Digital Repository Masters Projects Spring 2023 Improving Workplace Violence for Home Health Nurses Katie Haskell Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Haskell, K. 2023. Improving workplace violence for home health nurses. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Improving Workplace Violence for Home Health Nurses Project Title by Katie Haskell Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 2, 2023 Date Katie Haskell, BSN, RN, MSN Student 4.2.23 Student Name, Credentials Date (electronic signature) Jamie Wankier MSN, RN 4.17.23 MSN Project Faculty Date (electronic signature) 05/25/2023 Melissa NeVille Norton (electronic signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. Date 1 Improving Workplace Violence for Home Health Nurses Katie Haskell, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing 2 Abstract Healthcare workers are experiencing an increasing rate of workplace violence which affects job satisfaction and turnover. Education and training are imperative in dealing with workplace violence. Research indicated a need for workplace violence education in the home health environment. The purpose of this project is to present education and training on workplace violence situations specific to the home health setting and to train on the importance of documentation and event reporting. Education and training give home health care professionals tools to focus on patient care and improve job satisfaction. A review of the literature showed that workplace violence education increased the confidence of the health professional to handle these situations and improved job satisfaction. This MSN project consists of four areas of education and training: how to recognize and respond to signs of agitation, prevention techniques, selfdefense guidelines, and how to document and report on workplace violence events. The team lead will present education and training in a staff meeting, handouts, and discussion. Benefits of the project include enhanced home health staff safety, patient care improvements, and better administration and organizational effectiveness. A literature review indicated that more research needs to be done about workplace violence in the home health setting. As staff receives training, education, and discussions of patient scenarios, their confidence can increase in their ability to recognize and handle workplace violence, leading to improved reporting and decreased home health setting violent events. Keywords: workplace violence, homecare, education, training, home health setting, home health staff, violent events, reporting, job satisfaction 3 Workplace Violence Workplace violence has become a concern within healthcare because it contributes to job satisfaction, patient outcomes, burnout, and retention issues (Story et al., 2020). Workplace violence training is necessary to develop skills, recognize issues, and learn how to handle these difficult situations (Abozaid et al., 2022). Additionally, patient caregivers must feel confident identifying and using de-escalation skills to counteract workplace violence (Small et al., 2022). The home healthcare sector is the fastest-growing industry in the U. S. (Small et al., 2022). Unlike the hospital setting, home health caregivers offer individual care in a patient's home without additional staff or a security team. Existing workplace violence training and education are geared toward hospital settings, not home healthcare workers' environments, based in a patient's home (Small et al., 2022). Concerns in the home health setting include unpredictable work environments, hostile animals, uncertain escape routes, exposure to guns and weapons, high-crime neighborhoods, and caring for patients with complex physical and psychological conditions (Small et al., 2022). According to Schnelli (2021), aggressive behavior in home health patients is associated with cognitive, communication, and mobility difficulties. Commonly, these patients get frustrated by their lack of mobility and communication ability, taking it out on the caregivers, especially home health aides (Schnelli, 2021). Education and training targeting the home healthcare environment will give staff the confidence to recognize and handle violent situations, potentially enhancing job satisfaction (Story et al., 2020). Statement of Problem Workplace violence is a growing global healthcare threat (Day et al., 2022). Healthcare workers are four times more likely to require days off than in the private industry (Day et al., 4 2022). Workplace violence events have increased over the past decade, becoming a public health issue (Lakatos et al., 2019). There is an enhanced need to provide education and training related to workplace violence due to the isolation of the healthcare provider in the home setting (Abozaid et al., 2022; Karlsson et al., 2019; Schnelli, 2021; Small et al., 2022). Mento et al. (2020) demonstrated that staff retention improves, violent events decrease, job satisfaction improves, and favorable safety outcomes occur with adequate education and training. This MSN project aims to provide training, education, and the importance of event reporting for home health workers regarding workplace violence. The MSN project accomplishes these objectives by examining current literature to determine the extent of the problem to identify best practices to enhance the educational program for home health caregivers on handling workplace violence situations and reporting issues, thus potentially enhancing job satisfaction. Ways Project Contributes to Intended Recipients The intended recipients of this project are patients, families, home health staff, and managers. Patients and families can benefit from this project in several ways. According to Schnelli et al. (2020), patients with dementia, cognitive, or mobility issues benefit from educated home health caregivers trained to handle these violent events. Violent events decrease when there is continuity of care among staff and a focus on meeting the patient's needs (Schnelli et al., 2020). Furthermore, families benefit by witnessing and implementing the home care staff's techniques to manage the patient's care (Schnelli et al., 2020). This project will benefit patients and families since family caregivers can de-escalate situations and prevent potential workplace violence issues (Story et al., 2020). Home health caregivers benefit in several fundamental ways, including confidence and safety (Story et al., 2020). Increased confidence will improve job satisfaction and reduce burnout 5 and staff turnover (Story et al., 2020). Job turnover among home health aides is exceptionally high due to financial and personal stressors, injury, and emotional strain (Karlsson et al., 2019). Also, home health caregivers will be better prepared to handle complex and unsafe situations, decreasing caregiver injuries (Abozaid et al., 2022). Home health administration may benefit from this MSN project in various ways. The administration will experience engaged caregivers who are satisfied with their jobs, reducing staff burnout, turnover, and staffing issues (Mento et al., 2020). An essential part of implementing workplace violence education and training is a system for reviewing and evaluating workplace violence events to identify trends and rates of