Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression

Nurses' Perceptions of Engaging With Patients to Reduce Restrictive Practices in an Inpatient Psychiatric Unit

Despite the evidence of harmful effects of restrictive practices on patients and nurses, restrictive practices are still commonly used in the inpatient psychiatric settings. There has been a paradigm shift of a collaborative approach and implementation of patient engagement to reduce the use of restrictive practices. The purpose of this study was to explore nurses' perceptions of engaging with patients to reduce the use of restrictive practices in an inpatient psychiatric unit. This qualitative-descriptive study was conducted on an inpatient psychiatric unit of a large university hospital in Canada. Semistructured individual interviews were conducted with 6 nurses in 2016. Data generated by the interviews were coded and analyzed by thematic analysis. Four major themes emerged from the data analysis: unit engagement practices, managing the escalation by engaging with patient, engaging during the use of restrictive practices, and factors influencing engaging with patient to reduce restrictive practices. It is concluded that nurses perceive engaging with patients as possible and effective to reduce the use of restrictive practices despite identified barriers.

The attributes of successful de-escalation and restraint teams

Inpatient violence is a widespread problem on psychiatric wards often with serious consequences, and psychiatric hospitals have set up teams to de-escalate and restrain patients with aggression (D-E&R teams) which are specially trained to respond to it in a safe manner. Successful de-escalation and restraining of patients with aggression depend not only on the methods learned in training but also on the confidence of the team. Therefore, it is of great importance to understand the factors that enhance D-E&R teams' competence in managing patients with aggression in a successful and safe manner. The aim of this hermeneutic study was to identify and understand those factors. Purposive-expert sampling was used and twelve D-E&R team members with significant experience participated in the study. The central theme found was a safe team. Ensuring the safety of the team and its members was found to be a prerequisite for successful teamwork in managing patients with aggression in a safe manner. This central theme falls into two interacting domains: the internal dynamics of the team and the team's interaction with patients. Several themes, such as mutual trust, flexibility, and knowing one's role, influence these domains and hence strengthen or weaken the confidence and safety of the team. The findings of the study will contribute to a better understanding of these factors; understanding which could be used to improve the training, supervision, and quality assessment of D-E&R teams and hence lead to more safety in psychiatric wards.

The effect of a workplace violence training program for generalist nurses in the acute hospital setting: A quasi-experimental study

BACKGROUND

Workplace violence prevalence has attracted significant attention within the international nursing literature. Little attention to non-mental health settings and a lack of evaluation rigor have been identified within review literature.

OBJECTIVES

To examine the effects of a workplace violence training program in relation to risk assessment and management practices, de-escalation skills, breakaway techniques, and confidence levels, within an acute hospital setting.

DESIGN

A quasi-experimental study of nurses using pretest-posttest measurements of educational objectives and confidence levels, with two week follow-up.

SETTING

A 440 bed metropolitan tertiary referral hospital in Sydney, Australia.

PARTICIPANTS

Nurses working in specialties identified as a 'high risk' for violence.

METHOD

A pre-post-test design was used with participants attending a one day workshop. The workshop evaluation comprised the use of two validated questionnaires: the Continuing Professional Development Reaction questionnaire, and the Confidence in Coping with Patient Aggression Instrument. Descriptive and inferential statistics were calculated. The paired t-test was used to assess the statistical significance of changes in the clinical behaviour intention and confidence scores from pre- to post-intervention. Cohen's d effect sizes were calculated to determine the extent of the significant results.

RESULTS

Seventy-eight participants completed both pre- and post-workshop evaluation questionnaires. Statistically significant increases in behaviour intention scores were found in fourteen of the fifteen constructs relating to the three broad workshop objectives, and confidence ratings, with medium to large effect sizes observed in some constructs. A significant increase in overall confidence in coping with patient aggression was also found post-test with large effect size.

CONCLUSIONS

Positive results were observed from the workplace violence training. Training needs to be complimented by a multi-faceted organisational approach which includes governance, quality and review processes.

[Barriers to and facilitators for using a risk assessment tool to prevent violent behaviour in patients with mental health conditions: Perspectives of health care providers]

Regular assessment of risk of violence is shown to be effective in reducing violence in mental health services.

PURPOSE

To evaluate health care providers' use of a violence risk assessment tool on a mental health unit and the facilitators for and barriers to its use.

METHODS

A descriptive study using the Dillman approach and informed by the Knowledge to Action framework was conducted.

RESULTS

Twenty-six health care providers responded to the survey; 62% reported using the violence risk assessment tool available on their unit, but not on a daily basis. Common barriers were lack of knowledge of the tool, lack of resources and time, and negative attitudes toward patients. 42% of participants indicated the need for further training on violence risk assessment.

CONCLUSION

Despite high exposure to violence, health professionals were not conducting daily risk assessments. The barriers and facilitators identified provide direction for interventions that are necessary if the daily use of violence risk assessment tools is to be increased.

