De-escalation Techniques Research Articles

National examination of occupational hazards in emergency medical services

ObjectiveEmergency medical services (EMS) clinicians operate in environments that predispose them to occupational hazards. Our objective was to evaluate the frequency of occupational hazards and associations with mitigation strategies in...

"If certain tensions are present, it affects everyone": Multiple case study on processes of coercive measures.

"If certain tensions are present, it affects everyone": Multiple case study on processes of coercive measures. Abstract. Background: There is an urgent need to reduce coercive measures in psychiatric care. The interaction between patients, nursing staff and medical professionals influences the course of a coercive measure. Aim: The interaction before, during and after coercive measures will be described and compared from the perspectives of the parties involved in order to identify a potential for prevention and quality improvement. Methods: A multiple case study of three coercive measures was conducted, each consisting of interviews with three participants, case documentation, photos, and observation. The data material was analysed thematically with subsequent single-case and cross-case analysis. Results: The thematic analysis revealed three areas of tension: tension and relaxation, humaneness and dehumanisation, as well as safety and autonomy. The stage before coercion was characterised by interacting tensions and the influence of emotions and stress. In all cases, a verbal communication gap was present. During the coercive measure, the quality of interactions between patients and nurses determined their experience. After coercion, the impacts of the measure on the persons and their relationships as well as reflections were the focus. Conclusions: De-escalation techniques turn out to be a key issue, whereby special attention should be paid to emotional and nonverbal aspects in the future. The results underline the relevance of empathy and respect throughout the process for prevention as well as for quality of care. Debriefings of coercive measures should be conducted routinely.

Re-Envisioning Public Safety Through an Embedded Police Social Worker (PSW) Model: A Promising Approach for Multidisciplinary Resource Delivery and Diversion

Cities across the political spectrum in the United States are shifting toward co-responder models that involve social workers with police departments in some capacity, but research is lagging about the proper role of police social workers (PSWs). This case study explores how the micro and macro roles of the embedded PSW model can improve resource delivery and divert people in crisis away from the criminal justice system. Few research studies to date have explored the role and potential effectiveness of creating such a position within police departments. An analysis of 7 months of data found that the PSW was much more efficient than officers in making referrals for high-needs clients. Furthermore, high-needs clients were more likely to have unmet basic needs such as shelter, food, and health care, indicating that police departments may frequently interact with people who have high levels of such needs. Qualitative case notes also revealed that PSWs can divert individuals from the criminal justice system by using crisis intervention and de-escalation techniques on-scene with clients. This research has important implications for improving community safety and well-being, and this case study reveals that PSWs with micro and macro skills are a promising model for improving public safety and justice in the right context.

De-escalation Techniques for the Agitated Pediatric Patient.

De-escalation Techniques for the Agitated Pediatric Patient.

Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators.

Acute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care. We conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California. PECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%). ED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies.

The Influence of De-Escalation Techniques on Reducing Anger Responses in Drug Clients

Drug abuse is a concern because of the various impacts, one of the negative effects psychologically including tension/anxiety, upset and depressed, loss of self-control and unstable emotional state. Risk Violent behavior is a form of angry response that is expressed by making threats, injuring other people and or destroying the environment. Indonesia's national data for 2020, the risk of violent behavior is around 0.8% or 10,000 people. One of the treatments for the risk of violent behavior can be done with verbal de-escalation techniques. Methods: The design used in this study was pre-experimental with a one group pretest posttest design approach. Total population and sample of 27 respondents (1 treatment group) using total sampling technique. In this design, the treatment group was given verbal de-escalation techniques. The treatment group was given an examination before (pre-test) and after (post-test) verbal de-escalation therapy using the PANSS-EC Rating Scale to assess the patient's angry response at the Mitra Mulia Foundation, Banyuasin Regency. Results: Implementation of verbal de-escalation techniques has an effect on reducing angry responses in clients at risk of violent behavior. Conclusion: Actions that can be taken on clients at risk of violent behavior can be in the form of verbal de-escalation techniques.

