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© 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 [email protected]

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Page 1: A Conceptual Framework for Managing Workplace Violence ...healthcareviolence.com/uploads/3/4/7/1/3471691/manuscriptmaim... · A Conceptual Framework for Managing Workplace Violence-related

© 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

[email protected]

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© 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

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© 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

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© 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.

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© 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-

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© 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

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© 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.

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© 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

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© 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.

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© 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

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© 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.

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© 2014, Sally W. Gillam

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