Quality Improvement Project. 1 Quality improvement proposal Quality improvement proposal part 1: Assaults on inpatient Psychiatric unit Adella N. Kweyila University of Maryland, University College Professor Kimble 6/29/19 2 Quality improvement proposal Research Question: Does adequate staffing reduce the rate of assaults on an inpatient psychiatric unit over 6 months? Problem Statement Physical assault on staff in the inpatient psychiatric unit by patients ranges from unsuccessful attempt to attack, minor injuries or severe injuries and its prevalence in psychiatric setting currently is alarming. Although there are various forms of interpersonal conflicts in the psychiatric setting, assault is the most prevalent and it is raising serious safety concerns for staff especially the nurses. Staffs that provide direct care to patients, especially in psychiatric units end up feeling overwhelmed and scared by the assault in the workplace. The verbal aggression and assault, in most cases, affect the staff emotionally and this is evident from the exhibition of anger, frustration, fear, stress, and irritation when carrying out their duties. As such, the exposure of staff in inpatient psychiatric unit to assault has affected their psychological and physical health. Interventions: To begin with, the nurse to patient ratio should be address, taking into consideration the acuity of the unit. One of the interventions is having a psychological measurement of the effects of the stress occasioned by the assault. This is very important in coming up with ways of addressing it. Psychological measurement of the effects of assault on staff will involve the measures to be taken in addressing the interpersonal conflicts which may arise either among staff or patients. The second intervention is to develop a mechanism to manage risks and recognize imminent dangers. There is also the need to train and develop the capacity and accuracy of staffs 3 Quality improvement proposal who can recognize these increase risks of violence before it gets out of control in order to improve and sustain a high level of a safe working environment. Staff training on peer relationship at the workplace should be implemented. There should also be a training of staffs to develop a good working relationship among themselves and with the patients to have a safe and secure environment where the cases of assault are greatly reduced or no assaults. There is also the need to address the patient-related factors which contribute to assault of staff on the unit. Finally, there is the need to take care of the wellbeing of all staff working in inpatient’s psychiatric units to ensure that they can handle patient-related factors which contribute to the prevalence of assault cases. Literature Review There are several researches which have been carried out on the assault of staffs in inpatient psychiatric unit. The key focus on these studies has been on the patient assault, conflict related to the care of the patients, wellbeing of the staffs as well as their perception on safety and whether there is any correlation with the number of staffs in the inpatient psychiatric unit. Causes of Staff Assault Patient assault: Spector, Zhou and Che in their international review of the violence incidences directed to nurses established that at least 55% of nurses had faced violence while working in inpatient psychiatric unit (Spector, Zhou & Che, 2014). NURS410 University of Maryland University Quality Improvement Project

Quality Improvement Project. The authors noted that there is a high prevalence of physical assault of nurses in inpatient psychiatric unit than in any other unit. There is the general notion that statistics about assault of nurses in healthcare setting are underestimated because the nurses underreport them for fear of being accused of incompetence. Most of the nurses who are assaulted in inpatient psychiatric unit are young, mostly below 30 4 Quality improvement proposal years of age (Hilton, Ham & Dretzkat, 2017). Although their skills and experience are low, they are tasked with providing care directly to the patients hence they spend more time with them. Workplace social conflict: Research have established that at least 73% of Nurses experience cases of aggression in the workplace. (Specter et al, 2014). 75% of these cases are verbal aggression (Brekke et al., 2016). According to the Occupational Safety and Health Administration (OSHA), patients are the largest source of violence in healthcare settings, but they are not the only source. In 2013, 80 percent of serious violent incidents reported in healthcare settings were caused by interactions with patients, other incidents were caused by visitors, coworkers, or other people. (OSHA, 2015). The numbers above only include incidents that led to time away from work. While some data are available for other violent incidents, surveys show that many incidents go unreported, even at facilities with formal incident reporting systems. (OSHA, 2015). For example, a survey of 4,738 Minnesota nurses found that only 69 percent of physical assaults and 71 percent of non-physical assaults were reported to a manager, while one medical center found that half of verbal and physical assaults by patients against nurses were never reported in writing. Bullying and other forms of verbal abuse are particularly prone to underreporting. Reasons for underreporting include lack of a reporting policy, lack of faith in the reporting system, and fear of retaliation. (OHSA, 2015) Possible Impacts Emotional and psychological impacts: Another study done on the staffs working in inpatient psychiatric unit who have been assaulted in their units revealed that they are more likely to develop post-traumatic stress disorder which may lead to major depressions (Hilton, Ham & Dretzkat, 