Summary of evidence
This review compiled a comprehensive and actionable set of quality indicators with the potential to collect data at the structural, process, and outcome levels. These categories were adapted from the SEIPS model, which provides a reliable framework to understand patient safety from a sociotechnical approach, facilitating evaluation, planning, and research. 229 indicators were sorted into three categories: 84 being structural-related, 121 being process-related, and 24 being outcome-related. Process indicators tended to be more granular in their measurements, for instance, specific violent acts and interventions had their own unique indicators, which were further divided by risk levels. By comparison, structural and outcome indicators were less frequently utilized and tended to be less specific, suggesting these categories may be underutilized by contemporary approaches to WPV. Studies that reported structural indicators mainly derived utility from staff perceptions of WPV training and policies, while studies reporting outcome indicators utilized measures of adverse events, including lapses of safety and lost time. This review establishes a compilation of indicators across all three categories to serve as a starting point for health systems looking to incorporate comprehensive and actionable quality indicators.
Reviewers also compiled a list of validated survey instruments and questions from the literature. Some information cannot be captured through quantitative metrics; thus, it is important to collect qualitative data and feedback through methods such as surveys from healthcare providers, staff, volunteers, patients, caregivers and (chosen) family members to properly evaluate interventions and the current state of healthcare settings as they pertain to WPV. Articles included in this review utilized survey instruments and questions to measure the subjects' feelings such as stress, safety or fear of violence, in addition to capturing subjects’ perspectives on the effectiveness or ease of use of certain interventions. An outcome of the growing prevalence of WPV in healthcare settings is that staff’s morale and feelings of safety have diminished [10]. While quality indicators can measure the impact of an intervention and trends in workplace violence, it is important to collect complimentary bottom-up data through routine surveys or qualitative interviews to capture a fulsome view of WPV in healthcare settings.
The quality indicators and validated survey instruments and questions extracted in this review will be valuable to healthcare institutions' ability to adequately measure and evaluate WPV in their organizations. In recent decades, health systems have increasingly relied on data-driven systematic approaches to facilitate the continual improvement of their services. The steady increase in healthcare utilization [19] has made the quality of care and resource stewardship top priorities when providing efficient patient-centred care. Quantifying these complex and multi-dimensional metrics is a challenge that policymakers and investigators face when developing quality assurance and improvement strategies. Quality indicators have served as reliable metrics, allowing stakeholders to understand how effectively specific functions of health systems perform. Contemporary advancements in information technology and quality assurance theory have allowed indicators to become compelling and actionable sources of evidence. For instance, quality indicators have been pivotal to identifying gaps in acute care provision in emergency departments, enabling interventions to reduce wait times and improve triage across health systems [20]. Organizations can effectively use quality indicators to promote continuous efforts for stakeholders to improve performance and optimize outcomes [21]. Despite their well-documented potential, many health systems have yet to leverage quality indicators to tackle the increasingly prevalent issue of workplace violence in healthcare. This was apparent during our review of the relative sparsity of studies leveraging evidence-based quality indicators within this domain. Furthermore, we noted a lack of literature defining comprehensive and pertinent sets of indicators for measuring WPV in healthcare. Despite this, our review identified diverse and complex sets of indicators that were influential in measuring the burden of WPV in healthcare settings. These indicators were foundational to successful quality improvement (QI) initiatives within these settings. For instance, multiple studies reported indicators that measured the frequency of specific violent events and interventions. In one case, investigators utilized these indicators to demonstrate a significant reduction of restrictive interventions, patient self-harm, and staff injury after implementing patient-specific behaviour plans at a psychiatric hospital [22]. Other studies used indicators to measure changes in specific violent behaviours, such as bullying, verbal abuse, and physical abuse, in response to the implementation of risk assessment tools [23]. Another set of indicators focused on measuring staff perception of training on WPV prevention protocols and tools [24]. In several studies, training programs that received high staff approval were linked to increased usage of interventions and significant reductions in WPV incidents [23, 25]. Across all studies, quality indicators served to identify areas for improvement, track the quality of interventions, or contextualize resource allocation for specific challenges. Many studies applying these indicators reported positive outcomes with regards to reducing the burden of WPV and improving patient care outcomes.
