Sep 07, 2017, By: Gail Allison, RN, BHScN, MA, CRRN, Conor MacPhee, MA, Heather Noullett, BA
Violence in health care is a major occupational hazard. In British Columbia, the health-care sector accounts for 57 per cent of all time-loss claims due to acts of violence or force (WorkSafeBC, 2015).
Violence in health care has damaging consequences. Health-care workers can experience psychological trauma, physical injury, feelings of incompetence and time loss from work. Organizationally, the negative impacts of violence include decreased productivity, absenteeism, lack of trust and low morale.
Vancouver Coastal Health (VCH) is one of seven health authorities in B.C., serving 25 per cent of the population (more than one million people in 17 municipalities including First Nations communities). VCH provides violence prevention education to employees through the Provincial Violence Prevention Curriculum (PVPC), which was implemented in the health authorities in 2012. This mandatory program consists of four hours of online modules and an eight-hour classroom session.
Feedback from employees has indicated that although the program provides an effective introduction to violence prevention, it lacks site- and discipline-specific applicability. In response, the Workplace Health violence prevention specialists (VPS) team developed Violence Prevention Exercises (VPE), a scenario-based simulation training program.
When we started developing our program in April 2015, we reviewed the literature evaluating learning through simulation and confirmed it is a broadly accepted method of training medical and nursing students. It is particularly effective for reinforcing skills that rely on teamwork and communication (Lateef, 2010). Given the evidence supporting the use of simulation, we hypothesized that scenario-based training could be effective for reinforcing violence prevention skills. We predicted that participants would be more engaged in this type of training than in classroom-based education. Our plan was to bring the concepts in the PVPC to life by providing opportunities to apply them in realistic scenarios.
We designed the VPEs for application across a broad range of units where the risk for violence was highest, including residential care, mental health and substance use services, and emergency departments. In the initial delivery model, a VPS provided an interprofessional group of three to five individuals with a realistic scenario involving violence and aggression at their worksite. For example, exercises in EDs involved patients who were upset about the wait times; exercises in inpatient mental health units often included an agitated patient who was insistent about going outside for a cigarette.
Once the participants understood the scenario, the VPS prompted them to choose roles (e.g., patient, family member, staff). To ensure a safe, supportive environment, the VPS set ground rules for respectful, non-judgmental communication throughout the exercise. The participants simulated the scenario with the goal of effective de-escalation or safe disengagement, depending on the level of patient aggression. The simulation, which typically lasted about one to three minutes, was followed by a comprehensive debriefing, during which the VPS asked for respectful, constructive feedback on how the situation was handled. The VPS then led a review of the skills and concepts contained in the PVPC, such as effective communication techniques, awareness of body language and personal space, and team support.
We have a team of five specialists and a relatively small geographic area to cover, which makes it possible to deliver the VPEs at each worksite. This approach keeps costs and time investments to a minimum. The exercise and debriefing take about 20 minutes to complete, so additional budget to relieve the small groups of participants is not needed. To support managers, we sent out regular reminders of scheduled VPEs.
We introduced the VPEs at six volunteer pilot sites over a four-week period in June 2015 and had participation from 420 staff and physicians. The disciplines included nursing (registered nurses, registered psychiatric nurses and licensed practical nurses), social work, clinical support and medicine. Despite the pilot sites having different patient populations, staffing models and physical environments, we were able to generate site-specific scenarios for each unit.
After these first sessions, many participants reported they felt safer and more confident about using the communication and de-escalation skills learned in the PVPC to manage an aggressive or violent situation.
VPEs were phased into an additional 28 sites and units during the next 12 months. We knew it was vital to have a built-in sustainability plan, inclusive of clearly defined roles and responsibilities. Therefore, we recruited site champions to work with us and develop the skills necessary to facilitate the exercises. Members of this group had the opportunity to observe us facilitating, to co-facilitate, to facilitate with support and, finally, to facilitate independently, so the program could continue indefinitely. We would continue to support the site champions as needed.
The participants’ verbal and written feedback confirmed there is value in offering VPEs along with a debriefing session. There was agreement that site-specific scenarios allow participants to easily apply concepts learned in the classroom in their own working environment. Managers commented favourably on how few resources are needed to deliver the program.
During the Accreditation Canada site survey at the Vancouver General Hospital ED in October 2016, registered nurses commented on their increased sense of confidence and feelings of safety at work, attributing both of these to our program.
Through the pilot, we learned that agility in our approach was key to our success. When challenges were identified, we huddled and brainstormed to resolve them without losing momentum. For example, when a unit experienced difficulty scheduling VPEs as a result of limited staff availability or competing priorities, we met together and shared creative solutions such as making use of pre-scheduled staff meeting times. We could then take those solutions to a new unit with confidence, as they had been successful elsewhere.
We soon realized the benefit of having participants suggest their own scenarios. In this way, they are more engaged than when scenarios are provided to them. We wanted the exercises to be dynamic with multiple options for successfully resolving the situation, so we made a concerted effort to avoid prescribed learning outcomes. Participants are encouraged to direct and focus the exercise and the debriefing on skills they want to practise or review.
Leveraging existing relationships was an effective way to promote the program. The director of safety and prevention has a strong clinical operations background, and we drew on her many connections to secure new sites. We asked managers at the pilot sites to share their experiences with colleagues and communicate the value of the program. The response was positive, and a number of managers and directors contacted us to express interest.
We saw the need during the debriefings to reiterate the importance of reporting incidents of violence and aggression. Many participants told us they would not have reported an incident portrayed in the scenario had it actually occurred, either because they were not aware of the requirement to do so or because they did not think reporting it would help. By reviewing proper procedures, we can reinforce messages about the worker’s obligation to report incidents and the employer’s obligation to investigate reported incidents.
To date, VPEs have been implemented in more than 40 sites and units throughout the health authority. To improve our program, we are developing qualitative and quantitative methods for measuring its effectiveness. As VPEs are introduced to a new site or unit, we now ask participants to complete a short survey before they attend the session. We are planning to issue followup surveys at regular intervals thereafter to determine if there are any changes in confidence levels or safety culture.
With the success of our program, members of the VPS team have been asked to provide consultation to a provincial working group to determine how other health authorities can implement similar training programs, using the resources available to them.
As part of our efforts to promote the program and communicate its value, we recently produced a short video featuring two VPEs and testimonials from participants and managers. We are passionate about supporting staff by continuing to deliver the exercises in additional sites and units. We believe that by participating in VPEs, VCH’s staff, managers and physicians will be better prepared to deal with incidents of aggression and violence.
The authors gratefully acknowledge Anne Harvey, vice-president, Employee Engagement, and Kate Dickerson, executive director, Workplace Health, for their support of the VPE program; violence prevention specialists Roelof Pleysier, Ray Boldt and Moira Latimer for their integral role in the development and implementation of the program; and managers and site champions for their hard work, positive attitudes and passion in support of a safe and healthy workplace culture.
Lateef, F. (2010). Simulation-based learning: Just like the real thing. Journal of Emergencies, Trauma, and Shock, 3(4), 348-352.
WorkSafeBC. (2015). 2015 High risk strategy for health care.
Gail Allison, RN, BHScN, MA, CRRN, is director, Safety & Prevention, Workplace Health, Vancouver Coastal Health.
Conor MacPhee, MA, is a violence prevention specialist, Safety & Prevention, Workplace Health, Vancouver Coastal Health.
Heather Noullett, BA, is a violence prevention specialist, Safety & Prevention, Workplace Health, Vancouver Coastal Health.