Abstract
Background
The high incidence of workplace violence (WPV) in clinical mental health settings has caused a series of negative impacts on nurses, which has subsequently increased public concern. De-escalation (DE) is recommended as a training program which aims at providing nurses with skills and strategies to more effectively respond and manage WPV. Very few studies have examined the effectiveness of DE training, with current studies possessing various limitations due to their design and small sample sizes. By using a cluster randomized controlled design, the proposed study aims to evaluate the effectiveness of a CRCSE-based DE training programs among psychiatric nurses.
Method
A cluster randomized controlled trial, with a 6-month follow-up period after the end of the intervention, will be conducted among psychiatric hospitals in Guangdong, China. The randomization unit is each involved psychiatric hospital. Participants in the control group will be assigned to routine WPV management training, participants of the intervention group will undergo the same training while additionally receiving DE training. The DE training will include the following five modules: communication, response, solution, care, and environment (CRSCE). Primary outcomes are objective clinical indicators, which will be extracted from the information systems of the enrolled hospitals. These include the incidence of WPV, injuries caused by WPV, and the use of coercion (physical restraint and seclusion) by nurses. Secondary outcomes, aims at evaluating the effects of DE training on nurses, include the capacity of DE, DE confidence, level of job burnout, and professional quality of life. Data will be collected at baseline (T0), at 3 months (T1, intervention completed), and at 6 months after intervention (T2, follow-up).
Discussion
This study will offer trial-based evidence of the efficacy of a DE training program targeted at WPV among psychiatric nurses. DE training is expected to reduce both the total incidence and negative impacts of WPV, with additional improvements in psychiatric nurses’ co** skills.
Trial registration
Chinese Clinical Trial Registry, ChiCTR1900022211. Prospectively registered on 30 March 2019.
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Background
Workplace violence (WPV) includes any act or threat occurring at a person’s work site involving physical violence, harassment, intimidation, and other threatening or disruptive behaviors [1]. WPV towards healthcare workers has become a warning global issue, with the incidence varying from 8 to 38% [2]. WPV can occur in various manners, ranging from verbal threats to physical assaults. Noticeably, WPV against medical workers is greater in psychiatric wards than in other departments (emergency department, medical and surgical wards, outpatient, and laboratory service) [3]. It has been asserted that, among psychiatric nurses, the incidence of WPV during their career was approximately 100% [4, 5]. Other studies reported that approximately 56.1 to 70% of psychiatric nurses expressed experiences of being physically assaulted by patients at the workplace [6, 7]. In China, WPV-related issues have become increasingly serious, with approximately 82.4 to 94.6% of Chinese psychiatric nurses reporting that they had suffered from at least one type of WPV in the last year, with the incidences of verbal abuse, physical assaults, and sexual harassment being 78.6 to 92.1%, 61.5 to 81.9%, and 18.6 to 42.9%, respectively [10]. Moreover, a recent study reported that WPV contributed to increases in sick-leave taking among psychiatric nurses [11]. Besides physical injuries, Needham et al. [12] discovered that WPV also caused certain critical, non-somatic negative effects on psychiatric nurses. Exposure to WPV resulted in bio-physiological (depression, anxiety, and fear), cognitive (thinking of oneself as disrespected, violated, threatened, and robbed of one’s rights), emotional (anger, exhaustion, guilt, and self-blame), and social effects (doubts on job appropriateness and sense of insecurity) among psychiatric nurses, with some participants being diagnosed with post-traumatic stress disorder (PTSD). Approximately 75% of assaulted psychiatric nurses had complained that WPV had caused psychological burden [13]. Studies congruously claimed that WPV was a vital factor leading to anxiety (r = 0.242, P < 0.01) and depression (r = 0.115, P < 0.01) [13,14,43]. Current findings have confirmed that DE is a significantly utilized approach in dealing with WPV as well as in reducing the use of coercion, suggesting that DE is an indispensable component of standardized training programs for psychiatric nurses [ The CRSCE program is a multi-center, single blinded, cluster randomized controlled trial with a 6-month follow-up period. All stages of this trial are in accordance with the CONSORT guidelines. This trial will be conducted among 6 major public psychiatric hospitals in Guangdong, China. The involved psychiatric hospitals are Guangzhou Mental Health Center (GZ), Shenzhen Mental Health Center (SZ), the Third Hospital of Foshan City (FS), the Second Hospital of Huizhou (HZ), Shantou Mental Health Center (ST), and the Third Hospital of Meizhou (MZ). The number of wards (secured and non-secured) and nurses of the involved hospitals are shown in Table 1. This study has gained ethical approval from the IRB of GZ. Executives from the involved institutes will be informed and asked for their permission to conduct the study, with the help of the nurses. Informed consent will be obtained from all participants before they complete the surveys.