It is crucial to be cognizant of psychosocial factors and to engage a modern healthcare lens when utilizing the quality indicators listed in this review. WPV incidents are stressful, acute situations where the impact of unconscious biases can result in unwanted outcomes. Quality indicators predicated on these biases can harmfully attribute likeliness of aggression to certain patient characteristics and validate interventions that target specific demographics. For example, an indicator measuring the incidence of WPV related to care of psychiatric patients may suggest interventions that target patients with mental health issues regardless of their actual risk. Such interventions can lead to stigma and patient mistreatment that exacerbates the health disparities faced by commonly marginalized groups [26]. Therefore, it was important to identify and exclude literature and indicators that were incompatible with modern care delivery standards to minimize damaging effects to patient psychosocial safety. Three conceptual approaches to health disparity were given particular attention during the review process: (I) trauma-informed approach, (II) intersectional identities theory, and (III) minority stress theory. The trauma-informed approach recognizes that a patient’s individual circumstances can influence how they interact with healthcare services. Achieving this involves shifting away from blaming patients in favor of understanding the stressors underlying their behavior. The goal of the approach in the context of WPV is to use organizational policy and interventions to provide safe and effective care without re-traumatizing patients. This is of particular importance as re-traumatization has been shown to contribute to violent incidents when inappropriate treatment of patients living with trauma can trigger flight or fight responses [27]. Studies that focused on risk stratification based on staff perceptions of certain demographics were excluded from the review due to the potential of informing discriminatory and traumatizing interventions. For instance, one study asked hospital staff to record their agreement with the following statement: “patients from particular ethnic minority groups are more likely to become aggressive" [28]. Another study suggested the use of indicators and risk assessment based on behavioral cues including eye contact, tone and volume, anxiety, mumbling, and pacing [26]. In both cases, intrinsic patient characteristics were broadly framed as problematic, while their lived experiences and traumas were not adequately taken into consideration. The intersectional identities and minority stress theories both highlight the importance of acknowledging these unique experiences and stressors to understand how they influence health outcomes. In the context of WPV, they point to the historic mistreatment of certain identities and groups as stress-inducing factors that contribute to disproportionate rates of violence. Therefore, we posit that quality indicators should look to measure the effects of these root causes and their contribution to WPV incidents rather than focusing on the actions of specific demographics, which may contribute to further marginalization.
The introduction of novel quality indicators may require organizations to invest in solutions to manage the resulting higher volumes of data. Recent literature supports the utilization of automation and data visualization to systematically collect and report data from quality indicators in a way that is conducive to decision-making. A study conducted at a large hospital network found that automated data abstraction of quality measures significantly reduced processing time by up to 50% when compared with manual processing [29]. Research in the field of quality management suggests performance dashboards as effective instruments to visualize data in a way that is easily disseminated and digested by organizational decision-makers [30]. Despite its detailed coverage, it is important to note that in the emerging field of healthcare WPV QI, this reviews list of indicators is non-exhaustive and not broadly applicable to every healthcare environment. Quality indicators have varying utility based on the function of the healthcare system they serve [21]. For instance, indicators originally designed for acute or inpatient care settings, where security resources are more abundant, may fail to address the unique needs of less-equipped outpatient primary care. Therefore, organizations should rely on discussions with key stakeholders to distill and adapt quality indicators to fit their specific needs. Systematic approaches, such as the Delphi technique, can be leveraged to develop consensus amongst diverse stakeholders involved with WPV management. Ultimately, the set of indicators we identified through this review can serve as a foundation for healthcare organizations looking to manage WPV through an evidence-based, quality improvement approach.