Evidence Based Practice: For nurses, will the use of de-escalation techniques as compared to no use of de-escalation techniques reduce workplace violence?

C L I N I C A L

Natalie Cal Indiana Uni

Angie Lewi Indianapolis

Scott Showe Health, Ind

Norma Hal Indianapolis

For correspo Methodist H E-mail: ncal

J Emerg Nu Available on 0099-1767

Copyright © All rights re

http://dx.do

January 2

LITERATURE SYNTHESIS: PATIENT AGGRESSION RISK ASSESSMENT TOOLS IN THE EMERGENCY

DEPARTMENT

Authors: Natalie Calow, BSN, RN, Angie Lewis, BSN, RN, Scott Showen, BSN, RN, and Norma Hall, DNP, RN, Indianapolis, IN

M ultiple risk assessment tools have been developed to prevent violent behavior of patients. The purpose of a risk assessment tool is to prevent

injury to health care workers, prevent suicide, and de- escalate a patient before a violent act occurs. A risk assessment tool can be used by nurses to identify interventions and to protect themselves or their organiza- tion from potential poor decision making and poor outcomes when a violent event occurs.1

Risk assessment tools have been developed specifically for the emergency department and psychiatric, medical-surgical, and critical care units. Some adaptation of risk assessment tools has happened over the years depending on the setting in which the tool was used, inpatient versus outpatient. An important factor to consider when choosing a risk assessment tool is a review of the literature to determine the validity of the risk assessment tool because often there is no evidence that a particular tool is valid.1 A non-valid risk assessment tool can actually do more harm than good because the tool might give a worker a false sense of security.1

Aims and Objectives

Nurses play a vital role in controlling and de-escalating violent behavior in the emergency department. Evidence-

ow, Member, Indy Roadrunners Chapter, is LEAN Facilitator, versity Health Methodist Hospital, Indianapolis, IN.

s is Staff RN, Indiana University Health West Hospital, , IN.

n is Staff RN, Riley Hospital for Children, Indiana University ianapolis, IN.

l is Assistant Professor of Nursing, University of Indianapolis, , IN.

ndence, write: Natalie Calow, BSN, Indiana University Health ospital, 1604 N Capitol Ave, B107, Indianapolis, IN 46202; [email protected].

rs 2016;42:19-24. line 25 March 2015

2016 Emergency Nurses Association. Published by Elsevier Inc. served.

i.org/10.1016/j.jen.2015.01.023

016 VOLUME 42 • ISSUE 1

based risk management should be emphasized to assess and reduce violent behavior, but there appears to be a noticeable lack of assessment tools and interventions available.2 In addition, few programs are based on a systematic evaluation of outcomes, and there is little information available to support health care providers in choosing one program over another.3

The purpose of this systematic review of the literature was to evaluate the use of aggression risk assessment tools regarding workplace violence (WPV) in the emergency department and the reduction of the future risk of violence toward ED health care staff. The research question addressed in this systematic review was as follows: Does the use of an aggression risk assessment tool reduce the future risk of violence toward the health care worker? The focus was on reduction of potential violence toward staff in the ED setting.

Methods

Evaluation of the evidence was completed using a 7-step systematic review method.4 The 7 steps are formulating a research question, developing a research protocol, com- mencing a literature search, performing data extraction, conducting a quality appraisal, performing data analysis and reviewing the results of the included studies, and interpret- ing the results.4

The initial search inquiry used 3 electronic databases: CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus with Full Text, Medline, and PsycINFO. Limitations were set to include only research conducted in the period from January 2009 through September 2014, English-language studies, and research published in peer- reviewed journals. In an effort to gain the greatest depth of knowledge, the following search terms were used in multiple combinations: WPV, violence, patient aggression, patient assault, aggression risk assessment tool, violence risk assessment tool, predicting violent behavior, nursing, and emergency department. The initial search using the combination of search terms yielded 589 research journal

WWW.JENONLINE.ORG 19

CLINICAL/Calow et al

articles. Internet searches of government Web sites and professional organizations were also conducted, producing position statements, toolkits, and discussion papers regarding WPV in the emergency department. In addition, references of articles were scanned to identify additional relevant articles. A preliminary review of the literature for inclusion was conducted by reviewing the title of the article for relevancy (N = 589). A further review of the literature for inclusion was conducted by reviewing the abstract of the article (N = 56). Our final review of the literature for inclusion was conducted by a full review of the article (N = 13).

