Monitoring Health Care Worker Aggression Exposure
Monitoring Health Care Worker Aggression Exposure
The Aggression Exposure Pilot Study was conducted to obtain measures of worker exposure to patient aggression using a combination of a handheld counter and a log. The purpose was to assess the usefulness and efficiency of the counters with the intent to use them in a larger participatory action research study designed to examine exposure to workplace aggression in a more comprehensive way.The study was approved by the Institutional Review Board at both the hospital and the researchers' university.
The pilot study took place with clinical workers from the acute inpatient psychiatric setting, recruited by trained research staff during change of shift meetings. Clinical workers were provided with a brief explanation of the pilot purpose and methods. We recruited 11 workers across multiple shifts who agreed to allow the researchers to shadow them as they physically used the handheld counters to record their aggression exposure. Researchers also recorded field notes during the shadowing time.
A handheld counter, researcher-created log, the SOAS-R and PCC-SR scales, and unit-level rates of restraint and injury were the data collection methods piloted in this study. The small hand held counter (see author photo in Figure 4) was attached to a coil bracelet with one side marked 'v' for verbal events and the other side 'p' for physical events. As a clinical worker was exposed to an event, the researcher 'clicked' the counters to register the event and immediately after an event documented it on the log. Logs provided information on the patient; severity of event (range 1 to 5); date and time; risk factors present; and a brief event description. If no events occurred, a '0' was entered on the log (see Figure 5). The counters provided a worker exposure rate each shift. If completed by all workers, a patient rate of aggression and a trajectory of events across shifts can then be calculated by compiling the events by time, patient demographic information, and event descriptors. The SOAS-R and PCC-SR scales were completed by the participants. Routinely documented unit rates of restraint and injury were also collected to allow comparison between all measures during the pilot data collection period.
(Enlarge Image)
Figure 4.
Example of Handheld Counter
(Enlarge Image)
Figure 5.
Aggression Exposure Counter Shift Log
Worker event exposure in the pilot study demonstrated great variability. For example on the first day of the pilot, the participating clinical workers and researchers were not exposed, but a large number of other workers that shift were exposed to a patient who was yelling loudly, and then disrobed and jumped on the nurses' station. Over the prior six months there had been an average of two assaults and one injury per week due to aggression. Table 4 lists data from the pilot shifts. There were no restraints or injury reports returned over the 11 shifts. Use of counters indicated that four workers had exposure to 8 events (6 verbal, 1 both verbal and physical, 1 physical), while seven workers had no aggression exposure during the piloted shifts. Conversely, the end of shift form, the PCC-SR, indicated only 3 events, 1 verbal and 2 physical, across pilot shifts (Table 4).
The pilot study provided insight into data collection using the handheld counters and logs and similarities and differences from other data collection methods. A review of data collected and field notes recorded during the piloting of all measures helped to identify strengths and limitations of each measure and considerations for use in other clinical settings. An asset of use of the SOAS-R was the identification of the target, consequences, and interventions related to each event. This information was not consistently available from the counter/logs nor the PCC-SR. If completed consistently, the SOAS-R should identify the same events as the counter and logs, thus this would likely result in underreporting using the SOAS-R due to redundancy.
The PCC-SR identified aggressive events and patient conflict and containment, and nursing care activities (i.e. hygiene, medication administration), providing a measure of some nursing care demands. Nursing staff participation and 'buy-in' was important, and accuracy was dependent on the charge nurse's role and team communication. For example, on some units and shifts the charge nurse is visibly engaged in the milieu, while in others the charge nurse is scheduled to attend meetings and complete other duties. Despite this variability by unit, the charge nurse was aware of more severe events, providing information on the more serious or extreme events and neglecting lower level events like verbal aggression or refusal of meals or hygiene. The PCC-SR does not require the nurse to consult with all staff members to record events, relying on unit communication processes and thus may result in inaccuracies (i.e. minor or moderate incidents that are resolved may not be communicated). Single events involving many behaviors cannot be identified from this scale, thus if there were 3 verbal, 4 physical and 2 refusals of meal identified, this might represent a total of 4 or 9 individual events. The PCC-SR picked up events the other measures did not, but with the limitation that they were neither patient- nor worker-specific events.
Compared to the SOAS-R and PCC-SR, the counter logs collected worker exposure and narrative information about events. Use of counters measured worker exposure, and provided recognition of the difficult behaviors workers manage daily. Some staff felt using counters acknowledged and validated the work rarely noticed by themselves or others. In addition staff often identified renewed awareness of the need for good self care given the regular exposure to difficult behavior at work. To provide a more comprehensive perspective, logs should include post event information such as consequences (e.g., injury, damage, adverse patient or staff effects); interventions; whether events were documented or reported; and debriefing or care planning.