Standardizing and Improving Care for Pediatric Agitation Management in the Emergency Department.

Pediatric mental health emergency department (ED) visits are rising in the United States, with more visits involving medication for acute agitation. Timely, standardized implementation of behavioral strategies and medications may reduce the need for physical restraint. Our objective was to standardize agitation management in a pediatric ED and reduce time in physical restraints. A multidisciplinary team conducted a quality improvement initiative from September 2020 to August 2021, followed by a 6-month maintenance period. A barrier assessment revealed that agitation triggers were inadequately recognized, few activities were offered during long ED visits, staff lacked confidence in verbal deescalation techniques, medication choices were inconsistent, and medications were slow to take effect. Sequential interventions included development of an agitation care pathway and order set, optimization of child life and psychiatry workflows, implementation of personalized deescalation plans, and adding droperidol to the formulary. Measures include standardization of medication choice for severe agitation and time in physical restraints. During the intervention and maintenance periods, there were 129 ED visits with medication given for severe agitation and 10 ED visits with physical restraint use. Among ED visits with medication given for severe agitation, standardized medication choice (olanzapine or droperidol) increased from 8% to 88%. Mean minutes in physical restraints decreased from 173 to 71. Implementing an agitation care pathway standardized and improved care for a vulnerable and high-priority population. Future studies are needed to translate interventions to community ED settings and to evaluate optimal management strategies for pediatric acute agitation.

Interdisciplinary Simulation Training Reduces Restraint Use in the Emergency Department: A Pilot Study.

Introduction Safe and effective management of agitated patients poses multiple challenges for healthcare professionals. Patients placed in restraints because of agitated behavior are at a higher risk of complications, including death. This intervention was designed to provide emergency department staff a framework for de-escalation, improve teamwork, and reduce the use of violent physical restraints. Methods Emergency medicine nurses, patient support associates, and protective services officers underwent a 90-minute educational intervention in 2017. A 30-minute lecture focusing on communication and early use of medication for agitation was followed by a simulationusing standardized participants, then a structured debriefing. A standardized return-on-learning tool determined participants' reactions to and application of the educational intervention.Additionally, data was collected and reported as a ratio of number of restraints applied each month compared to total emergency department visits that month. Data were analyzed comparing the six months before the education and the subsequent six months after the education. Results A pilot group of 30 emergency department staff members completed the educational intervention.The intervention contributed to the overall decrease in restraint use in the department.Most participants (86%) felt more confident in their ability to manage agitated patients. Conclusion An interdisciplinary simulation-enhanced educational intervention successfully reduced use of restraints in the emergency department and improved staff attitudes toward de-escalation techniques for agitated patients.

Is mental health staff training in de-escalation techniques effective in reducing violent incidents in forensic psychiatric settings? – A systematic review of the literature

BackgroundInpatient violence is a relevant issue in forensic psychiatric settings. Relevant guidelines recommend that restrictive measures are to be used exclusively if de-escalation and other preventive strategies have failed and there is a risk of harm to patients or staff if no action is taken. However, restrictive measures are untherapeutic and can be harmful. In order to enable staff to intervene before inpatient violence or other serious incidents occur and thus to avoid restrictive measures, mental health staff training programs including de-escalation components are being adopted in general as well as forensic mental health settings. There is growing evidence for the efficacy of mental health staff training in de-escalation techniques in the field of general psychiatry. However, there are no reviews evaluating the effectiveness of these interventions in reducing violent incidents in forensic psychiatric settings. Here we present the first literature review on the effectiveness staff training in de-escalation techniques in the field of forensic psychiatry.MethodWe searched relevant databases for original research on the effectiveness of reducing violence in forensic psychiatric settings. Studies were included if they investigated staff training programs with de-escalation techniques in forensic mental health settings.ResultsA total of 5 relevant studies were identified. None of the studies was a randomized controlled trial. Four studies were before and after comparisons without control group. A one group post-test-only design was used in one study. Methodological quality was low. The maximum sample size was 112 participants. Results indicated no relevant impact of mental health staff training in de-escalation techniques on the rate of violent incidents in forensic psychiatric wards. However, staff seemed to feel safer following the training. Results have to be interpreted cautiously due to several methodological and content-related limitations.DiscussionEvidence for the effectiveness of staff training in de-escalation techniques on reducing verbal and physical aggression in forensic settings remains very limited. The existing definitions of terms like de-escalation, de-escalation training and de-escalation techniques in the healthcare context appear rather vague. Although some positive changes are reported across a variety of outcome measures it remains unclear to what extent staff training in de-esclation techniques contributes to a reduction in aggressive incidents and restrictive measures in forensic psychiatry. The clinical implications of this review are therefore limited. Yet, an important implication for future research is that a more comprehensive approach might prove worthwhile. Conducting a further review integrating a wide range of complex interventions aimed at the reduction of inpatient violence rather than focusing on de-escalation only, might be a worthwhile approach.