violent injuries and evaluate improvement measures (Story et al., 2020). According to Lakatos et al. (2019), tracking the connection between the etiologies and staff injuries is essential to develop preventative models of care. Through training and adequate reporting, along with quickly assessing trends and staffing concerns, adjustments to education and training can be made to meet individual and department needs (Lakatos et al., 2019). According to Vos (2019), the administration will benefit by having staff that feels supported and satisfied with their jobs and high staff morale, which leads to greater patient satisfaction. Improving workplace violence education and training can profoundly impact home health caregivers, patients, and home health departments by creating safer work environments, thus increasing job satisfaction (Story et al., 2020). Rationale for Importance of Project Research shows that workplace violence is increasing (Day et al., 2022; Lakatos et al., 2019; Small et al., 2022; Story et al., 2022). According to Story et al. (2020), the patients and visitors being cared for are often the individuals perpetrating violence against healthcare workers. Nurses have the highest risk of patient violence; however, prevention efforts are 6 hindered by their lack of understanding of why violence occurs, ineffective event tracking systems, and minimal education and training (Story et al., 2020). According to Mento et al.(2020), workplace violence can negatively impact health workers' psychological and physical health, such as increased stress and anxiety levels, anger, guilt, insecurity, and burnout. Working in a stressful environment can be unhealthy for caregivers, leading to burnout and staff turnover (Mento et al., 2020). Additionally, home healthcare workers can suffer from verbal abuse, which results in stress, sleep problems, burnout, job turnover, and poor job satisfaction (Karlsson et al., 2019). Abozaid et al. (2022) found that attending a training session on aggression management increased nurses' perceived confidence to deal with aggressive situations and positively influenced nurses' attitudes toward workplace violence (WPV) in the healthcare environment. In addition, it is equally important to track and monitor these violent events through a reporting system to identify trends and then modify education and training as indicated (Story et al., 2020). This MSN project will explore education and training on workplace violence for home health caregivers and whether adding education and tracking can increase job satisfaction. Providing support to home health professionals using a WPV prevention program and training can support a safe work environment that allows healthcare professionals to focus on patient care (Story et al., 2020). Literature Review and Framework A literature search was conducted to explore evidence regarding workplace violence, specifically concerning the home health setting. Research, non-research evidence, and evidencebased change frameworks were identified and reviewed. The framework selected for the MSN project is the revised model of Rosswurm and Larrabee; in this model, practitioners guide the 7 entire process of developing and integrating an evidence-based practice change (Melnyk & Fineout-Overholt, 2019). Framework This MSN project focuses on workplace violence among home health caregivers and proposes education and training specific to the home health environment and its unique challenges. For this education and training to be successful, workplace violence events must be reported and tracked using a reporting system that will identify any trends or modifications needed. The revised model of Rosswurm and Larrabee was chosen as the framework for the project due to its success in implementing evidence-based practice changes (Melnyk & FineoutOverholt, 2019). The Rosswurm and Larrabee model was developed to shift from an intuitiondriven practice to implementing evidence-based changes (White et al., 2019). The Rosswurm and Larrabee model uses clinical expertise, clinically relevant research, and patient preferences to produce the most effective, individualized patient care (Rosswurm & Larrabee, 1999). Within healthcare, change cannot be based on clinical experience alone; conducting a literature search is essential, critically appraises findings, and synthesizes the evidence (Rosswurm & Larrabee, 1999). There are six steps in the revised model of Rosswurm and Larrabee, which are (a) assess the need for change in practice, (b) locate the best evidence, (c) critically analyze the evidence, (d) design the practice change, and (e) implement and evaluate change in practice, and finally, (f) integrate and maintain change in practice (Melnyk & Fineout-Overholt, 2019). The Rosswurm and Larrabee model and the six steps apply to the MSN project because the project begins with identifying an opportunity for improvement or a practice change (Melnyk & Fineout-Overholt, 2019). The model's first step, assessing the need for change, recommends the development of a PICOT question to lead the proposed changes (Melnyk & Fineout- 8 Overhold, 2019). The PICOT question developed for the MSN project is: In-Home Health caregivers, what is the effect of workplace violence education on the caregiver's ability to navigate workplace violence situations? The second step in the Rosswurm and Larrabee model is to locate valuable evidence of the proposed change (Melnyk & Fineout-Overholt, 2019). The analysis of evidence in the second step of the model starts with searching databases, websites, journals, and other publications (Melnyk & Fineout-Overholt, 2019). During this MSN project, a systematic review of the literature using the PICOT question will occur, closely matching the second step of the framework model. The third step of the framework model is to critically analyze the evidence to determine if the evidence has the strength to support the practice change and is feasible (Melnyk & Fineout-Overholt, 2019). A rigorous literature analysis will occur during the MSN project, and then the sources will be organized into an evidence-based table. The fourth step in the Rosswurm and Larrabee model is to design a practice change which includes defining the proposed change, the resources needed, and how it will be evaluated and implemented (Melnyk & Fineout-Overholt, 2019). The practice change is supported by the evidence found in step three of the model, and team members need to determine how the data will be collected (Melnyk & Fineout-Overholt, 2019). For the MSN project, the proposed change will provide education and training on workplace violence specific to home health caregivers and the importance of reporting these events. Data will be collected in the monitoring of the pre and post-training survey and safety events. Step five of the framework model is implementing and evaluating the change in practice by following the plan designed initially in step four (Melnyk & Fineout-Overholt, 2019). Verbal feedback from the team members should be used to make changes to the implementation plan and determine whether the changes should be adapted, adopted, or rejected (Melnyk & Fineout-Overholt, 2019). For this MSN project, verbal feedback 9 will be obtained from the home health caregivers through surveys, staff