2023 14th Annual NUBE Conference

Background: Workplace violence is an increasingly serious problem that negatively affects healthcare workers in acute care hospitals, which has been well documented. It also adds to the overall financial burden through staff injuries and turnover. In 2022, Boston Medical Center identified that frontline staff get injured on the job at alarming rates, with 1 -2 reported assaults daily, and have expressed fears for their safety and well-being. Four major categories of patients at risk for agitation and escalation were identified, including those with psychiatric and substance use disorders, cognitive impairment, and neuro-diversity. The historical procedure for responding to an agitated patient was reactive and missed the opportunity to prevent a crisis. However, not much was known about the contributing factors and gaps in preventing and reacting to patient agitation.Quality Improvement

Methods: A stakeholder workgroup that included frontline workers, clinicians, and leadership was convened to evaluate the current state of agitation and patient on healthcare worker violence management and to make recommendations for a future ideal state. A systematic quality improvement process was used to understand the etiology of patient agitation, current processes, and resources used to manage workplace violence. Information collection included individual and group stakeholder interviews to conduct comprehensive root cause analyses and map out the current state. A scoping literature review of best practices and a gap analysis were used to identify and understand unmet needs, themes, and possible solutions.

Solutions: Based on our findings, the following solutions were proposed: Implementation of a proactive agitation screening for all adult inpatients using the Behavioral Agitation Rating Scale (BARS) embedded in the electronic health record. A team response to behavioral escalation led by behavioral response nurses and proactive rounding on patients at risk for agitation or withdrawal is in the process of implementation. Documentation and debriefing tools were built for the behavioral response nurses. Proposed outcome measures: The proactive agitation assessment and team response are expected to close current gaps in staff education and real-time clinical response and better address unmet patient needs. Initial outcome measures will include staff skills and an anonymous survey for staff to rate their self-efficacy in the proactive management and response to patient agitation. Additionally, the percentage of patients who experience agitation is measured with the BARS score and the use of violent and non-violent restraints. The number of workplace incidences will be trended over time, and early nurse retention data will be presented. The return on investment will be discussed to describe the financial impact of using a team to address workplace violence.
Conclusion: A rigorous quality improvement process was used to investigate the current state, root causes, and contributing factors of patient on healthcare worker violence. Participants will benefit from understanding how quality improvement methods can lead to a system-wide proactive approach that addresses patient agitation and escalation to reduce workplace violence.