HSE Health & Safety Executive Violence and aggression management training for trainers and managers A national evaluation of the training provision in healthcare settings Prepared by the University of Nottingham for the Health and Safety Executive 2006 RESEARCH REPORT 440 HSE Health & Safety Executive Violence and aggression management training for trainers and managers A national evaluation of the training provision in healthcare settings Part 1: Research Report Antonio Zarola BSc (Hons) MSc Dr Phil Leather BA MA PhD CPsychol AFBPsS Institute of Work, Health & Organisations (I-WHO) The University of Nottingham 8 William Lee Buildings Nottingham Science and Technology Park University Boulevard Nottingham NG7 2RQ The delivery of workplace violence management training constitutes a central part of the Healthcare sectors strategy for combating work-related violence and aggression. Given the priority which is thereby accorded to violence management training, there is an urgent need to carry out a rigorous and systematic evaluation of its impact and effectiveness. Without such an evaluation Healthcare organisations will have little, if any, reliable and valid evidence as to the effects and value of the training they invest in. In addition to its ability to contribute towards an organisation’s legal requirement to monitor and evaluate the effectiveness of any actions taken to prevent exposure to violence at work, evidence that is gathered from training evaluations is also fundamental to improving the content and delivery of such training. The training evaluation research that is herewith described set out both to directly assess the usefulness of violence management training and, on the basis of such evidence, to offer, in the opinion of the authors, clear guidance on good practice in the content and delivery of such training. A complementary practitioner report containing tools and guidance for violence management training is provided in Part 2. This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy. HSE BOOKS © Crown copyright 2006 First published 2006 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner. Applications for reproduction should be made in writing to: Licensing Division, Her Majesty's Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ or by e-mail to [email protected] ii ACKNOWLEDGEMENTS We would like to thank the Health and Safety Executive for funding this research. Particular thanks go to Josephine Gravell for her continued support and guidance throughout the project. We are also very grateful to John Grant and Judith Reilly for their help throughout the research process. We also extend our thanks to all members of the Steering Group and thank them for their input and guidance throughout this research. We also extend our gratitude to all the individuals who assisted and collaborated with us during the earlier and qualitative stages of the research. We are extremely grateful to all those participating organisations that have helped us in our research and extend this thanks to all the individuals who completed the questionnaires. We finally would like to thank Angeli Santos for all her help and support and Marissa Gousti for all her input. ABOUT THE INSTITUTE OF WORK, HEALTH AND ORGANISATIONS The Institute of Work, Health and Organisations (I-WHO) is a postgraduate research institute in the Faculty of Law & Social Sciences, University of Nottingham. It focuses on the contribution that applied psychology can make to occupational and public health and safety, and the management of related health services. Occupational psychology, occupational health psychology and health and clinical psychology are among its defining interests. Its contribution in these areas is recognised by the World Health Organisation and the Institute is a designated Collaborating Centre in Occupational Health. The Institute’s aims are fourfold. To be: x A world-class centre of excellence in research in applied psychology and related areas. x A quality provider of postgraduate education and training in vocational areas of applied psychology and related subjects. x Active and influential in policy and related legal research and in policy development. x A centre for the collection, evaluation and dissemination of information on research, education, practice and policy in its core areas. The Institute attempts to manage a healthy balance between its commitment to and investment in research, and related activities, and its ability to provide quality postgraduate education and training. iii iv CONTENTS EXECUTIVE SUMMARY ..................................................................................................vii 1. INTRODUCTION .......................................................................................................... 1 1.1 SCALE AND CONSEQUENCES OF THE PROBLEM ...................................... 1 1.2 MEETING THE CHALLENGE AND TACKLING THE PROBLEM................. 3 1.3 THE ROLE OF TRAINING AND THE NEED FOR EVALUATION................. 5 1.4 THE SCOPE AND OUTCOMES OF THE RESEARCH ..................................... 6 1.5 FOCUS OF THIS REPORT ................................................................................... 7 1.6 TOOLS AND CASES STUDIES........................................................................... 7 2. ASSESSING THE IMPACT OF TRAINING ............................................................... 9 2.1 RIGOROUS AND SYSTEMATIC EVALUATION ............................................. 