Violence against child protection workers: A study of workers' experiences, attributions, and coping strategies

Child protection workers (CPWs) are frequently exposed to client violence, both psychological and physical, in their line of work whether they operate in the community or in residential settings. Despite this known vulnerability, research on the subject has lagged. The current study sought to analyze CPWs' experiences with client violence, their interpretation of it, its perceived consequences and their coping strategies. Specifically, 30 CPWs working both in the community and in residential settings, took part in an in-depth, semi-structured interview. A thematic analysis revealed that CPWs view client violence as a recurring and pervasive problem in their line of work. Residential workers described a greater frequency of violence, especially physical violence. CPWs however perceived violence differently, with some viewing this problem as 'part-of-the-job' while others described client violence as a 'call-for-help' on behalf of clients. Perceived consequences varied in severity and breath. CPWs reported consequences at the psychological (e.g. fear, hypervilence, sadness, nightmares), organizational (e.g. loss of motivation, turnover intention, sick leaves) and clinical levels (e.g. emotional detachment from clients, avoiding clients). CPWs also described numerous coping strategies, some effective while others appeared short-sighted. This study concludes with recommendations with regards to client violence in child protection work.

Violence prevention in special education schools - an integrated practice?

Research has shown that employees in special education settings are at high risk for work-related threats and violence. Previous research has not yet been able to identify the essential components of training programs that offer protection from work-related threats and violence. Therefore, the aim of this study was to explore how employees in special education schools deal with prevention of work-related threats and violence. Group interviews were conducted with 14 employees working at 5 special education schools. Results show that employees use a wide range of prevention strategies drawing on specific violence prevention techniques as well as professional pedagogical approaches. We propose that the prevention of threats and violence in special education schools can be understood as an integrated pedagogical practice operating on three interrelated levels.

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

Effects of a Staff Training Intervention on Seclusion Rates on an Adult Inpatient Psychiatric Unit

The current article presents the effects of a 90-minute staff training intervention aimed at reducing inpatient psychiatric seclusion rates through strengthened staff commitment to seclusion alternatives and improved de-escalation skills. The intervention occurred at an 18-bed adult inpatient psychiatric unit whose seclusion rates in 2015 were seven times the national average. Although the project's primary outcome compared patient seclusion rates before and after the intervention, anonymous staff surveys measured several secondary outcomes. Seclusion rates were reduced from a 6-month pre-intervention average of 2.95 seclusion hours per 1,000 patient hours to a 6-month post-intervention average of 0.29 seclusion hours per 1,000 patient hours, a 90.2% reduction. Completed staff surveys showed significant staff knowledge gains, non-significant changes in staff attitudes about seclusion, non-significant changes in staff de-escalation skill confidence, and use of the new resource sheet by only 17% of staff. The key study implication is that time-limited, focused staff training interventions can have a measurable impact on reducing inpatient seclusion rates. [Journal of Psychosocial Nursing and Mental Health Services, 56(6), 23-30.].

Positive Effects of an Anti-Aggression and De-Escalation Training on Ward Atmosphere and Subjective Safety May Depend on Previous Training Experience

Anti-aggression and de-escalation (ADE) trainings of health-care professionals working on psychiatric inpatient wards have been shown to increase staff knowledge and confidence, which could be connected with higher subjective safety. Additionally, a potential reduction of aggressive incidents could improve ward atmosphere. Thus, the current study aimed to investigate the effects of ADE training on ward atmosphere and subjective safety. In 2015, an ADE training was established at the Psychiatric University Clinics (UPK), University of Basel. Nursing staff from 22 wards received theoretical and practical training over the course of 5 days. Ward atmosphere and subjective safety were assessed using the Essen Climate Evaluation Schema (EssenCES). A total of 46 people had been assessed in 2012 before training implementation (baseline), and 45 persons in 2016 after implementation. In the 2016 group, 23 people had previously participated in an ADE training, and 22 were first-time participants. Patients' coherence (p = 0.004), subjective safety (p = 0.004), and ward atmosphere (p = 0.001) were rated significantly higher by first-time ADE training participants compared to baseline, and patients' coherence (p = 0.029) and ward atmosphere (p = 0.011) were rated significantly higher by first-time ADE training participants than by nurses with prior ADE training. There were no significant differences regarding any EssenCES ratings by nurses with prior ADE training compared to baseline. ADE training was exclusively connected with higher ratings on most EssenCES scales for first-time participants. This indicates that the positive effects of ADE training may depend on previous training experience.

Patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for the management of violence and aggression in mental health settings

AIM

Investigate patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for aggression in mental health settings.

BACKGROUND

De-escalation techniques are the recommended first-line intervention for the management of aggression in mental health settings internationally, yet use of higher risk restrictive practices persists. This indicates de-escalation techniques are not used at optimum frequency and/or there are important factors limiting their use and effect.

DESIGN

Descriptive qualitative research using semi-structured interviews and Framework Analysis.

METHODS

Inpatient interviews (N = 26) exploring staff, patient and environmental factors influencing the use and effectiveness of staff de-escalation were conducted mid-2014. Three service user researchers led analysis.

