The participant's perspective: learning from an aggression management training course for nurses. Insights from a qualitative interview study

Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial

Background

Containment (e.g. physical restraint and seclusion) is used frequently in mental health inpatient settings. Containment is associated with serious psychological and physical harms. De-escalation (psychosocial techniques to manage distress without containment) is recommended to manage aggression and other unsafe behaviours, for example self-harm. All National Health Service staff are trained in de-escalation but there is little to no evidence supporting training's effectiveness.

Objectives

Objectives were to: (1) qualitatively investigate de-escalation and identify barriers and facilitators to use across the range of adult acute and forensic mental health inpatient settings; (2) co-produce with relevant stakeholders an intervention to enhance de-escalation across these settings; (3) evaluate the intervention's preliminary effect on rates of conflict (e.g. violence, self-harm) and containment (e.g. seclusion and physical restraint) and understand barriers and facilitators to intervention effects.

Design

Intervention development informed by Experience-based Co-design and uncontrolled pre and post feasibility evaluation. Systematic reviews and qualitative interviews investigated contextual variation in use and effects of de-escalation. Synthesis of this evidence informed co-design of an intervention to enhance de-escalation. An uncontrolled feasibility trial of the intervention followed. Clinical outcome data were collected over 24 weeks including an 8-week pre-intervention phase, an 8-week embedding and an 8-week post-intervention phase.

Setting

Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts.

Participants

In-patients, clinical staff, managers, carers/relatives and training staff in the target settings.

Interventions

Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) interventions included de-escalation training, two novel models of reflective practice, post-incident debriefing and feedback on clinical practice, collaborative prescribing and ward rounds, practice changes around admission, shift handovers and the social and physical environment, and sensory modulation and support planning to reduce patient distress.

Main outcome measures

Outcomes measured related to feasibility (recruitment and retention, completion of outcome measures), training outcomes and clinical and safety outcomes. Conflict and containment rates were measured via the Patient-Staff Conflict Checklist. Clinical outcomes were measured using the Attitudes to Containment Measures Questionnaire, Attitudes to Personality Disorder Questionnaire, Violence Prevention Climate Scale, Capabilities, Opportunities, and Motivation Scale, Coercion Experience Scale and Perceived Expressed Emotion in Staff Scale.

Results

Completion rates of the proposed primary outcome were very good at 68% overall (excluding remote data collection), which increased to 76% (excluding remote data collection) in the post-intervention period. Secondary outcomes had high completion rates for both staff and patient respondents. Regression analyses indicated that reductions in conflict and containment were both predicted by study phase (pre, embedding, post intervention). There were no adverse events or serious adverse events related to the intervention.

Conclusions

Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome.

Limitations

Uncontrolled design and self-selecting sample.

Future work

Definitive trial determining intervention effects.

Trial registration

This trial is registered as ISRCTN12826685 (closed to recruitment).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/101/02) and is published in full in Health Technology Assessment; Vol. 28, No. 3. See the NIHR Funding and Awards website for further award information.

Context

Conflict (a term used to describe a range of potentially unsafe events including violence, self-harm, rule-breaking, medication refusal, illicit drug and alcohol use and absconding) in mental health settings causes serious physical and psychological harm. Containment interventions which are intended to minimise harm from violence (and other conflict behaviours) such as restraint, seclusion and rapid tranquilisation can result in serious injuries to patients and, occasionally, death. Involvement in physical restraint is the most common cause of serious physical injury to National Health Service mental health staff in the United Kingdom. Violence to staff results in substantial costs to the health service in sickness and litigation payments. Containment interventions are also expensive (e.g. physical restraint costs mental health services £6.1 million and enhanced observations £88 million per annum). Despite these harms, recent findings indicate containment interventions such as seclusion and physical restraint continue to be used frequently in mental health settings. Clinical trials have demonstrated that interventions can reduce containment without increasing violence and other conflict behaviours (e.g. verbal aggression, self-harm). Substantial cost-savings result from reducing containment use. De-escalation, as an intervention to manage aggression and potential violence without restrictive practices, is a core intervention. 'De-escalation' is a collective term for a range of psychosocial techniques designed to reduce distress and anger without the need to use 'containment' interventions (measures to prevent harm through restricting a person's ability to act independently, such as physical restraint and seclusion). Evidence indicates that de-escalation involves ensuring conditions for safe intervention and effective communication are established, clarifying and attempting to resolve the patient's concern, conveyance of respect and empathy and regulating unhelpful emotions such as anxiety and anger. Despite featuring prominently in clinical guidelines and training policy domestically and internationally and being a component of mandatory National Health Service training, there is no evidence-based model on which to base training. A systematic review of de-escalation training effectiveness and acceptability conducted in 2015 concluded: (1) no model of training has demonstrated effectiveness in a sufficiently rigorous evaluation, (2) the theoretical underpinning of evaluated models was often unclear and (3) there has been inadequate investigation of the characteristics of training likely to enhance acceptability and uptake. Despite all National Health Service staff being trained in de-escalation there have been no high-quality trials evaluating the effectiveness and cost-effectiveness of training. Feasibility studies are needed to establish whether it is possible to conduct a definitive trial that can determine the clinical, safety and cost-effectiveness of this intervention.

