Understanding, Measuring, and Ameliorating Workplace Violence in Healthcare: A Canadian Systematic Framework to Address a Global Healthcare Phenomenon

Abstract

Background: Globally, healthcare institutions have seen a marked rise in workplace violence (WPV), especially since the Covid-19 pandemic began, affecting primarily acute care and emergency departments (EDs). At the University Health Network (UHN) in Toronto, Canada, WPV incidents in EDs jumped 169% from 0.43 to 1.15 events per 1000 visits (p<.0001). In response, UHN initiated a comprehensive quality improvement (QI) project to address WPV. This study presents the project's design, implementation, results, and key takeaways, aiming to showcase effective and trauma-informed strategies for mitigating WPV in healthcare settings. Methods: Our multi-intervention QI initiative was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 framework. We also leveraged the SEIPS 101 tools to aid in crafting each QI intervention. This approach amalgamated various methodologies to approach WPV, incorporating literature reviews, a modified Delphi method, qualitative interviews, surveys, quantitative data gathering and pragmatic interventions. Results: Our complex intervention contained a total of 12 subprojects. We reviewed existing literature (n=84) pertaining to WPV in healthcare. N = 229 quality indicators utilized to measure WPV in healthcare were extracted from the literature and underwent a Delphi process which yielded 17 quality indicators for a new organizational WPV dashboard. WPV theories were critically reviewed in the context of intervention development. Educational initiatives (n=2) were implemented including ad-hoc point of care training, as well as rollout of a comprehensive trauma-informed training program for WPV prevention, verbal de-escalation and management of escalated responsive behaviour. Further changes involved establishing a Code White Governance Committee, enhancing WPV reporting and addressing underreporting. Debriefing was structured into hot and cold debriefing models. Additionally, environmental indicators promoting mutual respect were introduced, alongside security enhancements including wearable video devices for all security guards and a 100% increase in ED security guards. Outreach initiatives were implemented including qualitative interviews with ED staff (n=75) and the development of a patient partner and community outreach group. Conclusions: WPV in healthcare is a complex phenomenon that urgently requires effective solutions. We developed a 13-step framework that offers guidance for healthcare institutions seeking to develop a systemic approach in addressing WPV tailored to their organization’s needs.

Developing a customised set of evidence-based quality indicators for measuring workplace violence towards healthcare workers: a modified Delphi method

“…This aligns with the literature as under-reporting of WPV is a frequently highlighted issue with many contributing factors that require addressing. 6 12 28–30 Similarly, our expert panel demonstrated strong support for indicators related to WPV education and training. Numerous articles advocate the need for education and training that incorporates concepts such as trauma-informed approach, de-escalation skills and agitation management in order to enhance safety and promote effective conflict resolution strategies.…”

“…This Delphi technique project was part of a larger organisational approach to addressing WPV within our institution. 6 The project was managed by a focused UHN Security QI Team, consisting of staff physicians (n=2), a security director (n=1), data project manager (n=1) and a research analyst (n=1). The team provided study oversight from design to knowledge dissemination.…”

“…These experts were identified in a previous process that used a People, Environment, Tools, Tasks Scan as outlined by the Systems Engineering Initiative for Patient Safety 101 toolbox. 6 18 In this scan, all functional units and people involved in addressing WPV at UHN were identified. This included individuals involved in clinical responses to WPV, WPV training and leadership roles.…”

“… 3 5 The EDs at the University Health Network (UHN) in Toronto, Canada, have observed the number of WPV incidents increase from 0.43 to 1.15 incidents per 1000 visits, an increase of 169% (p<0.0001). 6 The stressors of violent incidents, particularly in acute care settings, are known to contribute negatively to the quality of patient care and quality of life for healthcare providers (HCPs). 2 As a result, organisations need to find strategies to reduce the incidence and mitigate the impact of WPV in care settings.…”

“… 7 An important step of QI project planning includes identifying measurements to demonstrate change over time. 6 8 Quality measures or indicators help organisations identify areas for improvement and are integral in measuring the impact of QI interventions, including positive changes and unintended consequences. 9 10 Quality indicators tailored to the organisation have been demonstrated to further increase the likelihood of successful QI project completion.…”