meetings, and team huddles. The final step of the model is to integrate and maintain the change in practice (Melnyk & Fineout-Overholt, 2019). At this stage, stakeholders can approve implementing a new practice. Ongoing monitoring and evaluation will need to be done to determine if indicators are being met and outcomes improved (Melnyk & Fineout-Overholt, 2019). For the MSN project, feedback will be collected through the system-wide event reporting system. When events are reported, trends can be identified, and training customized to home health caregivers. Using Rosswurm and Larrabee's revised model, gaps between the research and the clinical setting will be identified to establish an evidence-based implementation change (Melnyk & Fineout-Overholt, 2019). Strengths and Limitations There are several strengths and weaknesses of the revised model of Rosswurm and Larrabee chosen for the MSN project. Strengths of the Rosswurm and Larrabee evidence-based model include that the model is based upon theoretical and research literature related to evidence-based practice, research utilization, and change theory (Rosswurm & Larrabee, 1999). Evidence-based models require the use of critical thinking skills that improve the quality of patient care (Rosswurm & Larrabee, 1999). The model helps guide the change process using an evidence-based practice model to identify gaps between research and implement that research in clinical settings (Melnyk & Fineout-Overholt, 2019). There are limitations to using the Rosswurm and Larrabee evidence-based model. According to Melnyk & Fineout-Overholt (2019), this model was developed in 1999, over 23 years ago. Another limitation of this model is that it needs to consider the patient's preferences which can be a significant factor in determining the success of the evidence-based model 10 (Melnyk & Fineout-Overholt, 2019). The revised evidence-based model of Rosswurm and Larrabee is over 23 years old and does not address patient preferences and barriers to change; there is significant value to using theoretical, research literature, and critical thinking skills to implement a practice change (Melnyk & Fineout-Overholt, 2019). Analysis of Literature Following the Rosswurm and Larrabee evidence-based model steps, a literature review was conducted to answer the PICOT question. After a thorough search of research and nonresearch literature, three major themes were identified. The themes included that healthcare staff had improved perception and increased confidence when working with an aggressive patient after participating in a workplace violence prevention (WPV) training program. Secondly, several unique challenges must be considered when providing care in the patient's home. Third, home health caregivers must recognize the importance of education and tracking in reporting violent events. Search Strategies A literature search was conducted to identify current evidence using Google Scholar, Weber State University’s Stewart Library’s OneSearch and Advanced Search (which span multiple databases), and CINAHL to direct initial exploration. Only articles from 2018 through 2022 were included in this literature review to keep the information current. The search included keywords of workplace violence, workplace violence in healthcare staff, home health care, contributing factors to workplace violence, quality improvement project, qualitative, quantitative, job satisfaction, training, education, and workplace violence in-home healthcare workers. Various Boolean combinations were created with the abovementioned keywords to create a broad search. 11 Education and Training The first theme identified in the literature found that workplace violence training programs increased healthcare workers' perception and confidence to handle violent situations (Abozaid et al., 2022; Day et al., 2022; Story et al., 2020). Abozaid et al. (2022) performed an intervention study (n = 99) among nurses in a teaching hospital. Training sessions were conducted to increase the nurse’s ability to identify and manage potentially violent situations effectively (Abazoid et al., 2022). Nurses reported increased confidence in dealing with aggression, and their attitudes toward the workplace violence program positively changed after attending the training session (Abazoid et al., 2022). Additionally, Day et al. (2022) conducted an intervention study (n=311) where a workplace violence training program was implemented with various healthcare staff. This program consisted of three videos demonstrating real-life scenarios of an agitated patient experiencing anxiety, verbal aggression and confrontation, and physical aggression and then showed de-escalation strategies (Day et al., 2022). These videos aimed to increase healthcare workers' confidence in coping with patient aggression and reduce the number of security calls for aggressive patient situations. Debriefing questions were discussed after each video, along with written and verbal feedback from the participants (Day et al., 2022). All participants reported increased confidence in managing situations with an aggressive patient, and the number of security calls also significantly decreased (Day et al., 2022). Furthermore, a quality improvement project conducted by Story et al. (2020) found that nurses had improved perception and increased confidence when working with an aggressive patient after participating in a workplace violence training program. Story et al. (2020) concluded that training should be concise and include an annual refresher. In contrast, Abozaid et 12 al. (2020) reported that comparing the reported incidence of workplace violence before and after implementing the program is not applicable, as these incidences are usually underreported. Underreporting violent events supports the idea that training sessions are needed more frequently, such as monthly or quarterly, to provide a refresher of information and encourage reporting (Small et al., 2022). Special Challenges Many factors can contribute to an increase in workplace violence. Providing care in the home is a beneficial service that reduces hospital stays and keeps people out of institutional facilities (Small et al., 2022). Home health care has unique safety challenges for caregivers since they work alone in unpredictable work environments (Small et al., 2022). A retrospective crosssectional study (n=1186) by Schnelli (2021) found that aggressive incidents in-home care occurred in patients with communication, cognitive, and mobility impairments. 