RESEARCH Select a minimum of 5 primary research studies from your literature search. Articles must justify the PICOT. Critically appraise the selected ar

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  1. Select a minimum of 5 primary research studies from your literature search. Articles must justify the PICOT.
  2. Critically appraise the selected articles. 
  3. Synthesize the findings of the articles to come up with a justified conclusion to your PICOT.
  4. All references and in-text citations must follow APA guidelines. 

See rubric in Syllabus Supplement for additional information and grading guidelines.



Patient Violence Against Nursing Staff and De-Escalation Courses: Literature Review


NSG 410 Research and Evidence- Based Nursing Practice

Dr. Coffin

Patient Violence Against Nursing Staff and De-Escalation Courses: Literature Review

Overview and Introduction

Patient violence against nursing staff is an ongoing, and rising, issue in the healthcare field not just in the U.S., but worldwide. According to The Joint Commission (2018), workplace violence (WPV) occurs four times more in nurses in hospital settings than any other worker in the private sector. Nurses working in emergency departments are at the greatest risk of verbal and/or physical assault than any other unit of nursing due in part to being the first point of contact with the patient from the outside (Wong et al., 2015). That being said, WPV still occurs in all nursing fields putting each nurse working bedside at risk. Using meticulous technique, a literature review was conducted using primary sources in the span of several weeks. Search terms such as “violence in nursing”, “workplace violence”, “occurrences”, and “de-escalation training” were combined and inputted into databases such as ProQuest, National Institutes of Health, and CINAHL with additional search terms applied when needed for clarification. The articles that will be discussed in this review were chosen because they are primary sources that moved the discussion forward on solutions to reduce patient violence against nurses. Knowles’ Adult Learning Theory was the theoretical framework used to guide this research with the understanding that adult learning is mainly self-directed and self- motivated, so in order to be able to implement successful education programs, such as that of this intervention, this understanding must be acknowledged (Casey, 2019). Comment by Rebecca Coffin: The problem is clearly presented and data is provided to show the magnitude of the problem Comment by Rebecca Coffin: Search terms are provided Comment by Rebecca Coffin: No need to use a theory to guide your paper, but you are welcome to do so if you wish Comment by Rebecca Coffin [2]: Great introduction!

Clinical Question

The clinical research question in focus for this literature review is as follows: Among nursing staff in acute hospital units, what is the effect of de-escalation training courses in reducing the number of violent events compared with learning de-escalation on the job, within 12 months of implementation. Comment by Rebecca Coffin [2]: PICOT

Appraisal of Articles

With Knowles’ Adult Learning Theory in mind, articles were chosen that exemplified the integration of adult learning into their interventions. In the article “Management of Aggressive Patients: Results of an Educational Program for Nurses in Non- Psychiatric Settings,” by Casey (2019), a non- experimental one-group, pre-post test design was used to evaluate the effectiveness of an education program that utilized multiple teaching strategies. The study recruited 36 registered nurses from a neurological unit in an adult hospital in southern United States. The program was delivered in a hybrid format over 6 weeks that utilized online presentations as well as in person classroom sessions. In line with the theoretical framework, the researchers utilized case studies to foster critical thinking, face to face role play was used demonstrate and build up de-escalation techniques, and group reflections were used to collectively bring together what was learned. Data was collected using self- reported Likert scale questionnaires that were validated by experts in emergency and psychiatric nursing. Analysis of the data concluded significant improvement in demonstration of preparedness and increased confidence in managing aggressive behaviors through the use of the designed educational program. Comment by Rebecca Coffin [2]: Don’t need to include the title of the article in APA style

The major limitation of the study was the small sample size not being significant enough to be generalizable. There was also time constraints limiting the amount of time for learning but was necessary in this study to feasibly allow maximum number of participants due to having to work around shift schedules. The researcher in this study recommends expanding similar interventions into other acute hospital units.

The article, “Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomized controlled trial” by Bowers et al. (2015) implemented 10 carefully selected interventions into a clustered randomized control trial to study its effects on rates of conflict and containment. The study came about from the understanding that there is a need for RCT’s in this topic. The study comprised of 15 psychiatric wards surrounding central London with inclusion criteria being acute psychiatric inpatient wards and were excluded if the wards had any major changes coming up in the course of the 18-month study, if they didn’t have a permanent nurse manager on post, and if the staff vacancy rate was greater than 30%. With these criteria put in place, nurses in the included wards chose to participate bringing the total number of participants to 564 (88% of the potential total). The confidence in this sample size was confirmed in each category with a power analysis. Baseline data was collected for 8 weeks, then participants had 8 weeks to implement the trained interventions, and 8 weeks additional were for observation of the implementation. This study was double blind in that both researchers and participants were unaware of which was the control and which was the intervention. Wards were visited 2-3 times a week by researchers who delivered and collected questionnaires and answered any questions about the interventions in order to ensure strong reliability. Results showed the interventions implemented in the Safewards interventions were significantly effective in reducing patient conflict and containment. Given that the primary source of data collection came from questionnaires, the main limitation of this study was missing data from unsubmitted questionnaires by charge nurses working the participating shifts. After accounting for these deficits however, they concluded that the missing data was not significant enough to shift the findings. The second limitation and recommendation for future research was that the study length was too short of a time period to really see significant change after implementation. Comment by Rebecca Coffin: Good critique! Look for whether a power analysis was performed in quantitative studies Comment by Rebecca Coffin [2]: What effect does this have on the study? Is this a good thing to do?

