The general objective of the project is to assess whether a violence de-escalating training for health professionals and of a publicly displayed Code of Conduct (a set of rules developed through a citizen science and co-design approach) for both health professionals and clients at the level of the health facility, can reduce the incidence and severity of episodes of violence, and to identify the most cost-effective way to implement these interventions in rural Democratic Republic of Congo (DRC) and in the mega city of Baghdad, Iraq.
The study will adopt a stepped-wedge cluster-randomized intervention trial (SW-CRT) design to assess the two intervention components, a violence de-escalating training and the implementation of the code of conduct co-developed during the formative qualitative phase. The study will adopt a closed cohort with repeated measurements on the same participants (nurses in DRC and junior doctors in Baghdad) and will involve the unidirectional transition of each enrolled cluster (health facilities in DRC and secondary hospitals in Baghdad) from the control (no intervention) to the intervention sequence in a randomized sequential manner according to a predefined roll out process.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
DOUBLE
Enrollment
798
* Individual educational component through a de-escalating violence training for health care workers (verbal and non-verbal de-escalating techniques) * Refreshment training in the form of collaborative learning
A publicly displayed code of conduct (a co-designed set of rules) for both HCWs and clients, delivered via a warning board at the level of the health facilities and secondary hospitals
Catholic University of Bukavu, School of Public Health
Bukavu, Democratic Republic of the Congo
Al-Mustansiriya University
Baghdad, Iraq
Incidence and severity of self-reported non-physical aggression
Number of self-reported non-physical aggression (verbal abuse, threats, ironic language, provocative or aggressive body language etc.) during the fulfillment of a professional activity in the last 6 months
Time frame: 6 months
Incidence and severity of self-reported physical aggression
Number of self-reported physical aggression during the fulfillment of a professional activity in the last 6 months
Time frame: 6 months
Level of confidence in coping with patient aggression
Instrument "Clinicians confidence in coping with patient aggression (CCPAI) (Thackreys, 1987)"
Time frame: 0, 6, 12, 18 months
Level of post-traumatic stress disorders (PTSD) among HCWs
Instrument "Post-traumatic stress disorder PTSD Checklist for DSM-5 (PCL-5)) (Weathers, F.W. et al. 2013)"
Time frame: 0, 6, 12, 18 months
Level of burnout among HCWs
Instrument "Level of burnout" (Malach 2005), burnout measure short version (BMS). The ten-item version of the BMS are evaluated on 7-point frequency scales, with a score of 4 or above indicating burnout.
Time frame: 0, 6, 12, 18 months
Psychological empathy among HCWs
Instrument "Jefferson scale of physician empathy (Hojat M et al. 2007)"
Time frame: 0, 6, 12, 18 months
Absenteeism
Number of sick leave spells taken by the HCWs during the study period
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Time frame: 0, 6, 12, 18 months
Intent to leave among HCWs
The shortened, six-item version of the turnover intention scale (TIS-6) (Bothma \& Roodt 2013), will be used to assess turnover intentions and as well as to predict actual turnover among HCWs. The TIS-6 scale is scored on a five-point Likert-type scale with scores ranging from 1 (never) to 5 ( always). A high score indicates stronger turnover intention.
Time frame: 0, 6, 12, 18 months
Economic cost of the intervention
Two types of costs will be considered: 1) direct costs of the intervention (e.g training costs, space or rent costs, costs to develop the code of conduct) and 2) direct costs due to health system disruption (e.g. health care services foregone or postponed, material etc.), cost incurred by the HCWs as a consequence of violent episodes including direct medical costs (e.g. hospital stay cost, consultation costs, laboratory costs), non-medical costs (e.g. transportation, meals etc.), and indirect costs (e.g. absenteeism, presenteeism).
Time frame: 18 months
Productivity loss (presenteeism)
Work Limitation questionnaire (WLQ) (Lerner D. et al. 2002). The WLQ consists of eight items investigating four domains (time management, physical tasks, mental-interpersonal tasks, and output tasks), which are calculated into scores ranging from 0 (no limitations) to 100 (highest limitations).
Time frame: 18 months
Health care workers health-related quality of life
European Quality of Life-5 Dimensions (EuroQol EQ-5D-5L) (Devlin NJ et al. 2017). The EQ-5D-5L questionnaire is self-assessed and it measures health outcomes on five dimensions (mobility, self-care, daily activities, pain/discomfort, and depression/anxiety) with five levels ranging from none to major complaints. Scores range from 0 (death) to 1 (full health).
Time frame: 0, 6, 12, 18 months