A qualitative system dynamics model for effects of workplace violence and clinician burnout on agitation management in the emergency department

Abstract

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.

Gender Differences for the Prevalence and Risk Factors of Workplace Violence Among Healthcare Professionals in Shandong, China

“…As we know, in Chinese families and traditional culture, men should take more responsibility in their families than women, and this makes them may care about their income. In this situation, a lower income level may result from a higher level of job burnout ( 53 ), which is also a risk factor for WPV ( 54 , 55 ). For male managers, they need to deal with more problems about WPV than females in their hospitals or departments because of the culture of female protection, which makes them at higher risk of WPV.…”

Emergency Department Restraint Safety

“…Due to this wide range of studies, the proper time to use restraints, the most effective types of restraints, and the proper management of agitated patients is an area of continual research. However, a troubling trend is present upon review of restraint literature -patient aggression in the healthcare sector is increasing [2,[7][8][9][10][11][12][13].…”

“…An increase in patient aggression is correlated with increased staff turnover and increased "burnout" in EDs [2,8]. When evaluating United States ED visits, agitation incidence was reported at 2.6% of all visits [14].…”

Violence against healthcare workers at the Emergency Department

“…Various responses to workplace violence can either contribute to or reduce the chance of clinician burnout. In a balancing feedback loop, the use of restraints appears to decrease agitation and the risk of assault, which leads to a perception of safety, which in turn reduces the use of restraints [8]. Mutual trust between clinicians also leads to a perception of safety which reduces stress.…”