14.8% of the patients showed aggressive behavior, but those receiving frequent hands-on care assignments were significantly higher for aggressive incidents than the rest of the group (Schnelli, 2021). Schnelli (2021) concluded that patients with dementia require specific education and skills training. Other research was conducted by Karlsson et al. (2019) in which survey data were collected to study the range of working conditions among home care aides. Five risk factors were identified to be associated with verbal abuse, which included patients with limited mobility, diagnosis of dementia, providing care in too small of a space, unclear care plan of what services are to be provided, and unpredictable hours (Karlsson et al., 2019). In contrast, Yesibas & Baykal (2021) concluded that one of the causes of workplace violence was the unrealistic demands of patients and their families, including misperceptions about patient rights. Patients 13 and families believed they had a right to disrespect health professionals even though they would not follow visiting hours and hospital regulations (Yesibas & Baykal, 2021). Additionally, (Karlsson et al., 2019) concluded that verbal abuse is the most common type of workplace violence in-home care aides and causes severe psychological and physiological harm. Situations where verbal abuse has occurred in the work environment can lead to burnout, sleep problems, stress, job turnover, and decreased job satisfaction (Small et al., 2022). Reporting System In addition to training home health caregivers on how to handle workplace violence events, it is also important that caregivers are trained on how to report these events using a reporting system. Research demonstrated several barriers to why caregivers do not report violent events (Abozaid et al., 2022; Small et al., 2022; Vos, 2019; Yesibas & Baykal, 2021). Educating on the prevention of workplace violence events is hindered by the lack of event tracking systems (Story et al., 2020). According to Abozaid et al. (2022), two-thirds of the participants needed to be informed that a caregiver reporting system existed. Only half of the workplace violence events were reported, and half described the reporting system as ineffective (Abozaid et al., 2022). Workplace violence can be reduced if identified as early as possible and managed (Abozaid et al., 2022). In a qualitative study (n=254) conducted by Small et al. (2022), surveys were sent to home healthcare workers to evaluate items in four categories. The categories were (a) training, policies, and procedures; (b) prevention strategies; (c) commitment to safety; and (d) violent events (Small et al., 2022). According to Small et al. (2022), 62.5% of employees said their employer offers workplace violence training, and 95.7% reported that they knew how to report workplace violence events. However, a question from the research explored if employees know 14 how to report workplace violence events and then, if so, why they are not doing it (Small et al., 2022). According to Abozaid et al. (2022), a possible explanation for underreporting is that caregivers believe the violent act is unintentional or even a part of the job. In a qualitative study (n=34) conducted by Yesibas & Baykal (2021), the researchers interviewed nurses exposed to violence in five different hospitals on various units. Nurses stated that they often ignored patients' violent acts but could not excuse acts of violence by family members (Yesibas & Baykal, 2021). Additionally, Vos (2019) reports that nurses have a strong sense of empathy, contributing to their underreporting of these violent events. Nurses often rationalize violence and say the patient is not responsible for their actions due to medical conditions and altered mental status (Vos, 2019). Small et al. (2022) also determined that a customer service approach can encourage workplace violence when the customer, or in this case, the patient, feels that they are always right. The research showed that customer service could contribute to caregivers underreporting, and even accepting this is normal (Small et al., 2022). Many different types of workplace violence can occur. These violent events must be tracked and monitored through a reporting system to identify trends and modify education and training as needed (Story et al., 2020). Furthermore, debriefing with the employee after a violent event is beneficial to determine what did and did not go well and how things could have been handled differently (Vos, 2019). Summary of Literature Review Findings and Application to the Project Current literature on workplace violence revealed that workplace violence continues to be a problem for healthcare workers (Abozoid et al., 2022; Day et al., 2022: Karlsson et al., 2019; Small et al., 2022; Schnelli, 2021; Yesibas & Baykal, 2021). Appropriate education and training must be provided to ensure that staff has the confidence to recognize and handle these difficult 15 situations (Abazoid et al., 2022; Day et al., 2022; Story et al., 2020). Evidence showed that workplace violence training increased healthcare staff's confidence and ability to deal with aggressive patients, resulting in improved job satisfaction (Abozaid et al., 2022; Karlsson et al., 2019; Mento et al., 2020; Small et al., 2022; Story et al., 2020). Staff can be prepared to recognize and de-escalate challenging situations through an education and training program on workplace violence. Several studies concluded that particular challenges are unique to the home healthcare environment (Karlsson et al., 2019; Schnelli, 2021; Small et al., 2022; Yesibas & Baykal, 2021). Additionally, research showed that home health caregivers work in unpredictable environments (Small et al., 2022). Verbal abuse is the most common workplace violence in the home and can contribute to psychological and physiological harm (Karlsson et al., 2019). The literature stated that risk factors for verbal abuse are working with patients with dementia, limited mobility of patients, working in small spaces, unpredictable hours, and unclear care plans (Karlsson et al., 2019). Schnelli (2021) concluded that workplace violence is more common in patients with cognitive, communication, and mobility impairments. Other findings showed several possible barriers to why home health caregivers do not report or underreport violent events (Abozaid et al., 2022; Small et al., 2022; Story et al., 2020; Yesibas & Baykal, 2021). Abozaid et al.(2022) stated that caregivers must receive training to report violent events, while Story et al. (2020) stated that more effective reporting systems should be implemented. Another possible barrier to reporting is that caregivers may feel that violent events are a part of the job and even excuse these acts on behalf of the patient (Abozaid et al., 2022; Yesibas & Baykal, 2021). Small et al. (2022) stated that a customer service approach can be detrimental if the customer believes they are always right. 16 These findings support the need for more robust studies and projects on workplace violence education. This information has helped substantiate this project's potential to improve home health caregivers' safety and job satisfaction by providing education and training specific to home health care workers. The evidence reviewed from the literature directs this MSN project’s goal of creating evidence-based education and training on navigating workplace violence situations. Project Methodology This MSN project aims to provide education and training on recognizing workplace violence, learning de-escalation and self-defense skills and reporting these events. The project objectives will be accomplished by providing education and training to home health staff. Several deliverables have been created to promote this project's introduction and implementation within the home health environment. The deliverables include (a) a PowerPoint presentation that will outline recognizing the signs of violence and how to respond, prevention techniques, documentation, and reporting, (b) an E-learning module recognizing and reporting