Educational programs and interventions for health care staff to prevent and manage aggressive behaviors in acute hospitals: a systematic review
Authors: Kynoch Kathryn , Liu Xian-Liang , Cabilan C.J. , Ramis Mary-Anne 
Published: October 2023

Objective:
The objective of this review was to determine the effect of educational programs that have been implemented in acute health care settings to manage or prevent aggressive behaviors toward staff perpetrated by patients, families, and/or visitors.

Introduction:
Health care staff working within acute- and tertiary-level hospitals are at high risk of exposure to aggressive behaviors by patients, their family, and/or visitors. Negative staff and organizational impacts reported in the literature include individual psychological or emotional distress and severe harm, increased absenteeism, high staff turnover, and awarded compensation. Reports of this kind of occupational violence are increasing globally, therefore, strategies to address prevention and/or management are needed to mitigate the risk of harm to staff and the wider hospital service. Various educational activities have been implemented to address the issue, but the overall effect of these is unclear.

Inclusion criteria:
Experimental and quasi-experimental studies were considered for inclusion if they reported on an educational program or intervention for staff working within an acute hospital setting and aimed at managing or preventing occupational violence perpetrated by patients, family, or visitors. Reports of implemented programs to address occupational violence, whether verbal or physical, were included. Studies were excluded if they reported on lateral upward violence or bullying, patients in psychiatric or dementia facilities, and pediatric patients, due to the specific care needs of these cohorts.

Methods:
The following databases were searched: PubMed, CINAHL, PsycINFO, Embase, ERIC, Cochrane Controlled Trials, and Scopus. Unpublished studies were sought from ProQuest Dissertations and Theses. To obtain a wider perspective of the issue, studies published in Chinese were also searched for in WanFang Database, China National Knowledge Infrastructure, and Chongqing VIP. A date filter of 2008–2023 was applied in a deliberate effort to expand from previous work. No language filters were applied. The review was conducted in accordance with JBI methodology for systematic reviews of effectiveness and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analaysis (PRISMA) guidelines.

Results:
The search process retrieved 4681 citations with a total of 32 studies representing 3246 health staff. The studies were either before and after or pre-test-post-test study designs. Methodological quality of studies was varied, with the main issues being absence of CIs within statistical analysis, limited detail on participant selection or attrition/non-response, and under-reporting of confounding factors. Educational programs varied in content and duration. Content delivery across the studies also varied, with a variety of didactic, role play, debriefing, group work, and simulation exercises reported. While studies reported some improvement in self-reported confidence levels, results were mixed for other outcomes. Determining overall effect of included studies is challenging due to heterogeneity within and across studies in intervention types, populations, measurement tools, and outcomes.

Conclusions:
This review is unable to determine which workplace educational programs were most effective on staff outcomes or on the number of occupational violence incidents. In future, educators and researchers could use the findings of this review to guide the design of educational programs and employ measures that are comparable to their settings.

Review registration:
PROSPERO CRD42020190538.

Supplemental digital content:
A Chinese-language version of the abstract of this review is available [http://links.lww.com/SRX/A33].