Objectives: The primary objective of this study was to evaluate the effectiveness of a half day training on de-escalation of violence against healthcare personnel regarding prevention and management of violence incidents versus a similar tertiary level hospital with no such training. Secondary objectives were to compare the overall satisfaction, burnout, fear of violence, and confidence in coping with patients’ aggression of the healthcare personnel in the two hospitals.

Design: Mixed method design, with a comparative cross sectional (quantitative) and Focus Group Discussions (qualitative) components.

Setting: Emergency departments of the two tertiary care hospitals in district Peshawar over six months starting in May 2018.

Participants: Healthcare personnel in the emergency departments of the two hospitals (trained vs untrained).

Outcome measures: Violence exposure (experienced/witnessed) assessed through a previously validated tool in the past 5 months. Burnout, confidence in coping with patient aggression and overall job satisfaction was also assessed through validated tools. The qualitative component explored the perceptions of healthcare personnel regarding the management of violence and the importance of training on de-escalation of violence through Focus Group Discussions (FGDs) in the two hospitals.

Results: The demographic characteristics of the healthcare personnel within the two hospitals were quite similar. The de-escalation training did not lead to a reduction in the incidences of violence, however confidence in coping with patient aggression and the overall satisfaction was significantly improved in the intervention hospital. The de-escalation training was lauded by the respondents as led to an improvement in communication skills, and the healthcare personnel suggested for scale-up to all the cadres and hospitals.

Conclusion: The study found significant improvements in the confidence of healthcare personnel in coping with patient aggression, along with better job satisfaction and less burnout in the intervention hospital following the de-escalation training.

Violence: Violence was assessed through a previously used questionnaire by ICRC in a study in Karachi (12,19). This tool had been developed by the Joint Programme on Workplace Violence in the Health Sector of the International Labour Office, the International Council of Nurses, the World Health Organization, and the Public Services International (20). Violence was defined as any individual or group`s aggressive behavior or exercise of power, which is socially non-acceptable, turbulent, and often destructive. Mainly the violence was assessed through whether the respondent had experienced/witnessed any form of violence in the past five months. Physical violence was defined as the use of “physical force against another person that results in physical, sexual, or psychological harm and includes beating, kicking, slapping, stabbing, shooting, pushing, biting and pinching, among others. Verbal violence was defined as “bullying, mobbing, harassment, and verbal abuse that humiliates, degrades or otherwise indicates a lack of respect for the dignity and worth of an individual.

Confidence in Coping with Patient Aggression: Confidence levels of healthcare personnel in dealing with agitated patients were also measured using a scale adapted from “Confidence in Coping with Patient Aggression Instrument “(CCPAI)” scale.  The scale has been previously validated with strong internal consistency (Cronbach’s alpha= 0.92) and comprises of ten items measured on a Likert scale with a total score of 40 (21). Each question has a Likert scale response from 1 (very uncomfortable) to 4 (very comfortable). Therefore, the higher the score, the better the confidence of the healthcare personnel in dealing with the patient aggression. 

Burnout: Patients and relatives’ aggression/violence towards healthcare personnel could lead to exhaustion and burnout in the healthcare personnel. Therefore work-related burnout was an important aspect to be included in the current research study and was defined as “a state of prolonged physical and psychological exhaustion, which is perceived as related to the person’s work” (22). Burnout scale, comprising eight questions having a total score of 40, was used to assess burnout among healthcare personnel. Each question has a Likert scale response from 1 “never seldom or to a meager degree” to 5 “always or to a very high degree. Therefore, the higher the score the more the burnout experienced by the respondent. The overall burnout was obtained by adding all the responses, and participants having a score of 20 or above were categorized as having a burnout.  

Fear: For the current study, fear was defined as the concern that one might experience some form of violence (physical or verbal violence) while working as healthcare personnel in the emergency department. This was measured by adapting the tool used in previous research (23). The responses were from strongly disagree to strongly agree regarding fear of physical or verbal violence. 

Job satisfaction: Job satisfaction was assessed through a single question as “on the whole, how satisfied are you with your present job. The responses were from very dissatisfied to very satisfied. 

.sav file can be opened in SPSS