1 Impacting Nurses’ Self-Efficacy in Managing Escalating Patients Elizabeth A. Corker College of Nursing, Michigan State University Doctor of Nursing Project Faculty Advisor: Dr. Jackie Iseler April 22, 2023 2 Table of Contents Abstract………………………………………..……………………………………………..……4 Introduction………………………………………..………..……………………………..………5 Background………………………………………..………..…………………………………..…5 Significance………………………………………..…………………………….……………...…6 Theoretical Framework………….………………..…………………………..……………...……8 Search Strategy………………………………..…………………………………………………..8 Synthesis of Findings..………………………….………………..………………………………..9 Methods………………………………………..…………………………………………………11 Project Site and Population………………………………………………………………11 Ethical Considerations/Protection of Human Subjects...………………………………...12 Setting Facilitators and Barriers……………..…………………………………………...12 Educational Session……………………..…...……..……………………………………13 Timeline………………………………………..………………………………………...13 Measurement Instrument/Tools…..……………………………………………………...14 Cost-Benefit Analysis……………………………………………………………………14 Analysis…………….…………………..………………………………………………...15 Sustainability Plan………………………………………..……………………………………...17 Discussions/Implications of Nursing…………………………………………………………….17 References………………….…………………..………………………………………………...19 Appendices Appendix A (PRISMA Diagram) ……………………………………………...……......22 Appendix B (Evidence Review Table)……………..……………………………….…...24 3 Appendix C (Evidence Level and Quality Guide)....………………………………..…...28 Appendix D (Literature Synthesis)……………….……………………………………...29 Appendix E (SWOT Analysis)..…………………..……………………...……………...30 Appendix F (Course Outline)……………………..……………………………………...31 Appendix G (Pre- and Post-Implementation Survey)..…………………………………..32 Appendix H (GANTT Chart)……………………………………………………………36 Appendix I (Cost-Benefit Analysis)……………………………………………………..37 Appendix J (Education Flyer)……………………………………………………………38 Appendix K (Data Analysis Tables)...……………………………...……………………40 4 Abstract OBJECTIVE: Violence in healthcare is an ongoing challenge nurses face across the continuum of care. Education on de-escalation techniques and safe disengagement techniques were shown to improve nurses’ confidence and ability to de-escalate stressful situations. The purpose of this evidence- based practice project was to determine the impact of an educational session on nurses’ self-efficacy in managing escalating patients. METHODS: This project utilized a survey of nurses’ perceptions of self-efficacy before and after an educational session. Nurses on medical-surgical and telemetry units were invited to participate in the educational session and survey. Demographic information was collected including age, role, education, experience with de-escalation training, and experience with incidences of workplace violence. RESULTS: Thirty-five nurses were surveyed for self-efficacy before and after the educational session, and pre- and post-test values were compared, with a statistically significant improvement in self-efficacy after the intervention. CONCLUSIONS: The results of this project indicated that education and training was effective in improving self-efficacy of nursing staff. The education that was effective included recognizing worsening or escalating behavior, appropriate interventions to reduce escalation, as well as how to manage violent behavior safely and effectively through disengagement techniques. Together these provided the knowledge and skills to empower nurses to address these stressful situations and give them the tools to prevent patients from becoming violent. 5 Impacting Nurses’ Self-Efficacy in Managing Escalating Patients Nurses encounter violence throughout their work so often it is an epidemic in U.S. healthcare (Honarvar et al., 2019). Violence toward nursing staff includes verbal, physical, and even sexual abuse. Violence can be perpetrated by patients, visitors, family members, co- workers, supervisors, and intimate partners. Long-term, life-changing, and permanent injuries, both the visible and invisible, result from these violent encounters. According to the National Institute for Occupational Safety and Health (2021), 20,870 workers were victims of workplace violence in 2019, and of those, 70% were healthcare workers. Managing difficult, or escalating, patient behavior is more of a challenge than ever. Patients and nursing staff are both stressed given political, social, and economic stressors. Escalating patient behavior may start as minor outward expressions of frustration and anxiety, and if left unaddressed, can develop to more intense displays such as punching, hitting, or kicking (McKnight, 2020). Emergency department and psychiatric nurses spend hours each year learning de-escalation techniques to aid in managing difficult patients to better reduce tension and the likelihood of violence. Medical-surgical and telemetry nurses are not always required to have de-escalation training. This lack of training, coupled with incidences of violence against nursing staff, promotes feelings of “unpreparedness, frustration, moral distress, and powerlessness” (Dahnke & Mulkey, 2021, p. 229). The purpose of this paper is to discuss workplace violence in the hospital setting and explore techniques and strategies to better equip healthcare staff to respond to escalating patients, thereby increasing their self-efficacy. Background In a 200-bed acute care community hospital in a suburban mid-Atlantic county, de- escalation education is only required in emergency and psychiatric settings. This education is 6 largely passive, consisting of lecture and discussion with minimal active learning scenarios where the learner manages a simulated patient. A study by Havaei et