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A workplace violence educational program: A repeated measures study Gordon L. Gillespie a,*, Sharon L. Farra b,1, Donna M. Gates a,2 aCollege of Nursing, University of Cincinnati, P.O. Box 210038, Cincinnati, OH 45221-0038, United StatesbDepartment of Nursing, Wright State University, University Hall 160, 3640 Colonel Glenn Hwy, Dayton, OH 45435, United States article info Article history:

Accepted 30 April 2014 Keywords:

Hybrid education Intervention Online learning Tabletop Web-based survey abstract Violence against healthcare employees is a profound problem in the emergency department worldwide.

One strategy to reduce the risk of violence is prevention focused education. The purpose of this paper was to report the learning outcomes of a workplace violence educational prevention program tailored to the needs of emergency department employees. A quasi-experimental design was used to determine the knowledge retention of program content following a hybrid (online and classroom) educational inter- vention. One hundred twenty emergency department employees that completed the workplace violence prevention program participated in the study. A repeated-measures analysis of variance was conducted to determine if individual test scores increased signiﬁcantly between baseline, posttest, and six month posttest periods. The results indicated a signiﬁcant time effect, Wilk’sL¼.390,F(2, 118)¼26.554, p<.001, h2¼.310. Follow-up polynomial contrasts indicated a signiﬁcant linear effect with means increasing over time,F(1, 119)¼53.454,p<.001, h2¼.310, while individual test scores became signiﬁcantly higher over time. It was concluded that the use of a hybrid modality increases the proba- bility that signiﬁcant learning outcomes and retention will be achieved.

2014 Elsevier Ltd. All rights reserved. Introduction Violence against healthcare employees is a profound problem in the emergency department setting worldwide (Albashtawy, 2013; Estryn-Behar et al., 2008; International Labour Organization, In- ternational Council of Nurses, World Health Organization, & Public Services International, 2002; Knowles et al., 2013).Kowalenko et al.

(2013)reported that on average an emergency department employee will experience 4.017 physical threats and 1.510 assaults per year. A primary prevention strategy, often recommended for preventing workplace violence (i.e., verbal abuse, threats, and as- saults) from patients and visitors, is educational programming (Beech, 2008; Gates et al., 2011a,b; Gillespie et al., 2010; Hardin, 2012; Kowalenko et al., 2012; Nau et al., 2009). Before violence education becomes the mainstay of a comprehensive violence management program, it is important to determine if employees’ knowledge increases from the educational content. The purpose ofthis paper was to report the learning outcomes of a workplace violence educational prevention program tailored to the needs of emergency department employees.

Background The authors found few descriptions of workplace violence educational programs in the peer-reviewed literature. Two exem- plars of workplace violence educational programs were presented byHartley et al. (2012)andGillespie et al. (2012). The following paragraphs provide a brief overview of each program.Hartley et al.

(2012)detailed an online violence program designed for healthcare employees. The program was described as a“mix of text, videos, and graphics to create an interactive learning experience”(Hartley et al., 2012, p.203). Because the authors did not provide program evaluation data for their program it was not possible to determine the degree to which employees learned the program content.

Gillespie et al. (2012)conducted a quasi-experimental study comparing two educational treatment strategies: (1) online content and (2) online and classroom-based content. The researchers found that both groups had a signiﬁcant increase in their learning of the violence program content. It was not reported if the emergency department employees were able to retain the new knowledge over time.

* Corresponding author. Tel.:þ1 513 558 5236.

E-mail addresses:[email protected](G.L. Gillespie),sharon.farra@wright.

edu(S.L. Farra),[email protected](D.M. Gates).

