A Conceptual Framework for Managing Workplace Violence...
Transcript of A Conceptual Framework for Managing Workplace Violence...
© 2014, Sally W. Gillam
A Conceptual Framework for Managing Workplace Violence-related QI Studies in the
Healthcare Workplace
Sally Gillam DNP, BSN, MAHS, RN, NEA-BC
Austin, TX
© 2014, Sally W. Gillam
Abstract
Background
Violence in health care facilities complicates patient care in an already complex environment.
Despite the increased volume of published literature on healthcare workplace violence since
1987, the first quality improvement (QI) study of the problem did not publish until 2014.
Aims
Violence-related QI study poses conceptual framework requirements different from those used
for previously published research studies. The new requirements called for adaptation of an
existing conceptual framework or the creation of a new framework. Efforts were initiated to
determine the best course of action and produce a viable conceptual framework.
Methods
The existing conceptual frameworks for workplace violence were compared and contrasted after
requirements were identified. A gap analysis determined if any of the existing frameworks were
appropriate to fulfill the new requirements, or if a new framework was needed.
Results
A new framework was developed to manage QI-related aspects of violence magnitude, actors,
influences and manifestations (MAIM). The MAIM framework fulfills a new need for readily
understood, extensible conceptual frameworks to support new violence-related QI literature.
Implications for Practice
The MAIM conceptual framework can serve as a common point-of-reference for new healthcare
violence-related QI and research studies. It can also be extended or modified to support
violence-related QI studies in non-healthcare fields.
Keywords:
Healthcare violence; workplace violence conceptual framework; workplace violence QI
© 2014, Sally W. Gillam
Background
A health care employee's risk of experiencing workplace violence varies by work area.
Staff who work in emergency departments (EDs), mental health settings and intensive care units
(ICUs) are at greatest risk. People who work in obstetrical/gynecological, and medical/surgical
areas also incur higher risks than people in other areas (Gillespie, Gates & Berry, 2013). These
violent events in health care workplaces pose threats to both patients and care givers. Violence
also complicates the delivery of care to patients.
Potential influences on workplace violence are many, especially in health care. Anxiety
may induce violent behaviors by individuals who aren't normally aggressive (Luck, Jackson, &
Usher, 2008). Illness or injury can also induce stress which may manifest as violent outbursts
(Gates, Ross, & McQueen, 2006). Alcohol, drugs and organizational characteristics can also
influence violent events (Gacki-Smith et al., 2009; Gillespie, Gates & Berry, 2013).
Need for a Conceptual Model
The National Institute for Occupational Safety and Health (NIOSH) defines workplace
violence as "violent acts (including physical assaults and threats of assaults) directed toward
persons at work or on duty" (National Institute for Occupational Safety and Health [NIOSH],
2002, p. 1). Despite this seemingly simple definition, workplace violence is a complex topic
(Cai, Deng, Liu, & Yu, 2010). Its attribute numbers, origins and interactions form dynamic
relationships, making the phenomenon difficult to predict or analyze.
Increased Focus on Workplace Violence
Increasing interest in the study of workplace violence calls for an adaptable conceptual
framework which can be readily understood, modified, and extended. The results of a Scopus
© 2014, Sally W. Gillam
search in Figure 1 show how published studies of workplace violence have increased since 1987;
the increase has been particularly dramatic since 2002.
Figure 1. Workplace Violence Journal Articles by Year (Title/Keyword/Abstract) - Scopus
Despite the increase in violence-related publications, no frameworks have yet been
created for violence-related quality improvement (QI) studies. The purpose of this paper is to:
(a) Explore the existing conceptual frameworks related to violence in the workplace, and (b)
report on the creation of a new conceptual framework to support violence-related QI studies.
Applicability of Existing Frameworks for New Study
Literature searches revealed several conceptual frameworks for workplace violence. The
author planned to use the "best fitting" existing framework as the conceptual model for a new
study. Despite the common general subject matter, the framework foci varied. Each framework
and its area of focus is shown in Table 1.
© 2014, Sally W. Gillam
Table 1.
