The elderly population in the United States continues to increase at an unprecedented rate. The aging process for many older adults includes declining cognitive abilities. In a study of cognitively impaired patients, 50.8% of the patients exhibited physically aggressive behaviors (Ryden, Bossenmaier, & McLachlan, 1991). When working with cognitively impaired elderly (CIE) patients, assaultive behaviors are one of the biggest challenges for care providers. Assaultive behaviors affect both the patient and the care providers. The quality of life for CIE patients is decreased when they become agitated to the point of assaulting their care providers. Assaultive behaviors also have several consequences for care providers including physical injuries, time lost from work, and psychological problems.
The purpose of this article is to answer the question: Does education related to the management of assaultive behaviors for staff working with CIE patients affect the number or severity of patient-tostaff assaults?
In one federal health care system located in the western United States, the highest number of patient-tostaff assaults has been in Extended Care Services (ECS). Indeed, assaults in the ECS exceeded those throughout the remaining areas of the hospital, including nine psychiatric units. Not surprisingly, nurses have been found to be the most frequently assaulted staff members (Lanza, 1988; Yassi, 1996).
While studies have identified the need for staff education related to the management of assaultive behaviors for staff working in psychiatry (Infantino & Musingo, 1985; Lehmann, Padilla, Clark, & Loucks, 1983; Rosenthal, Edwards, Rosenthal, & Ackerman, 1992), studies specific to the need for training of staff working with geriatric patients are less common (Burgio, Butler, & Engel, 1988; Liukkonen & Laitinen, 1994), and those that address the need for training of staff working with CIE patients are even fewer (Maxfield, Lewis, & Cannon, 1996). This paucity of literature presents a challenge for individuals interested in decreasing the number of assaults and subsequent injuries in long-term care and acute care settings.
Smith, Buckwalter, and Albanese (1990) found that participants' knowledge of issues related to elderly individuals such as the aging process, cognitive impairments and resultant behaviors, depression, and therapeutic interventions increased after an educational program on geriatric mental health. However, no behavioral consequences of the behavioral program were evaluated. Several studies have found a significant decrease in assaults among staff who had training in managing assaultive behaviors compared with those who had little or no training (Infantino & Musingo, 1985; Lanza, Kayne, & Hicks, 1991; Rosenthal et al., 1992). Martin (1995) collected data for 1 year prior to and 2 years after the development of an educational program for psychiatric nursing staff. The results of this study demonstrated a decrease in the number and severity of assaults after the training program. This study also found "a decline in the number of missed work days and cost to the system" (Martin, 1995, p. 214) as a direct result of staff injuries from assaultive patients. Other studies have measured actual costs to health care organizations that result from patient-to-staff assaults (Hunter & Carmel 1992; Lanza & Milner, 1989). However, the emotional costs to staff cannot be measured.
Figure. Trend of patient-to-staff assaults.
Two studies were found that evaluated the effectiveness of training for staff working with ClE patients. Cohn, Horgas, and Marsiske (1990) evaluated and found a behavioral management training program for nursing assistants to result in a sustained improvement in knowledge. Also found was "a positive relationship between test performance and self-assessed current caregiving performance" (Cohn et al., 1990, p. 23). Hagen and Say ers (1995) used a quasiexperimental, interrupted time series design to measure incidents of aggression for a period of 8 days prior to and 8 days after an educational program. They found a decrease in the incidents of assaults by "approximately 50%" (Hagan & Sayers, 1995, p. 13).
Topics to be included and teaching strategies to reduce assaultive behaviors have been suggested in the literature but were found to vary widely. Smyer, Brannon, and Cohn (1992) found that while nursing assistants' knowledge and job perceptions improved after an educational intervention, their job performance did not, suggesting the need for administrative support. Ferguson and Smith (1996) identified the need for staff education related to the following topics:
* A safe and therapeutic environment.
* Timing related to administering medications for agitation.
* Recognizing the early signs of behavior escalation for individual patients.
* Verbal interventions.
* Positive redirection methods.
