Background Over 1.7 million episodes of agitation occur annually across the United States in emergency departments (EDs), some of which lead to workplace assaults on clinicians and require invasive methods like physical restraints to maintain staff and patient safety. Recent studies demonstrated that experiences of workplace violence contribute to symptoms of burnout, which may impact future decisions regarding use of physical restraints on agitated patients. To capture the dynamic interactions between clinicians and agitated patients under their care, we applied qualitative system dynamics methods to develop a model that describes feedback mechanisms of clinician burnout and the use of physical restraints to manage agitation. Methods We convened an interprofessional panel of clinician stakeholders and agitation experts for a series of model building sessions to develop the current model. The panel derived the final version of our model over ten sessions of iterative refinement and modification, each lasting approximately three to four hours. We incorporated findings from prior studies on agitation and burnout related to workplace violence, identifying interpersonal and psychological factors likely to influence our outcomes of interest to form the basis of our model. Results The final model resulted in five main sets of feedback loops that describe key narratives regarding the relationship between clinician burnout and agitated patients becoming physically restrained: (1) use of restraints decreases agitation and risk of assault, leading to increased perceptions of safety and decreasing use of restraints in a balancing feedback loop which stabilizes the system; (2) clinician stress leads to a perception of decreased safety and lower threshold to restrain, causing more stress in a negatively reinforcing loop; (3) clinician burnout leads to a decreased perception of colleague support which leads to more burnout in a negatively reinforcing loop; (4) clinician burnout leads to negative perceptions of patient intent during agitation, thus lowering threshold to restrain and leading to higher task load, more likelihood of workplace assaults, and higher burnout in a negatively reinforcing loop; and (5) mutual trust between clinicians causes increased perceptions of safety and improved team control, leading to decreased clinician stress and further increased mutual trust in a positively reinforcing loop. Conclusions Our system dynamics approach led to the development of a robust qualitative model that illustrates a number of important feedback cycles that underly the relationships between clinician experiences of workplace violence, stress and burnout, and impact on decisions to physically restrain agitated patients. This work identifies potential opportunities at multiple targets to break negatively reinforcing cycles and support positive influences on safety for both clinicians and patients in the face of physical danger.

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Background: Healthcare providers, as well as healthcare students, have been found to harbor negative attitudes toward individuals with substance abuse disorders, impacting the care they give and subsequently creating poor patient outcomes.Purpose: This study seeks to determine the effectiveness of an educational intervention, grounded in theory, toward changing nursing student attitudes regarding patients with a substance abuse disorder. Methods: Nursing students participated in a teaching intervention, developed using the experiential learning theory, that utilizes modalities for each kind of learner aimed at reducing bias toward this population. The Medical Condition Regard Scale was used pre/post intervention to determine regard toward patients with the diagnosis of substance abuse. Results: Student nurses maintained the least favorable attitudes toward individuals who abuse substances in comparison with patients with the diagnoses of pneumonia or gastroesophageal reflux disease; there were significant differences in attitudes toward patients who abused substances before and after participation in the educational intervention, with postparticipation attitudes being significantly more positive than attitudes before participation. Students found the educational intervention and debriefing highly satisfactory. Implications: This educational intervention can provide a cost-effective, easy-to-replicate, time-efficient learning activity that could be added to undergraduate nursing curriculum.