Effectiveness of training on de-escalation of violence and management of aggressive behavior faced by health care providers in a public sector hospital of Karachi

Abstract

Background & Objective
Considering high burden of violence against healthcare workers in Pakistan APPNA Institute of Public Health developed a training to prevent reactive violence among healthcare providers. The purpose of this training was to equip healthcare providers with skills essential to control aggressive behaviors and prevent verbal and non-verbal violence in workplace settings. This study assesses the effectiveness of training in prevention, de-escalation and management of violence in healthcare settings.

Methods
A quasi-experimental study was conducted in October, 2016 using mixed method concurrent embedded design. The study assessed effectiveness of de-escalation trainings among health care providers working in emergency and gynecology and obstetrics departments of two teaching hospitals in Karachi. Quantitative assessment was done through structured interviews and qualitative through Focus Group Discussions. Healthcare providers` confidence in coping with patient aggression was also measured using a standard validated tool”.

Results
The overall self-perceived mean score of Confidence in Coping with Patient Aggression Instrument “(CCPAI)” scale was significantly higher in intervention group (Mean= 27.49, SD=3.53) as compared to control group (Mean= 23.92, SD=4.52) (p<0.001). No statistically significant difference was observed between intervention and control groups with regard to frequency of violence faced by HCPs post training and major perpetrators of violence..

Conclusion
De-escalation of violence training was effective in improving confidence of healthcare providers in coping with patient aggression.