INCLUSION AND EXCLUSION CRITERIA

Articles included in the synthesis of the literature were original research studies of any research design, written in the English language, published between the years 2009 and 2014, and published in peer-reviewed journals. Articles were also chosen based on answering the research question specifically addressing WPV in the ED setting and use of an aggression risk assessment tool. Because of the limited amount of research in the literature specific to violence risk assessment tools in the emergency department, the search was expanded to include violence risk assessment tools in the inpatient setting, including psychiatric and medical-surgical units.

Because the nature of this synthesis of the literature was to apply findings specifically to clinical practice in the ED and inpatient setting, research conducted in outpatient and extended-care facilities was excluded. Although multiple articles were available related to WPV in the ED setting, articles were excluded if they did not discuss the specific use of a tool to assess the risk of violent behavior from a patient toward a health care worker.

An exception to the inclusion criteria was the use of articles published in 2007 specific to the Staring, Tone and volume of voice, Anxiety, Mumbling, and Pacing (STAMP) violence risk assessment framework.5 Several studies following the 2007 publication of research related to the STAMP violence risk assessment framework have cited STAMP as foundational work regarding violence risk assessment specific to the emergency department.

LITERATURE SYNTHESIS

The literature showed that violence risk assessment tools have been implemented in various health care settings (Appendix Table). In total, the use of 9 different violence risk assessment tools emerged from the literature across the various settings, 3 in emergency departments, 4 in psychiatric settings, and 2 in medical-surgical inpatient units. Although one specific violence risk assessment tool

20 JOURNAL OF EMERGENCY NURSING

was not consistently implemented across the literature, variations of the STAMP violence assessment framework emerged in 3 articles specific to the emergency depart- ment,5–7 variations of the Brøset Violence Checklist (BVC) emerged in 2 articles specific to psychiatric units,8,9 and a variation of the M55 Violence Risk Assessment Tool emerged in 2 studies in medical-surgical areas.10,11

ED SETTING

Three violence risk assessment tools implemented in the ED setting emerged from the literature: (1) STAMP violence assessment framework5–7; (2) Assessment, Behavioral indicators, and Conversation (ABC) of violence risk assessment at triage12; and (3) five attributes of caring to avert violence (being safe, being available, being respectful, being supportive, and being responsive).13

Themes that emerged from the use of violence risk assessment tools in the ED setting are early identification of high-risk behaviors and use of de-escalation techniques that could avert violence and protect staff and patients from potential injury in the emergency department. Behaviors identified as high risk for escalation to a violent event are as follows: staring/glaring at the caregiver, tone/increased volume, anxiety, mumbling, pacing, aggressive statements, belligerence, clenched fists, demanding attention, irritabil- ity, and hostility. Behaviors identified as effective de-escala- tion skills portrayed by caregivers are expressing empathy, using clear communication skills, being safe, being calm, being available, being respectful, being supportive, and being responsive. Violence risk assessment tools in the emergency department focus on the current assessment of the behaviors of the individual and do not require knowledge of a history of violence.

The STAMP violence assessment framework has been shown to be an effective tool in the early identification of violent behavior. The ABC of violence risk assessment at triage has shown potential to be an effective tool; however, clear validity and reliability are uncertain and need further validation. Although the five attributes of caring to avert violence are effective de-escalation behaviors and have been shown to reduce escalation of violence when used in nursing practice, the focus is on nurse behaviors rather than on identification of the risk that patients may have to become violent and, thus, could use further validation.

INPATIENT UNIT SETTING

Six violence risk assessment tools implemented in the inpatient setting (inpatient psychiatric and medical-surgical

VOLUME 42 • ISSUE 1 January 2016

Calow et al/CLINICAL

units) emerged from the literature: (1) BVC (6-item tool used to assess confusion, irritability, boisterousness, physical threat, verbal threat, and attack on objects)8,9; (2) Phillips Aggression Screen Tool (PAST) (screens for previous aggressive behavior, screens for psychological trauma, and observed patient behavior)14; (3) Risk of Harm to Others Clinical Assessment Protocol (ROH CAP) (decision tree that incorporates the presence of acts of aggressive behaviors in the past 3 days, extreme behavior, violent acts, intimidation, and/ or ideation in combination with other mental health symptoms such as psychosis)15; (4) Hospital Aggressive Behaviour Scale–Users (HABS-U) (10-item tool used to assess non-physical and physical potential of aggression)16; (5) M55 Violence Risk Assessment Tool (11-item tool used to assess confusion/cognitive impairment, drug/alcohol intoxication, agitation, shouting/demanding, history of physical aggression, withdrawn behavior, threatening to leave, physically aggressive/threatening behavior, verbally hostile/threatening behavior, suspiciousness, and presence of auditory/visual hallucinations)10; and (6) Aggressive Behavior Risk Assessment Tool (ABRAT) (10-item tool incorporating 6 items from M55 Violence Risk Assess- ment Tool and 3 items from STAMP violence assessment framework and adding history of signs and symptoms of mania).11

