PURPOSE: This study aims to increase nurses’ willingness to confront patients exhibiting PIVA. The long term goal is to improve quality of care by creating a culture of safety, protective of both nurses and patients.
EBP QUESTIONS: (1) Is there a relationship between knowledge, perceived barriers, de-escalation behaviors, comfort level to confront PIVA, willingness to confront PIVA, personal characteristics, and professional characteristics for nurses working in medical-surgical environments? (2) Is there a difference in knowledge, perceived barriers, de-escalation behaviors, comfort level to confront PIVA, and willingness to confront PIVA following participation in an advanced practice nurse (APN) led PIVA education program, for nurses working in medical-surgical environments?
METHODS: This study will be conducted using a pre-experimental pre-test/ post-test design with a single group of medical-surgical nurses. Only one group will receive the intervention, an APN-led PIVA education program.
OUTCOMES: The medical-surgical nurses who participate in this APN educational intervention will experience an increased awareness of self-efficacy learning concepts, de-escalation techniques, perceived barriers to confronting PIVA as well as discovering one’s comfort level to confront PIVA with the ultimate goal of enhancing the quality of nursing care while creating a safer environment for patients and staff.
SIGNIFICANCE: PIVA education must incorporate the notion that patient behavior may change abruptly. Often verbal aggression, a leading indicator of pending conflict events, is not confronted by nurses. PIVA education may enhance the quality of nursing care delivered while keeping all involved in patient care delivery safer.
More specifically:
Problem
Patient-initiated verbal aggression (PIVA) has become an all too common occurrence (Park, Cho, & Hong, 2015) in hospitals, requiring skills other than therapeutic communication techniques taught in traditional nursing curricula. Many nurses, working in medical-surgical environments, indicate they lack both the knowledge and skills to safely care for patients displaying PIVA. The primary means of communication between patients and staff remains verbal interaction, unlike the surrounding global environment that relies on smartphones and other communication technologies. Patient demographics are changing, co-morbidities are more frequently identified and with evolving healthcare economics and technologies, the acute care environment has become an atmosphere of shorter lengths of stay (LOS), more complex care-delivery issues, and growing patient expectations. In turn, many patients demonstrate the behavioral health challenges associated with PIVA towards the healthcare staff providing care services (Gunenc, O’Shea, & Dickens, 2015); often in the absence of a formal, mental health diagnosis. This current-state description has become far more the standard within the confines of today’s acute care hospitals. Nurses form interpersonal relationships with patients through the use of therapeutic communication techniques that are taught in every undergraduate nursing school curriculum. However, these academia-taught communication skills are insufficient when patients exhibit PIVA behaviors that may cause harm to themselves or staff.
Purpose
This study will explore differences knowledge, perceived barriers, and de-escalation behaviors following participation in an advanced practice nurse (APN) led patient-initiated verbal aggression education program, for nurses working in medical-surgical environments. Nurse comfort level and willingness to confront PIVA, along with personal and professional characteristics will also be explored.
Specific Aims
This study aims to increase nurses’ willingness to confront patients exhibiting PIVA. The long term goal is to improve quality of care by creating a culture of safety, protective of both nurses and patients. Research questions will include:
Research Question 1. Is there a relationship between knowledge, perceived barriers, de-escalation behaviors, comfort level to confront PIVA, willingness to confront PIVA, personal characteristics and professional characteristics for nurses working in medical-surgical environments?
Research Question 2. Is there a difference in knowledge, perceived barriers, de-escalation behaviors, comfort level to confront PIVA, and willingness to confront PIVA following participation in an advanced practice nurse (APN) led PIVA education program, for nurses working in medical-surgical environments?
Scope and Importance
Aberrant patient behavior can create safety concerns for nurses assigned to patients exhibiting PIVA behaviors within the geographical footprint of an adult, medical-surgical, acute-care unit. Knowledge and communication skills obtained from a PIVA education program may enhance the quality of nursing care delivered while keeping all involved in patient care delivery safer.