Full text

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Pak J Med Sci March - April 2018 Vol. 34 No. 2 www.pjms.com.pk 1
INTRODUCTION
Violence against Health Care Providers (HCPs)
is a major problem in both developed and
developing countries. Fear of violence affects
the performance of HCPs and decreases their
responsiveness to healthcare needs of the patients
especially in emergency settings.1 Lack of security
may also decrease the condence of the patient
in availing services from the hospitals.2 While
the developed countries have made a signicant
progress in providing a safe work environment to
Correspondence:
Prof. Lubna Baig,
Pro-Vice Chancellor,
Dean APPNA Institute of Public Health,
Jinnah Sindh Medical University,
Karachi, Pakistan.
Email: lubna.shakil1983@gmail.com
* Received for Publication: December 19, 2017
* Revision Received: February 19, 2018
* Revision Accepted: February 25, 2018
Original Article
Effectiveness of training on de-escalation of violence
and management of aggressive behavior faced by
health care providers in public sector hospitals of Karachi
Lubna Baig1, Sana Tanzil2, Shiraz Shaikh3, Ibrahim Hashmi4,
Muhammad Arslan Khan5, Maciej Polkowski6
ABSTRACT
Background & Objective: Considering high burden of violence against healthcare workers in Pakistan
APPNA Institute of Public Health developed a training to prevent reactive violence among healthcare
providers. The purpose of this training was to equip healthcare providers with skills essential to control
aggressive behaviors and prevent verbal and non-verbal violence in workplace settings. This study assesses
the effectiveness of training in prevention, de-escalation and management of violence in healthcare
settings.
Methods: A quasi-experimental study was conducted in October, 2016 using mixed method concurrent
embedded design. The study assessed effectiveness of de-escalation trainings among health care providers
working in emergency and gynecology and obstetrics departments of two teaching hospitals in Karachi.
Quantitative assessment was done through structured interviews and qualitative through Focus Group
Discussions. Healthcare providers` condence in coping with patient aggression was also measured using
a standard validated tool”.
Results: The overall self-perceived mean score of Condence in Coping with Patient Aggression Instrument
“(CCPAI)” scale was signicantly higher in intervention group (Mean= 27.49, SD=3.53) as compared to
control group (Mean= 23.92, SD=4.52) (p<0.001). No statistically signicant difference was observed
between intervention and control groups with regard to frequency of violence faced by HCPs post training
and major perpetrators of violence.
Conclusion: De-escalation of violence training was effective in improving condence of healthcare
providers in coping with patient aggression.
KEYWORDS: De-escalation training and Health care provider, Violence.
doi: https://doi.org/--------------------------------------------
How to cite this:
Baig L, Tanzil S, Shaikh S, Hashmi I, Khan MA, Polkowski M. Effectiveness of training on de-escalation of violence and management
of aggressive behavior faced by health care providers in public sector hospitals of Karachi. Pak J Med Sci. 2018;34(2):---------.
doi: https://doi.org/ -------------------------------------------
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Pak J Med Sci March - April 2018 Vol. 34 No. 2 www.pjms.com.pk 2
Lubna Baig et al.
their health care providers, violence against health
care providers remains a signicant public health
problem in developing countries.3-5
Situation in Pakistan is dismal as hundreds of
HCPs have been killed in the last decade as a result
of terrorism, crime, sectarian divide and extremist
elements in the society.6 Previous studies have re-
ported that physical and verbal abuse of all kinds
is frequently experienced by HCPs working in ma-
jor public hospitals in Karachi, Pakistan.7,8 A recent
multicentre research conducted in Karachi reported
that around one third of all health care providers
had experienced some kind of violence in the past
12 months.9 The study identied immediate need of
effective interventions at various levels including
training of HCP’s to equip them with essential com-
munication skills, de-escalation of aggressive/vio-
lent behavior and management of Post Traumatic
Stress Disorder (PTSD) as a result of violence.
Evidence from various parts of the world supports
the effective role of trainings for de-escalation
of violence for HCPs. These trainings helped
in reducing impact and frequency of violence
and improved patient-providers` interactions in
healthcare settings.10-13 The ICRC and its team of
public health experts developed a training manual
for de-escalating aggressive behavior to prevent
violence against healthcare providers.
The content of the four hours de-escalation
training comprised of four modules which are:
1. Understanding Violence and Stress, (includes
information from baseline study regarding
burden and types of violence against healthcare
providers and major reasons of violence in
healthcare setting).
2. Escalation & De-escalation of violence (includes
techniques of de-escalation of aggressive
behavior using verbal & non-verbal techniques).
3. Management of Post-Traumatic Stress Disorder
(includes strategies for managing PTSD).
4. Patient-Communication Protocol (includes
techniques of active listening and empathic
communication, and methods of breaking bad
news in potentially violent situations).
Training included varied teaching methodologies
including brainstorming, videos based on scenarios
and role plays on doctor-patient interactions which
may potentially cause reactive violence. Master
trainers from AIPH conducted those trainings in
the public sector tertiary care hospital of Karachi
which were the intervention site.
This study aimed to assess the effectiveness of
training for prevention and de-escalation of violence
by HCP’s after four months. The ultimate aim was
to scale-up this intervention if results showed
better skills of the trained HCPs in de-escalation of
violence.
METHODS
This Quasi-experimental study using mixed
methods Concurrent Embedded design was
conducted in October, 2016. The study was conducted
among health care providers currently working in
Emergency, Gynecology & Obstetrics, Medicine
& Allied and Surgery and Allied departments of
two tertiary care teaching hospitals of Karachi. The
assessment was conducted simultaneously after four
months of de-escalation training at the intervention
hospital and a control hospital of similar scale where
trainings were not conducted.
The Quantitative assessment was done through
a structured questionnaire. Study participants for
intervention group were randomly selected from
a list of 147 healthcare providers (HCPs) who had
received des-escalation trainings at intervention
hospital while controls were selected from the
hospital where trainings were not conducted. The
HCPs at intervention hospital that were not working
at the time of data collection were excluded from the
study. With an assumption of overall 20% reduction
in the frequency of violence faced by all trained
healthcare providers in intervention group as
compared to control arm at 5% level of signicance
and a power of 80% the minimum sample size of
154 was obtained i.e. 77 in each group.
Participants from each study site were selected
using non-probability convenience sampling tech-
nique. For control arm, healthcare providers from
emergency and other departments who had been
working in these settings for at least past four
months were approached. Data was collected by
trained data collectors using structured question-
naire to collect information regarding frequency,
types and reasons of violence in control and inter-
vention groups. Condence levels of HCPs in deal-
ing with agitated patients was measured using a
tool adapted from “Condence in Coping with Pa-
tient Aggression Instrument “(CCPAI)” scale.14
Data was analyzed using SPSS version 20.
Descriptive statistics are reported as frequencies and
percentages. The intervention and control group
ware compared to identify possible differences
in their demographics, frequency of violence
experienced and aggregate CCPAI scale scores
using Chi-Square Test for categorical variables and
Independent T-test for quantitative variables.