1Tel.:þ1 937 775 2519.2Tel.:þ1 513 558 5500. Contents lists available atScienceDirect Nurse Education in Practice journal homepage: www.elsevier.com/nepr http://dx.doi.org/10.1016/j.nepr.2014.04.003 1471-5953/ 2014 Elsevier Ltd. All rights reserved. Nurse Education in Practice 14 (2014) 468e472 There remains few reported workplace violence programs in the literature (Kynoch et al., 2011). The programs available pro- vided evidence that short-term knowledge attainment occurs (Kynoch et al., 2011); however, there was a gap pertaining to the long term retention of violence program education. It was there- fore important to determine if workplace violence program con- tent could be maintained for a longer period of time (e.g., six months). If emergency department employees are not able to retain program content for extended periods of time, program content is not likely to affect a signiﬁcant reduction in an inci- dence rate for workplace violence. This paper begins toﬁll the scientiﬁc gap by reporting the knowledge attainment (immediate posttest) and retention (six month posttest) of a workplace violence educational program delivered to emergency department employees.

Methods Design A quasi-experimental design was used to determine the knowledge retention of program content following a hybrid educational intervention. The hybrid modality included both online and classroom components. The researchers hypothesized that there would be a signiﬁcant increase in learning retention for employees who completed the hybrid educational intervention as measured by program test scores. Institutional Review Board approval was granted from the University of Cincinnati and the two partnering hospital organizations.

Setting and sample Participants were recruited from the emergency departments of two separate healthcare systems in the Midwest United States. One system was a pediatric specialty system with two emergency de- partments, one community based and the other a Level 1 pediatric trauma center. The other system was a university-afﬁliated, teaching system with a Level 1 adult/pediatric trauma center and emergency department.

The only inclusion criterion was that participants complete all components of the hybrid education offered to the employees during summer 2011. Eligible participants were nurses, social workers, child life specialists, and unlicensed assistive personnel (seeFig. 1for attrition information). Completing the hybrid edu- cation was a requirement of the pediatric health system’s new workplace violence policy and not speciﬁc to this study. Approxi- mately 83% (n¼197) of 238 employees from the two pediatric emergency departments completed the training. Completing the hybrid education at the adult/pediatric system was required for members of the emergency department’s core workplace violence team and optional for all other employees. Approximately 19% (n¼30) of 156 employees from the adult/pediatric emergency department participated.

Power analysis A post hoc power calculation was determined using G*Power 3.0 (Faul et al., 2007). Given effect size .310, a¼.05, sample size 120, and three measurements per participant, our study yielded sufﬁ- cient power (>95%) to conduct the planned data analyses.

Workplace violence program Employees received a revised iteration of a hybrid educational program with online and classroom components designed toinform emergency department employees about workplace violence by patients and visitors. Theﬁrst component included three asynchronous online modules completed during June and July 2011. Module 1 focused on workplace violence prevention and included topics such as environmental safety, risk assessment, and communicating effectively with patients and visitors. Module 2 focused on safely managing workplace violence through a coordi- nated team approach. Module 3 focused on the post-incident response and included topics such as incident reporting and car- ing for victimized workers. Prior to starting Module 1, employees were prompted to complete a 20 question pretest on workplace violence. After completing Module 3, employees were prompted to complete a 20 question posttest on workplace violence. Questions were identical for the pretest and posttest. The answers were not given to participants. Employees were able to complete the training over multiple sittings with the program resuming where the employee last left the training.

The second component was an interactive two-hour classroom- based tabletop exercise during August/September 2011. For this component, employees watched a series of video vignettes depicting patient and visitor violence in the emergency depart- ment. This component prompted employees to discuss, apply, and collaborate with their interprofessional colleagues on how to best manage the incident of workplace violence depicted in each video vignette. Fig. 1.Attrition chart. G.L. Gillespie et al. / Nurse Education in Practice 14 (2014) 468e472469 Instrumentation The study instrument was a 20 question workplace violence test plus short demographic questionnaire. The test questions were developed to measure knowledge in preventing, managing, and reporting incidents of workplace violence. Test development con- sisted of initial item development by violence and education ex- perts. The items were then reviewed by a panel of violence experts and revised based on their feedback. Questions were leveled to test participants at multiple levels within Bloom’s taxonomy of educa- tional objectives (Bloom et al., 1956). Examples of test questions are presented inTable 1.