inappropriate behaviors created by Intermountain Health (Intermountain Health, n.d.), (c) a de-escalation pocket card developed for caregivers by Intermountain Health (Intermountain Health, n.d.), (d) an informational-poster for the main office area and (e) pre and post project implementation survey. A debriefing session with the administration and staff will occur to discuss project success and opportunities for growth (Vos, 2019). Description and Development of Project Deliverables Five items were created to aid in the implementation of this project. This section describes the deliverables in detail, with an explanation and the importance of each. 17 Workplace Violence Education and Training PowerPoint The first deliverable created is a PowerPoint presentation (see Appendix A). This presentation aims to provide home health staff members with education and training on workplace violence. The PowerPoint presentation will be presented at a unit staff meeting at the hospital under study. The presentation will educate home health caregivers on prevention techniques, recognizing and responding to signs of agitation, documentation, and the importance of reporting these events. Additionally, this presentation will be emailed to every staff member as a reminder of the information learned and can be referenced later. Recognizing and Reporting Inappropriate Behaviors Learning Module The second deliverable is an E-learning module created by Intermountain Health (Intermountain Health, n.d.) (Appendix B). After the completed pre-survey, the module will be assigned to all home health caregivers in week two of the timeline. This module contains information on different types of inappropriate behaviors, policies regarding disruptive behaviors, what to do if a staff member experiences one of these behaviors and the process of reporting events. Prevention techniques are discussed in the E-learning module, and how to apply them. Additionally, information will be given about resources available to all employees, such as human resources (HR), employee health, and the employee assistance program (EAP). Although this module is not specifically tailored to the home health setting, it has essential information that benefits all staff. Scenarios embedded in the E-learning training will measure participants' knowledge and skill level in handling workplace violence events. Staff meeting discussion in week three will review and discuss the above scenarios. 18 Caregiver handout of de-escalation pocket card The third deliverable is a caregiver de-escalation pocket card created by Intermountain Health (Intermountain Health, n.d.) (Appendix C). This pocket card describes seven deescalation skills, has post-crisis debriefing questions, and reflective listening reminders and phrases (Intermountain Health, n.d.). The rationale for this card is to provide the home health staff member with an easy-to-carry reference card reinforcing the skills learned above. Office Poster The fourth deliverable is a poster created to hang in the homecare office highlighting zero tolerance for workplace violence (Appendix D). The rationale behind the poster is to remind home health caregivers that workplace violence is not tolerated and that resources are available. In addition, the poster has resources for employees that may need to contact human resources, employee health, and the employee assistance program. Pre-and Post-Project Survey The last deliverable created for this project is a pre and post-project implementation survey (Appendix E). The pre-survey will be sent to all staff members electronically in week one of the timeline after the projects approval. The pre-survey will assess staff members’ baseline knowledge regarding workplace violence. The post-survey will be sent out electronically to all staff members in month three of the timeline to assess staff understanding of the educational presentation and materials handed out in week three. Plan and Implementation Process The first step of the implementation process will be for the project lead to meet with the homecare administrator and get approval for the project. The MSN project will be implemented after approval has been granted, and then a mandatory meeting will be scheduled for all home 19 health staff to attend in person or virtually. After the meeting is scheduled and approval obtained, the pre-survey will be sent out electronically to the staff with a completion deadline of one week. During week two of the project, an E-learning module, "Recognizing and Responding to Inappropriate Behavior," will be assigned to staff members with a completion deadline of 14 days. Deliverables will be printed out in preparation for a staff meeting. The project lead will be the presenter, taking place four weeks after the project has been implemented and occuring at Logan Regional Hospital in classroom eight. The project lead will show the PowerPoint presentation on workplace violence, and staff can ask questions at the end. There will be a discussion about the assigned E-learning module, patient scenarios will be reviewed, and a debriefing will occur. The pocket card deliverable will be shared with all staff, and they will be encouraged to keep it in an easy-to-reference place, such as their equipment bag. The project lead will demonstrate how to access and fill out an event report. For this project to be successful, it is crucial to get buy-in from all home health staff members. The home health staff will be asked to apply the learned prevention techniques and immediately recognize and respond to guidelines, documentation, and event reporting. The administrator will reinforce this information by giving reminders in daily huddles. In month two of the project implementation, the project lead will review pertinent information in a staff meeting, and a discussion will occur with staff feedback. Reminders will continue in daily huddles, and the project lead will monitor the reporting system to determine if there is an increase in events reported. In month three of the project implementation, all staff members will receive an electronic post-survey. Based on the findings of the post-survey, changes will be made to the presentation, and reinforcement of principles will 20 occur. The project lead will continue to evaluate the reporting system to identify trends and start monthly chart audits to document inappropriate behaviors in the patient's chart. Interdisciplinary Teamwork The home care interdisciplinary team comprises the administration, the project lead, the social worker, registered nurse, and the home health aide. Each discipline needs to share its expertise and knowledge with the team. The social worker, registered nurse, and home health aide each have a unique perspective. Collaboration and communication are imperative to ensure that the patient’s needs are being met and patient safety goals are achieved (Muller et. al., 2018). Potential safety issues can be identified by collaborating, and proactive steps are taken to prevent harm to the patient and caregiver (Muller et. al., 2018). Home Health Administrator. The home health administrator is a registered nurse who oversees all home health managers. Approval will need to be obtained from the administrator before implementing this project. The administrator must approve