9 3. AGAINST WHAT CRITERIA DO WE EVALUATE AGGRESSION AND VIOLENCE MANAGEMENT TRAINING? ...................................................................... 12 3.1 CAPABILITY AS A KEY CRITERION............................................................. 12 4. WHAT IMPACT DOES TRAINING HAVE ON PERCEIVED CAPABILITY AND OTHER IMPORTANT CRITERIA? ................................................................................... 17 4.1 WHAT HAPPENS IN GENERAL OVER THE COURSE OF TRAINING?..... 17 4.2 DO THE BENEFITS OF TRAINING LAST?..................................................... 20 5. WHAT IS IT ABOUT THE CONTENT OF TRAINING THAT DIFFERENTIATES HIGH FROM LOW IMPACT TRAINING? ....................................................................... 23 5.1 HIDDEN DIFFERENCES BETWEEN COURSES ............................................ 23 6. WHAT DOES ALL THIS MEAN FOR TRAINING IN VIOLENCE AND AGGRESSION MANAGEMENT? ..................................................................................... 27 6.1 SUMMARY OF KEY FINDINGS ...................................................................... 27 6.2 KEY MESSAGES AND RECOMMENDATIONS OF THE RESEARCH ........ 27 6.2.1 Common criteria: benchmarking positive practice....................................... 28 6.2.2 Training needs analysis, design and delivery ............................................... 29 6.2.3 Training evaluation....................................................................................... 29 6.2.4 Organisational learning and improvement ................................................... 29 6.3 FUTURE: RESEARCH AND PRACTICE.......................................................... 30 7. APPENDIX .................................................................................................................. 32 8. REFERENCES ............................................................................................................. 33 v vi EXECUTIVE SUMMARY Work-related violence is now considered by many as one of the most serious occupational hazards facing staff working in the Healthcare sector. With the growing evidence of the scale of the problem and the damage it causes, a number of strategic responses at both a local and national level have been launched to meet this challenge. What is clear from the positive action that is underway across the Healthcare sector is that there is no single solution to preventing workplace violence and aggression. Interventions to prevent and manage work-related violence must be considered within the broader context and framework of a total organisational response. What is also clear is that training is often held to be a primary element of the strategy for combating work-related violence. However, with the huge investment accorded to training in this area within the Healthcare sector the question is no longer “should we train?” but “is training worthwhile and effective?” The report by the NAO (2003) concluded that although there was lots of evidence of training in violence management being offered to staff within Healthcare there was little evidence based information regarding its effectiveness. Evaluation of the effectiveness of training programmes is critical because, without it, organizations have no good way to know whether training budgets are being spent wisely. In addition, it is important for any organisation to recognise whether the intervention prescribed (i.e. training in violence management) is suitable for the problem that has been diagnosed. This is also supported by the more recent Wales Audit Office (WAO) report which concluded that ‘it is essential that Trusts evaluate the quality and impact of the training they provide and take remedial action to improve the delivery of training’ (2005, pp. 39). On the evidence base available prior to the research documented in this report, the simple answer to the question ‘is training effective?’ was, by and large, ‘we don’t know’! On the basis of the substantial data gathered during the project we are now in much stronger position to assess the impact of violence management training. In addition, important lessons have been learned and can now be disseminated about how to evaluate violence management training. Furthermore, and arguably for the first time, we also have hard evidence to inform the broad contours of an effective curricula. This report details the key research findings in answer to two fundamental questions 1) what impact does violence management training have? and 2) what’s the broad content and curriculum of the most effective violence management training? A companion practitioner report specifically addresses the issues of how to evaluate training and in doing so offers a series of tools to support and guide those with a responsibility or interest in designing, delivering or managing violence management training. Why evaluate is, however, only one of the key questions that must be answered. The second equally crucial question is ‘what should training evaluations evaluate’? Although the case can be made to evaluate training on a variety of criteria, a key measure of the success or effectiveness of any programme of instruction is the realisation within a delegate that training has provided them with a healthy sense of belief in their capability to perform and to cope with the work situations that they might face. To date there is a relative paucity of well-designed evaluation studies into the effectiveness of the training to prevent and manage violence in Healthcare settings. Using a before, after and follow-up vii design, training programmes in violence management within Healthcare settings were evaluated. The key criterion against which training was evaluated was on the concept of capability. However the impact of training on other important variables (i.e. anxiety, fear of violence, etc.) was also determined. To this end the objectives of the research were as follows: 1. To examine a broader range of outcomes against which the effectiveness of violence management training can be assessed. 