al. (2019) found that the perception of certain settings such as the emergency department or psychiatric unit as being more violent has shifted to an overall heightened risk for violence that is hospital-wide. In addition, passive education does not provide enough support to staff to improve their confidence in handling these situations (Havaei et al., 2019). Havaei et al. suggest an active and engaging educational approach, such as mock code drills, is more beneficial for staff’s self-efficacy regarding de-escalation. Violence toward nursing staff is not limited to physical aggression, but also encompasses verbal abuse (Dahnke & Mulkey, 2021). Given the Coronavirus disease 2019 (COVID-19) pandemic, staffing crisis, and overall stress within healthcare systems, staff are increasingly vulnerable to the negative impact of violence within the workplace. Dahnke and Mulkey (2021) suggest that leadership acknowledgement of violence, in all its forms, as well as better education, encourages more reporting and job satisfaction for nursing staff. Widening the education to more settings and including dynamic education could further improve self-efficacy and empowerment of bedside nursing staff. Significance The cost of workplace violence in the healthcare setting is staggering. In 2017, hospitals spent an estimated “$1.1 billion in security and training costs to prevent violence within hospitals, and an additional $429 million in medical care, staffing, indemnity, and other costs as a result of violence against hospital employees” (American Hospital Association, 2018, para. 5). Healthcare workers are five times more likely to be injured due to workplace violence than any other type of worker (U.S. Bureau of Labor Statistics, 2017). “Healthcare workers accounted for 7 73 percent of all nonfatal workplace injuries and illnesses due to violence in 2018” (U.S. Bureau of Labor Statistics, 2017, para. 4). Not only are the financial costs high, but the impact on affected healthcare workers can be lifelong. At this small, community hospital, violence is a significant problem. According to reported events, violence perpetrated against nursing staff has increased significantly, including those resulting in injury to nursing staff. The requests for de-escalation training class seats doubled over the last year to provide more access to training for staff. To provide the requested education, the number of trained instructors was also doubled to four. In addition, the behavioral health team has conducted a pilot that involves rounding on patients at risk for violent or escalating behaviors based on the nurse’s assessment. Rates of violence are difficult to attribute to actual incidences due to staff hesitancy to report such events. According to staff, barriers to adequate and accurate data collection involves a mistrust in the reporting process, a perception that staff does not need to document workplace violence if the patient was ill or under the influence, and a belief that reporting does not change outcomes for staff or consequences for patients. Staff in the medical-surgical and telemetry areas are not part of de-escalation training, which staff in the emergency department and psychiatric areas receive. Violence is a problem for nurses throughout all hospital areas because it does not stop at the entrance to the inpatient elevators. Problem Statement Workplace violence from patients toward nursing staff is a problem across the continuum of care. While medical-surgical and telemetry staff are exposed to many of the same patient populations as other departments who receive de-escalation training, they do not receive any education or training at this facility. Would providing medical-surgical and telemetry nurses 8 active education and training on de-escalation techniques impact their self-efficacy in managing escalating patients? Theoretical Framework Jean Watson’s Model of Human Care is a theory that is particularly relevant to the research regarding de-escalation of agitated patients and reduction in workplace violence. Watson’s theory is based on 10 components of caring which shape the nurse-patient interaction and are essential to caring for the whole person (Marriner-Tomey, 1985). According to the theory, nurses must be aware of and express their feelings, to encourage patients to accept and do the same. De-escalation techniques require nurses to understand their own attitudes and emotions and expect patients to express their feelings without violence. Nurses must develop a “helping- trust relationship” in which being honest, warm, communicating effectively, and being empathic with the other person are crucial components of the relationship (Marriner-Tomey, 1985, pp. 167). De-escalation techniques rely on the nurses’ facial expressions and body language to reflect their verbal expressions to patients to build trust and therapeutic rapport (Marriner- Tomey, 1985). For these reasons, Jean Watson’s Model of Human Care is a pertinent theory to modern de-escalation planning and interventions. Search Strategy A search of PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was completed utilizing the words “de-escalation” and “nursing” and “training.” The initial search and inclusion criteria consisted of articles published between 2017 and 2022, written in the English language, and available in full text. A total of 58 articles were retrieved. Abstracts were read to determine appropriateness for inclusion. Articles not pertaining to the medical-surgical care area or acute care/hospital settings were excluded. Duplicate articles were 9 also excluded. After appropriate review, four articles were included, with