Aged from 18 to 60 years. Registered nurses engaging in mental healthcare. Are employed as full-time nurses. Student nurses and nursing interns. Personnel taking refresher trainings at engaged wards. Participants in the control group will receive routine WPV management training, participants of the intervention group will undergo the same training while additionally receiving CRSCE-based training. CRSCE is a 5-module training program, composing 104 learning hours, which will be completed in 3 months. The modules, objectives, and learning hours of routine WPV management training and the CRSCE program are presented in Table 2.
Primary outcomes are objective clinical indicators of the included wards, which will be extracted from the hospital information systems and their annual reports. The objective indicators include the frequency of WPV, injuries caused by WPV, and the use of coercion (physical restraint and seclusion). The objective indicators will be calculated as follows:
monthly WPV frequency = monthly numbers of WPV event / total monthly patient days × 1000 ‰; monthly frequency of injuries caused by WPV = monthly numbers of injuries caused by WPV / total monthly patient days × 1000 ‰ and; monthly frequency of physical restraint (or seclusion) = monthly numbers of patient days of physical restraint (or seclusion) / total monthly patient days × 1000 ‰. Secondary outcomes are collected in order to evaluate the impacts on the nurses. The De-escalating Aggressive Behavior Scale (DABS), Confidence in Co** with Patient Aggression Instrument (CCPAI), Maslach Burnout Inventory-General Survey (MBI-GS), and Professional Quality of Life Scale (Pro QOL), will all be used to evaluate the capacity of DE, confidence of DE, level of job burnout, and professional quality of life, respectively. The above survey instruments will be used after obtaining licenses. The flow chart of this study is presented in Fig. 1.
Sample size estimation is based on monthly frequency of WPV. Using the study by I. et al., (2004), we set a significant change of 12.1% (decreased from 17.8% by 5.70%), alpha error of 0.05, beta error of 0.20, the estimated number (N simple) of monthly records is 29 per group for simple randomized control trial [47]. The intra-class correlation coefficients (ICC), explains the inflation factor of cluster randomized controlled design trial, is set as 0.05 in proposed study [48]. Based on the numbers of wards of MZ and HZ (n = 8), the minimum number of 6-month follow-up record (m) is 48. The sampling size of cluster randomized controlled trial (N cluster) is calculated as: N cluster = [1 + (m− 1) * ICC] * N simple ≈ 98. The minimum number of recruited hospitals of each group (N) is calculated as: N = N cluster/ m ≈ 2.04 < 3, suggesting at least 3 hospitals per group. This is a cluster randomized controlled trial. The randomization unit is every involved psychiatric hospital. Involved psychiatric hospitals will be consecutively coded from 1 to 6 by a statistician not actively engaging in this study. By using an online random number generator, hospitals will be assigned to either the intervention or control group according to a 1:1 ratio. The statistician will then inform the research coordinator of the group allocations. Afterwards, the training schedule of each hospital will be designed according to its allocation. To ensure justice, when the intervention group has completed the CRSCE-based program, and follow-up data have been collected, the control group will also receive the same CRSCE-based training. This is a single-blinded study. Engaged nurses and their managers will not be aware of their hospital’s allocation. The surveys will be completed by research assistants who are not involved in the CRSCE training program. Primary outcomes will be continuously collected every month by extracting data from the hospital information systems (HIS) and their annual reports. Secondary outcomes are collected at baseline (T0), 3 months after intervention (T1, the end of intervention), and 6 months after intervention (T2, follow-up). Data collection will be completed by research assistants who are not aware of this study’s design. Statistical analysis will be performed using SPSS version 22.0 software (SPSS Inc., Chicago, IL, USA). Descriptive statistics will be reported as frequencies and percentages, if applicable. The Shapiro-Wilk test will be used in order to examine the distributions of the continuous outcomes. Quantitative variables will be presented using means and standard deviations or as the median and interquartile range. A Student’s t-test, Mann-Whitney U test, Chi-square test, or Fisher’s exact test will be adopted to compare the groups according to their normality distributions. Additionally, a repeated ANOVA will be used to explore the effectiveness of the CRSCE training program and further regression analysis will be performed, if appropriate. The statistical significance will be set at P < 0.05, two tailed, with a 95% confidence