Discussion of study design
The strengths of this study include active solicitation of event reporting, the fact that this is a prospective study and the study design enabling assessment of each intervention in the program.
In certain situations, it may be of interest to use an alternate-month study design, i.e. alternating On (intervention) and Off (control) periods which provide a series of before and after studies with interventions repeated over time [
25]. This type of study design can be used only when there is no residual affect during Off periods. It is particularly well-suited to assess the impact of IT tools [
26]. This design may be of particular interest when assessing the impact of an intervention in a single health care facility, which makes a randomized controlled study difficult to perform [
27].
Unlike a simple before/after study, this design offers the advantage of providing a control group that enables more thorough assessment of the impact of a repeated intervention at a health care facility.
Moreover, in addition to the overall effect, the effect of each of the 5 interventions can be assessed. It nonetheless requires the event measured to be sufficiently frequent during each alternating period.
Discussion of primary outcome criterion
All of the healthcare staff at the OED were trained to report acts of incivility/violence for each patient and/or relative coming to the unit. A number of scales exist to measure violence, such as the Overt aggression scale [
28]. We created a scale based on the findings of the French National Observatory of Hospital violence [
9]. Unlike other studies, which consider only physical violence, our scale also takes into account verbal abuse and rudeness. Although verbal abuse is often not included [
29], most studies consistently show that verbal abuse, threats and assaults are common [
13,
30,
31].
However, perceptions of what constitutes ‘abuse’, ‘threats’ or ‘assault’ may be less clear, which may have an impact on the reporting and subsequent handling of such incidents [
32]. The under-reporting of incivility/violence is a well-known phenomenon, namely when reports are made directly to the hospital administration [
18,
32‐
35]. Lack of time is the main reason for under-reporting given by healthcare professionals. The fact that incivility often goes unrecognized, due to habit and understanding of/empathy for patients, is also mentioned. In order to curb this under-reporting, healthcare professionals were trained using virtual cases (short clinical vignettes) in order to provide all staff enrolled in the study with a shared definition of incivility or violence (see Table
1). In addition, any act of incivility/violence toward healthcare care staff or other patients was recorded in the patient’s medical record, simultaneously alongside other essential medical information.
Discussion of the intervention
Several levels of interventions are possible: interventions at the patient level, interventions at the level of the healthcare professional facing acts of incivility/violence, and interventions regarding security [
36]. Interventions regarding healthcare professionals aim to enable medical staff to recognize signs of potentially violent situations and to know how to prevent the escalation of violence [
37,
38]. Although educational initiatives on managing patient aggression may assist in improving staff confidence and perception of safety, there are few data to prove that these programs actually reduce the number of incidents and their consequences in the long term [
15,
39,
40]. Security interventions involve checking of patients and interventions of the police [
41,
42]. In accord with the staff of the OED, we chose to develop primarily patient-centered actions in order to minimize patient discomfort during their visit to the OED.
There are a number of different theories of violence [
8,
20,
21]. The Frustration—Aggression theory is one of these, defined by a lack of understanding of the surrounding environment, which leads to frustration and then aggression. Our intervention is multifaceted, combining interventions on various dimensions that may influence the behavior of patients and/or those accompanying them, based on the Frustration-Aggression theory. The intervention was designed by a working group involving the different healthcare professional of the OED. Four types of approaches were selected: organizational, environmental, interpersonal, and security (video surveillance cameras). Our measures, which primarily target the experience and behavior of the patients, include implementation of a series of organizational and functional measures such as improving the conditions of patient admission and stays in the OED (cleanliness of the premises, clear signage, etc.), reduced waiting times (standardized triage and orientation procedure by admissions nurses), mediators in relation with waiting patients and those accompanying them, and security measures (video surveillance cameras and maintaining patients in the waiting room).
Since the 1990s, overcrowding of emergency units has been a problem affecting all developed countries [
43]. This phenomenon occurs when demand for emergency care exceeds a unit’s capacity to provide care within a reasonable waiting time. In France, overcrowding of emergency units has increased considerably over the last 20 years with an average increase of 5% per year. According to the Centers for Disease Control and Prevention, two-thirds of US metropolitan EDs experience overcrowding [
44]. This overcrowding, which previously affected mainly general emergency departments, now also affects OEDs. This flow of patients responsible for longer waiting times has led to a high level of patient dissatisfaction. This frequently results in administrative complaints, patients leaving before receiving care, and verbal or physical abuse of healthcare professionals. Waiting time is an indirect measurement of crowding, which is a contributing factor of violence [
5,
18,
45].
Waiting time is a well-known primary factor of patient dissatisfaction, as a result leading to incivility and violence against healthcare staff. By optimizing the order in which patients are treated (prioritization algorithm with call-up screen), we wish to reduce this waiting time and thus curb incivility by patients and/or those accompanying them [
4]. As well, this waiting time must be as bearable as possible and video messages (information on the OED and educational messages) should help to pass the waiting time and reduce the feeling of being abandoned in the waiting room.
The use of a triage algorithm should help to optimally prioritize patients for care. The principal of triage is defined as a dynamic decision-making process performed at patient admission in order to specify an order of priority for care [
46]. This algorithm is integrated in the IT system, which includes administrative check-in of patients when they arrive at the OED, the recording of data from the medical records and the prioritization of each patient in terms of OE. This type of tool has been shown as useful in reducing the number of patients that leave before being seen by a physician [
22] and in reducing waiting times [
43,
47]. This tool involves informatics work, with the cooperation of the hospital IT department, and the creation of an algorithm including all of the medical information potentially collected by the nurses at the OED admissions desk. The triage algorithm was design by physicians from the OED participating in the study. This work was based on the current French recommendations. Nurses are to be trained to use this tool. It is nurses who, in the OED studied, receive the patient once they have completed admissions procedures with the hospital administrative desk.
In a study published in Science, Keizer et al. examine the influence of environmental factors on the occurrence of deviant behavior in society [
48]. Likewise, in the OED, we can suppose that a well-organized, clean, well-lit waiting room is one factor in preventing incivility/violence against healthcare staff.
We will use a mediator whose role is to prevent the escalation of violence. De-escalation is a gradual resolution of a potentially violent and/or aggressive situation through the use of verbal and physical expressions of empathy, alliance and non-confrontational limit setting. However, nurses often require specialized training in this respect-based technique [
20]. In short, de-escalation involves defusing, negotiation and conflict resolution, [
49] with the aim of recognizing signs of impending violence and preventing it before it happens [
50]. While this technique is useful for minimizing violent behavior, not all nurses are trained to use these techniques [
49]. We have thus decided to entrust an external, specially trained third party with this task.
Workplace violence has emerged as a significant problem compromising security, self-esteem, work performance, relationships, and overall health of ED employees. There is a paucity of large, well-designed studies supporting any strategy aimed at preventing ED workplace violence [
36].