and allow time during working hours to receive this training and education. The administrator will review the educational materials and deliverables before handing them out to give input on what changes may be needed. To ensure continuity among all staff members, the administrator would be responsible for rolling out this information to all home health sites. Project Lead. This project's lead is a registered nurse who has worked in the home health field, providing direct patient care. The project lead will monitor the event reporting system, identify trends, and report findings to staff. The project lead promotes and reinforces these educational materials and deliverables. Social Worker. The social worker is a home health interdisciplinary team member who evaluates when the registered nurse, home health aide, or provider identifies behavior issues. The 21 social worker is responsible for creating a contract outlining the terms of patient and family behavior that must be met to continue receiving care from the home health agency. If the patient is not compliant with these terms, they will be discharged from home health services. The social worker is crucial in facilitating the care provided and meeting the patient’s needs. The social worker will attend the presentation and provide support and feedback to other staff members as needed. Registered Nurse. The registered nurse plays a vital role in the success of the implementation of the project. The registered nurse provides physician-ordered nursing cares to patients in their homes, including educating patients and families. The registered nurse assesses for potential safety concerns and is responsible for documenting them in the chart, notifying interdisciplinary team members, and documenting safety events in the reporting system. If a patient does have a behavioral issue, it is the responsibility of the registered nurse to contact the social worker and start the process of a behavioral contract. The registered nurse plays a vital role in the success of the project implementation. Additionally, the registered nurse is responsible for delegating tasks to the home health aide that need to be performed at each visit. They oversee the home health aide's care plan and follow up with the interdisciplinary team as needed. Home Health Aide. The home health aide is an interdisciplinary team member providing the most hands-on care. The aide needs to be aware of de-escalation techniques and self-defense guidelines since they are within close range of the patient. The home health aide should be trained on particular challenges in the home setting, such as dealing with patients with cognitive, communicative, and mobility impairments. The aide will be trained to report concerns to the registered nurse, who can follow up with the patient, family, social worker, and provider. The 22 aide is responsible for documenting disruptive patient behaviors in the chart and filling out an event report during their visit. Timeline A detailed timeline has been created to organize the implementation of this MSN project (see Appendix E). The implementation will begin as soon as approval is obtained from the home health administrator and manager. Once that happens, the staff meeting will be scheduled, and a pre-project survey will be sent out. The E-learning module is sent out and completed in week two, and deliverables are created. Month one is when the staff meeting will occur and is scheduled for two hours, allowing for the PowerPoint presentation, discussion, and debriefing of the patient scenarios in the E-learning module and handouts given. In month two, the home health manager will review pertinent information in a staff meeting and get feedback on the project's implementation. The manager will monitor the reporting system for trends and areas that need adjustment or elimination. In month three, a post-survey will be sent out, changes will be made to the project if needed, and the manager will continue to monitor the reporting system for increased use. This timeline will last approximately four months to plan, implement, and evaluate this project. Plan for Evaluation of Project Evaluating change is essential in determining whether the change resulted in the expected patient outcomes within a patient or practice setting (Melnyk & Fineout-Overholt, 2019). In order to determine the success of the MSN project, it is important to have a system in place to evaluate if the project was successful or not. For the MSN project, two surveys will be sent out electronically to all staff members; one before receiving the training and the other two months post-training. The questionnaires both 23 consist of the same five questions asking the staff member to answer “yes” or “no” to the following questions: recognizing signs of agitation, de-escalating situations, keeping safe in the patient's home, documenting behaviors in the patient's chart, and where to access the reporting system. The success of this project will be determined by an increase in “yes” answers from the pre-and post-survey questionnaires and an increase in event reporting. The manager will monitor the event reporting system online to determine if there has been an increase in safety events reported by the staff and identify any trends in the type of events reported. Safety event information will be shared with the staff to determine if any changes need to be made to the education and training. In addition the manager will be responsible to conduct monthly chart audits to evaluate if staff is documenting inappropriate behaviors in the patient’s chart. Results from the chart audits will contribute to future project changes. Ethical Considerations It is important when implementing any project to ensure that ethical principles and measures are being taken. Ethical principles influence how the evidence is evaluated and how those evaluations are conducted (Melnyk & Fineout-Overholt, 2019). Several ethical considerations need to be considered for this MSN project such as a patient’s right to receive care, protecting their privacy, and barriers to staff reporting workplace violence events. First, every patient has the right to receive unbiased healthcare (Narayan, 2019). When a patient's chart is labeled as having disruptive behavior, this can create a bias among the home health staff (Narayan, 2019). Every effort should be made to protect the staff member’s safety while attempting to provide the care that the patient needs. It is important that staff be aware of the patients history of disruptive behaviors in order provide a safe environment for the home 24 health staff. One way to decrease bias in the home health setting is to provide annual training on disrupting biases in the workplace. Another ethical consideration is protecting the staff members' privacy and survey answers. Staff will be encouraged to participate in both surveys, give honest feedback, and be reassured that answers are kept anonymous and confidential. Although the staff meeting is mandatory, participation in the pre and post-survey is not. Another ethical consideration is that the home health staff member may not feel comfortable reporting these events (Small et al., 2022). Staff may not want to report events for several reasons, such as the staff member may feel