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For Qualitative study two Focus Group
Discussions (FGDs) at each site (total of four FGDs)
were conducted with doctors and nurses working
in emergency and other relevant departments by
authors of this paper. Each FGD was recorded
and transcribed in Urdu and later translated into
English. The data was analyzed using thematic
content analysis. Both ‘manifest content’ (visible,
obvious components) and ‘latent content’
(underlying meaning) of the text was analyzed.
RESULTS
Quantitative data was collected from 141 HCPs
including: 71 from intervention and 70 from control
hospital. The FGDs included a total of 30 partici-
pants (14 in intervention and 16 in control arm).
The study participants in intervention and control
hospitals were comparable as no statistically
signicant differences were found between them
for socio-demographic variables. The departmental
afliations varied signicantly (p ;< 0.05) (Table-I).
There were no statistically signicant differences
regarding frequency of experiencing or witnessing
any kind of violence at work and types of major
perpetrators of violence in the last four months..
The healthcare providers of the intervention
hospital had higher average scores on CCPAI scale
(Mean=27.49, SD=3.53) as compared to control
(Mean=23.92, SD=4.52) (p<0.001) (Table-II).
The proportion of self perceived condence was
signicantly higher for eight out of ten items in
intervention group that received training on de-
escalation of violence as compared to control (Fig.1).
For qualitative data analysis coding of transcripts
was done by two independent researchers and
consensus was reached on three themes including
recall of training content, positive experiences and
recommendations.
HCPs in intervention group were able to recall
contents from training modules mainly related
to communication and de-escalation; however
majority was not able to recall strategies for
management of Post Traumatic Stress Disorder
(PTSD). When asked about PTSD module, HCP’s
Table-I: Demographic and occupational characteristics
of the study participants in Intervention
and Control groups.
Variable Intervention
(n=71)
Control
(n=70)
P
value
Age Mean (SD) 27.34 (6.17) 29.86 (8.55) 0.173
Gender
Male
Female
25 (35.2%)
46 (64.8%)
24 (34.3%)
46 (65.7%) 0.908
Current Position
Doctor
Nurse
Medical Student
50 (70.4%)
11 (15.5%)
10 (14.1)
54 (77.1%)
14 (20.0%)
2 (2.9%)
0.054
Department
Emergency
Gynecology &
Obstetrics
Medicine &
Allied
Surgery & Allied
21 (29.6%)
8 (11.3%)
10 (14.1%)
34 (48.6%)
19 (27.1%)
6 (8.6%)
34 (48.6%)
11 (15.7%) <0.001
Years of work experience
<1 yrs
1-5 yrs
>5 yrs
39 (54.9%)
19 (26.8%)
13 (18.3%)
32 (45.7%)
18 (25.7%)
20 (28.6%) 0.334
Table-II: Frequency of violence experienced
or witnessed by healthcare providers in
intervention and control groups.
Variable Intervention
(n=71)
Control
(n=70) p-value
Experienced
violence 17 (23.9%) 17 (24. 3%) 0.962
Witnessed
violence 31 (43.7%) 36 (51.4%) 0.356
None 28 (39.4%) 27 (38.6%) 0.916
No. of Times
violence was
faced by
those who
experienced
it: Mean (SD)
n=17
2.3 (1.16)
n=17
3.00 (1.83) 0.229
Perpetrator
Attendant
Patient
n=43
42 (97.7%)
1 (2. 3)
n=43
42 (97.7%)
1 (2. 3)
1.00
Fig.1: Comparison of individual items of CCPAI
scale between intervention and control groups.
Training on de-escalation of violence & management of aggressive behavior

