiology assistants ward secretaries etc. (response = 52%) 3multiple responses possible (Hahn et al. 2012a, 2012b)

7. INTERACTION • 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 • ... • Patient/Visitor • Gender • Age • Health condition: Physical illness, Mental state • Emotional condition • Knowledge (situational) • … InteractionViolence - Aggression • Interaction • Intervention or treatment • Information management • ....

8. INFLUENCE OR RISK FACTORSIN GENERAL HOSPITALS (Hahn et al. 2009; Hahn & Metzenthin, 2010; Afzali et al. 2010; Hahn et al. 2012a, 2012b, 2013) 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

9. RESULTS: EXAMPLE 1 - INTENSIVE CARE INFLUENCE OR RISK FACTORS

10. INFLUENCE OR RISK FACTORS IN GENERAL HOSPITALS (Participants: 2495 health care staff, in Hahn et al. 2012b)

11. INFLUENCE OR RISK FACTORS IN GENERAL HOSPITALS (Hahn et al. 2012a, 2012b)

12. 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)

13. 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.

14. BEST PRACTICE SAVEinHA global Strategies AddressingViolencE in Hospitals Advance notice Crisis Maybe Depression Escalation Recovery Intervention Protection of self and othersSecurity service Self-defense techniques Reflexion Aftercare for workers, patients, relatives of patients Documentation Group reflexion Intervention De-escalation Medication Prevention Early warning signs Safe environment Information strategy Interdisciplinary support and collaboration Security Service Aftercare and support Controlling Concept of advanced interdisciplinary training Normal behaviour SAVEinH Clear and suitable public information Clear Attitude & Definition Quality measures and Quality development programmes Technical and structural means and conditions Guideline & Standards

15. 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.

16. 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 de-escalation competences in a safe setting. • Increased level of learning due to experiencingown emotions combined with the training situation.

17. BEST PRACTICE SAVEinHStrategies AddressingViolencEinHospitals 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.

18. 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).

19. THANK YOU FOR YOUR ATTENTION For more information, please contact Sabine Hahn,sabine.hahn@bfh.ch