Background
Study aim
Methods
Study design
Study setting
Program | Description |
---|---|
RiskMan | A reporting system to record, notify and investigate health and safety incidents and near misses at work. |
Tap Out program | Nurses nominate to be swapped from one area of the ED to another in order to remove them from challenging patients or situations. |
Muster Slides | Highlight potentially challenging patients which allows the in-charge nurse to distribute them evenly among nurses to reduce compassion fatigue and mental injury. |
Accountability letter | A letter is sent on behalf of the hospital to a perpetrator of violence, informing them that their behaviour was inappropriate and that an alert will be placed on their medical record. |
Behavioural assessment unit | The unit is co-located with the ED but removes patients from the more chaotic environment of the main ED area. The aim is to fast-track the admission of patients with intoxication and mental health issues. |
Management plan | Management plans for complex patients include tailored strategies to prevent aggressive behaviour and de-escalate the specific patient when they become aggressive. |
Participant recruitment
Data collection
Focus Group Interview Guide | |
---|---|
1. Experience of reporting violence at work | |
2. The new reporting system | |
3. Perception and approach to perpetrators | |
4. Working with perpetrators to prevent violence | |
4.1. Accountability letter |
Data analysis
Level | Barriers | Enablers | Opportunities |
---|---|---|---|
Individual Professionals | Incident reporting process: • Lack of reporting • Experience with police | • Staff injuries | |
Individual Perpetrators | Type of perpetrator: • Complex patients, reoffenders and visitors | • Different approach: Prevent mental health patients in ED | |
Social Context | • High frequency violence | • Public education | |
Organisational Context | Initial response: • Accessing previous risk behaviour • Rewarding bad behaviour • Technical problems to report events Organisational action: • Lack of active follow-up | • Organisational culture and support • Tap Out program • Muster Slides • Management plan • Recording risk behaviour • Accountability letter | • Consequences for perpetrators • Apology letter • Security footage • Easier reporting process • Feedback to staff |
Economic and Political context | |||
Innovation (interventions) |
Reporting
Ethics approval and consent to participate
Research team and reflexivity
Results
Participant characteristics
Barriers, enablers, and opportunities for organisational follow-up
Barriers to follow-up
“We have a very high threshold, we tolerate so much, that it has to be a significant incident or a significant threat before we actually do something … it’s just water off a duck’s back, to be abused, threatened … ” (Participant 10)
“This system itself let me down. I wasn’t supported. And I went to the police and they basically turned a blind eye with some other associated issues that were out of their hands.” (Participant 4)
“The police officer saying something during the week, I was like, actually we do need to report this. That played a role.” (Participant 6)
“They’re frequent flyers. They come in and unfortunately they do have these personality disorders or anti-social personality disorders where they … they’re not deterred, and they thrive on conflict.” (Participant 8)
“They sent this man a letter saying, ‘we’re acknowledging what has happened and … we have a zero tolerance’. This man has an anti-social personality disorder, I almost feel like this is going to fuel him more because he was so angry that we hadn’t helped him.” (participant 8)
“It’s hard with family though, because I find it difficult to report. I want to report an incident, and I find it hard to do because they are not actually registered on the system, they don’t have any details about them, who they were.” (Participant 12)
“We have multiple [security alerts] a shift and attached to one of those is meant to be a Riskman … I could confidently say that when a code grey is called, no stat … if you call 15 code greys a day, there is no way you get 15 Riskmans associated with that. You might be lucky to get one.” (Participant 4)
“Flagging these patients is a big thing for us, so we can identify as soon as these people rock up to triage, that we can say, he’s a high risk … but you know, sometimes you don’t know until it’s too late”. (Participant 8)
“They scream and rant in the waiting room, and suddenly, bang (snaps fingers), they’re in the door, they get seen, they get sorted. Because nobody wants a carry-on.” (participant 17)
“The Riskman is too difficult, we don’t bother … You write in the notes ‘patient aggressive, code grey called’, and then you talk about the outcome with the code grey. But when it comes to Riskman, I don’t think we have any studies at all, or any evidence at all to show that we have code grey here in the department.” (Participant 3)
“The other thing is that what is reported doesn’t ever get any feedback … We don’t know what the repercussions were to the person that was abusive.” (Participant 7)
Enablers to follow-up
“This is probably a bad attitude … but you have to have a serious injury or something like that to then do a RiskMan. (Participant 8)
“For potential work cover” (Participant 3)
“Culture-wise they’ve really put a lot of effort in trying to say you will be supported. Our boss wants to be told, she’s not someone that would discourage you telling her”. (Participant 8)
“Yeah, I’d like to think I’d take advantage of it but like everyone else said, you don’t want to be putting someone else in that position. But it is nice to know in the back of your mind that if you’re really just can’t handle it anymore, there is the option to swap.” (Participant 7)
“It’s a very long process to get the management plan. So once that management plan is done … to me it’s a relief.” (Participant 3)
“Flagging these patients is a big thing for us, so we can identify as soon as these people rock up to triage, that we can say, he’s a high risk … but you know, sometimes you don’t know until it’s too late”. (Participant 8).
“It depends on who it is … Unfortunately, it’s probably only beneficial to some people. But I think everybody needs to be accountable and at least this is something that you can say ‘you’ve been told’ so you can’t pretend … ” (Participant 8)
Opportunities for follow-up
“I completely agree with that patient, it’s the frustration. You’re simply going ‘I know’ and it’s EMH (mental health team) that’s delayed’ or … ‘you can’t leave because you’ve been under a section 351’. You can say these … until EMH arrive, you can only tell her so many times. You can’t hurry them up.” (Participant 3)
“She had been waiting 16 hours as well, so she had been here for some time before she started to escalate.” (Participant 6)
“The (mental health clinician) knew her … and de-escalated it straightaway. The behaviour then stopped. It’s the knowledge about people, their access and appropriate mental health or care plan.” (Participant 15)
“There is a lack of education in the community about how EDs actually work. You know, it’s not a first in, first dressed. There are different streams, there are waiting times for those streams … they need to know what emergency is and what’s prioritised. It’s just a lack of education in the community.” (Participant 9)
Five opportunities for follow-up were highlighted at the organisational level.“I found it very beneficial because people would be [getting aggressive] and they would then watch the video … ” (Participant 12)
“what happens … a lot, is you say somebody is being verbally abusive, it happens a lot at triage, and a lot from relatives. You escalate it, but what happens is there is no comeback on them apart from their issue is resolved a lot quicker. Instead of it just being a clear cut ‘no, this is not how you behave … ’. What they want happens. And I find that … that’s just actually encouraging (violent) behaviour, even though we say we don’t have the tolerance, there is a massive tolerance already.” (Participant 15)
“Yeah, I don’t know … in all honesty, I wouldn’t really want to see this guy again.” (Participant 8)
“They could write a letter themselves, you know. Like document it.” (Participant 9)
“I have a really great rapport with (security), so I can pull up the video and I can have a look at it. But that is actively discouraged by the hospital. If they get caught, they get told off … But there is a resource there that we’re not allowed to use.” (Participant 3)
“I think they use them … when it was popular in the news, that was all footage … a lot of that was from us... If an incident happened, it would always be there to use.” (Participant 8)
“Quick and easy … something you can do then and there, present time. Maybe say, 5 minutes, I’ve got to sit down and do this.” (Participant 11)
“The follow-up is unclear, which doesn’t encourage you to do anything about it as well … Feedback would encourage reporting, if you knew some follow-up, through the police or your own system” (Participant 17)