Ryden et al. (1991) noted the need for staff to be able to identify triggering events, while Feldt and Ryden (1992) argued for the usefulness of an advanced practice nurse to teach and role model direct patient care. They also found the need for staff education related to cognitive impairment, triggers of aggressive behaviors, communication techniques, development of individualized care plans, and prevention of aggressive behaviors (Feldt & Ryden, 1992). Similarly, Mobily, Maas, Buckwalter, and Kelley (1992) recommended staff education cover topics related to the causes of dementia, cognitive and physical problems, and the problems associated with activities of daily living. They also suggested psychiatric nurses be used as consultants or providers for the training. Almost 2 decades ago, Williston Di Bella (1979) found the need for staff to recognize and manage their own feelings before they are able to manage a patient's behaviors. Thus, there is a great need to develop and systematically evaluate educational programs designed to manage assaultive behaviors in CIE patients.
PROGRAM EVALUATION DESIGN
A longitudinal, nonexperimental design was used to evaluate the effectiveness of an educational program on the management of assaultive behaviors with CIE patients. The effect of the program on the patients was measured by counting the number of patient-tostaff assaults and reviewing the severity of the resultant injuries. Data were collected and compared on a monthly basis for 1 year prior to the implementation of the educational program and during the 11 months of continued training. Included were current patients on the Geropsychiatric/Dementia Unit with an average census of 40 patients with advanced stages of dementia to the degree that their former caregivers could no longer provide the needed care. Thirty-two nursing staff (10 RNs, 11 licensed vocational nurses, and 11 nursing assistants) also participated in the program. The nursing staff were distributed over three shifts to provide 24-hour patient care. Both the patients and the nursing staff were relatively stable, with minimal turnover.
THE EDUCATIONAL PROGRAM
The educational program consisted of a combination of topics that were presented using several different strategies. First, management met to discuss the need for an educational program for staff and teaching strategies. This began administration's support of the educational program, which was continuous throughout the training period and was made evident through direct and indirect communication to the staff involved. Integral aspects of the communication were based on administration's concern regarding accurate incident reporting to justify staffing needs and a belief that caregivers are the most important aspect of the hospital. Administration gave clear and frequent messages to the nursing staff that it was not part of their job to be assaulted and they would not be viewed as having performed their job incorrectly should they report assaults.
Training began in May of 1996, with an all-day workshop. The importance of interdisciplinary teamwork and collaborative development of individualized treatment and care plans was the first topic of the day. The staff's use of themselves as their most effective tool and an awareness of how their mood, attitude, and motivation affected the ability to work with difficult situations and decreased the risk of assault followed. A discussion of self-control and the "fight or flight" response preceded participants writing an individualized plan for selfcontrol during an imagined assault. The issue of staff burnout generated a lively discussion. A detailed explanation of the stress model of assault and a discussion of the common knowledge model of assault assisted staff in identifying the causes of assaultive behaviors and the intervention that would be most effective (Smith et al., 1993). A discussion and identification of safe working attire and the environment were included in the workshop. Several teaching strategies were used throughout the workshop including lectures, discussions, role playing, active participation in prepared exercises, and return demonstrations of assault avoidance techniques. Participation was encouraged throughout the workshop, and questions were asked by the participants which frequently led to class discussions.
An advanced practice psychiatric nurse was hired to work 10-hour shifts as a special staff nurse to provide teaching and daily role modeling of patient care for all shifts. Based on a unit needs assessment, the nurse developed and provided ongoing training and unit inservices related to the following topics:
* Dementia process.
* Assault cycle.
* Individual patient problem solving regarding trigger identification and care planning.
* Identification and prevention of burnout.
* Assertive communication.
* Patient needs.
* Incident reporting.
Teaching regarding incident reporting included the importance of accurate reporting and how to use the new technology within the hospital's computer system which replaced the formerly used paper system. The nurse also led monthly practices of physical techniques and facilitated a team approach to solving individual assaultive behavior problems.
Data were collected through the use of the hospital's computer system which stores data regarding patient-to-staff assaults. An assault was defined as any physical contact initiated by a patient toward the staff that included hitting, punching, shoving, slapping, grabbing, kicking, biting, pinching, scratching, choking, or hair pulling. Incident reports, written by nursing staff, were evaluated for severity level of resultant injuries. Four levels of severity were used to categorize the levels of injuries which resulted from patientto-staff assaults:
* 0 for no injury.
* 1 for minor injuries such as pain after the initial assault, redness, swelling, or an injury which required first aid treatment without the need for a physician-prescribed treatment.
* 2 for an injury which required a physician-prescribed treatment or a personnel health visit.