2. To produce an evidence-based evaluation of the effectiveness of current violence management training programmes. 3. To establish how violence management training ‘works’ (i.e. the content of training) in terms of its impact on the broader range of criteria. In addition, the scope of the research was to: 4. To develop a general suite of tools and instructions for their use, covering: a. Assessment of training needs and the extent to which available training meets them; b. The evaluation of training; and c. An analysis of current provision against best-practice standards. 5. To develop a best-practice monitoring tool to inform those with a responsibility for assessing violence management training programmes by way of conducting a gap analysis of the training provision. 6. To provide a set of instructional case studies in the ‘best practice’ management of violence and aggression. (Objectives 4, 5 & 6 are documented in the companion practitioner report). The overall aim of the main research report, the practitioner report and the case studies is to inform and support the need for improved quality and standards and to act as a conduit for fostering greater communication and collaboration between those organisations with responsibilities for managing violence and aggression issues across the Healthcare sector. The main findings of the research were as follows: o In general, training in violence management across Healthcare organisations is having positive, but limited, short term benefits. What is clear from the research is that where training does not reflect a sound understanding of need, the impact of training is at best negligible and at worst negative (i.e. staff are leaving training feeling less capable in dealing with violence and aggression in the workplace). viii o Training tends to have the greatest degree of impact (i.e. change) and value (i.e. contributing to the protective sense of health and well-being) when the knowledge and skill topics emphasised within the overall programme are situated within the broader context of an organisation’s performance management in terms of its systems and procedures to prevent and manage violence and aggression. o There is a fundamental and integral role for the concept of capability in both research and practice aimed at better understanding, managing and preventing workplace violence and aggression. The term capability refers to staff member’s perceived ability, confidence and self- assurance that they have the necessary knowledge, skills and understanding to be able to deal and cope with the conflict situations that they might face in the work environment. This research has served to demonstrate the importance of capability by documenting 1) the critical role perceived capability in dealing with violence and aggression plays in influencing individual and organisational well-being and 2) its power and appropriateness as a benchmark criterion against which to judge the impact and effectiveness of violence management training. With respect to strategic action the key messages from this research are as follows: Training needs analysis, design and delivery o There is now a need for a common benchmark (i.e. criteria) against which the value and impact of all violence and aggression training can be judged irrespective of its focus, content, or delivery method. One common benchmark is that of capability. o What we do know about ‘effective’ training in violence management is that: a. The content tends to be broader rather than focusing on individual competence; b. The content tends to be more closely allied to perceived need; and c. The content needs to clearly demonstrate (i.e. include evidence) of a proactive organisational response to workplace violence. Training evaluation o The criteria against which training is to be evaluated needs to be broader, more meaningful and add value in terms of indicating the impact of training on both individual and organisational health. There needs to be a move away from a reliance on simple end of course reaction sheets. All training courses on violence management must be evaluated in terms of their impact on common benchmark criteria of which capability is one. o It is never enough to assume that any course ‘meets the bill’. Accreditation of training programmes provides a sound benchmark against which training can be reviewed, however this does and should not exclude any training programmes from rigorous, systematic and independent evaluations. An assessment of practical value, degree of learning and transfer has to be the final arbiter of training effectiveness and not accreditation in purely educational terms. o The underpinning rationale behind all aspects of training, training evaluation and indeed other aspects of the management of violence must be to do with continuous individual and organisational learning and development and not a ‘tick-the-box’ enforcement / compliance ix