interval (CI). All instruments used in this study have been examined for their validity and reliability. Part-time nurses are not available among the 6 involved institutes. Involved psychiatric hospitals are located in different cities of Guangdong Province, and therefore possible contamination between groups is unlikely. To improve the homogeneity of the intervention, during this study newly employed nurses of the involved institutes will be assigned to the training program and will be evaluated accordingly. Short-duration refresher courses will be monthly arranged to maintain accreditation and competency among psychiatric nurses of intervention group. WPV is prevalent in psychiatric hospitals, resulting in critically adverse impacts on nurses. This study will examine the effectiveness of interventions of reducing these WPV impacts. DE training is a recommended intervention for hel** psychiatric nurses in dealing with WPV, but more trial-based evidences are needed in order to support its effectiveness. To the best of our knowledge, this is the first study protocol evaluating the effectiveness of DE using a cluster randomized controlled trial. Compared to routine WPV management training, CRSCE is an additional and innovative training program for psychiatric nurses. The modules of CRSCE are expected to address the crucial components of DE, as well as the general mental health service backgrounds in China. Usually, the patient’s unmet demands are found to be a prominent cause of WPV; therefore, solution-oriented and humane care approaches are warranted, with these being achieved by appropriate communications and responses by healthcare professionals. In addition, therapeutic environments also have been found to influence the occurrence of WPV. Poor therapeutic environments have been found to cause greater numbers of complaints by patients around hospitals and medical staff, which, to some extent, could result in greater WPV incidences [24]. In China, the governmental investment into mental health services was limited [51]. Last, uncontrollable factors contributing to increased rates of aggression might influence the objective indicators. Despite the limitations above, this study is expected to evaluate the effectiveness of the CRSCE training program on WPV alleviation and its inherent benefits for nurses. The proposed trial had been prospectively registered at the Chinese Clinical Trial Registry (Registration Number: ChiCTR1900022211).Methods
Trial design
Settings and participants
Inclusion criteria
Exclusion criteria
Interventions
Outcomes
Sample size
Randomization
Blinding
Data collection
Statistical methods
Study quality control
Discussion
Trial status
Availability of data and materials
The datasets analyzed during the current study are not publicly available due because further data analysis may be undergoing, but are available from the corresponding author on reasonable request.
Abbreviations
- CCPAI:
-
Confidence in Co** with Patient Aggression Instrument
- DABS:
-
De-escalating Aggressive Behavior Scale
- DE:
-
De-escalation
- MBI-GS:
-
Maslach Burnout Inventory-General Survey
- Pro QOL:
-
Professional Quality of Life Scale
- WPV:
-
Workplace violence
References
Barling J, Dupré KE, Kelloway EK. Predicting workplace aggression and violence. Annu Rev Psychol. 2009;60:671–92.
World Health Organization. Workplace violence. 2012. http://www.who.int/violence_injury_prevention/injury/work9/en/print.htm. Accessed 20 May 2015.
Magnavita N, Heponiemi T. Violence towards health care workers in a public health Care Facility in Italy: a repeated cross-sectional study. BMC Health Serv Res. 2012;12:108.
Carmel H, Hunter M. Staff injuries from inpatient violence. Hosp Community Psychiatry. 1989;40:41–6.
Ewa M, Eija V. Threats and violence in Swedish care and welfare--magnitude of the problem and impact on municipal personnel. Scand J Caring Sci. 2010;16:376–85.
Abderhalden C, Needham I, Friedli TK, Poelmans J, Dassen T. Perception of aggression among psychiatric nurses in Switzerland. Acta Psychiatr Scand. 2010;106:110–7.
Itzhaki M, Bluvstein I, Bortz AP, Kostistky H, Noy DB, Filshtinsky V, et al. Mental health nurse’s exposure to workplace violence leads to job stress, which leads to reduced professional quality of life. Front Psychiatry. 2018;9:1–6.
Zeng JY, An FR, **ang YT, Qi YK, Ungvari GS, Newhouse R, et al. Frequency and risk factors of workplace violence on psychiatric nurses and its impact on their quality of life in China. Psychiatry Res. 2013;210:510–4.
Yang BX, Stone TE, Petrini MA, Morris DL. Incidence, type, related factors, and effect of workplace violence on mental health nurses: a cross-sectional survey. Arch Psychiatr Nurs. 2018;32:31–8.
Moylan LB, Cullinan M. Frequency of assault and severity of injury of psychiatric nurses in relation to the nurses’ decision to restrain. J Psychiatr Ment Health Nurs. 2011;18:526–34.
Phillips JP. Workplace violence against health Care Workers in the United States. N Engl J Med. 2016;374:1661–9.
