Patient Aggression Causes Nurse Injuries: The Need for Nurse Education on
Patient Aggression Predictor Tools for the Medical-Surgical Unit
Defining the Teaching/Learning Need
According to Kim, Ideker, and Tocheeney-Mannes (2011), nurses are subject to patient violence in all units of the hospital. However, until fairly recently, patient violence predictor tools have been developed only for psychiatric units and emergency departments, which may not be valid for use in other areas of the hospital (Calow et al, 2015). A review of current literature reveals that a need exists for a specific tool, tailored to patient risk factors for aggressive behaviors on medical-surgical units (Ideker, Toldecheeney-Mannes & Kim, 2011). The literature reveals that many general hospitals do not currently use a violence risk assessment tool (Calow et al, 2015). Therefore, nurses on medical-surgical units have a need to be educated about the availability and use of such predictor tools, to assess the potential for patient aggression while hospitalized: the following teaching/learning/analysis project attempts to fill this gap in nursing education, in an effort to protect nurses from injury on the job.
Identification Process of the Learning Need
Inspira Hospital in Vineland, NJ, is a general hospital that does not currently employ an assessment tool for predicting the risk of patient violence, yet the patient population is such that many risk factors for patient aggression exist: some of these factors include patients with delirium, dementia, alcohol abuse and drug abuse (Williamson et al, 2013). If Inspira decided to adopt a tool, such as the Aggressive Behavior Risk Assessment Tool (ABRAT), nurses would be empowered to assess the risk of patient aggression, which might in turn allow nurses to plan interventions to help prevent or de-escalate aggressive patient behavior towards nurses and other staff (Kim, Ideker, & Tocheeney-Mannes, 2011).
At a nursing staff meeting in October 2015, one of the nurses mentioned the increase in “Code Grey” alerts over the last several months, and asked the nurse manager and the group about what might be done to prevent harm to staff, related to aggressive patient behaviors on the medical-surgical unit. At the time, I was researching for this project, and found out that assessment tools exist that help nurses to predict potential risk for patient violence, which could help reduce “Code Grey” incidents and possible nurse injuries. The nurse manager decided investigation of such tools might be of benefit to her nurses, and she agreed to look into existing tools. I offered to get the ball rolling with my teaching/learning/analysis project, and the nurse manager Patty Sanchez, MSN-RN, gave me a “green light” to report back to her, and to share my findings with the staff on the third floor.
My preceptor Ellen Reeves, RN, also agreed that the nurses might benefit from learning about patient aggression predictor tools, because of the particular patient population served at Inspira Hospital; patients often include drug and alcohol abusers, patients with delirium/dementia and other cognitive impairment, who are often at a high risk for aggressive behavior (Williamson et al, 2013). From my experience at Inspira Hospital, I can say with certainty that about 40% of the patients I have served fit into the aforementioned categories, and I was present for 3 “Code Grey” events while attending clinical this semester. I completed a review of several existing tools, and I decided to teach the nurses on the third floor medical-surgical unit, about the benefits of using the ABRAT (Kim, Ideker, & Tolcheeny-Mannes, 2011) to assess patients for a risk of aggressive behavior while hospitalized.
Teaching/Learning Tool Development
My teaching tool is a brochure that I developed after the completion of extensive research on patient risk for aggression predictor tools. I developed the brochure at the literacy level of an associate’s degree prepared nurse, since that is the lowest level of education on the unit, and therefore, should meet all nurses’ literacy needs. A brochure is the easiest way to teach the nurses about the ABRAT (Kim, Ideker & Tolcheeny, 2011), because the room is too small to allow for any type of computer (example: Power Point) presentation. I planned to do a “teach and lunch” with any available nurses.
The teaching/learning tool is a tri-fold brochure. The first section of the brochure provides a rationale for using the ABRAT (Kim, Ideker, & Tolcheeny, 2011): our patient population includes those at high risk for aggressive behavior, such as delirium and dementia, alcohol abuse, and drug abuse (Williamson, 2013). The second section contains instructions on how to use the ABRAT (Kim, Ideker, & Tolcheeny, 2011) and the third section of the brochure provides an abbreviated list of ABRAT items to be checked off and scored as part of an admissions assessment. The back of the brochure provides an evidence-based rationale and reference citations for the teaching tool. In addition, I created a questionnaire for post-teaching: the questionnaire has items with a three point Likert Scale (sample response choices: never, sometime, often), to help me evaluate nurse opinions in regard to possible implementation of the ABRAT (Kim, Ideker, & Tolcheeny, 2011), with a final open-ended item for nurse comments or questions.
Scientific Support for Development of the Teaching/Learning Tool
The original survey of the literature revealed an article that reviewed “Code Grey” events, which are incidents in which patients act out aggressively towards other patients, visitors, but most often towards nursing staff. Williamson et al (2013) examined records of 6472 patients admitted to a medical-surgical unit over a six-month period from January to June of 2009, of which 221 patients were involved in “Code Grey” events. Williamson and colleagues (2013) studied patient records with a particular focus on patients involved in these events, to discover if any common factors existed among aggressive patients (p. 1144).