A voice of experience: Positive and negative experiences of mental health from a service user's/lived experience perspective.

WHAT IS KNOWN ON THE SUBJECT?: People with mental health problems are often left behind, forgotten and excludedLittle is known or written from a service user perspective about experiences of psychiatry, mental health nursing, Mental Health Tribunals and alternative approaches (such as counselling, peer support, psychological and recovery approaches, cognitive behavioural therapy-CBT and creative/art/music/drama/horticultural/dance therapies). WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper aims to remedy this gap in knowledgeIt focuses on positive and negative experiences of psychiatry, Mental Health Tribunals and alternative treatments from a service user's perspective. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The paper makes several recommendations. In brief, (1) psychiatrists need to listen more attentively rather than being focused on signs of psychosis; (2) de-escalation techniques (for example, talking calmly with the patient) should be used by nurses before physical restraint; (3) psychiatry should be less biomedical. Nurses and social care professionals deserve better training, time for and practice in alternative and more therapeutic forms of care; (4) carers need to be more involved; (5) there need to be better, more democratic, more open processes of law; (6) voluntary work and supported employment schemes should be run by health and social services for people who want to work and want to have a vocational life. This paper aims to describe the lived experience of mental illness, coercive treatment by psychiatry and mental health nursing, and the problematic case and bias of Mental Health Tribunals. It then looks at more positive experiences of alternative approaches and makes recommendations for improving mental health services and people's experiences of them.

SMI Adviser to Bring Hands-On Learning to Annual Meeting

SMI Adviser to Bring Hands-On Learning to Annual Meeting

Development of a Communication Tool for Handoffs Involving Patients Cared for by Sitters: An Evidence-Based Practice Project.

Communication has been found to be central to patient safety and colleague engagement. Poor communication was identified in a Level III trauma hospital in the midwestern US between "sitters" (staff members assigned to monitor patients identified as having safety concerns) and the nurses assigned to care for those patients, including lack of a formal handoff process. A Patient/Problem, Intervention, Comparison, Outcome (PICO) statement guided an evidence-based project and identification of an intervention to improve the handoff process. Using the evidence-based format of Situation/Background/Assessment/Recommendation (SBAR), a Patient Safety Attendant Handoff Form was developed and implemented. Initially, Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Certified Nursing Assistants (CNAs) were used as sitters, taking them away from other responsibilities. A formal position, Patient Safety Attendant (PSA), was created to perform the sitter role. The Patient Safety Attendant Handoff tool was made an official hospital form and implemented as a new standard of practice. Analysis of data from completed forms identified the top reasons for assigning a sitter were mental health and behavioral concerns. In a six-month post-implementation survey, most PSAs reported receiving adequate information about the patients during handoffs using the new form. Using SBAR for the Patient Safety Attendant Handoff Form improved communication between RNs and PSAs and also enhanced communication between PSAs. A key safety feature of the form is the Recommendation section which includes "triggers to avoid," de-escalation techniques, and things the patient enjoys. Developing a structural model from the aggregated data on the completed forms helped in analyzing the information.