* 3 for death.
Data were collected for 1 year prior to the initiation of the intervention and for 11 months during the continuation of the intervention. A simple tally sheet was the only tool used to track the number of patient-tostaff assaults and severity of injuries on a monthly basis.
A total of 57 patient-to-staff assaults were reported for 12 months prior to implementation of the training program. For the 1 1 month period of time when the training was continued, a total of 99 patient-tostaff assaults were reported. During the 12 months prior to the implementation of the educational program, the nursing staff experienced 42 incidents categorized as Level 0, 13 incidents that were Level 1, and 2 Level 2 injuries. During the period of 11 months in which the educational program was in progress, 62 of the injuries to the nursing staff were categorized as Level 0, 27 were Level 1 injuries, and 10 were Level 2 injuries. There were no Level 3 injuries to the nursing staff during either period of time.
During the 12 months prior to the implementation of the educational program, there were a total of seven resultant Level 1 injuries to patients, requiring medical attention. During the period of 1 1 months in which the educational program was in progress, a total of three Level 1 injuries to patients were incurred as a result of patient-to-staff assaults. There were no Level 2 or 3 injuries reported for either period of time. This demonstrates a reduction of minor injuries to patients by 58% from the period prior to the intervention to the period that the intervention was in progress.
The data collected in this program evaluation demonstrates a nearly two-fold increase of reported incidents of patient-to-staff assaults from the period prior to implementation of the educational program to the 1 1 months during which the program was in process. When considering this great difference, it ís possible the pre-intervention reporting of incidents of patient-to-staff assaults may not have been truly accurate. While it is possible the incidents of assault may have nearly doubled, it also is possible that staff education increased the accuracy of reporting. This would support prior studies which identified a problem with underreporting of patient-to-staff assaults (Lanza, 1988; Lion, Snyder, & Merrill, 1981; Tardiff & Sweillam, 1982). Another possible explanation for the increase in reported assaults could be a reactive effect, also known as the Hawthorne effect. That is, the nursing staff were aware of the educational program and its focus on patient-to-staff assaults, and the fact that they were being studied may have increased the number of reported assaults. The increase of reported patient-to-staff assaults has made an impact in the administration of the ECS of one federal health care system with the authorization for the hiring of new personnel to supplement the existing staff. Therefore, there was a hidden benefit for staff to increase incident reports.
Data were collected for 1 year prior to the beginning of the educational program to determine if there was a trend in the number of patientto-staff assaults in process. As shown in the Figure, a slight trend was observed toward an increase in the number of assaults prior to the implementation of the educational program. It is interesting to note the similar patterns that exist from September to December during both periods of time. The reason for this time-related pattern is unknown.
Support for the educational program is demonstrated by the 58% decrease in the resultant injuries experienced by patients. While this evaluation did not attempt to measure quality of life for the patients, the findings support its enhancement.
IMPLICATIONS FOR NURSING
An educational program that reduces injuries to patients or staff that are a result of patient-to-staff assaults is of interest to the care providers and institutions that care for CIE patients because it is a relatively simple program to implement and is cost effective when compared to the costs involved when staff or patients are injured.
Education related to the reporting of patient -to-staff assaults is imperative to accurately evaluate the effect of an educational program on the management of assaultive behaviors related to the number of assaults and the injury severity. Administrative support encourages accurate reporting of assaults by increasing staff awareness that they are not seen as performing their job poorly if they are assaulted and that assaults are not part of the job. Accurate reports of assaultive incidents will provide administration with the information needed to assist staff to better perform their difficult jobs with this challenging population.
Studies related to the effectiveness of an educational program on the management of assaultive behaviors may be demonstrated more completely by comparing the number of patient-to-staff assaults for a period of time prior to the implementation of the program compared with the same type of assaults after completion of the training program. Future research also should focus on the accuracy of assault reporting to allow for more precise evaluation of staff education effectiveness.
Cost analysis also would be helpful in evaluating an educational program's effectiveness. This could be performed by evaluating the cost of the educational program and comparing it to the costs involved with injured staff, including their replacement, medical costs, subsequent stress, and staff turnover. Finally, a study of which teaching strategies are most efficacious would be important to increasing the cost effectiveness and time effectiveness of the educational program.
- Burgio, L.D., Butler, R, & Engel, B.T. (1988). Nurses' attitudes towards geriatric behavior problems in long-term care settings. Clinical Gerontologist, 7(3/4), 23-34.
