Optimizing the Use of the Behavioral Activity Rating Scale (BARS) to Reduce Patient-on-Nurse Workplace Violence (WPV) in a Surgical Intermediate Care Unit of a Large Metropolitan Hospital

Date of Doctor of Nursing Practice Project Completion

Spring 2026

Faculty Advisor

Francine Snow, DrPH, MSN, RN, CNE, NPD-BC

Abstract

Purpose

Workplace violence (WPV) against nurses remains a significant safety concern in the Surgical Intermediate Unit (SIMU) of a large metropolitan hospital, a high-acuity care setting. During the recent fiscal year, SIMU reported 10 patient-on-nurse WPV incidents, which exceeded the organization’s threshold of five incidents. This quality improvement (QI) project aimed to evaluate the effectiveness of optimizing the use of the Behavioral Activity Rating Scale (BARS) within the hospital’s Epic electronic health record (EEHR) to reduce WPV incidents among nurses in the SIMU. The project's goal was to reduce WPV incidents by 50% within a three-month intervention period.

Background

WPV against nurses often results in burnout, decreased job satisfaction, and physical and emotional stress. Although the BARS was readily available and easily accessible in the EEHR to evaluate the risk of agitation in SIMU patients, SIMU nurses did not utilize it, limiting early recognition of patient agitation. According to Cai et al. (2023) and Pereira et al. (2023), a thorough behavioral risk assessment, staff training, and early intervention are effective strategies for reducing WPV.

Methodology

Situation Prevention Theory (SPT) provided the theoretical foundation for this QI project, as it guides efforts to reduce opportunities for aggression through early identification of patient agitation and prompt intervention (Cai et al., 2023). The project was implemented using Plan-Do-Study-Act (PDSA) cycles to support iterative testing, workflow integration into EEHR documentation, audit feedback monitoring, and reinforcement during shift huddles. Data were collected through weekly EEHR chart audits, monthly incident reports from the organization’s electronic incident report system (EIRS), and pre- and post-intervention SIMU nurse surveys. The project included 38 SIMU nurses across both day and night shifts who participated in the intervention and evaluation process.

Results

The primary outcome was achieved, with no reported WPV incidents during the implementation period (Weeks 3-10), compared to 10 incidents at baseline. The process measure, SIMU nurses’ BARS documentation compliance, increased from 0% at baseline to over 80% during several weeks of implementation, with improvements also observed at the shift level. The project’s balancing measures—nurses’ confidence in using the BARS tools to assess patient agitation, and perceived burden of using the BARS—both improved after the intervention.

Implications

Project findings indicate that integrating the BARS tool into SIMU’s routine workflow helped with early recognition of patient agitation, leading to a safer clinical environment. Because the BARS tool was already part of the organization’s EEHR, the project intervention was low-cost and easy to maintain through ongoing education, huddles, and audit-feedback. Likewise, this QI initiative supports the broader use of this approach not only in high-acuity patient care settings like the SIMU but also in other high-risk, non-psychiatric units. Future efforts should prioritize long-term monitoring, onboarding support for new nurses, and assistance for float or registry nurses who are not permanently assigned to the SIMU. The implementation period was short, limiting the number of PDSA cycles completed during the project.

Keywords

Workplace violence, Behavioral Activity Rating Scale, agitation assessment, quality improvement, nursing safety

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