Procedures During May 2011, all employees from the partnering emergency departments were administratively enrolled into a learning man- agement system (LMS) for the workplace violence educational program using theﬁelds ofﬁrst name, last name, occupation, study site, and employee email address. Information for the demographic ﬁelds was provided by the emergency department administrators after securing Institutional Review Board approvals.

Beginning June 1, 2011, notiﬁcations that the LMS was ready for employees to complete the training were initiated by the emer- gency department educators and automated from the LMS. Edu- cators were provided weekly Microsoft Access (Redmond, WA) database reports of employee progression for the online training.

The LMS closed on July 31, 2011.

Next, employees signed up for a classroom-based tabletop ex- ercise. Dates and times of the sessions were determined by the emergency department educators and were scheduled to accom- modate day shift, evening shift, and night shift employees. All sessions were led by the study’s principal investigator and/or two trained department educators for consistency in program delivery.

Weekly Microsoft Access database reports were emailed to the emergency department educators to monitor employees’ progression.

From November 2011 to February 2012, the sample was recruited and signed informed consent documentation for studyparticipation. Study consent included a provision to allow the pretest and posttest data completed during their workplace violence training to be used as research data for analysis in this study.

Enrolled participants were emailed a link to complete a 6- month posttest during March 2012. The email and posttest link were automated from the LMS and were distributed weekly for three weeks. Twenty participants did not access the 6-month posttest and three participants started, but did notﬁnish the 6- month posttest indicating their withdrawal from the study. The data from participants who withdrew were not used in the analyses.

After data collection was closed, the pretest (Time 1), posttest (Time 2), and 6-month posttest (Time 3) data were extracted from the LMS and imported into IBM SPSS Statistics 21 (Armonk, NY). All identiﬁers (i.e.,ﬁrst name, last name, email address) were removed from the database leaving only non-identiﬁable demographic var- iables in the database prior to analysis.

Data analysis The study sample was described with means and ranges for in- terval data and frequencies and percentages for nominal and ordinal data. Test scores for Time 1, Time 2, and Time 3 were reported as means. A repeated-measures analysis of variance (ANOVA) using the Wilk’sLstatistic was conducted to determine if individual test scores changed signiﬁcantly between Time 1, Time 2, and Time 3.

The Wilk’sLstatistic is used to assess changes within subjects with a repeated measures study design. Alpha was set at .05.

Results One hundred twenty employees completed the study pro- cedures. The majority was female (n¼ 104, 86.7%), white (n¼11 2 , 93.3%), and a registered nurse (n¼86, 71.7%). SeeTable 2for additional demographic data. The mean test score at Time 1 was 58.5% (range 25e85%), Time 2 was 61.8% (range 25e85%), and Time 3 was 66.8% (range 40e90%). SeeFig. 2for the boxplot distributions Table 1 Sample workplace violence program test questions. Correct responses are identiﬁed by underlined text.

Question Answer options What is the emergency department worker’sﬁrst priority when dealing with an escalating patient?a. Resolve the situation as quickly as possible.

b. Remove the patient from the emergency department.

c. Increase your distance from the patient .

d. Immediately call the police department.

What should the emergency department worker say or do when a patient shows signs of increasing escalation (e.g., derogatory name calling, cursing) and additional help is needed from the coworkers standing nearby?a. Use aﬁrm voice and say,“Call security!” b. Look at the patient and say, “You will not talk to me like that.” c. Document the event in the medical record.

d. Use a hand gesture to indicate help is needed .

The physician informed the mother of a two-year-old critically ill patient that test results indicate the patient may have cancer. The mother becomes verbally and physically violent. After the violence stops, what intervention should be performedﬁrst?a. Evict the mother from the emergency department, b. Tell your coworkers about the violent event .

c. Complete an incident/safety event report.

d. Expedite the patient’s admission to the pediatric ICU. Table 2 Demographic characteristics of the study sample (n¼120).

