Pardon the Interruption: Assessing the Implementation, Operation, and Sustainment of Hospital-Based Violence Intervention Programs in the United States

Abstract

Background: Hospital-based violence intervention programs (HVIPs) are public health interventions to prevent violent re-injury. We know little about the experience of HVIPs during the early stage of implementation. Specifically, we do not understand the factors that help or hinder programs from achieving stable operation. A threat of survivorship bias exists, as programs failing to reach operational status are not represented in the literature. HVIPs hinge on the ability of violence prevention professionals to assist the recovery of intentionally injured patients to prevent further spread of violence. Yet, we know little about the tactics these professionals use, or whether the tactics developed by one violence prevention professional transfer to another. While there is published guidance on initial program implementation, there is limited evidence or guidance about factors influencing long-term HVIP sustainability. Methods: Semi-structured interviews were conducted with 18 HVIP leaders regarding the barriers and facilitators to program implementation (Study #1). Interviews were conducted between December 2023 and March 2025 and were organized around a nine-stage blueprint for starting an HVIP, developed by the American College of Surgeons. Leaders were asked to articulate the barriers and facilitators encountered during each stage of implementation in as much detail as possible. Inductive coding was used to identify themes emerging at each stage. Semi-structured interviews were also conducted with hospital-based violence prevention professionals to identify tactics used in everyday work (Study #2). Interviews were organized around 10 “hinge points” on the patient’s recovery continuum deemed integral to program success, identified a priori. Inductive thematic analysis was used to identify individual tactics. The Action Actor Context Target Time (AACTT) rubric helped ascertain essential information about each tactic. Finally, a three-round Delphi study was conducted with leaders of established programs to prioritize factors critical for achieving long-term HVIP sustainability (Study #3). Participants submitted factors influencing their program’s sustainability in Round 1. Responses were synthesized using inductive thematic analysis and returned to participants for refinement in Round 2. Maximum-difference scaling with hierarchical Bayes estimation helped prioritize factors by importance in Round 3. This dissertation addressed these gaps in our knowledge through primary data collection across three studies:Study #1: assessed the barriers and facilitators facing HVIPs actively in the early stages of program implementation. Study #2: identified the tactics violence prevention professionals use to meet the recovery needs of violently injured patients while preventing future violence exposure. Study #3: developed a prioritized list of factors influencing the achievement of long-term HVIP sustainability. Results: Barriers to implementation included insufficient program infrastructure to secure outside investment in an HVIP; challenges hiring violence prevention professionals with criminal histories; and maintaining relationships with community organizations mistrustful of the hospital system. Key facilitators included early identification of executive-level hospital champions; hospitals budgeting for initial HVIP funding; and external capacity-building support to grow program infrastructure. Interviews in Study #2 surfaced 214 tactics used by violence prevention professionals. Tactics addressing the initial bedside encounter (n=49) and trustbuilding with patients and families (n=44) represented both the largest and most diverse share of those identified (n=96). Navigating administrative bureaucracy was particularly challenging and required a distinct set of tactics. (n=39) Comparably few tactics engaged patient retention (n=11) or aftercare as patients exited the program (n=3). Finally, 27 sustainability factors were initially synthesized from 108 submissions by 32 participants in Round 1. Leaders added four factors and removed three during Round 2, with 28 factors rated in Round 3. Participants prioritized frontline violence prevention professionals in six of the first nine factors. Funding-related factors (e.g., government grants, operating support) received moderate priority. Administration (e.g., hospital leadership) and community stakeholders (e.g., community champions) received lower priority. External institutions (e.g., police) received lowest priority. Significance: Study #1 represents the first known attempt to identify and describe the barriers and facilitators influencing early HVIP implementation. These findings may equip nascent HVIPs to recognize and respond to factors that accelerate or hinder implementation. Study #2 is the first known study focusing on the role of the hospital-based violence prevention professional. Dissemination of tactics used to conduct their work will strengthen the skillsets of current HVIP professionals, while enhancing the training of future violence prevention personnel. Findings may support the creation of practical, readily deployable toolkits to translate tactical insight to diverse contexts where HVIPs operate, including HVIPs not yet established. Finally, Study #3 represents the first known study of HVIP sustainability. Priorities for program stability differ from priorities in blueprints for program startup (Study #1). Results may indicate the need for program adaptability during their implementation journey and for HVIP leadership to recalibrate priorities over time.