Project Summary
Workplace violence in inpatient psychiatric settings is an acute issue faced by the U.S. healthcare system. Noticeably, while this problem is prevalent in many medical departments, the rates of patient aggressive behaviors are especially concerning in the identified facilities. Thus, according to Lu et al., annual levels of verbal and physical violence are approximately 85% (as cited in Jang et al., 2021).
A literature review by Odes et al. (2021) supports this fact about inpatient psychiatric settings having the highest rates of such incidents. Thus, statistics show that there are about 7.8 cases per hundred full-time medical workers each year (Odes et al., 2021). This severe issue leads to many other concerns, such as growing costs and employee turnover.
Upon review of several significant incidences of patient-on-staff violence, the validity, effectiveness, and sensitivity of the Violence Risk Assessment (VRA) that is currently used on inpatient psychiatric units in a large state-operated psychiatric hospital in the Midwest should be explored further. Due to the patient population, individuals admitted to this hospital naturally score “moderate” or “high” on the current VRA, which primarily comes from static factors (i.e., age, presence of mental illness, past violent behavior), and dynamic factors (e.g., current mental status, current symptoms, clinical behaviors) factor into the violence rating less.
As a result, it has been identified that patients’ acute risk of violence may not be predicted as the VRA is not sensitive enough. Thus, interventions to mitigate the risk of acute violent episodes may not be implemented timely. The VRA in current use at this facility has not been validated, peer-reviewed, or established as being a statistically sound instrument. Furthermore, there is no documented reliability that would indicate the VRA, in fact, measures the risk of a violent episode as it is hoped to.
The Brøset Violence Checklist (BVC) was developed specifically to assess imminent violence within psychiatric hospitals (Sarver et al., 2019). As mentioned by Anderson and Jenson (2019), it has been validated and shown to be a reliable measure of violence risk, especially compared with other existing violence assessment tools. It has adequate predictive power, is simple to use, quick to administer, and takes into account dynamic risk factors (Anderson & Jenson, 2019; Brathovde, 2020).
Yuniati et al. (2020) assessed the sensitivity specificity of the BVC. The researchers utilized a total sample of 112 patients in a forensic hospital, 26 of which became violent. The BVC was used to assess their risk of violence proceeding the violent event, and the BVC instrument was calculated to have a sensitivity value of 65.4% (correctly identified them to be violent), specificity of 94.2% (correctly predicted NO violence), a positive predictive value of 77.3% (true positive), and a negative predictive value of 90.0% (true negative). This paper will focus on the implementation of the BVC tool to assess risk in the inpatient psychiatric setting.
Competencies
Different skills and personal and professional characteristics can be identified as crucial for healthcare leadership to be effective and productive. Many elements of outstanding management are focused on performance and organizational values. Broome and Marshall (2020) outline several models of competencies. Thus, two leadership skills, one from Huston’s list and the other from the Adams Influence Model are explored in this paper as the most important to sustainability and success.
Overall, one might agree that change cannot be implemented and maintained effectively in an inadequate or adverse setting. Therefore, the first competency to discuss is “the ability to create organization cultures that permeate quality healthcare and patient/worker safety” (Broome & Marshall, 2020, p. 189). Indeed, it is possible to achieve successful application of efficient tools only if the attention and values of the staff and leaders are initially focused on the high quality and safety of services. Otherwise, the lack of these two elements can interfere with the proper identification and overcoming of barriers that are present when implementing a change.
Next, leaders need to pay increased attention to improving their relationships with patients and workers. Thus, the second important competency is communication traits, which are the proficiency that one has when interacting and relating with others (Broome & Marshall, 2020, p. 189). It is noticeable that this component from Huston’s list can be correlated with the competencies of interpersonal understanding and relationship building from the Health Leadership Competency Model developed by the National Center for Healthcare Leadership in Chicago, Illinois (Broome & Marshall, 2020, p. 188).
Overall, without adequate communication skills, a healthcare leader cannot explain the need for a change, motivate employees provide substantial feedback, and maintain respectful, productive, and inspiring relationships. Communication skills promote a better understanding within a medical team and ensure that a change is discussed, implemented, and maintained correctly and the facility’s sustainability and success.
Management Principles
Further, it is essential to identify evidence-based management (EBM) principles that are related to leadership and can be effectively used to guide the plan for this project. In general, as stated by Guo et al. (2019), evidence-based management is “making decisions about the management of employees, teams, or organizations through the conscientious, explicit, and judicious use of four sources of information” (p. 25). These sources are data and information gathered, processed, and stored by the medical organization itself, the most reliable scientific research findings, professional judgment and experience, and concerns and values of the key stakeholders.
Consequently, this project’s plan should be guided and informed by these four sources of data. Specifically, numerous relevant resources, such as recent peer-reviewed articles and academic books, are used to explore the topic, provide evidence for the effectiveness of the selected violence risk assessment tool, and then propose the plan for its implementation in the chosen setting.