This study understood that there was a lack of quantitative research on violence against nurses in the form of randomized control trials, so the research design itself was created with the hopes of being the trailblazers for future research to continue RCT’s in the study of this concept. By explicitly highlighting each limitation set forth in their study, they were able to use their limitations to pave the path for future research.

In the study “Educational and Managerial Policy Making to Reduce Workplace Violence Against Nurses: An Action Research Study” Hemati- Esmaeili et al. (2018), look beyond education at the bedside nurse level to go a step up the ladder to include managerial interventions. This study took place in Iran but many issues presented in this study are parallel universally to many other hospital settings. With a sample size of 44 nurses confirmed by a p value test, a workplace violence prevention program was developed in conjunction with the development of a new nursing position called the violence prevention nurse, whose role was to screen patients and their families upon arrival to the hospital for potentially aggressive behaviors. Careful analysis using SPSS software analyzed the results of the self-report surveys and focus groups and concluded that the implementation of the program significantly reduced fear associated with these violent events because the nurses felt more prepared to handle them. This study went a step further than the previously discussed studies by including a managerial intervention where a protocol was put in place of how to take care of staff who had been attacked. Comment by Rebecca Coffin [2]: Good point to highlight!

This study did an excellent job of highlighting the need for interventions that are individualized to each unique unit. They explained that many aspects of the design, such as altering the questionnaire scales used to better suit Iranian culture, was a big step in improving fidelity in the study because the nurses could answer more accurately. Unique to this study and also not included in the previously mentioned studies, was a follow up survey four months after conclusion of the study. Researchers could still see strong evidence of the interventions being implemented. Follow up studies should be included in future research in this topic to measure long term effects. Comment by Rebecca Coffin [2]: That is a good thing to do to check how long the effect lasts

The study “Coordinating a Team Response to Behavioral Emergencies in the Emergency Department: A Simulation- Enhanced Interprofessional Curriculum further enhance the findings from all the previously mentioned studies by integrating teamwork into simulation scenarios using larger sample sizes. Wong et al. (2015) hoped that through implementation of an interprofessional curriculum into simulation enhanced education, teamwork and staff attitudes toward patient violence would improve. Ten 3-hour simulation sessions were conducted for this study. In the simulation, formal roles were predetermined, meaning each member of the healthcare team knew exactly what their roles were immediately once a violent event was occurring. The study recruited 162 ED staff members. Surveys used to collect data were published from a British nursing education group that showed reliability and internal validity. Data collected was reflective of participant’s changing attitudes through the duration of the course. Risk for bias in response was present though in that evaluators of the program were in leadership positions within the participating department, which may have confounded responses with staff members answering in responses favorable to the evaluators. As was the main theme with all the studies discussed thus far, the main limitation of the study was time constraints and lack of longitudinal data. Comment by Rebecca Coffin: Another great critique!

Given the emotional magnitude of this research topic, it was necessary to include a qualitative study into this review to increase the magnitude of its relevance to the nursing profession and place further emphasis that research in this field is what the people directly involved want. The qualitative phenomenological study “The Patient Care Paradox: An Interprofessional Qualitative Study of Agitated Patient Care in the Emergency Department” by Wong et al. (2016), took their research further from the previously discussed study to look at the experience of these healthcare workers to provide a broader perspective of ED patient violence. Convenience, but purposive, sampling was used to recruit participants. This study took careful measures to reduce bias in all aspects of the study. For example to balance out and decrease bias during data collection, the research team consisted of 2 board certified ED physicians, but also 2 nurses working outside of the ED (palliative and midwifery) so as to maintain an insider/ outsider approach and to bracket potential personal biases which could have skewed the data collection. In the research design, 1 member of the research team with no prior relationships to any of the participants was trained for qualitative data collection while another member assisted in equipment setup and took field notes. The interview process was standardized and data was cross-checked. Interview responses and focus group discussions were all recorded, transcribed, and later professionally transcribed by a third party. In this study, data saturation was reached at 31 participants. Comment by Rebecca Coffin: Spell out “two” Comment by Rebecca Coffin: Here also, “two” should be spelled out Comment by Rebecca Coffin [2]: Spell out numbers <10 per APA style Comment by Rebecca Coffin [2]: Good!