RESULTS

Data were synthesized in three deductive themes relating to staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. The dominant view was that restrictive practices, rather than de-escalation techniques, are used in response to escalating patient behaviour. Under-use of de-escalation techniques was attributed to: lack of staff reflection on culture and practice and a need to retain control/dominance over patients. Ward rules, patient factors and a lack of staff respect for patients diluted their effectiveness. Participants identified a systematic process of de-escalation, rule subversion, reduced social distance and staff authenticity as enablers of effective de-escalation.

CONCLUSION

This study investigated patient perspectives on staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. Our framework of barriers and enablers provides indicators of organizational/behaviour change targets for interventions seeking to reduce violence and restrictive practices through enhanced de-escalation techniques.

Challenges of Nurses' Empowerment in the Management of Patient Aggression: A Qualitative Study

BACKGROUND

Patients' aggression in the mental care setting is a global health problem with major psychological, physical, and economic consequences; nurse empowerment to manage this aggressive behavior is an important step in psychiatric nursing. The aim of this study was to explore psychiatric nurses' experiences of the challenges of empowerment in the management of patients' aggression.

MATERIALS AND METHODS

This qualitative study was performed among 20 nurses working in a major referral psychiatric center in Iran during 2014-2016. The purposive sampling method was used for selecting the participants. Data were collected through semi-structured interviews, observations, and filed notes. Inductive content analysis was used for data analysis.

RESULTS

Three categories and ten subcategories were identified: inefficient organizational policy (limited human resources, mandatory shifts, shortage of protective equipment, lack of motivational sparks); insufficient job growth (failure to implement training programs, insufficient effort for job competence, lack of clinical guidelines); and deficiencies in the organizational culture (inadequate autonomy and authority, lack of the culture of prevention, culture of fault and blame after an incident).

CONCLUSIONS

Psychiatric nurses were not satisfied with organizational empowering conditions for the management of patients' aggression and reported low levels of access to learning opportunity, receiving support and essential resources that led to unnecessary use of containment measures. Managers must make every effort to create organizational context that make it possible to empower nurses for optimal practice.

Metasynthesis: An Original Method to Synthesize Qualitative Literature in Psychiatry

BACKGROUND

Metasynthesis-the systematic review and integration of findings from qualitative studies-is an emerging technique in medical research that can use many different methods. Nevertheless, the method must be appropriate to the specific scientific field in which it is used. The objective is to describe the steps of a metasynthesis method adapted from Thematic Synthesis and phenomenology to fit the particularities of psychiatric research.

METHOD

We detail each step of the method used in a metasynthesis published in 2015 on adolescent and young adults suicidal behaviors. We provide clarifications in several methodological points using the latest literature on metasyntheses. The method is described in six steps: define the research question and the inclusion criteria, select the studies, assess their quality, extract and present the formal data, analyze the data, and express the synthesis.

CONCLUSION

Metasyntheses offer an appropriate balance between an objective framework, a rigorously scientific approach to data analysis and the necessary contribution of the researcher's subjectivity in the construction of the final work. They propose a third level of comprehension and interpretation that brings original insights, improve the global understanding in psychiatry, and propose immediate therapeutic implications. They should be included in the psychiatric common research toolkit to become better recognized by clinicians and mental health professionals.

Evaluation of an Education and Training Program to Prevent and Manage Patients' Violence in a Mental Health Setting: A Pretest-Posttest Intervention Study

Workplace violence can lead to serious consequences for victims, organizations, and society. Most workplace violence prevention programs aim to train staff to better recognize and safely manage at-risk situations. The Omega education and training program was developed in Canada in 1999, and has since been used to teach healthcare and mental health workers the skills needed to effectively intervene in situations of aggression. The present study was designed to assess the impact of Omega on employee psychological distress, confidence in coping, and perceived exposure to violence. This program was offered to 105 employees in a psychiatric hospital in Montreal, Canada. Eighty-nine of them accepted to participate. Questionnaires were completed before the training, after a short period of time (M = 109 days) and at follow-up (M = 441 days). Repeated-measures ANOVAs and Cohen's d effect sizes were calculated. Results demonstrated statistically significant improvements in short-term and follow-up posttest scores of psychological distress, confidence in coping, and in levels of exposure to violence. This study is one of very few to demonstrate the positive impact of this training program. Further research is needed to understand how to improve the effectiveness of the program, especially among participants resistant to change.

A Co-operative Inquiry Into Generating, Describing, and Transforming Knowledge About De-escalation Practices in Mental Health Settings

De-escalation is concerned with managing violent behaviour without resorting to coercive measures. Co-operative Inquiry provided the conceptual basis for generating knowledge regarding de-escalation practices in acute mental health care settings. The research included service users and staff members as co-researchers and knowledge was generated in dynamic research cycles around an extended epistemology of knowing: experiential, presentational, propositional, and practical. Through this process, co-researchers became de-escalation learners, implementing de-escalation practices while transforming violence management. Neighbouring mental health communities' involvement strengthened the transformation process and assisted in validating the research results.