an additional two articles identified for inclusion from source material. See Appendix A for the full PRISMA diagram. Synthesis of Findings The Johns Hopkins Nursing Evidence-Based practice model was used to analyze each article for levels of evidence, design, weaknesses, and strengths (see Appendix C). Subjects of focus in the research included nursing and medical students, medical-surgical nurses, and nurses working in areas at the highest risk of violence. Common themes include de-escalation training, measurement of confidence as an outcome, and restraints. De-escalation Training Training across all the research articles focused on recognizing escalation, interventions, steps to prevent further escalation, and techniques to manage violent behaviors (Al-Ali et al., 2016; Goh et al., 2020; Ferrera et al., 2017; Lamont and Brunero, 2018). De-escalation training utilized by Goh et al. consisted of two hours of video and lecture education, including how to recognize stages of escalation and verbal techniques to utilize, medications used to assist in chemical restraint, and how to physically manage “dangerous, aggressive, or violent patients” (Goh et al., 2020, p. 2). Classroom education was followed by hands-on instruction allowing students to practice the skills learned through the lecture portion. Ferrera et al. (2017) identified techniques utilized in behavioral health settings and adapted them to the acute care setting. In- person and online, recorded educational sessions were used to teach the Ten Domains of De- escalation. Overall, the importance of the implementation of the training led to a decrease in the violent occurrences for nursing staff when compared to pre-intervention. In the study by Lamont and Brunero (2018) subjects went to a one-day workshop to learn de-escalation techniques, 10 assessment and management techniques, as well as “breakaway techniques”, which specified how to disengage from an individual if they do become physically violent. Implementation of de- escalation, evasive techniques, and planning improved nurses’ confidence in addressing agitated patients in this study (Lamont and Brunero, 2018). Al-Ali et al. (2016) utilized multiple one-day sessions consisting of slide presentations, group discussions, case studies, and role playing to better teach the topics. Included in their education was defining workplace violence, approaches to address and recognize, interventions, monitoring, and reporting. All sessions were taught by the same Clinical Nurse Specialist who was trained in workplace violence prevention. Restraints For Goh et al. (2020), education also consisted of restraining a student volunteer and debriefing the students afterward regarding their experiences. This topic was unique to these researchers but focused on developing empathy and better understanding of the patients’ perspective and experience in being restrained. Their research hinged on the idea that knowledge about restraints and de-escalation translates into improved, more confident practice and care for escalating and violent patients after graduation. Researchers focused on the characteristics of the care team in their approach toward escalating patients and stated, “Empathy and non-judgmental attitudes are vital not only in facilitating interactions with patients, but also in reducing and eliminating the use of restraint” (Goh et al., 2020). This is a unique perspective that could prove important toward the use of restraints with escalating patients. Confidence as Outcomes All the authors measured confidence of nursing staff as an outcome and compared pre- and post-implementation (Al-Ali et al., 2016; Goh et al., 2020; Ferrera et al., 2017; Lamont and Brunero, 2018). Al-Ali et al. (2016) indicated that post-intervention, nurses’ attitudes toward 11 their ability to address physical and verbal violence was enhanced. Goh et al. (2020) measured confidence utilizing a questionnaire targeting specific skills taught including verbal de-escalation skills, managing physical escalation, and physical and chemical restraints. Ferrera et al. (2017) measured utilizing the Confidence in Coping with Patient Aggression Instrument. Lamont and Brunero (2018) evaluated their activities using the Continuing Professional Development Reaction questionnaire and the Confidence in Coping with Patient Aggression Instrument. Across all studies, researchers reported a statistically significant increase in participants’ beliefs about their abilities in responding to aggressive, verbally abusive, and even physically aggressive patients (Al-Ali et al., 2016; Goh et al., 2020; Ferrera et al., 2017; Lamont and Brunero, 2018). Methods Project Site and Population The implementation setting was a small community hospital in a suburban mid-Atlantic county. The intervention implementation included participants that work on medical- surgical/telemetry inpatient units of the hospital. This population is approximately 300 individuals, and a convenience sample of volunteers was included in the project. All staff nurses and certified nursing assistants (CNAs) on several medical-surgical telemetry units were invited to participate in this project. Opportunity was given to nurse leaders to participate in the training as well. Nurses include licensed practical nurses (LPNs), as well as Registered Nurses (RNs) prepared at the associates’, bachelor’s, master’s, and doctoral level. A power analysis using G*Power 3.1.9.7 (Faul et al., 2009) indicated the inclusion of 34 participants was expected to have 80 percent power to detect an effect size of 0.5 standard deviations based on a five percent 2-sided significance level for statistical analysis of within-subject differences pre- and post- survey. 