Needham I, Abderhalden C, Halfens Phd RJG, Fischer JE, Dassen T. Non-somatic effects of patient aggression on nurses: a systematic review. J Adv Nurs. 2005;49:283–96.
Hsieh H-F, Shen S-H, Li Y-C. Predictors of depressive symptoms among psychiatric nurses who suffered from workplace violence. J Eng Appl Sci. 2017;12:3218–21.
Chen WC, Huang CJ, Chen CC, Der Wang J. The incidence and risk factors of workplace violence towards female nurses reported via internet in an acute psychiatric hospital. Arch Environ Occup Health. 2011;66:100–6.
Zhao S, **e F, Wang J, Shi Y, Zhang S, Han X, et al. Prevalence of workplace violence against Chinese nurses and its association with mental health: a cross-sectional survey. Arch Psychiatr Nurs. 2018;32:242–7.
Ridenour M, Lanza M, Hendricks S, Hartley D, Rierdan J, Zeiss R, et al. Incidence and risk factors of workplace violence on psychiatric staff. Work. 2015;51:19–28.
Tonso MA, Prematunga RK, Norris SJ, Williams L, Sands N, Elsom SJ. Workplace violence in mental health: a Victorian mental health workforce survey. Int J Ment Health Nurs. 2016;25:444–51.
Saragoza P, White SG. Workplace violence: practical considerations for mental health professionals in consultation, assessment, and Management of Risk. Psychiatr Clin North Am. 2016;39:599–610.
Hamrin V, Iennaco J, Olsen D. A review of ecological factors affecting inpatient psychiatric unit violence: implications for relational and unit cultural improvements. Issues Ment Health Nurs. 2009;30:214–26.
Gillespie GL, Gates DM, Miller M, Howard PK. Workplace violence in healthcare settings: risk factors and protective strategies. Rehabil Nurs. 2010;35:177–84.
D’Ettorre G, Pellicani V. Workplace violence toward mental healthcare workers employed in psychiatric wards. Saf Health Work. 2017;8:337–42.
Vaaler AE, Morken G, Linaker OM. Effects of different interior decorations in the seclusion area of a psychiatric acute ward. Nord J Psychiatry. 2005;59:19–24.
Van Wijk E, Traut A, Julie H. Environmental and nursing-staff factors contributing to aggressive and violent behaviour of patients in mental health facilities. Curationis. 2014;37:1–9.
Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers. 2016. https://www.osha.gov/Publications/osha3148.pdf. Accessed 18 Mar 2020.
Cornaggia CM, Beghi M, Pavone F, Barale F. Aggression in psychiatry wards: a systematic review. Psychiatry Res. 2011;189:10–20.
Magnavita N. Violence prevention in a small-scale psychiatric unit: program planning and evaluation. Int J Occup Environ Health. 2011;17:336–44.
**ao A, He H, Sun B, Rao D, Ning Y, Rosenheck RA. Comparison of attitudes of the psychiatrists and nurses towards patients with mental illness in a Chinese psychiatric hospital: implications for training. Asia Pac Psychiatry. 2016;8:104–5.
Aixiang X, Junrong Y. Suggestion for reducing the use of physical restraint in mental health settings. Riv Psichiatr. 2017;52:212.
Ye J, **ao A, Yu L, Guo J, Lei H, Wei H, et al. Staff training reduces the use of physical restraint in mental health service, evidence-based reflection for China. Arch Psychiatirc Nurs. 2017;32:488–94.
Abderhalden C, Needham I, Dassen T, Halfens R, Haug HJ, Fischer JE. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. Br J Psychiatry. 2008;193:44–50.
Needham I, Abderhalden C, Meer R, Dassen T, Haug H, Halfens R, et al. The effectiveness of two interventions in the management of patient violence in acute mental inpatient settings: report on a pilot study. J Psychiatr Ment Health Nurs. 2004;11:595–601.
Olver J, Love M, Daniel J, Norman T, Nicholls D. The impact of a changed environment on arousal levels of patients in a secure extended rehabilitation facility. Australas Psychiatry. 2009;17:207–11.
Scanlan JN. Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far a review of the literature. Int J Soc Psychiatry. 2010;56:412–23.
National Institute of Clinical Excellence. Violence: the short-term Management of Disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. London: National Institute for Clinical Excellence; 2005.
Lavelle M, Stewart D, James K, Richardson M, Renwick L, Brennan G, et al. Predictors of effective de-escalation in acute inpatient psychiatric settings. J Clin Nurs. 2016;25:2180–8.