2017). It is important to note that assault from colleagues and superiors has 5 Quality improvement proposal more negative effects compared to that of the patients. On the aspect of physical health, the assault of staff in inpatient psychiatry unit is the leading cause of physical injury in most of the US hospitals. In most cases, the staffs who fall victim experiences psychological stress, pain, and even muscle tension. Research has also established that work-related stress is likely to cause health complications on the staff (Hsieh et al., 2018). The cases of assault for the staff at the workplace negatively affect their perception of safety. Chua and his colleagues in their research, notes that the psychiatric nurses in most cases lack job satisfaction irrespective of their number in one unit. In their study, they note that the physical and psychological health behavior of staff working in inpatient psychiatric unit is negatively affected by the prevalence of assault cases (Chua et al., 2017). NURS410 University of Maryland University Quality Improvement Project

Quality Improvement Project. This is because the staffs always feel insecure and unsafe in their workplace which impairs the operations especially the enforcement of the hospital and or unit rules. The conflict among the staff also erodes the confidence of safety and security. Staff need to work together to prevent the cases of assault and implement the measures meant to improve their safety in the workplace. Essentially, it’s a great liability to the hospital when the safety of staff on the units is in jeopardy. Assault in the unit have cost implications in terms of compensation, medical care, and litigation, among other costs (Foster, Cuzzillo & Furness, 2018). The moral and performance of the staff are affected and in most cases the hospitals experience a high rate of staff turnover. Therefore, adequate staffing alone cannot help in reducing cases of staff assault. Possible Interventions Psychological measurement: According to Spector, Zhou and Che, staff affected by assault in the course of their duty have varying reactions. The effects of the assaults also reflect 6 Quality improvement proposal the ability of staff to deal with stress factors or their sensitization over the same (Spector, Zhou & Che, 2014). It demonstrates the ability of individuals to react to stressors both immediately and in the long term. Psychological measurement has been identified as one of the interventions available (Hilton, Ham & Dretzkat, 2017). This kind of intervention will help staffs in handling stressor in the workplace which in the long term will help in reducing cases of assault. It is worth noting that staffs who are at high risk of assault from patient are those who have high exposure to conflict. Different researchers have shown that the main causes of assault to staff are a social conflict which is aggravated by the inability of many staff to deal with stressors (Chua et al., 2017). A psychological measurement of the stress effects on the staff will help to deal with the complexity between stress, assault, and the overall physical and psychological wellbeing of staff in inpatient psychiatric unit. Hsieh and his colleagues while discussing the symptoms of psychiatric nurses who have been assaulted notes that it is important to train staff to be able to identify the danger and recognize any potential violence in their workplace. In their study they note that, staffs in inpatient psychiatric unit in most hospitals have a very low ability to identify potential incidences of violence (Hsieh et al., 2018). Most of the staffs have a low level of accuracy in recognizing potential danger at work. The psychiatric nurses’ plays a very critical role in identifying potential risk of violence in the workplace and therefore any intervention taken in place will only succeed to the extent in which they will support it. Most of the assault incidences on the staff occur in the course of offering care (OSHA, 2015). The training of staff should also focus on their interaction with inpatients especially within the limited setting, denial of the patients’ requests, involuntary medication and how to secure their compliance with the rules. It should also cover the areas of therapeutic communication and mental health assessment during the nurse-patient interaction 7 Quality improvement proposal (Chua et al., 2017). NURS410 University of Maryland University Quality Improvement Project

Quality Improvement Project. It is important to ensure that all the staff has the relevant skills and knowledge to apply when measuring the danger posed by a mental patient. Training and development of the staff : Foster and his co-authors in their study noted that training will help staff in knowing the impact that mental problem has on patient, knowing them, and understanding their point of reference and having a clear knowledge about their history of violence (Foster et al., 2018). This is important in observing the situation and identifying the behavioral pattern of a patient which may result in violence. When staff is faced with a violent situation, they should be able to apply their knowledge and skills to handle the patient effectively. The main factors contributing to the assault of staff in inpatient psychiatric unit are both internal; from the patient and external related to the environment. Proper training of staff will ensure that they can work effectively as a team and manage aggressive behaviors especially on the patients. Besides, it is important to always carry out safety checks within the unit/facility. Research has established that most of the weapons used by the patients to assault staff are within the hospital environment (Byers et al., 2017). All potential weapons whether in the custody of the staff or the