- Cohn, M.D., Horgas, A.L., & Marsiske, M. (1990). Behavior management training for nurse aides: Is it effective? Journal of Gerontological Nursing, /6(11), 21-25.
- Feldt, K.S., & Ryden, M.B. (1992). Aggressive behavior: Educating nursing assistants. Journal of Gerontological Nursing, 18(5), 3-12.
- Ferguson, J.S., & Smith, A. (1996). Aggressive behavior on an inpatient geriatric unit. Journal of Psychosocial Nursing, 34(3), 2732.
- Hagen, B.F., & Sayers, D. (1995). When caring leaves bruises: The effects of staff education on resident aggression. Journal of Gerontological Nursing, 27(1 1), 7-16.
- Hunter, M., & Carmel, H. (1992). The cost of staff injuries from inpatient violence. Hospital and Community Psychiatry, 43(6), 586-589.
- Infantino, J.A., & Musingo, S.Y. (1985). Assaults and injuries among staff with and without training in aggression control techniques. Hospital and Community Psychiatry, 36,1312-1314.
- Lanza, M.L. (1988). Factors relevant to patient assault. Issues in Mental Health Nursing, 9, 239-257.
- Lanza, M.L., Kayne, H.L., & Hicks, C. (1991). Nursing staff characteristics related to patient assault. Issues in Mental Health Nursing, 12, 253-265.
- Lanza, M.L., & Milner, J. (1989). The dollar cost of patient assault. Hospital and Community Psychiatry, 40, 1227-1229.
- Lehmann, L.S., Padilla, M., Clark, S., & Loucks, S. (1983). Training personnel in the prevention and management of violent behavior. Hospital and Community Psychiatry, 34, 40-43.
- Lion, J.R., Snyder, W-, & Merrill, G.L. (1981). Underreporting of assaults on staff in a state hospital. Hospital and Community Psychiatry, 32(7), 497-498.
- Liukkonen, A., & Laitinen, P. (1994). Reasons for uses of physical restraint and alternatives to them in geriatric nursing: A questionnaire study among nursing staff. Journal of Advanced Nursing, 19, 10821087.
- Martin, K.H. (1995). Improving staff safety through an aggression management program. Archives of Psychiatric Nursing, 9(4), 211-215.
- Maxfield, M.C., Lewis, R.E., & Cannon, S. (1996). Training staff to prevent aggressive behavior of cognitively impaired elderly patients during bathing and grooming. Journal of Gerontological Nursing, 22(1), 37-43.
- Mobily, PR., Maas, M.L., Buckwalter, K..C, & Kelley, L.S. (1992). Geriatric mental health: Staff stress on an Alzheimer's unit. Journal of Psychosocial Nursing, 30(9), 25-31.
- Rosenthal, T.L., Edwards, N.B., Rosenthal, R.H., & Ackerman, BJ. (1992). Hospital violence: Site, severity, and nurses' preventive training. Issues in Mental Health Nursing, 13, 349-356.
- Ryden, M. B., Bossenmaier, M., & McLachlan, C. (1991). Aggressive behavior in cognitively impaired nursing home residents. Research in Nursing and Health, 14, 87-95.
- Smith, M., Buckwalter, K., & Albanese, M. (1990). Geropsychiatric education programs: Providing skills and understanding. Journal of Psychosocial Nursing, 28(12), 812.
- Smith, P.A., Fox, L., Johnson, L., Nihart, M.A., Schindler, M., & Smiar, N. (1993). Professional Assault Response Training: Revised. (Available from Professional Assault Response Training [PART], 6105 Glenhurst Way, Citrus Heights, CA 95621-1720)
- Smyer, M., Brannon, D., & Cohn, M. (1992). Improving nursing home care through training and job redesign. The Gerontologist, 32, 327-333.
- Tardiff, K., & Sweillam, A. (1982). Assaultive behavior among chronic inpatients. American Journal of Psychiatry, 139, 212215.
- Williston Di Bella, G.A. (1979). Educating staff to manage threatening paranoid patients. American Journal of Psychiatry, 136, 333-335.
- Yassi, A. (1996). Assault and abuse of health care workers in a large teaching hospital. Canadian Medical Association Journal, 151(9), 1273-1279.