incompetent, should have done something different, or that inappropriate behavior is a part of the job (Abozaid et al., 2022; Yesibas & Baykal, 2021). Staff might be afraid that the patient and family will be upset with them for reporting these behaviors and that the patient might have to be discharged from service. During the presentation, a discussion will occur about possible staff barriers to reporting. Staff will not face retaliation for reporting events and will be used as a learning experience. Reinforcement of reporting these violent events is needed to identify trends and track events (Story et al., 2020). Discussion Workplace violence events are underreported; therefore, their impact goes unnoticed (Abozoid et al., 2022). Staff experiences many barriers to reporting violent events, and they may not know how to report them or if reporting system is in place (Story et al., 2020). Staff may experience shame associated with workplace violence incidence, believing it is part of their job and that the customer is considered right (Abozaid et al., 2022; Small et al., 2022; Yesibas & Baykal, 2021). Violence should not be tolerated, and these occurrences must be shared and tracked with the interdisciplinary team to help develop future interventions (Vos, 2019). 25 Education and training in recognizing and responding to signs of agitation benefit staff members, families, and future staff. Evidence-based solutions, implications to nursing, this project’s strengths and weaknesses, and additional research recommendations will be discussed. Evidence-based Solutions for Dissemination After the third month of the project implementation, the results will be disseminated in several ways. First, the home health staff of the Logan branch will meet for a regularly scheduled staff meeting. A Power point will be presented during the meeting with the results of the pre-and post-survey, event reporting, and a discussion about the project implementation will be had. Second, the results from the discussion, survey data, and event reporting will be compiled into a written report and presented to the manager and home health administrator for further dissemination. The report will help the administrator and other executive leadership team members decide whether to implement this project throughout other home health offices. Finally, this project will be shared with Weber State University faculty and peers through a poster presentation and project review. Significance to Advance Nursing Practice The project can have significant benefits for the nursing profession and those who work in home health care and experience workplace violence. First, staff members will benefit from education and training on prevention techniques, recognizing and responding to signs of agitation, self-defense guidelines, required documentation, and reporting. The education provided will increase staff confidence in recognizing and handling violent behaviors (Abozaid et al., 2022; Day et al., 2022; Story et al., 2020), potentially affecting job satisfaction (Story et al., 2020). Additionally, administration will benefit from this project having staff that can recognize signs of agitation and de-escalate situations, ensuring patient and staff safety. In 26 addition, staff will become more proficient in recording workplace violence events by submitting a safety report, allowing the manager and administration to track these events, and making changes to training and education if needed. The project can benefit future staff members by having the training and education already in place upon hire and tailored to situations in the home health setting. Additionally, patients’ families can benefit from education from the registered nurse, social worker, or home health aide on handling patients more prone to violent events due to cognitive impairments (Schnelli, 2021). Finally, patients will benefit by receiving care from trained staff members who can implement prevention and de-escalation techniques as indicated, keeping the patients safe in the home setting. Implications The MSN project prepares home health staff members to recognize and respond to signs of agitation, prevention techniques, self-defense guidelines, and how to document and report on workplace violence events. The home health staff will gain knowledge, and increased confidence in treating the patient in their homes, benefiting the patient and family (Day et al., 2022; Schnelli et al., 2020). Several limitations have been identified in this project implementation. The staff and family may choose not to participate in the MSN project. Also, the project is being implemented in a rural home health setting using a small sample size and this may not apply to other home health settings. One limitation is that staff members may choose to refrain from implementing these techniques, properly report them, and participate in the pre-and post-survey. The presentation offered to staff will include discussing barriers and solutions for home health staff. Also, family members may choose to refrain from implementing the education and training provided by staff members. Families need to be receptive to the education provided and implement the 27 recommendations by the home health staff to provide a safe work and home environment (Schnelli et al., 2020). If families cannot provide a safe environment for staff members to work in, then staff cannot continue providing care to the patient. To address this possible limitation in the future, a discussion will happen with the family upon admit on the importance of providing a safe environment for the home health staff to work in. Another limitation is that the project is being implemented in one setting which is a rural home health branch using a small sample size. The results from this project may yield different results from an urban home health setting with a large sample size. However, if this project is successful, this workplace violence program could be used in other home health offices of similar size and setting. Recommendations The MSN project literature review indicated that workplace violence training and education benefit healthcare staff members and can increase job satisfaction (Abozaid et al., 2022; Karlsson et al., 2019; Mento et al., 2020; Small et al., 2022; Story et al., 2020); however, there has not been enough research regarding workplace violence in the home health setting. The home health setting has its unique challenges (Karlsson et al., 2019; Schnelli, 2021; Small et al., 2022; Yesibas & Baykal, 2021) due in part to unpredictable work environments (Small et al., 2022). Schnelli (2021) suggested that workplace violence occurs most often in patients with cognitive, communicative, and mobility impairments. Additionally, violent events need to be tracked and monitored through a reporting system to identify trends and modify education and training as needed (Story et al., 2020). Several possible barriers have been identified as why home health staff either do not report or underreport violent events (Abozaid et al., 2022; Small et al., 2022; Story et al., 2020; Yesibas & Baykal, 2021) such as believing it is a part of their job 28 and excusing violent acts on behalf of the patient (Abozaid et al., 2022; Yesibas & Baykal, 2021). Therefore, it is imperative that staff receive education and training specific to the home health environment, identify barriers to reporting, and track workplace violence events. More research needs to be conducted to address challenges in the home health setting. Conclusion Workplace violence is rising, especially in healthcare (Lakatos et al., 2019). Staff education and training should be customized to the home health environment (Karlsson et al., 2019). As staff receives training and education and engages in discussions of patient scenarios, their confidence will increase, potentially leading to improved reporting and decreased violent events (Day et al., 2022; Vos, 2019). Increased reporting, education, and training can be modified to the home health setting, and a decrease in violent events will increase staff confidence and job satisfaction. This project aids in assisting home health staff in utilizing the education and training tools to de-escalate events, properly document and report them, and educate families on how to implement these tools. 