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Service Delivery Innovation Profile

Regular Meetings of Patients and Staff Reduce Violent Episodes by 85 Percent on Inpatient Psychiatric Unit


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Snapshot

Summary

An inpatient psychiatric unit at Edith Nourse Rogers Memorial Veterans Hospital holds regular 30-minute "community" meetings focused on violence prevention, with all on-duty unit staff and patients attending. Led by a mental health professional and based on a semistructured protocol, these informal meetings serve as a forum for staff and patients to express concerns, review recent episodes of violence and abuse, and brainstorm strategies to prevent such episodes in the future. The program reduced violent episodes on the original unit by 85 percent. However, in a nationwide study in eight hospitals, the program was not associated with lower aggression rates (updated March 2014).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the number of violent episodes on the unit, as well as a multisite study of the method in eight inpatient psychiatry units (updated March 2014).
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Developing Organizations

Edith Nourse Rogers Memorial Veterans Hospital
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Date First Implemented

2004
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Patient Population

Vulnerable Populations > Mentally illend pp

Problem Addressed

Patient-perpetrated violence and abuse directed at staff occurs often in health care settings, with incidents involving nurses in psychiatric care settings being particularly common. Frequently used interventions to prevent such violence have not been particularly effective.
  • A common occurrence: A study found that 13.2 percent of health care workers had been the victim of patient-perpetrated physical violence over the previous year, while 38.3 percent had been the victim of verbal assaults or abuse during this time.1 Nurses remain most susceptible to such violence and abuse, particularly those working in psychiatric settings.2 One study found that, over a 1-week period, more than 20 percent of psychiatric nurses had been the victim of a physical assault, while more than half had been verbally assaulted.3
  • Ineffectiveness of common prevention strategies: The typical strategies used to prevent violence—including flagging the charts of potentially violent patients, using restraints, training nurses to assess the potential for violence, and adopting zero-tolerance policies—have generally had limited impact. For example, patients with no previous history of violence or abuse often perpetrate assaults; patient restraints may actually increase aggressive behavior; nurse assessments of a patient's potential for violence may not be reliable; and institutional policies often do little to prevent violence perpetrated by mentally incapacitated or uncooperative patients.2

What They Did

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Description of the Innovative Activity

An inpatient psychiatric unit at Edith Nourse Rogers Memorial Veterans Hospital holds regular 30-minute "community" meetings focused on violence prevention, called Violence Prevention Community Meetings (VPCM), with all on-duty unit staff and patients attending. Led by a mental health professional and based on a semistructured protocol, these informal meetings serve as a forum for staff and patients to express concerns, review recent episodes of violence and abuse, and brainstorm strategies to prevent such episodes in the future. Key elements of the program include the following:
  • Meeting logistics: The 30-minute VPCM occurs three times each week, twice on the day shift and once on the evening shift. All on-duty unit staff and patients (except those restrained or in seclusion) attend. The meetings are scheduled as a regular part of unit activities. Unit-based mental health professionals who have at least 1 year of experience on a psychiatric unit run the sessions, with leadership rotating among all eligible individuals, regardless of position.
  • Opening and introductions: Each meeting begins with the leader reminding participants of its purpose and introducing all staff and patients in attendance. The leader sets the ground rules for respectful behavior and encourages all attendees to voice their thoughts, concerns, and ideas related to unit-based violence and abuse, including prevention strategies.
  • Informal agenda, focused on high-priority issues: The leader does not follow a formal agenda but rather selects topics to be discussed based on the general concerns raised by participants or recent violent episodes. Remaining calm, direct, and empathetic throughout the session, the leader engages attendees in a discussion of high-priority topics, such as the following:
    • Institutional policies regarding violence
    • Unit expectations related to behavior
    • Staff and patient concerns about violence
    • A review of recent violent episodes, including why they occurred, how they were resolved, and staff and patient reactions
    • Warning signs of impending violence
    • Methods for summoning assistance and identifying resources
    • Strategies for preventing violence and diffusing potentially violent situations
  • Summary and followup actions: At the conclusion of the meeting, the leader summarizes the discussion and highlights necessary followup actions related to particular issues or patients. Staff are assigned to follow up on the recommendations, and the leader reviews the actions and outcomes at the following meeting.

Context of the Innovation

The Edith Nourse Rogers Memorial Veterans Hospital, a U.S. Department of Veterans Affairs (VA) long-term care facility, specializes in geriatric and psychiatric care, including mental health services, general medicine, psychiatry, dentistry, geriatrics, and ambulatory care. The 30-bed psychiatric unit treats approximately 840 patients annually. Dr. Marilyn Lanza, who served as Associate Chief of Nursing Research for many years, spearheaded this program based on her longstanding interest in researching strategies to better understand and prevent violent episodes on psychiatric units.

Did It Work?

