The purpose of this quality improvement initiative was to improve the safety of nurse-to-patient interactions at the project facility through skilled communication. This process involved two aims:
- Gap analysis: Evaluate non-mental health nurses for baseline communication skills in de-escalating aggressive patients.
- Provide resources: Build the communication skills of non-mental health nurses in dealing with patient aggression through creating and implementing a Behavioral Emergency Response Team (BERT) program.
Background:
The unacceptable behavior of patient and visitor aggression toward nurses, common in psychiatric and emergency department settings, has now emerged in non-mental health settings (Hopkins, Fetherston, & Morrison, 2014; Pompeii et al., 2015; Zicko, Schroeder, Byers, Taylor, & Spence, 2017). This finding was noted in the large academic medical center of this project, where aggressive patient encounters in general care settings increased steadily during 2017.
This trend poses safety risks for clinical environments because nurses who work outside the mental-health setting may lack the skills needed to avoid or mitigate patient aggression (Rutledge et al., 2013; Zicko et al., 2017). Without appropriate resolution, aggressive encounters have caused physical and psychological harm to nurses, harm to patients and visitors, increased healthcare costs, and reduced quality of patient care (Pompeii et al., 2015; Shafran-Tika, Chinitz, Stern, & Feder-Bubis, 2017; Zicko et al., 2017).
Effective nurse-to-patient communication has been shown to reduce patient aggression, while suboptimal communication can lead to and/or intensify aggressive encounters (Angland, Dowling, & Casey, 2014; Najafi, Fallahi-Khoshknabm, Ahmadi, Dalvandi, & Rahgozar, 2018; Shafran-Tika et al., 2017). The American Association of Critical-Care Nurses (AACN) included skilled communication as a standard for healthy work environments and suggested that “Nurses must be as proficient in communication skills as they are in clinical skills” (Harmon, DeGennaro, Norling, Kennedy, & Fontaine, 2018). Clearly, skilled nurse-to-patient communication in non-mental health settings creates healthy work environments by eluding or limiting patient aggression. BERT programs have been shown to provide nurses with these skills (Lamont & Brunero, 2018; Zicko et al., 2017).
Methods:
A pilot group, consisting of 627 non-mental health nursing employees, was invited to complete an electronic survey. The questionnaire gathered cross-sectional data for a gap analysis, while also serving as the baseline for a pretest-posttest quality improvement model.
Survey questions were based on validated tools (Nemeth et al., 2017; Rutledge et al., 2013; Zicko et al., 2017) for measuring the attitude and skill of nursing staff in working with aggressive patients. The survey was finalized after considering input from content experts.
Findings:
The baseline survey was completed or partially completed in January 2018, by 52% of the pilot group (327 of 627). Participants lacked the competency needed to safely avert and de-escalate aggressive patient behaviors:
- 79.5% had never been trained in approaches for dealing with aggressive patients and visitors.
- Of those who did report having received prior training, only 32.8% felt the previous training was effective.
- 60.8% had responded to aggression from patients or their visitors by reciprocating emotionally reactive communication.
- Only 13.3% felt confident in their ability to use skilled communication and other approaches to reduce patient or visitor aggression.
Response:
Upon identifying this substantial gap in communication skills, the organization responded by creating a quality improvement project as follows:
- Designed training for pilot nurses in avoiding and addressing patient aggression through skilled communication.
- Created a BERT response team, training select staff to support pilot participants during aggressive patient encounters through specialized communication and tactical de-escalation techniques.
- Developed a system allowing pilot area nurses to activate the BERT response.
The pilot group is currently receiving the training; a go-live of the BERT response team will go into effect once all pilot participants are trained. Outcome measures from this portion of the project will be available for the 2019 STTI conference but are not available at this time.
Conclusions:
The first aim of this project was met by identifying non-mental health nurses at the facility as being unskilled in communicating with aggressive patients. This concerning trend is in line with nursing publications, including Rutledge et al. (2013) who found non-emergency department nurses had less knowledge and skill for averting patient aggression. The pilot nurses of this project will overcome this gap by developing stronger communication skills, and forging safer patient care environments through participation in the BERT program.
Clinical Relevance:
Nurses from organizations who prioritize for workplace safety are less likely to be victims of workplace violence (Shea, Sheehan, Donohue, Cooper, & De Cieri, 2017). It is of paramount importance for organizations to limit patient aggression through identifying the skill gaps in nursing communication and providing additional resources for ongoing skilled nurse-to-patient communication.
The facility of this project is working to build communication skills and safer clinical environments by implementing a BERT program. Sharing project results will support other institutions in evaluating the safety of their current environment and creating like programs.