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

2. BERN 2

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

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 4

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) 5 5

6. PREVALENCE AND CONSEQUENCES IN THE GENERAL HOSPITAL SETTING 6 Prevalence of violence & aggression % In the past 12 months 1 51 Verbal Physical Threats 46 17 16 In the week prior to data collection 1 11 Verbal Physical Threats 67 20 7 3 multiple responses possible Consequences of violence & aggression % In the past 12 months 1 Emotionally upsetting90 Physical15 Participants: 2495 health care staff, nursing staff, medical doctors, physical therapists, occupational therapists, nutritionists, medical assistants, radiology assistants ward secretaries etc. (response = 52%) (Hahn et al. 2012a, 2012b)

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

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

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

10. Higher riskLower risk ProfessionMedical doctors Professional levelStudents Attitude Aggression is emotionally letting off steam Preventive measures against violence is important AgeYounger staff up to age 30 Patients’ ageOver 65 years Visitor contact Husbands, wives, partners, siblings Training in aggression management Yes (only 16% have a training in aggression management) (Participants: 2495 health care staff, in Hahn et al. 2012b) INFLUENCE OR RISK FACTORS IN GENERAL HOSPITALS 10

11. PatientCharacteristics Healthcognitive impairment, pain, substance intoxication, withdrawal, mental or behavioural disorders, disorders of the blood and immune system Emotionsfrustration, dissatisfaction, anxiety and stress Orientation deficits in comprehending the situation, low level of information provided Ageover 65 years (geriatric wards for patients between 71 and 80 years, surgery for patients between 18 and 24 years) Genderresults inconsistent VisitorCharacteristics Emotionsanxious, having excessive demands, insecure in the situation, dissatisfied with therapy Orientationlow level of information (Hahn et al. 2012a, 2012b) INFLUENCE OR RISK FACTORS IN GENERAL HOSPITALS 11

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) 12

13. 13 -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. THERE IS NO WORLD WITHOUT AGGRESSION OR VIOLENCE…. 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 SAVEinH A global Strategies Addressing ViolencE in Hospitals Security Service Advance notice Escalation Crisis Recovery Maybe Depression Prevention Early warning signs Safe environment Information strategy Intervention De-escalation Medication Intervention Protection of self and others Security service Self-defense techniques Reflexion Aftercare for workers, patients, relatives of patients Documentation Group reflexion Concept of advanced interdisciplinary training Interdisciplinary support and collaboration Aftercare and support Controlling SAVEinH Quality measures and Quality development programmes Technical and structural means and conditions Normal behaviour Clear Attitude & Definition Guideline & Standards Clear and suitable public information 14

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. 15

16.  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 experiencing own emotions combined with the training situation. BEST PRACTICE EDUCATION AND TRAINING WITH SP’s 16

17. 17 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. BEST PRACTICE SAVEinH Strategies Addressing ViolencE in Hospitals 17

18. 18 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 THERE IS NO WORLD WITHOUT AGGRESSION OR VIOLENCE…. 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 19