An Organizational Ethnography Exploring the Implementation of a Hospital-Based Violence Intervention Program: First Year Processes and Outcomes

Background and Purpose

Community-based gun violence is at epidemic levels in cities across the U.S. Hospital-based violence intervention programs (HVIP’s) seek to engage youth victimized by community violence in case management services while they receive treatment in the hospital for their injuries. These programs can reduce violence recidivism, criminal activity and aggressive behaviors, while improving employment and educational outcomes. While an emerging best practice, there is limited information about how to best implement HVIP’s across multiple hospital systems within a single geographic area. This organizational ethnography explored the organizational, professional and client level factors that facilitated and hindered the implementation of an HVIP across four large level-one trauma centers in a metropolitan city in the Midwest with high rates of community-based gun violence.

Methods

This three-year longitudinal study used multiple data sources including: (1) in-depth, qualitative interviews with a purposive sample of 40 multidisciplinary professionals across medicine, public health, social work, nursing, and pastoral care who were directly involved in the creation and implementation of the HVIP program; (2) longitudinal interviews with approximately 25 first-year clients enrolled in the program; and (3) three years of field notes from observations, meeting minutes and extant program documents. Interviews were guided by a semi-structured protocol developed with input from key informants who were leaders within the HVIP program to enhance authenticity and credibility. Interviews were coded and analyzed using ATLAS TI software. Thematic analysis was used to develop an in-depth understanding of how professional and client participants perceived the main facilitators and barriers to the implementation of the HVIP program and the aspects of the program needing improvement. This process involved generating initial codes that were attached to data within and across transcripts, which were then compared and contrasted to generate categories and general themes grounded in the data. Trustworthiness was established through peer-debriefing, triangulation, memo-notes, theoretical sampling, analysis of counter-narratives, and continuing interviews until saturation.

Results

Several themes emerged from the data. First, meeting client’s basic needs (i.e. bills, rent, food) and transportation were important factors leading to retention. Second, participants also identified services focused on employment, housing, education, medical and mental health services as important for client retention. Third, the development of efficient and organizationally relevant communication strategies between ER, trauma and program case managers were vital to enhancing program functioning. Fourth, the importance of explicit data sharing agreements and IRB coordination were important to program development; Fifth, important case manager characteristics and skills were highlighted that included reliability, persistence, having a nonjudgmental and caring attitude, and possessing active listening skills. Finally, family-based care coordination, caseload management and supervision structure were identified as program-level factors important to successful implementation.

Conclusions and Implications

Effective implementation of hospital-based violence intervention programs across hospital systems requires transdisciplinary teamwork and continued communication and coordination between multiple systems and organizations. Program success relies heavily on strategic, longitudinal relationships within and across hospital systems and with outside university, funding and community partners.