29 References Abozaid, D. A., Momen, M., Ezz, Nahla Fawzy Abou El, Ahmed, H. A., Al-Tehewy, M. M., ElSetouhy, M., El-Shinawi, M., Hirshon, J. M., & Houssinie, M. E. (2022). Patient and visitor aggression de-escalation training for nurses in a teaching hospital in Cairo, Egypt. BMC Nursing. 21(1), 63-63. https://doi.org/10.1186/s12912-022-00828-y Centers for Medicare & Medicaid Services. (2020). Medicare and home healthcare. www.medicre.goc/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf Day, S. W., Sharp, J., Jackson, G. L., Johnson, R. L., Smith, K. A., Cao, X., & Likes, W. (2022). Management of aggressive patient situations: Program development, implementation, and evaluation. American Nurse Today, 17(4), 34. Intermountain Health. (n.d.). De-escalation skills pocket card. https://intermountainhealth.sharepoint.com/sites/PV/Shared%20Documents/Forms/AllIte ms. aspx?id=%2Fsites%2FPV%2FShared%20Documents%2FWorkplace%20Violence% 20Pocket%20Card%207%20Skills%20DeEscalation%2Epdf&parent=%2Fsites%2FPV%2FShared%20Documents Intermountain Health. (n.d.). Recognizing and Responding to Inappropriate Behaviors ELearning Module Content. Intermountain Health. (n.d.). Preventing Workplace Violence. Intermounatin.net. https:intermountainhealth.sharepoint.com/sites/pv Karlsson, N. D., Markkanen, P. K., Kriebel, D., Gore, R. J., Galligan, C. J., Sama, S. R., & Quinn, M. M. (2019). Home care aides’ experiences of verbal abuse: A survey of characteristics and risk factors. Occupational and Environmental Medicine (London, 30 England), 76(7), 448–454. https://doi.org/10.1136/oemed-2018-105604 Lakatos, B. E., Mitchell, M. T., Askari, R., Etheredge, M. L., Hopcia, K., DeLisle, L., Smith, C., Fagan, M., Mulloy, D., Lewis-O’Connor, A., Higgins, M., & Shellman, A. (2019). An interdisciplinary clinical approach for workplace violence prevention and injury reduction in the general hospital setting: SAFE response. Journal of the American Psychiatric Nurses Association, 25(4):280–288. https://doi.org/10.1177/1078390318788944 Melnyk, B. M. & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare: A guide to best practice. (4th ed.). Philadelphia, PA: Wolters Kluwer. Mento, C., Silvestri, M. C., Bruno, A., Muscatello, M. R. A., Cedro, C., Pandolfo, G., & Zoccali, R. A. (2020). Workplace violence against healthcare professionals: A systematic review. Aggression and Violent Behavior, 51, 1–8. https://doi.org/10.1016/j.avb.2020.101381. Muller, M., Jurgens, J., Redaelli, M., Klingberg, K., Hautz, W.E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: A systematic review. BMJ Open, 8(8), e022202-e022202. https://doi.org/10.1136/bmjopen-2018-022202 Narayan, M.C. (2019). Addressing implicit bias in nursing: A review. The American Journal of Nursing, 119(7), 36. https://doi.org/10.109/01.NAJ.0000569340.27659.5a Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. Image: The Journal of Nursing Scholarship, 31(4), 317–322. https://doiorg.hal.weber.edu/10.1111/j.1547-5069.1999.tb00510.x Schnelli, A., Ott, S., Mayer, H., & Zeller, A. (2021). Factors associated with aggressive behavior in persons with cognitive impairments using home care services: A 31 retrospective cross‐sectional study. Nursing Open, 8(3), 1345–1359. https://doi:10.1002/nop2.751 Small, T. F., Smith, C. R., Hutton, S., Davis, K. G., & Gillespie, G. L. (2022). Workplace Violence Prevention Training, Safety Resources, and Commitment to HHCWs’ Safety. Workplace Health & Safety, https://doi.21650799221076871. Story, A. R, Harris, R., Scott, S. D., & Vogelsmeier, A. (2020). An evaluation of nurses' perception and confidence after implementing a workplace aggression and violence prevention training program. The Journal of Nursing Administration, 50(4), 209-215. https://doi.org/10.1097/NNA.0000000000000870. Vos, J. (2019). Workplace violence: How can we feel safe at work?Virginia Nurses Today, 27(4), 19–19. White, K. M., Dudley-Brown, S., & Terhaar, M. F. (2019). Translation of evidence into nursing and healthcare. (3rd ed.). Springer Publishing Connect 32 Appendix A Workplace Violence Education and Training PowerPoint 33 34 35 36 37 38 Appendix B Recognizing and Responding to Inappropriate Behaviors E-Learning Module Content Figure 1 E-Learning Module This E-learning module will be assigned online and takes approximately 20 minutes. The first section of the module:  Informs staff members that inappropriate behaviors are not tolerated  Refers to company policies  Encourages staff to speak up The following section educates on:  Recognizing and responding  Having situational awareness  Different types of inappropriate behaviors 39 The third section instructs staff members on the following:  What to say  Actions to take  How to deal with those with cognitive impairments  Alerts that can be placed in the patient's chart The fourth section consists of the following:  Four different scenarios varying in location and situation  The participant is required to answer the appropriate response The last section of the module instructs on:  Reporting and different resources that the staff member has, such as HR, compliance, employee health, and EAP  A staff member will not experience any retaliation for reporting. Note. Recognizing and Responding to Inappropriate Behaviors E-Learning Module. From Intermountain Health, n.d. 40 Appendix C Caregiver handout of de-escalation pocket card Figure 1 De-Escalation Skills Pocket Card 41 Note. Caregiver pocket card. From Intermountain Health, n.d. (https://intermountainhealth.sharepoint.com/sites/PV/Shared%20Documents/Forms/AllIte ms.aspx?id=%2Fsites%2FPV%2FShared%20Documents%2FWorkplace%20Violence% 20Pocket%20Card%207%20Skills%20DeEscalation%2Epdf&parent=%2Fsites%2FPV%2FShared%20Documents). 42 Appendix D Office Poster Note. Access poster at this link. 43 Appendix E Pre- and Post-Survey Pre- and Post-Survey 1. I know how to recognize the signs of agitation. a. Yes b. Maybe c. No d. Neutral 2. I know how to de-escalate situations. a. Yes b. Maybe c. No d. Neutral 3. I know how to keep myself safe in a patient’s home. a. Yes b. Maybe c. No d. Neutral 4. I know where to document behaviors in a patient’s chart. a. Yes b. Maybe c. No d. Neutral 5. I know where to access the reporting system (SafetyNet). a. Yes b. Maybe c. No d. Neutral 44 Appendix F Timeline