The needs of communities, patients, and healthcare workers are taken into consideration when proving the need to use the identified tool to reduce the prevalence of workplace aggression in inpatient psychiatric facilities (Guo et al., 2019). Eventually, the experiences and judgment of professionals, as well as the setting’s involvement, are also used as the primary sources for this evidence-based project.
Next, some other principles of EBM are highlighted by the research. Thus, according to Locke and Pearce (2023), better job performance can only be achieved in the presence of higher intelligence. This can be defined as an ability to critically search and apply the available knowledge and one’s own experience.
What is more, Locke and Pearce (2023) indicate that teams should be composed of emotionally stable leaders and members so that their own judgments or concerns do not prevail over relevant data and scientific findings.
Lastly, there should be mutual trust and reliance in the group (Locke & Pearce, 2023). This principle of evidence-based management refers to leadership as an ability to maintain trust and orient others’ experiences and judgment in case these are the only sources of information available for current decision-making.
Leadership Theory
A specific leadership theory can be applied to the project in order to guide it. Thus, according to Brewer (2023), adaptive leadership is quite effective in cases when a change is introduced. Adaptive leaders have the required emotional intelligence, creativity, transparency, and the tendency to maintain a culture of honesty and collaboration, which empowers them to help their employees better accept the change.
Brewer (2023) indicates that “the core principles and behaviors of adaptive leadership can provide a practical framework for navigating significant changes while enabling a positive culture,” energizing the staff (para. 3). When applying this theory to this project, one can notice that it will help leaders step back to assess the situation and employees’ different reactions and identify adaptive, not technical problems (Brewer, 2023).
For instance, worker resistance, stress, or confusion are well understood and managed by adaptive leaders. Consequently, if nurses resist the implementation of the new risk assessment tool, the facility’s leadership will find it important to understand the position of the staff, protect their voices, and eliminate this uncertainty.
Project Plan and Evaluation
Cost to Implement
Project Budget
The implementation of this project will include both expenses and revenue. Firstly, specific spending will include costs to access the copyrighted tool (the Brøset Violence Checklist) and then successfully introduce it into the facility. For instance, it might be costly to incorporate the tool into the current electronic health record (EHR). Additional spending will be used to train nurses to use the checklist and conduct stakeholder engagement events, such as presentations about the efficiency of the instrument.
Expenses on addressing potential errors during the initial stages of implementation should also be considered. The revenue will refer to reduced costs due to lower workplace violence rates. Medical employees’ satisfaction and performance will grow, which will cause an increase in the facility’s income.
Cost-Effectiveness
When analyzing this project’s costs and benefits, one must refer to statistics. For instance, on average, $15,500 is spent yearly by hospitals in lost wages, while hiring new nurses can cost an employer up to $103,000 (OSHA, 2015). Thus, it is quite expensive for medical facilities to face incidents of patient violence, and the benefits of this project, which are the reduction of the rates of workplace violence and increased levels of employee satisfaction and retention, outweigh the costs.
SWOT Analysis
There are several strengths, weaknesses, opportunities, and threats that the implementation of the proposed violence risk assessment tool has for the organization.
Strengths
The strength of the project is that the selected tool can be easily used and quickly integrated. According to Anderson and Jenson (2019) and Brathovde (2020), the Brøset Violence Checklist is the best used in inpatient psychiatric settings. The tool is practically and scientifically robust and “can be easily integrated into daily practice, as it is inexpensive, user-friendly and time-efficient” (Hvidhjelm et al., 2023, p. 9).
Lastly, it has high sensitivity, specificity, and positive and negative predictive values (Anderson & Jenson, 2019). Nurses and physicians in the chosen facility are possibly acquainted with other tools, meaning that they have some required skills and competencies.
Weaknesses
One weakness of the project is the fact that the chosen setting is a state-operated inpatient facility, which can cause some challenges when introducing the change. Additionally, the computerized record is dated and cannot be edited easily, meaning that issues or barriers can appear during the integration of the violence risk assessment tool’s forms into the medical record.
Opportunities
The project’s opportunities include the availability of technological systems required for the tool’s integration. The rates of workplace violence are growing, which will motivate the facility’s leadership to contribute better to the project’s success. Another opportunity of the project is that nurses are likely to actively engage in its implementation as they are interested in enhancing healthcare in general and patient/worker safety in particular.
Threats
Threats involve the fact that it is difficult to manage a large system change, and there may be worker resistance. It is possible that the key stakeholders will not be adequately engaged in using and promoting the selected tool, which will negatively affect the project’s results. Further, other tools might be found more practical, beneficial, and evidence-based, which will reduce the project’s value.
Current Organizational Structure/Setting
The setting selected for the implementation of this project is a 110-bed state-operated inpatient psychiatric hospital, which is a division of direct care and treatment (DCT). The facility isoverseen by a medical director, an administrator with an additional clinical director, and a director of nursing and nursing department. There are also 7 advanced practice registered nurses (APRNs), 3 psychiatrists, and several medical services and other ancillary staff members. All these managers and employees are considered the key stakeholders in the project, so it is essential to take effective steps to engage them in utilizing the tool.
