Implementing de-escalation in emergency units in psychiatric and general hospitals in Slagelse – a pilot study

Abstract

Background: During the last decade, 21% of all people admitted to psychiatric hospital in Denmark were subjected to coercive measures, like mechanical restraint; preventing this is a difficult task. Hospitals used mechanical restraints for patients assessed to be in a dangerous situation towards themselves or to others. Especially patients who presented with physical and psychiatric illness were at risk of being subjected to mechanical restraints. To learn avoiding subjecting this group to mechanical restraints, this pilot-study investigates whether an integrated restraints-reduction and violence-management-program, developed in psychiatric context, is helpful for general-hospitals. There is a lack of research-based knowledge about the effects of restraints reduction and violence management-programs in general-hospitals. Existing studies focus on mental-healthcare and suggest that organizations must look beyond staff-training to achieve meaningful reductions in aggressive incidents and staff-injuries, such as circumstances related to management and cultural beliefs. Furthermore, there is limited knowledge about what kind of violence, staff in general-hospitals experience. Mental-healthcare-services–Region Zealand developed a concept to manage conflicts and prevent threat, violence and coercion. The concept looks beyond scholastic staff training by including an awareness of interactional processes in the working culture and in collaboration processes. The concept embeds proactive interventions, where staff help the patients/visitors gaining control, by verbally redirecting them towards a calmer personal space through systematic de-escalation processes. The concept includes: 1) Implementing a de-escalation guideline. 2) Following a training-program, 3) Developing mutual collaboration processes between staff and patients/visitors. Hypotheses: Successful de-escalation prevent violence and use of coercive measures will be reduced. Aims: 1- Identify aggressive and violent incidences. 2- Implement and evaluate de-escalation-strategies in general-emergency-units in a partnership with psychiatric-emergency-units. 3- Learn how de-escalation-strategies developed in psychiatric context can be use-full in general- hospitals. 4- Encourage mutual collaboration between staff in psychiatric-emergency-unit and in general-emergency-unit, to establish mutual learning processes. 5- To investigate whether staff in emergency-units is qualified to cope with violence and aggression after education and training in de-escalation approaches. Method and design: We designed the study as an exploratory, descriptive implementation study based on action-research-principles. Staff are involved in the research as co-researchers encouraging/promoting professional competences among the involved through a systematic reflection on personal clinical experiences. The study is undertaken from 2017-2018 and involve 400 staff working in emergency units (n=3) in a psychiatric and general hospital in Region Zealand (approximately 290.000 inhabitants). The patients’ short length of stay and the patients’ physical and psychiatric problems challenge these units. Data collected for evaluation: Staff-Observation-Aggression-Scale, coercive interventions, injuries among staff, and qualitative data through field observations, interviews, and questionnaires. Expected results: 1- Staff will: A) establish raised awareness of how to prevent violence and thereby prevent use of mechanical restraints B) gain knowledge about how to manage conflicts and prevent negative violence spiral. 2- Produce knowledge about whether an education and training concept of integrated conflict-management and coercion-prevention is useful, in context of both psychiatric- and general-hospitals. Perspectives: We anticipate that this training approach will significantly reduce the use of mechanical restraints and reduce work-related injuries among staff.

Keywords

• de-escalating
• integrated care
• psyciatry and general emergency departments