Statistical analysis using chi-square, bi-variate, and logistical regression (Williamson et al, 2013) were used to compare common factors between the two groups of patients: those who were involved in a “Code Grey” event, and those who were admitted to the medical-surgical unit who were not involved in a violent event (p. 1147). Williamson et al (2013) discovered that certain characteristics appeared to contribute to a higher level of risk for patient aggression. Some of these factors included: diagnosis of dementia or delirium (40% more likely to become aggressive), drug or alcohol abuse (15% more likely to become aggressive), and age above 65 years (9% more likely to become aggressive) (p. 1146). Furthermore, out of the 121 “Code Grey” incidents, 29 nurses suffered minor injuries, six nurses suffered long-term disability injuries, and one nurse died related to a fall which occurred during a “Code Grey” incident (p. 1146).
Research on the topic of patient aggression risk assessment tools revealed articles on the M55 (Ideker, Tolcheeny-Mannes & Kim, 2011) which is a violence risk assessment tool created for use in psychiatric units and mental hospitals. The authors performed a six month study of the M55 (an assessment tool for risk of patient aggression) in a medical-surgical unit, and found that it showed low sensitivity for aggressive behavior, and was not a valid instrument outside the psychiatric unit. However, a logical regression analysis of M55 use in the medical-surgical unit did show a 95% confidence interval for aggressive behavior in patients over 65 years of age (Ideker, Tolcheeny-Mannes & Kim, 2011, p. 2456).
Kim, Ideker and Tocheeny-Mannes (2011) used their research on the M55 to create their own tool, the Aggressive Behavior Risk Assessment Tool (ABRAT). The authors used certain characteristics noted later by Williamson et al (2013) and Calow et al (2015), which the authors borrowed from the M55 (examples: physically aggressive, verbally hostile, history of aggressive acts, history or signs/symptoms of mania, threats to leave, shouting tone of voice) for the first six items on the ABRAT (Kim, Ideker, & Tolcheeny-Mannes, 2011, p. 350). The authors added five additional items from the STAMP (Staring, Tone, Anxiety, Mumbling and Pacing), which is a tool that is strictly used in the psychiatric unit or emergency department to assess for impending patient violence (Calow, 2015). Kim, Ideker and Tocheeny-Mannes added the following items to form the ten item ABRAT: confusion/cognitive impairment (i.e. delirium/dementia or other), anxiety, agitation and alcohol/drug use (2011, p. 351).
The ABRAT was tested in six medical-surgical units over a six month period, using a data set of 2063 admissions (Kim, Ideker, & Tolcheeny-Mannes, 2011, p. 350).The authors used a multivariate logistical model to analyze data obtained from the ABRAT, which was administered to all patients on admission. Out of the total number of patients, 505 patients acted physically threatening, and 330 patients acted verbally threatening towards nursing staff, with 56 cases where “Code Grey” was called by a nurse (p. 353). With a score of 2 (moderate risk) on the ABRAT, a patient was up to 75% likely to have an aggressive incident. With a score of 3 (high risk) on the ABRAT, a patient was up to 85.7% likely to have an aggressive incident while hospitalized on a medical-surgical unit (p. 353). The ABRAT has high specificity, and a 95% confidence interval for predicting patient aggression (p. 354). The safety of nurses can be increased with the use of the ABRAT, which was specifically designed for use on the general medical-surgical floor (Kim, Ideker, & Tolcheeny-Mannes, 2011). Teaching about the use of this tool could lead to acceptance by nurses, and potential implementation on the medical-surgical unit; in turn, implementation of the ABRAT or similar tool, can help protect nurses, staff, other patients, and visitors who are in contact with potentially aggressive patients.
Reception of the Teaching/Learning Tool by Medical-Surgical Nurses
I obtained permission from nurse manager, Patty Sanchez, MSN-RN, to come to the third floor medical-surgical unit at Inspira Hospital on Tuesday, October 27, 2015, from 12PM to 2PM, which are the hours that the majority of floor nurses eat lunch. I placed a flier up at both nursing stations about the teaching session, for one week prior to the teaching. I provided a light lunch for participants in my teaching session. Nine medical-surgical nurses received the teaching, drawn from the group of 12 nurses assigned to the floor; the teaching was split into two sessions.
I employed communication by first having a short three to five minute discussion about acts of patient aggression encountered by the nurses while working on the unit. 50% of nurses revealed that they had been on the receiving end of patient aggression such as shouting/demanding behavior, and 30% of nurses said they had been involved in “Code Grey” events, in which security was called to the patient’s room.