To begin with, support from the mentioned stakeholders can be achieved through careful communication of the project’s primary values and expected positive outcomes. Thus, Nilsen et al. (2020) believe that humans’ basic need to maintain their environment’s stability might strengthen the staff’s resistance to the proposed modifications.
However, when they “recognize the value of the change, including perceiving the benefit of the change for patients,” they become more invested and interested in promoting it (Nilsen et al., 2020, p. 1). Providing relevant statistics and evidence-based research on the strengths and positive impacts of the Brøset Violence Checklist can motivate the stakeholders because they all strive to improve patient outcomes and enhance workplace safety.
Additionally, they need to learn that not only the clients but also the facility itself and all individual employees will receive different advantages, including reduced financial spending and improved physical and mental health of the staff (Odes et al., 2021). In that case, all stakeholders will want to participate in the implementation of the change to ensure its success.
What is more, nurses can be encouraged to utilize the identified tool if they understand that it is neither a challenging nor time-consuming process. In other words, nurses’ motivation will increase once they are persuaded that the benefits of the project outweigh the possible costs, with the latter referring to the additional time and effort the nurses will spend (Nilsen et al., 2020).
Eventually, it is possible to take a recent real-life case of workplace violence that has caused much trouble to the facility in question and consider its negative impact, including the costs. Comparing them with the costs of implementing the project and then considering the expected positive outcomes might engage the leadership and prove the need for this change.
Organizational Systems Impact
Lastly, it is crucial to outline the key effects that the organizational systems will experience due to the project’s implementation. One of the main outcomes is the improved quality of care in the country and in the facility, particularly. Indeed, the better the staff can assess violence risk and predict potential cases of aggression in advance, the more likely it is for them to prevent incidences of patient inappropriate behaviors in general. Rates of aggression will decrease severely, raising the community’s trust in the facility and the reputation and image of the latter.
What is more, other units run by this organization, including smaller 16-bed CBHH facilities, a forensic hospital, and community-based services under DCT, will enhance consistency across these divisions. All employees will refer to the same risk assessment tool and utilize it in the same manner, preventing cases of patient violence. If the rates grow again, it will be possible to analyze the implementation in general, find gaps or issues, and update the use of the tool across all divisions.
References
Anderson, K. K., & Jenson, C. E. (2019). Violence risk–assessment screening tools for acute care mental health settings: Literature review. Archives of Psychiatric Nursing, 33(1), 112-119. Web.
Brathovde, A. (2020). Improving the standard of care in the management of agitation in the acute psychiatric setting. Journal of the American Psychiatric Nurses Association, 27(3), 251-258. Web.
Brewer, S. (2023). Using adaptive leadership to engage, empower, and energize. Practice Management, 13(1). Web.
Broome, M. E., & Marshall, E. S. (Eds.). (2020). Transformational leadership in nursing: From expert clinician to influential leader (3rd ed.). Springer.
Guo, R., Berkshire, S. D., Fulton, L. V., & Hermanson, P. M. (2019). Predicting intention to use evidence-based management among US healthcare administrators: Application of the theory of planned behavior and structural equation modeling. International Journal of Healthcare Management, 12(1), 25-32. Web.
Hvidhjelm, J., Berring, L. L., Whittington, R., Woods, P., Bak, J., & Almvik, R. (2023). Short-term risk assessment in the long term: A scoping review and meta-analysis of the Brøset Violence Checklist. Journal of Psychiatric and Mental Health Nursing, 00, 1-12. Web.
Jang, S., Son, Y. J., & Lee, H. (2021). Prevalence, associated factors and adverse outcomes of workplace violence towards nurses in psychiatric settings: A systematic review. International Journal of Mental Health Nursing, 31(3), 450-468. Web.
Locke, E. A., & Pearce, C. L. (Eds.). (2023). Handbook of principles of organizational behavior: Indispensable knowledge for evidence-based management. John Wiley & Sons.
Nilsen, P., Seing, I., Ericsson, C., Birken, S. A., & Schildmeijer, K. (2020). Characteristics of successful changes in health care organizations: An interview study with physicians, registered nurses and assistant nurses. BMC Health Services Research, 20(147), 1-8. Web.
The Occupational Safety and Health Administration [OSHA]. (2015). Workplace violence in healthcare [PDF document]. Web.
Odes, R., Chapman, S., Harrison, R., Ackerman, S., & Hong, O. (2021). Frequency of violence towards healthcare workers in the United States’ inpatient psychiatric hospitals: A systematic review of literature. International Journal of Mental Health Nursing, 30(1), 27-46. Web.
Sarver, W. L., Radziewicz, R., Coyne, G., Colon, K., & Mantz, L. (2019). Implementation of the Brøset Violence Checklist on an acute psychiatric unit. Journal of the American Psychiatric Nurses Association, 25(6), 476-486. Web.
Yuniati, W., Putra, K. R., & Widasmara, D. (2020). Factors affecting the success of psychiatric nurses in conducting risk assessment of violence behavior. International Journal of Nursing Education, 12(4), 252-257. Web.