Sublingual dexmedetomidine: repurposing an anesthetic as an anti-agitation agent

ABSTRACT Introduction Especially when acutely ill, individuals with schizophrenia and bipolar disorder can present with agitated behavior. The initial approach to agitation management are non-pharmacologic strategies such as verbal de-escalation techniques; however, pharmacologic interventions may be needed. Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist, and a sublingual formulation has been approved in the US for the treatment of agitation associated with schizophrenia and bipolar disorder in adults. Areas covered The authors review the published literature on sublingual dexmedetomidine using the US National Library of Medicine’s PubMed.gov resource. Pharmacodynamics, pharmacokinetics, and efficacy and tolerability findings are summarized. The authors also provide a discussion to its potential place in the treatment armamentarium. Expert opinion Sublingual dexmedetomidine is an effective and well-tolerated pharmacologic option for the treatment of agitation associated with schizophrenia and bipolar disorder. The sublingual method of administration allows for a rapid onset of action with treatment effects beginning as early as 20 minutes after administration. Adverse effects include somnolence, hypotension, oral paresthesia, hypoesthesia, and dry mouth. Further study will be needed to evaluate sublingual dexmedetomidine in real-world patients receiving concomitant psychotropic medications.

RESPONDING TO CRISES: STRATEGIES FOR LAW ENFORCEMENT WHEN ASSISTING CITIZENS IN CRISIS

On November 23, 2022, Dr. Dara Rampersad presented Responding to Crises: Strategies for Law Enforcement When Assisting Citizens in Crisis. The presentation was followed by a question-and-answer period with questions from the audience and CASIS Vancouver executives. The key points discussed were how first responders can protect themselves and their mental health, and various de-escalation techniques to use in times of crisis. Received: 2023-01-06Revised: 2023-01-11

APA Resource Document Outlines Principles on Use of Seclusion, Restraint

APA Resource Document Outlines Principles on Use of Seclusion, Restraint

Transferability of Mental Health Simulation Skills to Practice: A Nursing Post-Graduate Follow-Up Study.

The purpose of the current descriptive qualitative follow-up study was to explore perceptions of post-graduate nurses regarding transferability of student-learned mental health simulation knowledge and skills to actual acute care practice settings. The study used a survey design of eight questions on SurveyMonkey® and there were 11 participants. Questions were specific to knowledge and skills learned as students in three mental health simulation labs and whether they transferred to post-graduate acute care practice settings. Thematic analysis identified the following main themes: Learned Effective De-Escalation Techniques, Felt More Prepared With Psychiatric Assessments, and Feeling Empathy for Patients Hearing Voices. Subthemes were Being Therapeutic With Patients and More Confident in Psychiatric Emergencies. Post-graduate nurses described being able to transfer use of student-learned mental health simulation knowledge and skills to acute care practice settings. [Journal of Psychosocial Nursing and Mental Health Services, 61(7), 39-45.].

999 ‘emergency’ – the immersion of student health care professionals within the The SIMEX series disaster and emergency response exercise (2022)