N% Sex Female 104 86.7% Male 16 13.3% Race White 112 93.3% Black/Other 8 6.7% Ethnicity Hispanic 2 1.8% Non-Hispanic 110 98.2% Educational attainment High school 1 .8% Some college 16 13.3% Associate degree 26 21.7% Bachelor’s degree 69 57.5% Master’s degree 8 6.7% Primary work shift Day shift 49 40.8% Evening shift 35 29.2% Night shift 26 21.7% Variable shift 10 8.3% Occupation Registered nurse 86 71.7% Respiratory therapist 6 5% Child life specialist 2 1.7% Paramedic 14 11.7% Patient care assistant 12 10% G.L. Gillespie et al. / Nurse Education in Practice 14 (2014) 468e472 470 of test scores. SeeTable 3for summary statistics for the participant test scores.

A repeated-measures ANOVA was used to measure the within- subjects’effects. The factor measured was time of test measure- ment (Time 1, Time 2, and Time 3) with the dependent variable being workplace violence test scores. The results for the repeated measures ANOVA indicated a signiﬁcant time effect, Wilk’s L¼.390,F(2, 118)¼26.554,p<.001, h2¼.310. Follow-up poly- nomial contrasts indicated a signiﬁcant linear effect with means increasing over time,F(1, 119)¼53.454,p<.001, h2¼.310, while individual test scores became signiﬁcantly higher over time.

Discussion Finding a signiﬁcant increase in knowledge post completion of the online modules was an expected result. A similarﬁnding was reported byGillespie et al. (2012)following the completion of the original version of this violence program using a sample from hos- pitals not afﬁliated with the health systems of the current sample.

Given appropriate content and presentation, an increase in knowl- edge was anticipated following an online educational experience.

There is a large body of evidence to support positive learning out- comes when active learning strategies (e.g., tabletop exercise) were used. A recent meta-analysis, commissioned by the U.S. Department of Education, examined rigorous research in online learning and found that students in online courses tended to perform equal to those in traditional face-to-face classes (Means et al., 2010).

An importantﬁnding of this research is the signiﬁcant increase in learning (test scores) at six months following completion of the tabletop exercise when knowledge retention may be anticipated to falter.Means et al. (2010)found in their meta-analysis that students in hybrid or blended modalities (combined online and face-to-face) had superior learning outcomes to those in the classroom alone. So while online learning appears to be equal to, but not superior to conventional classroom instruction (statistically equivalent), hybrid approaches may be superior (mean effect sizeþ.35,p<.001) to solely classroom instruction. The authors suggested that additional learning materials and the opportunities for collaboration may result in the observed learning advantages (Means et al., 2010). This assertion was supported by the research ofCastle and McQuire (2010)who examined 4038 course assessment summaries for stu- dents’self-reported learning. Findings from the study suggest that along with content and instructor competence, those modalitiesproviding the highest degree of learner interaction foster the greatest learning.Gillespie et al. (2013)reported qualitativeﬁndings using the same population as the current study that there was a high degree of facilitated engagement between the instructors and employee learners during the tabletop exercise sessions.

The use of the tabletop exercise following the online modules was designed to foster high degrees of interaction and cooperation among the participants and the course facilitators. Collaborative learning, a key active learning strategy in our program, is an in- tellectual undertaking where participants work cooperatively to become educated on a particular subject (Koehn, 2001). The Insti- tute of Medicine Report (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011) on the future of nursing described the importance of preparing nurses to work collaboratively and effectively with other health professionals within the healthcare system. Collaborative learning can beneﬁt participants academically, socially, and psychologically (Kinyon et al., 2009; Panitz, 1999). Outcomes of collaborative learning include enhancement of learning and critical thinking skills (Feingold et al., 2008; Panitz, 1999). As a result of this collaborative experience, learners in the violence program may have been able to retain their knowledge long term in the context of how interpro- fessional colleagues must interact to prevent and manage work- place violence. This collaborative experience also may have accounted for the signiﬁcant increase in the test scores following the tabletop exercise.