patients should be confiscated. There is also a need for hospitals to establish a security office where the security officers (if applicable) carry regular screening among the staff and patients to ensure there are no weapons within the working environment. There should be careful adaptation of the hospital environment to minimize the incidences in which the patients could access and use a weapon. Prompt reporting of assaults for evaluation: Assaults should be reported in a timely fashion to risk management so the necessary training can take place to prevent future incidents caused by the same behavioral issues or triggers. Healthcare has some unique cultural factors that may contribute to underreporting or acceptance of workplace violence. (OSHA, 2015) For 8 Quality improvement proposal example, caregivers feel a professional and ethical duty to “do no harm” to patients. Some will put their own safety and health at risk to help a patient, and many in healthcare professions consider violence to be “part of the job.” Healthcare workers also recognize that many injuries caused by patients are unintentional and are therefore likely to accept them as routine or unavoidable. Another consideration is unwillingness among healthcare workers to stigmatize the perpetrators due to their illness or impairment. Summary The literature review has shown that there are both external and internal factors which contribute to the assault of staff in inpatient psychiatric unit and adequate staffing alone cannot address the problem. Delusion and hallucination may influence the patients to engage in violent acts. External factors such as the invasion of the personal space, disagreements, struggle over property and use of abrasive words have been associated with assault of staff by patients. NURS410 University of Maryland University Quality Improvement Project

Quality Improvement Project. Most of the patients associate the coercive conduct of the staff as the main cause of their provocation leading to assault incidences. There is a need to come up with a way of handling aggression from both the staff and patients. For the staff, they should avoid any behavior which can trigger any form of aggression on the patients. The hospital should come up with effective ways to support the well-being of staff. It is also evident that staffs working in inpatient psychiatric unit always expect assault to occur and some even think that it cannot be avoided. Adequate staffing is not the only solution to the assault issues. Most of the staff may underreport the cases of assault for fear of being victimized or seen as incompetent. Therefore, the supervisors must monitor and ensure that cases of assault are well documented and addressed. This should not diminish the interventions of the 9 Quality improvement proposal hospital administration to intervene to ensure the safety and security of the staff. The prevalence of assault cases requires policy and procedural interventions. Both internal and external factors contributing to the same needs to be addressed to ensure the working environment is safe. The literature available suggests that, assault cases are as a result of violence from patient and staff conflict. The conflict among the staff is not likely to occur in a hospital setting where there are good leadership, effective communication and efficient staff practices. Although most of the hospitals have a proper protocol to protect the staff against assault by the patients, the cohesion `also critical in preventing and addressing incidents where assault of the staff is likely to occur. 10 Quality improvement proposal References Foster, K., Cuzzillo, C., & Furness, T. (2018). Strengthening mental health nurses’ resilience through a workplace resilience programme: A qualitative inquiry. Journal of Psychiatric and Mental Health Nursing, 25(5-6), 338-348. Foster, K., Shochet, I., Wurfl, A., Roche, M., Maybery, D., Shakespeare‐Finch, J., & Furness, T. (2018). On PAR: A feasibility study of the promoting adult resilience programme with mental health nurses. International journal of mental health nursing, 27(5), 1470-1480. Hilton, N. Z., Ham, E., & Dretzkat, A. (2017). Psychiatric hospital workers’ exposure to disturbing patient behavior and its relation to post-traumatic stress disorder symptoms. Canadian journal of nursing research, 49(3), 118-126. Hsieh, H. F., Wang, H. H., Shen, S. H., & Li, Y. C. (2018). Predictors of depressive symptoms among psychiatric nurses who suffered from workplace violence. Journal of advanced nursing, 74(2), 425-432. Kelly, E. L., Fenwick, K., Brekke, J. S., & Novaco, R. W. (2016). Well-being and safety among inpatient psychiatric staff: the impact of conflict, assault, and stress reactivity. Administration and Policy in Mental Health and Mental Health Services Research, 43(5), 703-716. Occupational Safety and Health Administration. (2015). Workplace violence in healthcare: Understanding the challenge. Retrieved from https://www.osha.gov/Publications/OSHA3826.pdf Spector, P. E., Zhou, Z. E., & Che, X. X. (2014). Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: A quantitative review. International journal of nursing studies, 51(1), 72-84. 11 Quality improvement proposal Zheng, Z., Gangaram, P., Xie, H., Chua, S., Ong, S. B. C., & Koh, S. E. (2017). Job satisfaction and resilience in psychiatric nurses: A study at the institute of mental health, singapore. International journal of mental health nursing, 26(6), 612-619. Zicko, J.M., Schroeder R.A., Byers, S., Taylor, A.M., & Spence, D.L. (2017) Behavioral emergency response team: Implementation improves patient safety, staff safety, and staff collaboration. Retrieved from http://web.b.ebscohost.com.ezproxy.umuc.edu/ehost/pdfviewer/p …NURS410 University of Maryland University Quality Improvement Project