Variables
The independent variable for this study is the APN-led patient-initiated verbal aggression (PIVA) education program. Dependent variables include knowledge, barriers, de-escalation behaviors, comfort level to confront PIVA, and willingness to confront PIVA. Nurse personal and professional characteristics will also be explored.
Incidence/Statistics
Workplace violence in healthcare settings is exploding while known to be significantly under-reported (US-OSHA, 2015). Incidents of serious workplace violence defined as incidents requiring time away from employment are occurring at a rate four times more often or 7.8 cases per 10,000 full-time employees which is more than any other industry inclusive of construction and manufacturing as reported by the United States Occupational Safety and Health Administration (US-OSHA, 2015). Further data analysis indicates that “patients are the largest source of violence [or 80%] in healthcare settings” (US-OSHA, 2015, p.2).
Additional review indicates that “verbal aggression [has become] a common form of communication [between patients and the nurses caring for them accounting] for a significant proportion of the violence and aggression that occurs in the nursing workplace" (McLaughlin, Gorley, & Moseley, 2009, p. 735). Within a 12 month period, 413 of 762 nurses or 54% participating in a research survey located in a mid-Atlantic, urban community hospital reported verbal abuse by a patient (Speroni, Fitch, Dawson & Dugan, 2014). A more alarming research study found that 39.6 % of the participating nurses or 981 of 2,478 nurses reported emotional abuse which then rose to 77.6% when reporting verbal threats of violence during the last five shifts worked (Roche, Diers, Duffield & Catling-Paull, 2010). Similar results have been found by Veterans Administration officials when researching this topic in 2011 (VA-OIG, 2013). Upon review of 889 patient records, 56.6% of the time, healthcare staff encountered verbal aggression or verbal attacks (VA-OIG, 2013).
Verbal aggression can occur in the forms of abusive language, shouting, threats, racism, being argumentative or verbally challenging (Stewart & Bowers, 2012). Yet one’s ability to confront conflict inclusive of reporting may be enhanced or inhibited by individual self-efficacy beliefs (Bandura, 1977). Knowing that each identified form of verbal aggression is a negative stressor for the nurse experiencing such events, these incidents negatively impede self-esteem, can create negative work performance behaviors and/ or eventual ‘burn-out’ (McLaughlin, Bonner, Mboche & Fairlie, 2010) which are counter-productive circumstances within any profession especially nursing.
There remains wide variation (17% to 94%) in the reporting of verbal aggression encounters by nurses in the general, acute-care setting both nationally and internationally (Edward, Ousey, Warelow, & Lui, 2014). The phenomenon of “widespread under-reporting” (Stone, McMillan, Hazelton, & Clayton, 2011, p. 194) is perceived to exist related to external barrier factors such as behavioral scenarios will not change if reported and/ or reporting of the incident may create perceived, additional retribution for the reporting nurse (Stone, McMillan, Hazelton, & Clayton, 2011). Whether reported or not, this is an experience that should be treated with zero-tolerance and with appropriate training prevented.
Addressing the Gaps
PIVA is increasing at a disquieting rate (US-OSHA, 2015, Speroni, Fitch, Dawson & Dugan, 2014; VA-OIG, 2013; Roche, Diers, Duffield & Catling-Paull, 2010). For direct-care, medical-surgical nurses to be able to effectively manage PIVA situations, additional knowledge must be acquired regarding verbal cues that may lead to PIVA, self-efficacy learning principles, potential barriers to confronting PIVA, one’s comfort level as well as willingness to confront PIVA along with de-escalation techniques. There is presently a literature gap of how these constructs collectively can assist the acute-care nurse in more effectively being able and willing to confront PIVA when it occurs. This study seeks to add to the body of nursing literature on how an advanced practice nurse (APN) led patient-initiated verbal aggression education program can increase nurses’ willingness to confront patients exhibiting PIVA with the stretch goal of improving the quality of care by creating a culture of safety, protective of both nurses and patients.
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