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at intervention hospital said, i) “Nobody has
experienced this kind of disorder; perhaps we have
not applied it that is why we have forgotten it”, ii)
“We get over stress very quickly realizing that some
form of violence is inevitable in our eld.”
HCPs at the intervention group acknowledged
that training helped them control their temperament
in a challenging environment and also enabled
them to effectively practice active listening and
empathy. One of the HCP mentioned that, “I learnt
how to respond to different behaviors of patients
and maintain composure”. They also felt that their
counseling practices have improved and they felt
more condent communicating with patients and
avoid lengthy altercation and possible violence.
The control group said that they lack condence
in dealing with aggression, one HCP said, “Running
away is the best option”. HCPs in control group
managed aggression and violence by applying self
learnt strategies including counseling of patient,
maintaining silence when abused, and agreeing
with perpetrators to control violence. HCP’s, in
control group strongly emphasized the need of
training for coping with aggression and violence
at work (Table-III). The training topics and needs
identied by HCPs in control group were similar
to the content covered through des-escalation
trainings conducted.
Suggestions from intervention and control group:
1. The participants from both groups strongly
recommended that de-escalation trainings must
be institutionalized and included as part of
medical and nursing curricula at undergraduate
level.
2. The participants from both groups also
recommended periodic refreshers for HCPs in
practice.
3. Both groups suggested that training should
be conducted in short sessions of one or two
hours as attending a four hours are difcult to
manage within their busy work schedules.
4. HCPs in both groups also emphasized the
need of raising public awareness on respecting
HCPs a doctor said: “Denitely communication
by healthcare provider matters a lot but equally
important is societal behavior towards healthcare
providers”
DISCUSSION
This is the rst study of its kind in Pakistan which
attempted to assess the effectiveness of trainings for
de-escalating and managing violence in healthcare
settings. We found that HCPs in intervention group
had higher perceived condence levels and coping
skills to deal with aggression when compared with
the control group. We did not nd any statistically
signicant differences in the frequency of patient
aggression faced by HCPs in intervention and
control groups. These nding are consistent with
ndings reported by a systemic review published
in 2015 which included studies published between
January 2000 and September 2011. The systematic
Review of 9 studies reported improved condence
levels and coping skills to deal with aggression
among HCPs who received des-escalation of
violence trainings but no change in frequency of
patient aggression incidents.12 The reduction in the
incidence of aggression and violence in healthcare
settings requires multipronged strategies in
addition to training for de-escalation of violence.
These strategies should include improved secure
working conditions for the HCPs, media awareness
campaigns regarding respect for HCPs, legal
protection to HCPs and above all increasing literacy
level of general public.15-17
We found that HCPs in intervention group
acknowledged that de-escalation training had
improved their attitude and temperament towards
aggression expressed by patients and their
attendants. These ndings are consistent with
studies conducted by Grenyer and Collins.18,19 In
the Grenyer study statistically signicant increase
was observed in understanding of aggression and
violence management strategies among the HCPs’
after attending violence management training.18
This study also found increase in condence.18 In
the evaluation study by Collins` of Prevention and
Management of Aggressive Behaviour Programme
it was found that training had a positive effect on
nurses attitude.19
Our results are also congruent with the study
conducted in Stockholm, Sweden, which showed
that violence prevention and management training
can inuence the HCPs attitude and can improve
work place environment in healthcare settings.20
We found that HCPs who had received de-
escalation of violence training could recall most
of the training content except the training related
to PTSD. This in our opinion could be due to the
perceived usefulness of training and that they may
have used some of the strategies suggested in the
training for de-escalation of violence. This could
also explain why PTSD training module was not
recalled as it may not have been utilized as much.
The study participants suggested multipronged
approaches to reduce incidence of violence in
healthcare settings. HCPs from intervention and
control groups suggested similar interventions in-
Lubna Baig et al.