Conceptual Frameworks Relating to Workplace Violence
# Framework Author/date Focus Comments 1 Therapeutic Management of
Patient Aggression
Finfgeld-
Connett (2009)
Therapeutic model based on:
Normalization
Downplay of negativity
Reality grounding
Limit setting, Reciprocity
Person/context
centeredness
Creativity/flexibility
Team-based approach
Behavioral model
2 Haddon Matrix Haddon (1980)
Runyon,
Zakocs and
Zwerling
(2000)
Generalized model for factors
relating to work-related
injuries, including injuries
from violent events. Focused
on:
Phase (pre-event, event,
post-event)
Humans
Vehicle/weapon
Environment (physical/
sociocultural)
General model
3 Ecological Occupational
Health Model of Workplace
Assault
Levin et
al.(2003)
Influences of violent acts by
patients and the consequences
of violence.
Victim-centric
model
4 Direct and Indirect Paths for
Victim Vulnerability
Factors for Workplace
Aggression among
Penitentiary Workers
Mierlo and
Bogaerts
(2011)
Victim vulnerability factors
and (maladapted) coping
strategies
Victim-centric
model
5 Conceptual Framework for
Disruptive Behavior
Walrath, Dang,
and Nyberg
(2010)
Four major concepts:
Triggers,
disruptive behaviors,
responses, and
impacts
General model
Conceptual Framework Requirements for a QI Violence Study
The second step in exploring the current frameworks was to identify the general attributes
needed for a conceptual framework to be applicable to QI study. To accomplish this, violence-
© 2014, Sally W. Gillam
related attributes identified in the literature were grouped by general characteristics. The major
attribute groups are described in detail in the following sub-sections.
Magnitude
The magnitude of a violent event is manifested in terms of severity (victim injury or
death) and/or in its frequency of occurrence if the violence is repetitive in nature. Such
considerations were documented by May and Grubbs (2002), Mooij (2012), and Tyrer et al.
(2007).
People
The people involved in a violent healthcare event, such as patients, family members, care
givers, professional colleagues or incidental visitors to the patient care unit were grouped and
classified as actors. Aggressors and victims both fall into this attribute group; future refinement
of the model may cause this group to split to accommodate the differences between aggressors
and victims. These attributes were identified and described by Ben Naten, Hanukayev, and Fares
(2011), Pai and Lee (2011), and Winstanley and Wittington (2004).
Background Factors
Background factors which influence how a violent event surfaces and transpires were
grouped and classified as influences. These factors are:
Care giver staff behaviors which may be favorably impacted by training to assist in
de-escalating or diffusing violent events. This attribute is described in detail by
Cahill (2008).
Social factors such as drugs and alcohol use by assailants, which have been
highlighted repeatedly in recent years regarding their effects on violence in the health
© 2014, Sally W. Gillam
care work place. Literature authored by May and Grubbs (2002), Ferns (2006) and
Luck et al. (2008) treat such factors as pivotal within the problem domain.
Socio-demographic factors such gender, age or ethnic differences between victims
and assailants which have been shown to correlate with incidents of health care
workplace violence (Ben Naten et al., 2011).
Psychological factors such as frustration, separation from family members and long
wait times which have been implicated with violent events in the healthcare
workplace (May & Grubbs, 2002; Crilly et al., 2004).
The nature of a patient’s illness or injury may influence a violent event. Such
considerations include head injury, hypoxia, endocrine disorders, prescription side
effects and various psychiatric, conduct or hyperkinetic disorders (Ferns, 2006) .
Manifestation
The manifestation of a violent incident is reflected by the general actions of an assailant.
Assailant actions may manifest as verbal or threatening behaviors, or may transpire as physical
attacks on victims. Both manifestations are consistent with the definition of workplace violence
as per NIOSH (2002).
Comparison of Existing Frameworks Against Detailed Requirements
A coverage matrix, shown in Table 2, summarized gaps and commonalities between the
candidate frameworks and the required attribute groups. Coverage gaps were ubiquitous,
indicated by the shaded areas of Table 2.