Themes that emerged from the use of violence risk assessment tools in the non-ED setting are early identification of aggressive/violent behavior and use of early restraint and/or seclusion that could avert violence and protect staff and patients from potential injury. Behaviors identified as high risk for escalation to a violent event are similar to behaviors identified for violence risk assessment tools used in the emergency department (staring/glaring at the caregiver, tone/ increased volume, anxiety, mumbling, pacing, aggressive statements, belligerence, clenched fists, demanding attention, irritability, and hostility); however, an additional assessment factor related to a recent history of violence in the days or weeks leading up to hospitalization was identified. In the inpatient setting, violence risk assessments of every patient were completed on admission to assess for early signs of aggression and the need for early intervention.

The BVC is the most prevalent violence risk assessment tool noted in the literature and shows the best validity and reliability. The additional violence risk assessment tools PAST, ROH CAP, HABS-U, and ABRAT have been shown to be effective tools in the early identification of violent behavior; however, further validation and reliability testing are recommended. The M55 Violence Risk Assessment Tool showed initial reliability and validity; however, one study has shown that this tool only predicted a small percentage of patients identified as at risk of becoming violent compared

January 2016 VOLUME 42 • ISSUE 1

with those who actually became violent, demonstrating the need for further evaluation prior to generalization.

Results

The STAMP tool was found to be used most frequently in the literature to identify patient behaviors leading up to a violent act in the ED setting.5–7 The BVC or a modification of the BVC was found to be the risk assessment tool most commonly used on the inpatient side of the hospital.8,9

Inpatient risk assessment tools were included in this literature review because of the adaptability of the tools to the ED patient population. Questions related to patient history of violence toward others might require further investigation on arrival to the emergency department if the inpatient risk assessment tools are implemented in the ED setting.

The inpatient risk assessment tools focused more on the reduction of seclusion and restraint use in patients, whereas the ED risk assessment tools focused on the identification of risk factors leading up to a violent act to reduce injury to staff. One inpatient study found the M55 tool unreliable at predicting patient aggression because the tool only identified a minority of the violent patients.10 The 12 other studies found their tools to be useful at predicting patient aggression and mitigating staff injury.

Limitations

A small sample size was noted for all the ED studies (N = 196) compared with the inpatient studies (N = 19,372). The reason for the small sample size in the ED studies is unknown, and further research in the ED setting studying the usefulness of risk assessment tools is recommended. Family members and non-psychiatric patients were not prevalent subject matters in this literature review but can be the source of violent acts. More research on this topic is suggested, and suggested interventions to mitigate violence would be useful.

Discussion

The findings suggest that the STAMP tool and the BVC are the most prevalent risk assessment tools used in the hospital to reduce violence toward staff members, which is consistent with previous research articles. No studies were found to dispute the validity or sensitivity of these 2 tools in our literature review. The STAMP tool and the BVC have distinctive observational behaviors to identify the potential for patient violence. Once a patient has been identified as at risk of being violent on arrival to the emergency department, interventions can be implemented to mitigate

WWW.JENONLINE.ORG 21

CLINICAL/Calow et al

the risk of violence toward staff members. De-escalating techniques were noted to be the most common interven- tions used with aggressive patients.

The STAMP tool was developed specifically for ED nursing practice, and the BVC can be easily modified to adapt to the ED setting. More research is needed on the use of the inpatient tools in the ED setting. Knowing the violent history of patients is a limitation to using the BVC, although some hospitals might have access to the violent history of patients. A recommendation would be for hospitals to document violent behavior of patients in the patient’s medical history record. A history of violence is an indication of a patient’s tendency toward violence.

Using a risk assessment tool is imperative for emergency nurses in recognizing behaviors that proceed to violent behaviors and often lead to staff injury. The increase in ED violence in recent years has led nurses to want to take precautionary steps to protect themselves and others from injury. Hospitals need to implement violence prevention training to educate staff on the observational behaviors of patient aggression and the de-escalating techniques used to calm patients before violent acts occur. A risk assessment tool can be used to help identify patients at risk of being violent and provide staff with reminders on possible interventions to use with patients while providing care.