12 The key stakeholders in this project were the nursing personnel, as well as hospital leadership, clinical education department, patients and families, all of whom benefit from education, skills in de-escalation, and enhanced self-efficacy of nursing staff. Ethical Considerations/Protection of Human Subjects This DNP project was reviewed by Michigan State University and the organization’s Internal Review Board (IRB) deemed it non-human research. The educational session was completely voluntary, and details of the session were provided prior to starting. Through an informational flyer, (Appendix I) posted on the units, emails, and through unit huddles and other meetings, any nursing personnel was invited to attend the educational session. The benefits of participation include increased knowledge and confidence. The risks to participants were minimal and largely related to loss of confidentiality. No personal health information was collected, and any information collected was de-identified. The survey completed by hospital staff was both optional and anonymous. All data collected was protected within a password-secured laptop, stored within a locked cabinet, within a locked office. Participants are not identifiable in any publications or reports on the project or data. The topic may be upsetting to some participants, though none experienced this during the project period. If a participant expressed feelings of distress, the contact information for the system’s Employee Assistance Program would have been provided. Participants were instructed they may end their involvement in the project at any time without penalty or employment implications, though no participants chose to end the project early. Setting Facilitators and Barriers One anticipated barrier to the project was funding for staff to attend training. After approaching nursing leadership, it was decided that participants in the educational program were 13 able to attend the training using the organization’s strategic training budget cost center. This budget request was approved by senior leadership. Educational Session The educational session started with an introduction to an understanding of what crisis, or an escalating patient, looks like (see Appendix F). By defining certain behaviors those in crisis may exhibit, corresponding appropriate behaviors were also taught to help de-escalate the situation. Core concepts such as empathetic listening, rational detachment, situational awareness, and therapeutic rapport were established. Communication skills were highlighted, with significant focus on verbal communication, and how to specifically address issues such as shouting, cussing, and confrontational questions. Discussion of the crisis response within the hospital setting also occurred, including when and how to call a ‘code green’ or behavioral emergency, security’s role in those emergencies, and the importance of debriefing with both the patient and staff. Definitions of workplace violence were also covered, along with appropriate reporting instructions and resources. Finally, safe disengagement techniques were demonstrated and taught to the participants. Return demonstration was incorporated. This education was developed based on the effective strategies described in the literature and based on knowledge acquired from resources on the topic (Al-Ali et al., 2016; Goh et al., 2020; Ferrera et al., 2017; Lamont and Brunero, 2018, McKnight, 2020). Timeline The total timeline to complete the intervention was expected to be 8-10 weeks, and the project met this expectation. The project required this span of time to ensure inclusion of an adequate number of participants accommodating for staffing challenges and to obtain classroom space. 14 Measurement Instruments/Tools Self-efficacy refers to an individual’s belief in his or her capacity to execute behaviors necessary to produce specific performance attainments (Bandura, 1977, 1986, 1997). Self- efficacy reflects confidence in the ability to exert control over one’s own motivation, behavior, and social environment. The measurement instrument was used to determine if implementing a two-hour educational session, covering de-escalation training and disengagement techniques, improved nurses’ confidence in managing escalating patient situations was the General Self- Efficacy Scale (GSE) (Schwarzer & Jerusalem, 1995). The GSE was developed by Schwarzer and Jerusalem and is a valid and reliable tool used by a variety of disciplines and across 26 languages to measure self-efficacy across the adult population (Schwarzer & Jerusalem, 1995). The GSE is 10 questions that are scored with a Likert scale and given a number value from 1 through 4. All the question responses are totaled to give a final score from 10 to 40, with a higher score indicating greater self-efficacy of the respondent. Demographic information including participants’ age, nursing role, education, experience, experience with de-escalation training, and exposure to workplace violence within the past year was also gathered. See Appendix G for the full survey utilized. Surveys including the GSE and demographic information were collected from participants at the start of each educational session. After the education, the question on workplace violence experience and the GSE were surveyed again. Each survey was coded so that the pre- and post-implementation scores within participants could be matched and measured. Cost-Benefit Analysis Development of the educational session and carrying out the DNP project required no cost to the organization. Training material