Research C, Guidelines A. The prevention and management of aggression - a good practice statement; 1996.
Price O, Baker J. Key components of de-escalation techniques: a thematic synthesis. Int J Ment Health Nurs. 2012;21:310–9.
Hallett N, Dickens GL. De-escalation: a survey of clinical staff in a secure mental health inpatient service. Int J Ment Health Nurs. 2015;24:324–33.
Hallett N, Dickens GL. De-escalation of aggressive behaviour in healthcare settings: concept analysis. Int J Nurs Stud. 2017;75:10–20.
Nau J, Halfens R, Needham I, Dassen T. Student nurses’ de-escalation of patient aggression: a pretest-posttest intervention study. Int J Nurs Stud. 2010;47:699–708.
Baig L, Tanzil S, Shaikh S, Hashmi I, Khan MA, Polkowski M. Effectiveness of training on de-escalation of violence and management of aggressive behavior faced by health care providers in public sector hospitals of Karachi. Pakistan J Med Sci. 2018;34:294–9.
Fröhlich D, Rabenschlag F, Schoppmann S, Borgwardt S, Lang UE, Huber CG. Positive effects of an anti-aggression and de-escalation training on ward atmosphere and subjective safety may depend on previous training experience. Front Psychiatry. 2018;9:134.
Bowers L, James K, Quirk A, Simpson A, Stewart D, Hodsoll J. Reducing conflict and containment rates on acute psychiatric wards: the Safewards cluster randomised controlled trial. Int J Nurs Stud. 2015;52:1412–22.
Stewart D, Van der Merwe M, Bowers L, Simpson A, Jones J. A review of interventions to reduce mechanical restraint and seclusion among adult psychiatric inpatients. Issues Ment Health Nurs. 2010;31:413–24.
Borckardt JJ, Madan A, Grubaugh AL, Danielson CK, Pelic CG, Hardesty SJ, et al. Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital. Psychiatr Serv. 2011;62:477–83.
Du Md, Wang X, Yin S, Shu W, Hao R, Zhao S, et al. De-escalation techniques for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2017: 1–24.
Chow S-C, Shao J, Wang H, Lokhnygina Y. Sample size calculations in clinical Research. Third Edit. Boca Raton: Taylor & Francis Group; 2018.
Loh DA, Choo WY, Hairi NN, Othman S, Mohd Hairi F, Mohd Mydin FH, et al. A cluster randomized trial on improving nurses’ detection and management of elder abuse and neglect (I-NEED): study protocol. J Adv Nurs. 2015;71:2661–72.
**ang YT, Yu X, Sartorius N, Ungvari GS, Chiu HFK. Mental health in China: challenges and progress. Lancet. 2012;380:1715–6.
Mental Health Comission. Mental Health Commission Seclusion and Physical Restraint Reduction Strategy. Dublin; 2012. https://www.mhcirl.ie/File/SecandPPR_KnowRev.pdf.
Nursing Center of National Hospital Administration Institute. Guidelines for Data Sets of Nursing-Sensitive Quality Indicators (In Chinese). 2018 Versi. Peking: People’s Medical Publishing House; 2018.
Acknowledgements
We would like to acknowledge Huiai Violence Prevention and Management Group (HVPM) for dedication in CRSCE training program. Besides, the first author, Junrong YE, is very delighted to welcome his daughter Youyou YE came to the world on December 5, 2019.
Funding
This study is funded by governmental program named Guangdong Science of Medical Technique Program, the grant number is A2018440; by Guangzhou Health Science and Technology Guidance Project, the grant number is 906283101031. These funding will support the design and data collection of proposed study.
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This manuscript was in collaboration between all authors. JY, AX, and CW conceived this study. ZX, LY, SL, and JL participated in sampling methods design. YL, YX, and YZ participated in statistical methods design. JY, AX, and ZX drafted and revised this protocol. All authors had read and approved the final manuscript. JY, AX, and CW were listed as co-first authors because they contributed equally to the study. JY was assigned to be the corresponding author.
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The proposed study had obtained ethics approval from IRB of Affiliated Brain Hospital of Guangzhou Medical University. Written informed consent will be obtained from participants before the surveys.
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Ye, J., **ao, A., Wang, C. et al. Evaluating the effectiveness of a CRSCE-based de-escalation training program among psychiatric nurses: a study protocol for a cluster randomized controlled trial. BMC Health Serv Res 20, 642 (2020). https://doi.org/10.1186/s12913-020-05506-w
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DOI: https://doi.org/10.1186/s12913-020-05506-w