A Quality Improvement Project to Reduce Events of Visitor Escalation in the Intensive Care Nursery

BACKGROUND

Escalating and aggressive visitor behaviors have become increasingly common in healthcare settings nationally, negatively impacting staff and patients alike. Most healthcare providers do not innately possess the specific skills to manage such behaviors. Management of escalating and aggressive behaviors presents a particularly bedeviling challenge when staff safety must be balanced with the needs of parent-neonate bonding.

PURPOSE

In the Intensive Care Nursery (ICN), the frequency of aggressive and hostile incidents from visitors increased such that the staff felt frustrated by and uneasy about their work environment.

METHODS

The ICN convened an interprofessional team to strategize interventions aimed at consistently managing aggressive behavior and supporting the staff after aggressive and/or hostile visitor encounters.

FINDINGS

Following staff education and training, the unit launched a de-escalation management algorithm in July 2018 that assisted in identifying high-risk families at admission and drove consistent action and management of all visitor behaviors. In the 12 months following the intervention, the frequency of behavioral escalation decreased by 75% and staff perception of safety increased by 25%.

IMPLICATIONS FOR PRACTICE

Collaborating with staff to design consistent strategies to manage aggressive and escalating visitor behavior can improve safety and improve employee satisfaction in the ICN.

IMPLICATIONS FOR RESEARCH

Additional research on the effectiveness of the algorithm in other ICNs and alternative areas of practice is needed. Furthermore, validation of a staff perception survey measuring the impact of escalating visitor behaviors on employees would be an important next step in this research.Video abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=43.

Aggression Management Training in Undergraduate Nursing Students: A Scoping Review

Recent events and media coverage have put aggression and violence toward healthcare workers on the agenda of many governments and healthcare providers. Shown to cause poor job satisfaction, attrition and higher rates of turnover, aggression and violence toward healthcare workers is a substantial problem in the provision of quality care. We aim to determine the feasibility of providing aggression management training to undergraduate nursing students to better prepare them for the workforce. This review found seven studies utilizing various methods of providing aggression management training to students. Delivery was diverse in terms of format, content and duration, and the efficacy of training was typically determined in a pre- and post-test fashion. The findings in reviewed studies indicate significant improvements in competence and attitudes, however some methodological caveats exist. We conclude that aggression management training for undergraduate nursing students is indeed feasible within certain constraints: methodological approaches to demonstrating efficacy need to evolve beyond pre- and post-test designs and changes in content delivery incorporating new and novel methods, such as simulation, need to be considered and incorporated. Aggression management training should be considered as essential in the nursing curriculum in order to provide neophyte nurses with the skills and capabilities to manage aggression and violence in their future workplaces.

Effects of Structured Group Counseling on Anger Management Skills of Nursing Students

BACKGROUND

Anger management is an important skill for nurses to prevent conflicts in the health care environment. Efforts, beginning with nursing education, are required to improve this skill and evaluate the effects. This study aimed to evaluate the effects of a structured counseling program on improving the anger management skills of nursing students.

METHOD

The study had an experimental design with pre- and posttests. Twenty-six undergraduate nursing students who were randomly assigned to the groups participated. The authors conducted eight counseling sessions with the experiment group and no intervention with the control group. Data were collected using the State-Trait Anger Expression Inventory.

RESULTS

The counseling group had higher anger control and repression scores and lower trait anger scores after the counseling, compared with the control group.

CONCLUSION

This counseling improved the students' anger management skills. Therefore, such programs should be integrated into the services provided for nursing students. [J Nurs Educ. 2017;56(3):174-181.].