consisted of the use of classroom space, PowerPoint 15 slides, and handouts. Staff participation in the project was budgeted for by senior nursing leadership, who recognized the need for a WPV prevention educational program for staff, and to ensure participants were paid for their time to attend the class. Participants were paid to attend using the organization’s strategic training budget cost center. In the future, to meet Joint Commission standards, the organization will have to determine funding for employees to participate in annual training on WPV. The educational session is one option to fulfill Joint Commission requirements in support of accreditation. The salary of one Clinical Nurse Specialist (CNS) would be sufficient to ensure the organization can continue to teach the course. The organization would benefit from other work done by the CNS, including quality improvement and evidence-based practice projects driven by the CNS throughout the rest of the year. Cost savings potential arises from prevention of harm and improvements in proficiency, not just for this project, but also through ongoing work by the CNS. Additionally, there is potential cost savings through the reduction in incidences in workplace violence. Improving the work environment by decreasing WPV may lead to increased retention and decreased nurse turnover, positively impacting the organization’s personnel costs. According to the Occupational Safety and Health Administration, or OSHA, (2015) one estimate of annual costs relating to workplace violence injury treatment and lost wages was $94,156. If the CNS can improve these costs to the organization, it would provide additional financial benefit. Analysis The statistical package used for data analysis was SPSS 29. Data was entered into SPSS 29 and double-checked for accuracy manually and statistically. Means and standard deviations were calculated for all continuous variables. Descriptive statistics were used to describe the 16 sample as collected on the demographic survey, including age, nursing role, education, experience, experience with de-escalation training, and exposure to workplace violence within the past year. To address the question; Would providing medical-surgical and telemetry nurses active education and training on de-escalation techniques impact their self-efficacy in managing escalating patients?, differences in the mean scores on the GSE pre- and post-intervention were analyzed using a paired-samples t-test. Relationships of experiences with de-escalation training, and exposure to workplace violence in the past year with other sample characteristics were explored. A sample of 35 staff members were recruited. Eighty-nine percent of those surveyed were RNs, and 11% were CNAs. Mean age of participants was 37 years (SD = 11.2). Of those that participated, 9% had a high school diploma, 9% had an Associate’s degree, 74% had a Bachelor’s degree, 5% had a Master’s degree, and 2% had a Doctorate. Most nurses were an RN 2, which is a nurse with at least 1 year of experience; this is the second step on a 4-step clinical ladder. Both before and after the intervention, which included the definitions of WPV, 77% of participants indicated they had experienced WPV. That the same number of staff indicated they experienced WPV pre- and post-intervention suggests that staff had a good understanding of what WPV is, and that the intervention provided no new insight to participants. If knowledge of the definition of WPV is not an issue, underreporting may be part of the problem and organizational culture. According to staff, there is a mistrust in the reporting process, a perception that staff does not need to document WPV if the patient was ill or under the influence, and a belief that reporting does not change outcomes for staff or consequences for 17 patients. Knowledge of WPV could be related to first-hand experience, since more than three- quarters of participants reported that they experienced WPV. Perhaps those who chose to attend the class did so because of their experiences . Some staff participated at the encouragement of their leadership because of experiencing a particular act of WPV. A paired samples t-test was performed to compare pre- and post- GSE scores. There was a significant difference in total GSE score between pre-intervention (M=[31.66], SD = [3.48]) and post-intervention groups (M=[34.66], SD=[4.47]); t(34) = [-6.77], p<.001]. Statistical significance was revealed in the difference between the pre- and post- intervention analysis, indicating the education improved nurses’ perception of self-efficacy. See the tables in Appendix K for further details and breakdown of data analysis. Sustainability Plan Ongoing planning is underway regarding how best the organization will continue to provide the education in the intervention. Currently, the plan is that all nursing personnel at orientation will be receiving the education provided during this project. This presents an exciting opportunity to continue collecting data on the intervention and its’ effectiveness on related outcomes. Additionally, staff will need ongoing, annual training, which will likely fall to the Clinical Education staff or a Clinical Nurse Specialist, or both. Discussions/Implications of Nursing Staff who participated in a 2-hour de-escalation and workplace violence course had a statistically significantly and higher self-perception of self-efficacy. Since 2022 and the early inception of this project, Joint Commission instituted standard HR.01.05.03, requiring organizations to provide staff ongoing WPV education and training (The Joint Commission, 2021). This indicates the ongoing