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Results

The program reduced violent episodes on the original unit by 85 percent. In a nationwide study of the method in eight acute, locked psychiatric units of the Veterans Health Administration, overall rates of aggression fell in both the intervention hospitals (0.6-percent decline per week) and the control hospitals (5.1-percent decline)(updated March 2014).
  • Initial, significant reduction in violence: Violent episodes on the original unit decreased from a mean of 4.7 during the 3-week period before implementation to a mean of 0.73 during the 9-week testing period for the program, representing an 85 percent reduction. (A 4-week "transitional" period preceded the testing, during which time program leaders introduced the concept and evaluated various meeting formats.)
  • Spike after program temporarily suspended: Violent episodes on the original unit increased to a mean of 2.84 during a 4-week period after the meetings were temporarily halted. Even with this increase, the incidence of such episodes remained 41 percent below pre-implementation levels.
  • Drop back to initial levels after reinstatement: These results convinced program leaders to make the meetings a permanent part of activities on the original unit. After the program relaunched, violent episodes again declined, back to the level achieved during the earlier test period. Rates of violence have remained at this low level since reinstatement of the program.
  • Results of nationwide study: In a 21-week nationwide study of the VPCM, all patients and staff on the eight inpatient, locked psychiatry units participated in the intervention (VPCM) or as a control (treatment as usual). The VPCM was conducted during treatment weeks—4 through 18. Rates of aggression declined by only 0.6 percent per week in the intervention hospitals and by 5.1 percent per week in the control hospitals (updated March 2014).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the number of violent episodes on the unit, as well as a multisite study of the method in eight inpatient psychiatry units (updated March 2014).

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Protocol development: Dr. Lanza and colleagues (including national experts in assaultive behavior) developed a protocol for the VPCM, including who should lead the sessions, how they should be run, potential content/topic areas to be covered, and other aspects of the meetings.
  • Institutional approval: Dr. Lanza sought and obtained approval to test the concept from the hospital's Institutional Review Board.
  • Staff training: Dr. Lanza held a meeting with unit staff on each shift to describe the VPCM (e.g., its purpose, how it should be run) and share the protocol. She also designated the most experienced unit staff member to lead the initial session.
  • Pilot testing: The unit conducted a 20-week pilot test of the concept, which included a 3-week baseline period before implementation, a 4-week period to introduce the concept and test various meeting formats, a 9-week testing period when the community meetings were held, and a 4-week period when meetings were temporarily halted.
  • Program reinstatement: As noted, the success of the pilot test led to the program becoming a permanent activity on the unit.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing staff participate in the meetings as part of their regular duties.
  • Costs: The program requires no development or ongoing operating costs.
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Funding Sources

Department of Veterans Affairs; National Institute for Occupational Safety and Health; Edith Nourse Rogers Memorial Veterans Hospital
The Department of Veterans Affairs and the National Institute for Occupational Safety and Health have provided grant funds to support evaluation of the program's impact at Edith Nourse Rogers Memorial and other VA hospitals.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Allow established patients to orient new ones: Patients typically rotate in and out of psychiatric inpatient units, creating an ongoing challenge in acclimating new patients (some of whom may have violent tendencies). This issue can be addressed by encouraging established patients to describe the purpose and content of the VPCM to new patients. This exchange will help new patients understand the expectations of unit staff and feel comforted by the focus on safety.
  • Address staff concerns: Some unit-based staff may express concerns about patients becoming involved in discussions about violence, believing that participation may give them the idea to become violent. To address such concerns, program leaders should emphasize that experience to date suggests that the meeting has the opposite effect, making patients less, not more, prone to violence.

Sustaining This Innovation

Making the meeting an established part of the unit's weekly schedule of staff and patient activities will ensure that it becomes embedded in unit operations.

Spreading This Innovation

Thirteen inpatient psychiatric units within VA hospitals have implemented and are currently evaluating this program.

More Information

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Contact the Innovator

Marilyn Lanza, DNSc, ARNP, CS, FAAN
Nurse Researcher
Edith Nourse Rogers Memorial Veterans Hospital
200 Springs Road
Bedford, MA 01730
(781) 687-2388
E-mail: marilyn.lanza@va.gov

Innovator Disclosures

Dr. Lanza has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Lanza ML, Rierdan J, Forester L, et al. Reducing violence against nurses: the violence prevention community meeting. Issues Ment Health Nurs. 2009;30:745-50. [PubMed]

Lanza ML, Kazis L, Lee A. Using the violence prevention community meeting protocol. Journal of American Psychiatric Nurses Association. 2003;9(3):86-9.

Lanza ML. Community meeting: review, update, and synthesis. Int J Group Psychother. 2000;50(4):473-85. [PubMed]

Footnotes

1 Gerberich SG, Church TR, McGovern PM, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study. Occup Environ Med. 2004;61(6):495-503. [PubMed]
2 Lanza ML, Rierdan J, Forester L, et al. Reducing violence against nurses: the violence prevention community meeting. Issues Ment Health Nurs. 2009;30:745-50. [PubMed]
3 Hesketh KL, Duncan SM, Estabrooks CA, et al. Workplace violence in Alberta and British Columbia hospitals. Health Policy. 2003;63(3):311-21. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 13, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 18, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.