Conclusions

Violence toward health care workers in the emergency department is growing at an alarming rate, causing safety and financial concerns to health care organizations. The evidence from this literature synthesis supports the use of a standardized violence risk assessment tool to help in early identification of aggressive behavior. Few violence risk assessment tools have been discussed in the literature specific to the emergency department; however, violence risk assessment tools from inpatient settings may be adaptable to the ED setting. Use of a standardized violence risk assessment for early identification of aggressive behavior, paired with early de-escalation interventions and/or seclu- sion, could reduce escalation to violent behavior, decreasing the risk of injury to health care workers.

REFERENCES 1. Brown S, Langrish M. Evaluation of a risk assessment tool to predict

violence behaviour by patients detained in a psychiatric intensive care unit. J Psychiatr Intensive Care. 2011;8(1):35-41.

22 JOURNAL OF EMERGENCY NURSING

2. Fluttert F, Van Meijel B, Webster C, Nijman H, Bartels A, Grypdonck M. Risk management by early recognition of warning signs in patients in forensic psychiatric care. Arch Psychiatr Nurs. 2008;22(4):208-16.

3. Farrell G, Cubit K. Nurses under threat: a comparison of content of 28 aggression management programs. Int J Ment Health Nurs. 2005;14(1):44-53.

4. Wright R, Brand R, Dunn W, Spindler K. How to write a systematic review. Clin Orthop Relat Res. 2007;455:23-29.

5. Luck L, Jackson D, Usher K. STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments. J Adv Nurs. 2007;59(1):11-19.

6. Wilkes L, Mohan S, Luck L, Jackson D. Development of a violence tool in the emergency hospital setting. Nurse Res. 2010;17(4):70-82.

7. Pich J, Hazelton M, Sundin D, Kable A. Patient-related violence against emergency department nurses. Nurs Health Sci. 2010;12(2):268-274.

8. van de Sande R, Noorthoorn E, Wierdsma A, et al. Association between short-term structured risk assessment outcomes and seclusion. Int J Ment Health Nurs. 2013;22(6):475-484.

9. Clarke D, Brown A, Griffith P. The Brøset Violence Checklist: clinical utility in a secure psychiatric intensive care setting. J Psychiatr Ment Health Nurs. 2010;17(7):614-620.

10. Ideker K, Todicheeney-Maanes D, Kim S. A confirmatory study of violence risk assessment tool (M55) and demographic predictors of patient violence. J Adv Nurs. 2011;67(11):2455-2462.

11. Kim S, Ideker K, Todicheeney-Mannes D. Usefulness of aggressive behaviour risk assessment tool for prospectively identifying violent patients in medical and surgical units. J Adv Nurs. 2011;68(2):349-357.

12. Sands N. An ABC, approach to assessing the risk of violence at triage. Australas Emerg Nurs J. 2007;10(3):107-109.

13. Luck L, Jackson D, Usher K. Conveying caring: nurse attributes to avert violence in the ED. Int J Nurs Pract. 2009;15(3):205-212.

14. Jayaram G, Samuels J, Konrad S. Prediction and prevention of aggression and seclusion by early screening and comprehensive seclusion documentation. Innov Clin Neurosci. 2012;9(7–8):30-38.

15. Neufeld E, Perlman C, Hirdes J. Predicting inpatient aggression using the InterRAI risk of harm to others clinical assessment protocol: a tool for risk assessment and care planning. J Behav Health Serv Res. 2012;39(4):472-480.

16. Waschgler K, Ruiz-Hernandez J, Llor-Esteban B, Garcia-Izquierdo M. Patients’ aggressive behaviours towards nurses: development and psychometric properties of the Hospital Aggressive Behaviour Scale- Users. J Adv Nurs. 2012;69(6):1418-1427.

17. Gates D, Gillespie G, Smith C, Rode J, Kowalenko T, Smith B. Using action research to plan a violence prevention program for emergency departments. J Emerg Nurs. 2011;37(1):32-39.

18. The Joanna Briggs Institute. New JBI Levels of Evidence. Published 2014. http://joannabriggs.org/assets/docs/approach/JBI-Levels-of- evidence_2014.pdf. Accessed October 26, 2014.