need for education across all disciplines within hospital 18 organizations, reinforcing the idea that WPV occurs anywhere, and all staff need to be prepared to address it safely. The current sustainability plan is for all nursing personnel to receive WPV prevention education at orientation, as well as part of ongoing education for staff already in the organization. Continuing to collect data on the intervention and its’ effectiveness on related outcomes, including rates of WPV and reporting, could present a potential future research study. While participants in the intervention had a good understanding of what WPV is, 77% reported experiencing WPV in the past year, and many stated during the class they did not report it. It is likely that WPV is still underreported, not just in this organization, but nationwide. Therefore, continuing to provide education on reporting and removing barriers to reporting may improve staff’s willingness to report incidences of WPV and better capture WPV in the healthcare industry. Conclusion Based on the available evidence and strength of that evidence, further research is needed on de-escalation education and training for medical-surgical nurses, as well as across nursing disciplines. The results of this project indicated that education and training was effective in improving confidence of nursing staff. The education that was effective included active elements of recognizing worsening or escalating behavior, appropriate interventions to reduce escalation, as well as how to manage violent behavior safely and effectively. Together these provided the knowledge and skills to not only empower nurses to address these stressful situations and also the tools to prevent patients from becoming violent. Future research is needed to determine if these improvements and changes persist after the educational session, perhaps at the six- and 12-month mark post-intervention, and whether this medium of ongoing education continues to be effective. 19 References Al-Ali, N. M., Al Faouri, I., & Al-Niarat, T. F. (2016). The impact of training program on nurses’ attitudes toward workplace violence in Jordan. Applied Nursing Research, 30, 83–89. https://doi.org/10.1016/j.apnr.2015.11.001 American Hospital Association. (2018, January 18). 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(2021, August 11). Occupational violence - fast facts. Centers for Disease Control. https://www.cdc.gov/niosh/topics/violence/fastfacts.html U.S. Bureau of Labor Statistics. (2017, August 31). Workplace violence in healthcare, 2018. Injuries, Illnesses, and Fatalities. https://www.bls.gov/iif/oshwc/cfoi/workplace-violence- healthcare-2018.htm 22 Appendix A PRISMA Diagram Identification Records identified through database searching (n= 58) PubMed: 46 CINAHL: 12 Record screened Record excluded for not (n=58) meeting criteria (n=46 ) Screening Duplicate records removed (n= 6) Eligibility Record reviewed (n= 6) Record included in Additional records synthesis (n= 4) identified through hand Included searches of evidence (n=2) 23 Appendix A. 2009 PRISMA flow diagram. From: Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., & The PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta- analyses: The PRISMA statement. PLOS Medicine, 6(6). 24 Appendix B Evidence Review Table Utilized the Johns Hopkins Evidence Level and Quality Guide (Appendix C) Problem Statement: Would providing medical-surgical and telemetry nurses training on de- escalation techniques impact their self-efficacy in managing escalating patients? Article Design/ Sample/ Measurement Results LOE and Relevance Citation Purpose Setting and Quality; to Instruments Strengths and Problem Weaknesses Al-Ali et Quasi- 100 nurses Utilized “The Significant IIB; strengths: As the al. (2016) experimental across Framework difference training authors pre-test, post- critical care Guidelines for between staff applied to note (p. test survey of units addressing performance multiple 87), the training. (28.9%), workplace before and nursing units training A Clinical medical- violence in the after the and settings, measures Nurse surgical health sector” training shows possiblethe Specialist wards for training program, no generalizabilit confidence trained all (51.5%), An Arabic statistically y for training of nurses groups, and emergency version of significant regardless of to address training department “The Attitude difference setting. violent/esc occurred in a (13.4%), toward Patient between Utilized alating one-day and Physical legal, safety multiple scenarios, session for outpatient Assault training but each group. areas Questionnaire methods, not authors Training (6.2%) at a by Poster and just a slide did not included large Rayan was presentation. measure education on hospital in utilized by the outcomes workplace Jordan team Weaknesses: such as violence, this study was events approaches to completed in a where manage military nurses are escalating/viol hospital in injured or ent patients, Jordan, so harmed. recognition of question as to violent its’ patients, applicability interventions across settings available in the workplace, and monitoring of violence. This utilized slide presentations, group discussion, a case scenario, and role play. 25 Goh et al., Pre-test post- 249 nursing Measured Empathy and II B “Empathy (2020) test, quasi- students students’ confidence Strengths: and non- experimental and 50 confidence in significantly focus on judgmental design medical utilizing de- improved empathy as a attitudes are Mental health students escalation, after the motivator for vital not only nurses and undergoing physical, and intervention