© 2014, Sally W. Gillam
Table 2.
Coverage Matrix
Candidate
Framework
Attribute Requirements
Severity/Magnitude People Manifestations Influences/
Mitigating
factors
Injury
Severity
Occurrence
Frequency
Victims/
roles
Assailants Physical Threats
1. Therapeutic
Management
of Patient
Aggression
(Finfgeld-
Connett,
2009)
Not
addressed
Not
addressed
Core
concept
Core
concept
Not
addressed
Not
addressed
Core concept
2. Haddon
matrix
(Haddon,
1980; Runyon,
et al., 2000)
Not
addressed
Not
addressed
Human Human Not
addressed
Not
addressed
Environment
3. Ecological
Occupational
Health Model
of Workplace
Assault (Levin
et al., 2003)
Describe
d but not
included
in model
Described
but not
included in
model
Sense of
risk,
worker
attitude
Co-
workers
versus
residents
Described
but not
included
in model
Described
but not
included
in model
Workplace
and
environment
factors
4. Direct and
Indirect Paths
for Victim
Vulnerability
Factors for
Workplace
Aggression
(Mierlo and
Bogaerts,
2011)
Describe
d but not
included
in model
Described
but not
included in
model
Core
concept
Described
but not
included
in model
Described
but not
included
in model
Described
but not
included
in model
Core concept
5. Conceptual
Framework
for Disruptive
Behavior
(Walrath et
al., 2010)
Not
addressed
Not
addressed
Provider
attributes
Not
addressed
Disruptive
Behaviors
Disruptive
Behaviors
Triggers,
Attributes
© 2014, Sally W. Gillam
Applicability of Existing Frameworks
In summary, the number of coverage gaps highlighted by Table 2 were surprising, given
the number of studies on workplace violence published after 1987. The gaps revealed that none
of the models were expansive enough to support a QI-based violence study.
Forming a New Framework
Given the lack of existing frameworks to support new QI study, a new framework was
needed. Thus, a new framework was built around the four major attribute groups identified from
the literature.
Attribute Dimensions and a New Framework
The groupings identified in the coverage analysis appeared independent (a change to an
attribute in one group doesn't change attributes in other groups). Although multi-dimensional
scaling (Kruskal, 1964; Torgerson, 1952) wasn't used to formally prove orthogonality between
the four attribute groups, the word dimension was informally adopted to refer to the groups in
light of their independent nature. Use of the term is consistent with violence-related studies by
Estrada, Nilsson, Jerre, and Wikman (2010), Katrinli, Atabay, Gunay, and Guneri Cangarli
(2010), and Ramirez et al. (2012).
The first letter of each dimension (magnitude, actors, influences and manifestation) was
used to form a new acronym and name the model. The resulting MAIM conceptual framework
is shown in Figure 2.
© 2014, Sally W. Gillam
Figure 2. The MAIM conceptual framework.
Using the MAIM Framework
The MAIM framework does not require all dimensions to be defined or engaged to set
the context for study. For example, a QI study can evaluate the effectiveness of a hospital
nonviolent crisis intervention training initiative using a correlation and regression-based model
which leverages three of the four MAIM dimensions: Influences (behaviors/training), magnitude
(frequency), and actors (care givers). The author recently completed one such study (Gillam,
2014). The framework assisted the formulation of the study as it allowed the dimensions to be
© 2014, Sally W. Gillam
viewed abstractly while the study context was formed. Ultimately, the study proposal included a
modified version of Figure 2 which highlighted the affected attributes; the highlights were
accompanied by detailed descriptions of the study intervention. Use of the MAIM framework
also facilitated review and approval by committees for academic review and hospital ethics.
Conclusion
Future violence-related studies will need flexible conceptual frameworks which can
incorporate and manage attributes in increasingly complex ways. The MAIM conceptual model
recently served as a framework for the first QI-based study of a violence-related phenomenon
(Gillam, 2014). Given the success of that study, and having incorporated key attributes from
earlier published work, MAIM may also serve as a conceptual framework for new violence-
related QI study.
© 2014, Sally W. Gillam
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