After the warm-up discussion, I introduced my teaching tool, and handed out a tri-fold brochure to each participant. I explained the items listed in the brochure, and used questioning to check for understanding, as I taught about each section of the tri-fold brochure. The nurses seemed very interested in the material, and all nurses communicated verbally, that they were in general agreement that the ABRAT (Kim, Ideker, & Tolcheeny-Mannes, 2011) or similar patient aggression predictor tool would be of benefit to the nurses on the unit. After about 15 minutes of teaching and discussion, I asked the nurse participants to fill out the post-teaching evaluation. My subsequent review of the post-teaching evaluation questionnaire, revealed that the majority of nurses felt that the particular patient population we serve is often at increased risk for aggressive behavior. The majority of nurses also expressed the opinion that the use of the ABRAT or similar tool could help protect nurses from injury, related to risk for patient aggression, while hospitalized on the medical-surgical unit. I believe that the teaching was valuable, and was well-received by the target population of nursing staff.
Reflection on the Teaching/Learning Process
The inception of my initial idea to teach and advocate for a means with which to reduce violent patient incidents, or the potential for nurse injury, occurred in early October when a “Code Grey” was called. I was at the nurse’s station doing my electronic charting when I heard shouting from half-way down the hall, and then a voice over the intercom sounded “Code Grey…Room 340.” Shortly after the code was called, I saw three security guards rush to that room. I later learned that the patient had become extremely anxious and agitated, and wanted to leave against medical advice; the patient subsequently became verbally threatening toward the nurse. The patient pushed the nurse as well, but by the time security arrived, the patient had fled the room and the hospital. No injuries were incurred by the nurse, fortunately. After this event, I wondered if there was a way to help prevent such events from happening.
About two weeks later at the monthly staff meeting, a nurse asked her question about the increase in “Code Grey” incidents, and by that time I had already begun researching and found several evidence-based tools to predict patient aggression. I was able to collaborate with the nurse manager, who gave me the “green-light” to teach about my findings for this project to the nurses on her floor. I also collaborated with my preceptor Ellen Reeves, RN, and she provided a sounding board and feedback for my ideas while I developed my learning tool, and Ellen also made suggestions on how to present it to the nurses on the floor. After researching many scholarly articles, I located a plethora of information on common factors that lead to a risk for patient aggression, and I found several tools for assessing this risk, but only the ABRAT (Kim, Ideker, Tolcheeny-Mannes, 2011) was specifically developed for the medical-surgical floor.
Next, I looked into available resources that I could use for teaching about what I had learned, and I conceptualized using a brochure, along with a post-teaching evaluation questionnaire, as the most efficient means to present the teaching concepts. I especially had to employ a lot of critical thinking, because the space was limited to a small lunch room with no available technology, which is why I decided on using a brochure as a teaching tool. Furthermore, I had to think of a time for my teaching session which would be convenient for the nurses, so I obtained permission to do a “teach and lunch.” By providing the teaching at lunch time, I was able to avoid asking nurses to take time away time from their nursing duties. Plus, since I brought lunch for the nurses, this provided encouragement to attend my teaching session, which was a very successful method. Lastly, after doing more critical thinking, I decided to go down to the hospital on a non-clinical day, so the delivery of my teaching session would not interfere with my clinical duties.
Nursing is a stressful occupation, even without the additional worries of workplace violence. I provided the nurses on the medical-surgical unit with education on the ABRAT, as one example of a simple, quick tool that can alert nurses to the potential for patient aggression during hospitalization (Kim, Ideker, & Tolcheeny-Mannes, 2011). My brochure and post-teaching questionnaire encouraged the nurses on the medical-surgical unit to realize that tools exist that will empower them to reduce patient aggression, and in turn, may help to avoid nurse injuries at work. I felt that my project was successful, and my future goal is to work with management on implementing a patient violence risk predictor tool. If the ABRAT is adopted, my teaching tool (brochure and post-teaching evaluation) could be useful in teaching nurses about the ABRAT throughout the hospital, to assist nurses in developing interventions to prevent and/or de-escalate aggressive patient behaviors (Kim, Ideker, & Tolcheeny, 2011).
Calow, N., Lewis, A., Showen, S., & Hall, N. (2015). Literature synthesis:
Patient aggression risk assessment tools in the emergency department.
Journal of Emergency Nursing, 3 (25), 1-6.
Ideker, K., Mannes, D. & Kim, S.C. (2011). A confirmatory study of the Violence
Risk Assessment Tool (M55) and demographic predictors of patient violence.
Journal of Advanced Nursing, 4 (26), 2455-2464.
Kim, S.C., Ideker,K. & Mannes, D. (2011). Usefulness of aggressive behavior
risk assessment tools for prospectively identifying violent patients in
medical and surgical units. Journal of Advanced Nursing, 8 (2), 349-359.
Williamson, R., Lauricella, K., Browning, A., Tierney, E., Chen, J., Joseph, S.,
Sharrock, J., Trauer, T., & Hamilton, B. (2013). Patient factors associated
with incidents of aggression in a general inpatient setting. Journal of
Clinical Nursing 1(23), 1144-1154.
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