improving the in facilitating psychiatrist mental chemical quality of interactions provided health restraints; care, increased with patients, education on training, a satisfaction familiarity but also in signs of university with the with restraints reducing and aggression, offering learning and the impact eliminating de-escalation medical and process/content of restraints to the use of techniques, nursing , as well as reduce their restraint” restraint programs empathy use (Goh et al., methods, and Weaknesses: 2020). concluding assumes that with a student learning these volunteer who aspects was translates restrained, directly into complete with later practice- debriefing students have a gap between acquiring the knowledge and putting it into practice 26 Ferrara et Small, non- N=11 Measured Confidence III B Implementati al. (2017) experimental, Medical- confidence via levels post- Strengths: on of the single-group, surgical Thackrey’s training (p design of the training led pre- and post- nurses Confidence in <0.004) study helped to a decrease test design Coping with to incorporate in the violent Patient Medical both hesitant experiences Measuring Aggression residents and early- when confidence in Instrument requested the adopter nurses compared to de-escalation after utilizing training pre- techniques the Ten based on intervention. with medical- Domains of experiences Weaknesses: surgical De-escalation and small sample nurses dealing by Richmond effectiveness size, non- with agitated et al, 2012. with patients, experimental patients so this inter- design disciplinary approach could be seen as an additional result 27 Lamont & Quasi- Nurses Evaluation of Statistically II B Implementati Brunero experimental from the educational significant on of de- (2018) study of units/wards day was increase in escalation, nurses using deemed completed with participants’ Strengths: evasive pretest- ‘high risk’ the Continuing beliefs about power techniques, posttest for violence Professional their ability analysis and planning Subjects went from a 440- Development scores in yielded a improved to a one-day bed tertiary Reaction these sample size of nurses’ workshop to hospital in questionnaire categories: 71 nurses, confidence in learn de- Sydney, and the creating a which the addressing escalation Australia Confidence in risk authors met agitated techniques Coping with assessment patients and managing Patient and Weaknesses: difficult Aggression management patients Instrument plan, use of de-escalation techniques, use of evasive techniques, confidence in dealing with an agitated patient 28 Appendix C Evidence Level and Quality Guide Johns Hopkins Nursing Evidence-Based Practice 29 Appendix D Literature Synthesis Study Design Level of Education Restraint Confidence Evidence on use and as outcome de- empathy measure escalation techniques Al-Ali et Quasi- II B x x al., (2016) experimen tal Goh et al., Quasi- II B x x x (2020) experimen tal Ferrara et Non- III B x x al. (2017) experimen tal Lamont & Quasi- II B x x Brunero experimen (2018) tal study 30 Appendix E SWOT Analysis Strengths Weaknesses • Organization is actively seeking WPV • Ongoing education may create additional education educational needs/demand • Classroom space available • Staff eager for knowledge, training Opportunities Threats • Recent Joint Commission requirements • Costs of ongoing education beyond the changed to reflect need for WPV project for the hospital may be a burden prevention • Training can create savings if it improves outcomes 31 Appendix F Course Outline I. Definition of Workplace Violence II. Introduction of the crisis model a. Define patient’s behaviors within the crisis continuum b. Define appropriate corresponding staff behaviors to de-escalate the crisis behaviors III. Key concepts of de-escalation a. Empathetic listening b. Rational detachment c. Therapeutic rapport IV. Communication Skills a. Nonverbal b. Paraverbal c. Verbal 1. Additional techniques to address verbal escalation, such as limit setting V. Key tips in the crisis response a. Code Green b. Security’s role c. Situational awareness d. Debriefing 1. For both the patient and staff VI. Disengagement techniques 32 Appendix G Pre and Post Implementation Survey Pre-Survey Age: _____ years I am a(n): qLPN qRN qCNA Education (if applicable): qAssociate’s qBachelor’s qMaster’s qDoctorate Role: qCNA qNurse Resident/RN I qRN II qRN III qRN IV qCharge Nurse qManager qClinical Specialist/CNS qOther:____________________ How many years of experience do you have practicing in your role? _____ years_____months Have you had de-escalation training in the past? qYes qNo Have you experienced workplace violence (WPV) in the last year? qYes qNo Please think about the following questions especially as they pertain to your ability and confidence to deal with a situation at work where a patient or family member is escalating or violent. Not at all true Hardly true Moderately true Exactly true 1. I can always manage to solve difficult q q q q problems if I try hard enough 2.If someone opposes me, I can find the q q q q means and ways to get what I want. 3. It is easy for q q q q me to stick to 33 my aims and accomplish my goals. 4. I am confident that I could deal efficiently with q q q q unexpected events. 5. Thanks to my resourcefulness, I know how to q q q q handle unforeseen situations. 6. I can solve most problems if q q q q I invest the necessary effort. 7. I can remain calm when facing difficulties q q q q because I can rely on my coping abilities. 8. When I am confronted with a problem, I q q q q usually find several solutions. 9. If I am in trouble, I can q q q q usually think of a solution. 