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Table-III: Perceptions and Practices of health care providers regarding management of violence.
Intervention Control
FGD1 Gynae FGD 2 ER FGD1 Gynae FGD 4 ER
Recall of
training
Content
-How to control and
balance temperament
-How to respond to
aggressive behavior
-Right way to counsel
patients
-How to calm down an
aggressive patient
-How to identify likely
violence and deal with it
-Talk less and
communicate with one
person only
-Listen carefully to
patients/attendants and
try to understand what
they said
Not applicable
Positive
Experiences
-Dealt aggression by
listening to patients/
attendants and
explaining the process
of care
-Helped a patient in
getting prompt care
-Made patients
understand the course
of disease to help them
cope with it
-Explained the situation
beforehand
-Tried to calm down
attendants and talk to
immediate relative
-Didn’t react to anger:
stayed quiet and then
explain
Training
Needs Not applicable
-How to communicate
bad news
-How to deal with
aggression
- How to counsel a
patient/attendant
-How to
Communicate with
senior staff
-Stepwise approach to
breaking bad news
-Dealing aggression
-How to communicate
the progress of serious
patients
-How to remain polite
while interacting with
angry attendants
Recomm-
endations
-Should be mandatory
before House Job and
included in medical
curriculum
-Refreshers every 6
months-1year
-Should be divided into
two sessions
-Should be
contextualized for
different settings and
different levels of
people
-More scenarios should
be added
-Should be included in
Nursing Curricula
-Refreshers should be
done
-Timing should be
exible
N/A
Trainings should
be given at
undergraduate level
-Trainings should
comprise of real life
scenarios
-Training material
should be realistic
and correlate with the
environment and type
of situation
-Duration should be
two hours
Training on de-escalation of violence & management of aggressive behavior

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Pak J Med Sci March - April 2018 Vol. 34 No. 2 www.pjms.com.pk 6
Authors:
1. Prof. Dr. Lubna Baig, MBBS, MPH, MMEd FCPS, PhD.
2. Dr. Sana Tanzil, MBBS, FCPS.
3. Dr. Shiraz Shaikh, MBBS, FCPS.
4. Dr. Ibrahim Hashmi, MBBS.
5. Dr. Muhammad Arslan Khan, MBBS.
Aga Khan University, Karachi, Pakistan.
6. Mr. Maciej Polkowski, MA.
International Committee of Red Cross, Islamabad, Pakistan.
1-4: APPNA Institute of Public Health,
Jinnah Sind Medical University, Karachi, Pakistan.
cluding raising awareness regarding respect for
HCPs, incorporation of violence prevention train-
ings in medical and nursing curricula at undergrad-
uate level and refresher trainings for trained HCPs.
These ndings are in concordance with the studies
done by Oostrom & Mierlo, and Lehmann et al.10,21
The study participants also recommended
regular refresher courses to maintain learning for
HCPs already in practice. These recommendations
are consistent with the suggestion of HCPs in
previously conducted studies.22-24
Limitations of the Study: the scale of this study is
limited to comparison of two tertiary care hospitals
of Karachi which may not be a representative
sample of all HCPs in Karachi.
CONCLUSION
De-escalation training was found effective in
improving condence of healthcare providers in
coping with patient aggression. There is a need
to upscale and institutionalize de-escalation of
violence trainings for HCPs.
Ethical approval: Ethical approval for this study
was obtained from Institutional Review Board
(IRB) of Jinnah Sindh Medical University and Dow
University of Health Sciences. Informed consent was
obtained before each interview and condentiality
of participants was ensured.
Grant Support & Financial Disclosures: This
research and the training manual were funded by
International Committee of Red Cross (ICRC).
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Author`s Contribution: LB: Conceived the idea, designed
the study and the de-escalation of violence training
manual, and did nal edits on the manuscript. ST:
Participated in coding and analysis and wrote the rst
draft of manuscript. SS: Participated in coding and
statistical analysis, did the training on de-escalation
of violence and wrote the methodology section of the
manuscript. IH: Participated in data collection, coding
and data analysis, also wrote the introduction section
of the manuscript. MAK: Participated in data collection,
training on de-escalation of violence, coding and wrote
the results section. MP: Participated in conceptualizing
the project and edited the last draft.
Lubna Baig et al.