VOLUME 42 • ISSUE 1 January 2016

APPENDIX TABLE Highlights of evidence synthesis

(Continued) Objectives LOE a Sample Setting ED tool Non-ED

tool Major findings

Gates et al17

Violence prevention and management interventions

Level 5N = 97 3 Midwestern US hospitals

Haddon Matrix

•Majority of planned strategies supported by all participants

•Before assault •During assault •After assault

Pich et al7 Literature review exploring patient- related violence against nurses/ focus on emergency department

Level 5N = 53 ED/mental health facilities in Australia

STAMP •Abuse against nurses accepted part of job

•Under-reporting of violence

•Control of access •Education and training •Environmental design of emergency department

•Patient management plans •Debriefing

Luck et al5

Components of observable behavior that indicate potential for patient violence in emergency department

Level 4N = 3 33-bed emergency department in public hospital in Australia

STAMP •Observation and interviews confirmed assessment components and associated cues as indicators of potential for violence

Waschgler et al16

Development and testing of Hospital Aggressive Behaviour Scale

Level 4 N = 1,489 11 public hospitals in Spain

Hospital Aggressive Behaviour Scale

•Statistically significant correlations between Hospital Aggressive Behaviour Scale and job satisfaction, burnout, and psychological well-being

Kim et al11

Evaluate usefulness of ABRAT for identifying violent patients

Level 3 N = 2,063 6 medical-surgical units in California

ABRAT •10 items selected for ABRAT tool from 3 sources

•3% of patients admitted to medical-surgical units were found to be violent

Jayaram et al14

Identification of potential aggressors among patients and development of documentation tool

Level 3N = 229 Psychiatric unit Phipps Aggression Screening Tool

•Highly significant differences between aggressive/non-aggressive groups for LOS, cost, and illness complexity

•Seclusion decreased

Appendix

(continued at the next page)

Calow et al/CLINICAL

January 2016 VOLUME 42 • ISSUE 1 WWW.JENONLINE.ORG 23

Appendix Table (Continued)

Objectives LOE a Sample Setting ED tool Non-ED tool

Major findings

Wilkes et al6

Creation of violence assessment tool

Level 5N = 23 Nurses in emergency department or academics

Violence assessment tool for emergency department

•Delphi technique to refine violence assessment tool

•17 items chosen •Feedback obtained from experts

Neufeld et al15

Examination of risk assessment algorithm in predicting patient aggression

Level 4 N = 6,425 Mental health facility

RHO CAP •Moderate- and high-risk patients identified

•Patients at high risk were 2 times more likely to display physical aggression

Ideker et al10

Violence risk assessment tool usefulness

Level 3N = 2,063 Medical-surgical unit

Violence Risk Assessment Tool (M55)

•M55 not a useful tool for identifying violent patients

•Only minority of violent patients identified

van de Sande et al8

Investigate validity of observation tool to aid in clinical decision making pertaining to violent patients

Level 3N = 301 4 acute psychiatric wards

BVC and Kennedy Axis V

•Various factors related to seclusion of patients, both dynamic and static

Clarke et al9

Trial of violence checklist

Level 3N = 48 11-bed psychiatric ICU

BVC •Use of seclusion decreased during study

•Tool has been implemented as a routine part of patient care

Luck et al13

Nurse attributes to avert violence in emergency department

Level 4N = 20 33-bed Australian emergency department

5 attributes to reduce violence

•5 attributes to avert, reduce, and prevent violence: being safe, available, respectful, supportive, and responsive

Sands12 Use of violence risk assessment strategy in triage

Level 5 ED triage in Australia

ATS •Best strategy for managing aggression is prevention

•Structured behavior observations at triage

•De-escalation •Security •Debriefing

Highlights of evidence synthesis. ABRAT, Aggressive Behaviour Risk Assessment Tool; ATS, Australasian Triage Scale; BVC, Brøset Violence Checklist; ICU, intensive care unit; LOE, level of evidence; LOS, length of stay; RHO CAP, Risk of Harm to Others Clinical Assessment Protocol; STAMP, Staring, Tone and volume of voice, Anxiety, Mumbling, and Pacing.

a Joanna Briggs Institute Criteria18

• Level 1: Experimental Designs • Level 2: Quasi-Experimental Designs • Level 3: Observational - Analytical Designs • Level 4: Observational - Descriptive Designs • Level 5: Expert Opinion and Bench Research

CLINICAL/Calow et al

24 JOURNAL OF EMERGENCY NURSING VOLUME 42 • ISSUE 1 January 2016