What is aggressive behavior?
The International Labour Organization uses the term "workplace violence" defined as "any action, incident or behaviour that departures from reasonable conduct in which a person is threatened, harmed, injured in the course of, or as a direct result of, his or her work". Experiencing aggressive behavior at work can affect people's ability to do their job well, can cause physical and mental health problems, and can also affect home life. Aggressive behavior may lead to absences from work; some people might leave their job if they experience aggressive behavior.
Why we did this Cochrane Review
Aggressive behavior exhibited by patients and their families, friends, and carers is a serious problem for healthcare workers. It may affect the quality and safety of the care that healthcare workers can provide.
Education and training programs have been developed to try to reduce—or eliminate—aggressive behavior at work. These programs are intended to teach and train healthcare workers about:
• their organization's policies and procedures;
• how to assess risks; and
• strategies to control or reduce the chances—and effects—of experiencing aggressive behavior.
What did we do?
We searched for studies that investigated how well education and training programs prevented or reduced aggression toward healthcare workers.
We included randomized controlled studies, in which the programs that people received were decided at random and studies in which effects of a program were measured before and after among people who completed the program and in another group of people who did not take part.
We wanted to know if education and training programs could:
• reduce the number of incidents of aggressive behavior in healthcare workplaces;
• improve healthcare workers' knowledge, skills, and attitudes toward aggressive behavior; and
• reduce any personal adverse (unwanted or negative) effects noted among healthcare workers who experienced aggressive behavior.
Search date: we included evidence published up to June 2020.
What we found
We found nine studies including 1688 healthcare workers (including healthcare support staff, such as receptionists) who worked with patients and patients' families, friends, and carers. These studies compared the effects of receiving an education and training program to the effects of not receiving such a program.
Studies were conducted in hospitals or healthcare centers (four studies), in psychiatric wards (two studies), and in long-term care centers (three studies) in the United States, Switzerland, the United Kingdom, Sweden, and Taiwan.
All programs combined education with training provided either online (four studies) or face-to-face (five studies). In eight studies, the people taking part were followed for up to three months (short-term), and in one study for over one year (long-term).
What are the results of our review?
Education and training programs did not reduce the number of reports of aggressive behavior toward healthcare workers (five studies), possibly because these programs made healthcare workers more likely to report these incidents.
An education and training program might improve healthcare workers’ knowledge of aggressive behavior in the workplace in the short term (one study), but we are uncertain whether this would be a long-term effect (one study).
Education programs might improve healthcare workers' attitudes toward aggressive behavior in the short term (five studies), although these results varied depending on the type and length of the program provided.
Education programs might not affect healthcare workers' skills in dealing with aggressive behavior (two studies) and might not affect whether unwanted or negative personal effects were noted after healthcare workers experienced aggressive behavior (one study).
How reliable are these results?
We are not confident in the results of our review because these results were reported from a small number of studies—some with small numbers of participants—and because some studies showed large differences in results. We identified problems involving the ways some studies were designed, conducted, and reported. Our results are likely to change if further evidence should become available.
Key message
Although an education and training program might increase healthcare workers' knowledge and positive attitudes, such a program might not affect the number of incidents of aggressive behavior that healthcare workers experience.
More studies are needed, particularly in healthcare workplaces with high rates of aggressive behavior.
Education combined with training may not have an effect on workplace aggression directed toward healthcare workers, even though education and training may increase personal knowledge and positive attitudes. Better quality studies that focus on specific settings of healthcare work where exposure to patient aggression is high are needed. Moreover, as most studies have assessed episodes of aggression toward nurses, future studies should include other types of healthcare workers who are also victims of aggression in the same settings, such as orderlies (healthcare assistants). Studies should especially use reports of aggression at an institutional level and should rely on multi-source data while relying on validated measures. Studies should also include days lost to sick leave and employee turnover and should measure outcomes at one-year follow-up. Studies should specify the duration and type of delivery of education and should use an active comparison to prevent raising awareness and reporting in the intervention group only.
Workplace aggression constitutes a serious issue for healthcare workers and organizations. Aggression is tied to physical and mental health issues at an individual level, as well as to absenteeism, decreased productivity or quality of work, and high employee turnover rates at an organizational level. To counteract these negative impacts, organizations have used a variety of interventions, including education and training, to provide workers with the knowledge and skills needed to prevent aggression.
To assess the effectiveness of education and training interventions that aim to prevent and minimize workplace aggression directed toward healthcare workers by patients and patient advocates.
CENTRAL, MEDLINE, Embase, six other databases and five trial registers were searched from their inception to June 2020 together with reference checking, citation searching and contact with study authors to identify additional studies.
Randomized controlled trials (RCTs), cluster-randomized controlled trials (CRCTs), and controlled before and after studies (CBAs) that investigated the effectiveness of education and training interventions targeting aggression prevention for healthcare workers.
Four review authors evaluated and selected the studies resulting from the search. We used standard methodological procedures expected by Cochrane. We assessed the certainty of evidence using the GRADE approach.
We included nine studies—four CRCTs, three RCTs, and two CBAs—with a total of 1688 participants. Five studies reported episodes of aggression, and six studies reported secondary outcomes. Seven studies were conducted among nurses or nurse aides, and two studies among healthcare workers in general. Three studies took place in long-term care, two in the psychiatric ward, and four in hospitals or health centers. Studies were reported from the United States, Switzerland, the United Kingdom, Taiwan, and Sweden.
All included studies reported on education combined with training interventions. Four studies evaluated online programs, and five evaluated face-to-face programs. Five studies were of long duration (up to 52 weeks), and four studies were of short duration. Eight studies had short-term follow-up (< 3 months), and one study long-term follow-up (> 1 year). Seven studies were rated as being at "high" risk of bias in multiple domains, and all had "unclear" risk of bias in a single domain or in multiple domains.
Effects on aggression
Short-term follow-up
The evidence is very uncertain about effects of education and training on aggression at short-term follow-up compared to no intervention (standardized mean difference [SMD] -0.33, 95% confidence interval [CI] -1.27 to 0.61, 2 CRCTs; risk ratio [RR] 2.30, 95% CI 0.97 to 5.42, 1 CBA; SMD -1.24, 95% CI -2.16 to -0.33, 1 CBA; very low-certainty evidence).
Long-term follow-up
Education may not reduce aggression compared to no intervention in the long term (RR 1.14, 95% CI 0.95 to 1.37, 1 CRCT; low-certainty evidence).
Effects on knowledge, attitudes, skills, and adverse outcomes
Education may increase personal knowledge about workplace aggression at short-term follow-up (SMD 0.86, 95% CI 0.34 to 1.38, 1 RCT; low-certainty evidence). The evidence is very uncertain about effects of education on personal knowledge in the long term (RR 1.26, 95% CI 0.90 to 1.75, 1 RCT; very low-certainty evidence). Education may improve attitudes among healthcare workers at short-term follow-up, but the evidence is very uncertain (SMD 0.59, 95% CI 0.24 to 0.94, 2 CRCTs and 3 RCTs; very low-certainty evidence). The type and duration of interventions resulted in different sizes of effects. Education may not have an effect on skills related to workplace aggression (SMD 0.21, 95% CI -0.07 to 0.49, 1 RCT and 1 CRCT; very low-certainty evidence) nor on adverse personal outcomes, but the evidence is very uncertain (SMD -0.31, 95% CI -1.02 to 0.40, 1 RCT; very low-certainty evidence).
Measurements of these concepts showed high heterogeneity.