Other components of the workplace violence course likely positively affected learning. Reporting on how people learn, the National Research Council (2000)described the movement from memorization to understanding as the ability to transfer knowledge to situations. Critical to transfer were motivation, contextual meaning, and active learning strategies. Motivation was linked to the usefulness of information learned (National Research Council, 2000). Participants in the workplace violence program were taught information that was directly applicable to their work environment. The tabletop exercise provided contextual meaning by using video case studies that were both realistic and applicable to the environment in which the acquired knowledge would be applied (Gillespie et al., 2012). Active learning was achieved through collaboration in responding to the unfolding case study thus improving the potential transfer of the information from the online modules (Gillespie et al., 2012). The use of these strategies promoted learning and potential transfer with enhanced learning retention.

Another critical component of the learning and retention pro- cess is initial learning. TheNational Research Council (2000) described initial learning as the presentation of the foundational materials which form the basis of the new knowledge. The suc- cessful transfer of learning is dependent upon the degree of mastery of the original subject. Without an adequate level of initial learning, transfer cannot be expected. The modules offered the initial basis for learning that was built upon by the discussion during the tabletop exercise. Using the online modules as prepa- ration for the tabletop exercise allowed class time to be spent on application and synthesis of collaborative activities.

The amount of time on task was also critical for learning. Stu- dents needed both time to learn and time to process information. Fig. 2.Boxplot distributions displaying participant test scores. Table 3 Summary statistics for participant test scores.

Mean Standard deviationPaired difference (T 2 T n)Paired difference (T 3 T n) Time 1 (T 1) 58.5 10.6 3.208 8.250 Time 2 (T2) 61.8 10.1e5.042 Time 3 (T3) 66.8 9.3 5.042e G.L. Gillespie et al. / Nurse Education in Practice 14 (2014) 468e472471 Learning cannot be rushed; information integration is a complex activity requiring sufﬁcient time (National Research Council, 2000).

The sequential completion of the online modules and the tabletop exercise over a three to four month time period allowed for both initial learning and transfer. The sequential and prolonged engagement with the content allowed learners to build upon knowledge gained in each activity (Gillespie et al., 2013).Cooper (1998)recommended“chunking”of information where informa- tion is presented in smaller units to decrease cognitive load, because working (short-term) memory is limited and long-term memory is unlimited. For this purpose, the online program mod- ules were presented as 15 shorter units. By providing the content within each module as short presentations and allowing learners several weeks to complete the online learning, learners were more likely to store program content in their long-term memory. Using both strategies resulted in knowledge gains, but the greatest in- crease to both learning and retention occurred following the tabletop exercise reﬂecting the complementarity of the active learning strategies used in our program.

Conclusion The use of hybrid modalities increases the probability that learning outcomes will be achieved. Online learning alone is effective in obtaining some learning outcomes, but to have signif- icant learning and retention hybrid methods are needed. Implica- tions for both educators involved in the education of new nurses and members of staff development are twofold. Students need to be prepared for learning: initial presentation of materials by reading, completing online modules, listening to podcasts,et ceterais essential. Highest levels of retention are obtained when initial learning builds upon and is reinforced by collaborative and active learning strategies where opportunities to apply and synthesize concepts is used. Future research is needed to determine if the synergistic effect of our hybrid program can be replicated with additional populations and with other hybrid programs.

Funding This study was funded by the Dean’s Teaching/Learning Project Award (University of Cincinnati College of Nursing). Dr. Gillespie’s time for analyzing the data and writing the manuscript was sup- ported by the Robert Wood Johnson Foundation Nurse Faculty Scholars program. The funding sources had no role in the study procedures or approval of the studyﬁndings.

Conﬂict The authors declare that they have no competing interests.

Contribution The authors provided the following contributions to this manuscript submissiond Dr. Gillespie was responsible for all aspects of the study including study conception and design, human subjects pro- tections, execution of the study, analysis and interpretation of data, and preparation and revision of the manuscript.

Dr. Farra was responsible for study conception and design, execution of the study, analysis and interpretation of data, and preparation and revision of the manuscript.

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