As part of the SIMEX Series exercise [1] the University hosted a simulated mass casualty incident where Nursing/Allied Health students were joined by colleagues from the local Hospital Trust to treat simulated patients with a variety of presentations. The exercise was an educational activity and at key points in the simulation, action was paused to enable everyone to learn from significant injuries. The students involved were able to assist the emergency team to test disaster event response and build vital skills including interpersonal communication, supporting distressed patients, de-escalation techniques, and recognition of deteriorating patients. Nursing students assumed the roles of Band 5 Nurses and were allocated a shift. Also participating were Radiographer and Operating Department Practitioners students. Each student was designated an area (e.g. minors, majors) and was linked with a Nurse from the Acute Trust who coordinated care. The exercise used 43 simulated casualties, consisting of drama and healthcare students. Professional actors helped to support the authenticity of the event, especially around some of the more complex injuries such as a lady who required a Perimortem C Section and a patient presenting with schizophrenia. An amputee actor played the role of a person who required an amputation as a result of the simulated emergency. He was able to draw upon his own experience adding depth to the role. Simulations were designed in coordination with the hospital team to rehearse treatment of uncommon presentations. Further scenarios were developed to enable the students to achieve their proficiencies and to display the professional values required to support patients in challenging situations. Initial feedback has been very positive, highlighting how the event has helped the students build upon and consolidate the fundamental skills required to be confident and competent in their future roles [2]. We are currently awaiting formalised evaluation from a partnering university who undertook pre- and post-evaluation from all ‘players’. Immediate feedback included the students using language such as ‘empowered’, ‘empathy’, ‘unity’, and ‘team spirit’ to describe their experiences. Furthermore, the students identified that the exercise had high-fidelity and enabled them to embark on interprofessional learning to test not only their physical skills but also their emotional intelligence. Following the success of SIMEX 2022, discussions surrounding SIMEX 2023 have commenced and it is hoped the event will expand to a larger number of students across the Faculty, in line with Nursing and Midwifery Council Standards [3]. 1. The Simex Series Disaster & Emergency Response Exercise. 2. Nursing and Midwifery Council (2018) Standards of proficiency for registered nurses. 3. Nursing and Midwifery.(2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing. associates

Patients' and staff members' experiences of restrictive practices in acute mental health in-patient settings: systematic review and thematic synthesis.

Recent guidance has called for the reduction of restrictive practice use owing to growing concerns over the harmful physical and psychological effects for both patients and staff. Despite concerns and efforts, these measures continue to be used regularly to manage challenging behaviour in psychiatric in-patient settings. To undertake a systematic review of patients' and staff members' experiences of restrictive practices in acute psychiatric in-patient settings. A systematic review and thematic synthesis was conducted using data from 21 qualitative papers identified from a systematic search across three electronic databases (PsycInfo, Embase and MEDLINE) and citation searching. The protocol for the review was pre-registered on PROSPERO (CRD42020176859). The quality of included papers was examined using the Critical Appraisal Skills Programme (CASP). Four overarching themes emerged from the experiences of patients: the psychological effects, staff communication, loss of human rights and making changes. Likewise, the analysis of staff data produced four themes: the need for restrictive practices, the psychological impact, decision-making and making changes. Patient and staff experiences of restrictive practices were overwhelmingly negative, and their use carried harmful physical and psychological consequences. Lack of support following restraint events was a problem for both groups. Future programmes seeking to improve or reduce restrictive practices should consider the provision of staff training covering behaviour management and de-escalation techniques, offering psychological support to both patients and staff, the importance of effective staff-patient communication and the availability of alternatives.

2.126 Developing a Model Curriculum to Improve De-Escalation Skills of Child and Adolescent Psychiatry Physicians in Training

Many studies have examined the effectiveness of de-escalation training in reducing the use of seclusion and restraint in adult inpatient psychiatry settings, but few have published their training materials or adapted these techniques to child and adolescent populations. This project applies de-escalation techniques to child and adolescent patients and creates a model curriculum accessible to residency and fellowship programs across the nation.

Gender, police-community contacts, and situational outcomes

Abstract Recent research in policing focuses on the nature of the police-citizen interaction itself. However, little of this research prioritizes the role that community member gender plays in these interactions. We examine how gender can influence a range of police outcomes including de-escalation and procedurally just policing behaviors. Using body-worn camera (BWC) footage from over 700 police-community member encounters, this study examines how gender, along with other situational factors including contact type, guardianship, and levels of resistance influence a range of police outcomes. Findings indicate that while gender did not directly influence police action, other situational characteristics of police encounters did. Police training protocols should focus on how police can account for some of these characteristics to improve decision-making and increase use of de-escalation techniques.