10. I can usually handle whatever q q q q comes my way. 34 Post-Survey Now that you know more about Workplace Violence, please answer these questions. Have you experienced workplace violence (WPV) in the last year? Yes No Please think about the following questions especially as they pertain to your ability and confidence to deal with a situation at work where a patient or family member is escalating or violent. Not at all true Hardly true Moderately true Exactly true 1. I can always manage to solve difficult q q q q problems if I try hard enough 2.If someone opposes me, I can find the q q q q means and ways to get what I want. 3. It is easy for me to stick to my aims and q q q q accomplish my goals. 4. I am confident that I could deal efficiently with q q q q unexpected events. 5. Thanks to my resourcefulness, I know how to q q q q handle unforeseen situations. 6. I can solve most problems if q q q q I invest the necessary effort. 7. I can remain calm when q q q q facing 35 difficulties because I can rely on my coping abilities. 8. When I am confronted with a problem, I q q q q usually find several solutions. 9. If I am in trouble, I can q q q q usually think of a solution. 10. I can usually handle whatever q q q q comes my way. 36 Appendix H GANTT Chart Task August September October November December January February March April Project proposal x x approval Education x x x x development Advertising, x x recruitment Education offered, pre- and post- x x x education surveys, data collection Data and outcomes x x analysis Completion x x of paper 37 Appendix I Cost-Benefit Analysis Benefits Costs CNS practicing in Maryland annually: able to Averages $118,564 or ~$57/hr (Salary.com, practice beyond just development/teaching n.d.-b) WPV training program 2 hours of education, 2x month=$228 for 4 hours of education by the CNS/month Potential savings: cost of WPV to the [$94,156] (Occupational Safety and Health organization annually (estimate) Administration, 2015). 2 hours of educational time meets Joint 2-hour educational time for nursing staff, to Commission standard for the year include RN at approx. $37/hr. (Gillette, 2023), and CNA at approx. $19/hr. (Salary.com, n.d.- a) Per RN: estimate $74/yr for WPV education Per CNA: estimate $38/hr for WPV education 38 Appendix J Educational Session Flyer Recruiting Email Dear Clinical Nurses, You are invited to participate in an evidence-based practice project on self-efficacy of nurses in addressing escalating patients. The purpose of this project is to assess self-efficacy of nursing staff, especially as it relates to de- escalation skills, and to provide education on how to address escalating patients and family members safely within our care. Educational sessions will be scheduled for 2 hours on several days and times throughout the upcoming weeks and months. Before and after the education, the nurse’s sense of self-efficacy as it relates to addressing escalating situations will be assessed using a survey. No personal identifying information will be collected, so I hope that you feel comfortable to share your honest perspective and feedback. Please consider taking the time to participate in this evidence-based practice project that will assist us in ensuring education provided on topics of interest meet the needs of our nursing teams. If you wish to participate in the project, please contact Liz Corker at ecorker@frederick.health or 240-566-3225. Regards, Liz Corker BSN, RN, CCRN, CEN DNP Student, Michigan State University 39 Recruitment Flyer ATTENTION CLINICAL NURSES CALL FOR PARTICIPANTS! You are invited to participate in an evidence-based practice project on self-efficacy of nurses in addressing escalating patients. This study is being conducted by Liz Corker, a DNP student at Michigan State University. The purpose of this project is to assess self-efficacy of nursing staff, especially as it relates to de- escalation skills, and to provide education on how to address escalating patients and family members safely within our care. Educational sessions will be scheduled for 2 hours on several days and times throughout the upcoming weeks and months. Before and after the education, the nurse’s sense of self-efficacy as it relates to addressing escalating situations will be assessed using a survey. No personal identifying information will be collected, so I hope that you feel comfortable to share your honest perspective and feedback. Please consider taking the time to participate in this evidence-based practice project that will assist us in ensuring education provided on topics of interest meet the needs of our nursing teams. If you wish to participate in the project, please contact Liz Corker at ecorker@frederick.health or 240-566-3225. 40 Appendix K Data Analysis Tables Table 1. Paired Samples T-Test Mean N Std. Deviation Std. Error Mean Pre-total 31.66 35 3.48 .59 Post-total 34.66 35 4.47 .756 t df Two-sided p Pre- total & -6.765 34 <.001 post-total Table 2. Descriptive Statistics N Range Minimum Maximum Mean Std. Deviation Age 35 43 18 61 36.6 11.2 Experience 34 37.6 1 38.6 9.1 9.4 Years Table 3. Demographics N Percent License RN 31 88.6 CNA 4 11.4 Education HS or Less 3 8.6 Associate’s 3 8.6 41 Bachelor’s 26 74.3 Master’s 2 5.7 Doctorate 1 2.9 Role RN 1 Nurse Resident 1 2.9 RN 2 21 60 RN 3 3 8.6 Charge Nurse 2 5.7 Manager 1 2.9 CNS 1 2.9 CNA 4 11.4 Hospital Supervisor 2 5.7 Table 4. Workplace Violence Personal and Educational Experience N Percent De-escalation Education in the Past No 16 45.7 Yes 19 54.3 Workplace Violence Experience Past Year Pre-Intervention No 6 17.1 Yes 27 77.1 Post-Intervention No 8 17.1 42 Yes 27 77.1