Step Three: Describing Desired Outcomes

Now that you have evaluated the present status of your emergency department and you are armed with information about what areas are in need of improvement, our next step is to focus on defining your project goals. It is vitally important in this step to define reasonable, achievable and measurable goals so that an action plan can be developed with these outcomes in mind. This step defines how you will respond to the information uncovered by your assessment. It acknowledges that you believe improvement is necessary but also that it is well within your reach and achievable.

Tips for Developing Outcomes Prevent, Response, Report outcomes Toolkit Resources Summary and Next Steps


Developing Outcomes

In this toolkit, you will find a project plan template that has a specific area for you to define the outcomes of this project and can later be used to fill in your action items to achieve these outcomes. You may want to collaborate with staff to enumerate and prioritize the goals and outcomes that will guide your violence prevention and response program. One way to get started is to review your emergency department assessment and list ALL of the improvement goals that would address ALL of the issues and problems uncovered during your assessment. It is important that you describe all the outcomes that you want to achieve as a first draft, then sort and prioritize and select those that are most important to you and the staff.

Here are some tips for developing and selecting outcomes that will guide your action plan for this violence reduction and mitigation project:

  • As a frame of reference, it may be helpful to review the OSHA recommendations for management committment and employee involvement to effectively deal with workplace violence. You can review these high level points by accessing the summary document, OSHA Recommendations: Management commitment and employee involvement.
  • Use the list of possible outcome statements located in the sample project plans in this toolkit to help you word your outcomes in a way that represents the the solution to the problem you are trying to solve. Don't overthink the language; perfect wording is not important as long as your outcome is descriptive enough that you are able to circle back after your re-evaluation (Step Five) and measure whether your outcome has been met.
  • It's important to explain the endpoint as the outcome and leave the action items to the plan for achievement (Step Four is designing your action plan).
  • You may identify that some outcomes are related…you can’t have one without the other. For example, if you are are going to institute a new policy for 100% reporting of violent incidents, staff identification of what qualifies as a violent incident should be part of your outcomes.
  • Don’t overstate or make goals so big they are unachievable, for instance, "eliminate violent behavior in our emergency department". Be realistic…know what you have control over and what you must better manage rather than stating absolutes.
  • Include some type of measurable number when it is appropriate and realistic; percent improvement can be a great motivator, can be tied to incentives and can be adjusted as you re-evaluate your status and adjust your outcomes in future improvement cycles.
  • Consider addressing direct, observable hazards to safety first, especially when prior reports show that a deficiency that could have been corrected would have resulted in the avoidance of violence.
  • State your outcomes in the positive voice whenever possible to emphasize that your efforts are quality improvement and not a punitive response to a bad situation, in other words, increasing the positive rather than decreasing the negative.
  • No harm in correcting the easiest things first especially if they are high visibility, necessary to staff safety and will contribute to ongoing staff and/or administrative "buy in".

Let's take a few minutes to review the process for developing your list of outcomes. To begin, analyze the present data that you collected in Step Two. Make sure you ask important questions about why certain incidents occur but be careful not to draw conclusions or cause and effect without sufficient evidence. To help narrow down the outcomes that are most important to your department, approach the problem by using our three areas of focus: Prevent, Respond, Report.


PREVENT: Collect assessment data from your department and to begin, focus on occurrences that you and your staff believe could have been prevented if alternative prevention procedures and protocols had been in place. Consider safety promotion…what realistic prevention goals do you have for your department? Minimally, every unit should be able to demonstrate that the staff is well educated in identification of high-risk patients, handling of escalating behaviors and knowledge of prevention protocols that are in place. Prevention outcomes can quickly become too broad so be sure that you are specific enough in stating the expected outcome so that action items are well directed to the results you are expected to produce.

Remember that an effective prevention program is a combination of:

  • Physical and environmental safety measures
  • Patient and family-focused safety measures (patient and family safety policies)
  • Staff-focused safety measures including education, protective behavior training (de-escalation) and high risk identification

Download the Project Plan Template and insert your outcomes related to prevention of violence in your emergency department.

Nurses who percieved their hospital administration and emergency department management as being committed to eliminating workplace violence were less likely to have experienced workplace violence.