The Aggression Exposure Pilot and Lessons Learned
The Aggression Exposure Pilot Study was conducted to obtain measures of worker exposure to patient aggression using a combination of a handheld counter and a log. The purpose was to assess the usefulness and efficiency of the counters with the intent to use them in a larger participatory action research study designed to examine exposure to workplace aggression in a more comprehensive way.The study was approved by the Institutional Review Board at both the hospital and the researchers' university.
Setting and Participants
The pilot study took place with clinical workers from the acute inpatient psychiatric setting, recruited by trained research staff during change of shift meetings. Clinical workers were provided with a brief explanation of the pilot purpose and methods. We recruited 11 workers across multiple shifts who agreed to allow the researchers to shadow them as they physically used the handheld counters to record their aggression exposure. Researchers also recorded field notes during the shadowing time.
Data Collection
A handheld counter, researcher-created log, the SOAS-R and PCC-SR scales, and unit-level rates of restraint and injury were the data collection methods piloted in this study. The small hand held counter (see author photo in Figure 4) was attached to a coil bracelet with one side marked 'v' for verbal events and the other side 'p' for physical events. As a clinical worker was exposed to an event, the researcher 'clicked' the counters to register the event and immediately after an event documented it on the log. Logs provided information on the patient; severity of event (range 1 to 5); date and time; risk factors present; and a brief event description. If no events occurred, a '0' was entered on the log (see Figure 5). The counters provided a worker exposure rate each shift. If completed by all workers, a patient rate of aggression and a trajectory of events across shifts can then be calculated by compiling the events by time, patient demographic information, and event descriptors. The SOAS-R and PCC-SR scales were completed by the participants. Routinely documented unit rates of restraint and injury were also collected to allow comparison between all measures during the pilot data collection period.
(Enlarge Image)
Figure 4.
Example of Handheld Counter
(Enlarge Image)
Figure 5.
Aggression Exposure Counter Shift Log
Pilot Results
Worker event exposure in the pilot study demonstrated great variability. For example on the first day of the pilot, the participating clinical workers and researchers were not exposed, but a large number of other workers that shift were exposed to a patient who was yelling loudly, and then disrobed and jumped on the nurses' station. Over the prior six months there had been an average of two assaults and one injury per week due to aggression. Table 4 lists data from the pilot shifts. There were no restraints or injury reports returned over the 11 shifts. Use of counters indicated that four workers had exposure to 8 events (6 verbal, 1 both verbal and physical, 1 physical), while seven workers had no aggression exposure during the piloted shifts. Conversely, the end of shift form, the PCC-SR, indicated only 3 events, 1 verbal and 2 physical, across pilot shifts (Table 4).
Lessons Learned
The pilot study provided insight into data collection using the handheld counters and logs and similarities and differences from other data collection methods. A review of data collected and field notes recorded during the piloting of all measures helped to identify strengths and limitations of each measure and considerations for use in other clinical settings. An asset of use of the SOAS-R was the identification of the target, consequences, and interventions related to each event. This information was not consistently available from the counter/logs nor the PCC-SR. If completed consistently, the SOAS-R should identify the same events as the counter and logs, thus this would likely result in underreporting using the SOAS-R due to redundancy.
The PCC-SR identified aggressive events and patient conflict and containment, and nursing care activities (i.e. hygiene, medication administration), providing a measure of some nursing care demands. Nursing staff participation and 'buy-in' was important, and accuracy was dependent on the charge nurse's role and team communication. For example, on some units and shifts the charge nurse is visibly engaged in the milieu, while in others the charge nurse is scheduled to attend meetings and complete other duties. Despite this variability by unit, the charge nurse was aware of more severe events, providing information on the more serious or extreme events and neglecting lower level events like verbal aggression or refusal of meals or hygiene. The PCC-SR does not require the nurse to consult with all staff members to record events, relying on unit communication processes and thus may result in inaccuracies (i.e. minor or moderate incidents that are resolved may not be communicated). Single events involving many behaviors cannot be identified from this scale, thus if there were 3 verbal, 4 physical and 2 refusals of meal identified, this might represent a total of 4 or 9 individual events. The PCC-SR picked up events the other measures did not, but with the limitation that they were neither patient- nor worker-specific events.
Compared to the SOAS-R and PCC-SR, the counter logs collected worker exposure and narrative information about events. Use of counters measured worker exposure, and provided recognition of the difficult behaviors workers manage daily. Some staff felt using counters acknowledged and validated the work rarely noticed by themselves or others. In addition staff often identified renewed awareness of the need for good self care given the regular exposure to difficult behavior at work. To provide a more comprehensive perspective, logs should include post event information such as consequences (e.g., injury, damage, adverse patient or staff effects); interventions; whether events were documented or reported; and debriefing or care planning.