Three themes were discovered as a result of these interviews. The first is the patient care paradox: that in the process of providing high- quality care for these potentially aggressive patients, staff are putting themselves at greater risk of a violent incident, and finding a balance is not easy. Under this theme, direct quotes were included that talked about injuries many of the participants sustained as a result of trying to provide quality care. The second theme was that teamwork is key to resolution of a violent situation, however, pre-existing conflicts up the linear ladder of command make it hard to fluidly work as a team. In this particular hospital, quotes were included that talked about how techs can’t do anything to de-escalate a situation unless the nurse is involved, and the nurse can’t prophylactically prevent a violent incident unless he/she gets orders from a doctor, and it causes delay in action when not all members are on the same page. The third theme was environmental factors that further exacerbate aggressive behaviors such as lack of privacy, volume of people. The main limitation of this study is that while data saturation was reached, this data may not be generalizable to all ED’s because it was conducted in a heavy volume, urban ED in New York City. Researchers also stated that descriptions of patient population were reliant on descriptions from participants and not confirmed with demographic statistical data, thus increasing the likelihood of personal and recall bias. Comment by Rebecca Coffin [2]: Fantastic review of the articles! The articles were relevant to the PICOT and you captured all the highlights


A literature review was conducted using five primary sources to examine the effect of de-escalation courses and interventions on patient violence against nursing staff in acute hospital units. Across each article presented in this literature review was the same recurring theme: change needs to occur to decrease the rate of patient violence against nurses and healthcare staff. The articles in review were not limited to the United States to allow a comparison of occurrence of patient violence worldwide. The similarities in research topic of each of these articles is enough to attest to the ongoing need for a long-lasting intervention. Each article highlighted that this is a significant problem that is only getting worse with time. Each article was able to recognize that any intervention showed improvements than no intervention. Comment by Rebecca Coffin [2]: Was there one intervention that was better than others? Why or why not?

Limitations encountered in the search for literature included a saturation of studies conducted in emergency departments and psychiatric wards. The study by Casey (2019) was conducted in an adult neurological unit but even in their discussion they explained how they borrowed scales more suited for emergency departments. Another limitation noted in these studies was that no matter what statistical data is published on rates of workplace violence in nursing, the number is always higher because there is always the incidences that don’t get reported. One strength of these studies was their use of self-report data collection to foster an outlet for these nurses and healthcare workers to have their thoughts heard that they might otherwise have been too scared to report for fear of job security or backlash. The limitation of time led to many gaps and inconsistencies in the results of a number of these studies. For example, the articles by Wong(year) and Bowers (year)both explained how implementing a new protocol for an entire hospital unit is a very time- consuming task in and of itself. They both explained how by the time their interventions were taught at the level suitable to continue on with the study, weeks had already gone by. In both discussions, it was highlighted that longer time for data collection would have allowed more significant results. Research must continue on this topic for the improvement of the nursing field as a whole. Comment by Rebecca Coffin [2]: Not surprising, I’m sure! Comment by Rebecca Coffin [2]: Yes but what do we know about the limitations of self-report? Comment by Rebecca Coffin [2]: Nicely done! I think you could have had a more definitive conclusion, but you did a great job in comparing / contrasting the studies overall

References Comment by Rebecca Coffin: References are formatted per APA guidelines

Bowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomized controlled trial. International Journal of Nursing Studies, 52(9), 1412-1422.

Casey, C. (2019). Management of aggressive patients: Results of an educational program for nurses in non-psychiatric settings. MEDSURG Nursing, 28(1), 9-21.

Hemati-Esmaeili, M., Heshmati-Nabavi, F., Pouresmail, Z., Mazlom, S., & Reihani, H. (2018). Educational and managerial policy making to reduce workplace violence against nurses: An action research study. Iranian Journal of Nursing and Midwifery Research23(6), 478–485.

The Joint Commission. (2018). Physical and verbal violence against health care workers. Sentinel Event Alert.

Wong, A. H., Wing, L., Weiss, B., & Gang, M. (2015). Coordinating a team response to behavioral emergencies in the emergency department: A simulation- enhanced interprofessional curriculum. The Western Journal of Emergency Medicine, 16(6), 859-865.

Wong, A. H., Combellick, J., Wispelwey, B.A., Squires, A., & Gang, M. (2016). The patient care paradox: An interprofessional qualitative study of agitated patient care in the emergency department. Academic Emergency Medicine, 24(2), 226-235.

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