Emergency Department Violence Surveillance Study, ENA, November 2011


RESPOND: Despite best efforts to prevent violent incidents from occurring, the reality is that even in an environment of planned awareness, violent acts can still occur. Often best efforts cannot silence verbal abuse and despite a prepared and vigilant staff, sometimes there is no recognizable escalation behavior and no time to intervene before a physical event occurs. For this reason, it is our recommendation that staff be sufficiently trained to contain an incident when appropriate and also to know when the best response is to get staff, patients and visitors to safety while security officers and/or authorities are called. When documenting outcomes, consider whether the evaluation of your emergency department revealed policies and procedures that outlines administration approved employee response to violent occurrences. Outcomes in this area should include:

  • An understanding of effective containment procedures and training to minimize the risk of injury to the patient, staff and visitors
  • Outcomes reflecting respect of a patient's rights to the extent that they are not reliquished secondary to threatening behavior
  • The role and actions of each member of the care team (nurses, security officers, physicians, management) in response procedures, if not already clearly defined

Retrieve your Project Plan Template and insert your outcomes related to response to violence in your emergency department.

Patients were the main perpetrators in all incidents of physical (97.8%) and verbal (92.3%) violence (as reported by study respondents). More than three-quarters of incidents of physical violence against emergency nurses (82.0% reported by study respondents) occurred in a patient's room, 24.0% in a corridor/hallway/stairwell/elevator and 14.6% at the nurses' station. Among study respondents, the most frequently reported activities that the emergency room nurses were involved in at the time of a physically violent incident were triaging a patient (40.2%), restraining or subduing a patient (34.8%) and performing an invasive procedure (29.4%).

Emergency Department Violence Surveillance Study, ENA, November 2011


REPORT: Reporting is one of the more important aspects of an ongoing quality improvement initiative in the area of emergency department workplace violence because it give us an accurate picture of the problems that need to be solved to make a safer workplace. Reporting, when done correctly, also provides a legal representation of what events took place during an occurrence and may be admissible as evidence should criminal charges apply to the occurrence.

When developing outcomes in your department related to reporting, consider what your evaluation in Step Two revealed about your staff's current level of reporting. If "zero-tolerance" is used an an outcome measure, make sure that the outcome you articulate can be realistically done every time in the environment of reporting that currently exists. Of course, we suggest that "zero-tolerance" be applied to reporting and not violent occurrences (since that is not completely under our control) and understand that "zero tolerance reporting" means every occurrence is reported, no exceptions.

Outcomes related to reporting also need to take into account the staff perceptions of the value of reporting an occurrence and the chain of responsibility and policy enforcement for reporting. Remember that outcomes regarding reporting and the actual forms used to report need to satisfy hospital administration policies, including human resources and risk management, and still must adequately convey the details of the occurence and protect the victim.

Retrieve your Project Plan Template and insert your outcomes related to reporting violence in your emergency department.

Research shows that the majority of nurses who experienced one or more forms of violence did not report the incident to either employers of law enforcement authorities. Some of the reasons that contribute to the under-reporting of violence included a perception that assaults are part of the job, a belief among employees that reporting will not benefit them, a concern that assaults may be viewed as evidence of poor job performance and a lack of institutional policies.

Emergency Department Violence Surveillance Study, ENA, August 2010

The following is a list of toolkit resources and references used in Step Three: Describing Desired Outcomes:

In this step, we have discussed the development of outcomes that address the three approaches to emergency department workplace violence, prevention, responding and reporting. Your tasks at the completion of this step have been to:

  1. Review the assessment of your emergency department that was accomplish during the last step and extract priority outcomes that define what you hope to accomplish and achieve when this plan is fully implemented.
  2. Download the Poject Plan Template and review the sample project plans available in this toolkit.
  3. From the list or from your own notes and observations of your emergency department's assessment, select a manageable number of outcomes that represent what your goals will be for this project.
  4. Include a timeline for achievement for each outcome. Remember, you can alter this timeline as you further develop your plan. The assignment of action items or interventions toward achieving our outcomes, often makes the timeline more clear and can give us a real understanding of how long it might take to accomplish our goals.
  5. If applicable, include threshholds to achieve as part of your outcomes (for example, an outcome might state that your department will submit written reports for 90% of all verbal abuse and 100% of all physical violence against staff members.

Our next step will cover selection of action items used to help achieve your goals. These action items will be included on your Project Plan Template, so have that handy while we move on to Step Four: Designing and Implementing your Action Plan.

Designing and Implementing your Action Plan