Editor’s note: first published by Mad In America on July 30th 2024
A novel, trauma-informed approach to deescalation training in psychiatric settings may improve care and reduce coercion.
Despite the advocacy of service users and clinical guidelines calling for de-escalation strategies to be used over restrictive techniques in managing aggression in mental health settings, coercion and force are still commonly applied.
In a step forward, a recent study published in the Journal of Psychiatric and Mental Health Nursing, led by Andrew C. Grundy of the University of Manchester, indicates that codesigned and co-delivered trauma-informed de-escalation training is more likely to be embraced and implemented by mental health staff.
The authors write:
“This study illuminates the characteristics of de-escalation training likely to enhance acceptability and uptake for mental health professionals working in ward environments. A trauma-informed approach to de-escalation, which focuses on creating trauma-sensitive clinical environments, was acceptable and impactful on trainees from different service settings. The model of facilitation, whereby training content was co-delivered by service user, carer, and staff facilitators, was a key factor in the acceptability and perceived impact of the training package.”
This innovative training, which emphasizes trauma-informed practices and collaborative delivery by service users, carers, and staff, is seen as beneficial and impactful by its participants. While trainees found the training worthwhile, they also expressed a desire to see the training adapted to specific psychiatric wards and contexts.
Although clinical guidelines call for de-escalation to manage violence and aggression in mental health settings, research has shown that mental health staff often rely on restrictive techniques. According to the authors of the current work, standard de-escalation training is likely not impactful or accepted by mental health staff. The goal of the current research was to investigate mental health staff’s view of a codesigned, co-delivered de-escalation training program in various inpatient psychiatric settings.
The researchers developed a de-escalation training program for psychiatric settings under the guidance of training specialists, academics, clinical staff, service users, carers, and a lived experience advisory panel. The training program consisted of 4 modules: Introduction to Trauma, Creating Trauma-sensitive Clinical Environments, Verbal De-escalation, and Sensory-based De-escalation, which included compassionate engagement with voices. Additionally, the program introduced practices designed to apply the training to real-world situations, including:
- a codesigned welcome guide to give to patients on admission
- a welcome team
- a set of standards for ward rounds
- a collaborative antipsychotic-prescribing model
- an environmental audit led by a service user fortnightly (bi-weekly)
- a “here to help” lanyard to identify a staff member available to deal with patient needs
- a patient handover sheet to capture service user perspectives on the past shift
- feedback boxes for both staff and service users, routinely reviewed with senior management
- a model of post-incident debrief
- reflective sessions for staff led by ward psychologists
- sensory plans devised with OTs
- sensory equipment
The authors recruited ten psychiatric wards to participate in their de-escalation training program. Two acute inpatient wards, two psychiatric intensive care units, and six forensic psychiatric units (two low security, two medium security, and two high security) participated. Two hundred fourteen mental health staff members completed the training.
The training took place over seven hours at an NHS training venue. One academic/nursing/training specialist, one service user, and one carer delivered the training. After receiving the training, mental health staff were invited to complete the Training Acceptability Rating Scale (TARS), an assessment designed to measure the acceptability and impact of a training program. 211 of 214 mental health staff completed the TARS assessment.
The codesigned and co-delivered de-escalation training was generally well-liked by the participants. The training program scored a median of 33/36 in terms of acceptability and 23/27 in terms of perceived impact. The majority of participants ‘strongly agreed’ that the training program was generally acceptable (57.8%), effective and beneficial (55%), and had high social validity (50.2%). 46.5% ‘strongly agreed’ that the program was consistent with best practices, 49.8% ‘strongly agreed’ that the training was appropriate, and 48.6% ‘strongly agreed’ that the training was unlikely to cause harm.
Most participants found the trainers competent and engaging. A Majority gave the highest rating possible for trainer competence (77.6%), covering the intended material (64.9%), how the trainers related to trainees (76.3%), and how motivating the trainers were (66.4%). 2/3 was the most common score given for whether the training improved understanding (47.4%), helped develop skills (51.7%), increased confidence (49.3%), and whether trainees would use the training in the future (46.9%).
The researchers identified five overarching themes from the open-ended TARS questions about the most helpful parts of the training, suggested changes, and other comments:
Modules of Interest
Seven participants reported that the training’s focus on de-escalation was the most helpful aspect, and nine said the same about the program’s trauma-informed approach. Thirty-three participants identified specific modules as the most helpful. Twenty-four said the section that covered working with service users hearing hostile voices was the most helpful. Four reported that the introduction and its focus on the neuroscience of trauma was the most helpful section. Five said the same about the sensory intervention sections, while four found the verbal de-escalation sections most beneficial.
Multiple Perspectives
Thirty-nine participants identified the service user and carer trainer perspectives as the most helpful aspect of the training, and 17 reported that they valued sharing their experience. Eight participants especially appreciated the lived experience perspectives around hearing voices.
Modes of Delivery
Eight participants commented that the training delivery was ‘good or great.’ Twelve participants commented that they especially enjoyed the group work, with five indicating that they would like more group interaction. Eight people commented that they appreciated the presentation of videos as part of the training. Eight participants also found the presentation of case studies and examples helpful.
Molding to Context
Seven participants believed the training was applicable and appropriate to their practice. Five participants reported that it needed to be better tailored for practical use in psychiatric wards.
Modifying Other Elements
Several participants suggested other changes that could be made to the training. One trainee felt unprepared for the program. Another commented that the training should use terms like ‘service user’ or ‘person’ rather than ‘patient.’ One participant suggested that interventions should be discussed after each section, and one wanted follow-up info on the training, writing, ‘How has it worked/been implemented?’
The authors acknowledge several limitations to the current work. The TARS assessment does not evaluate whether or not the participants believe the training program can be implemented in their specific working environment. It only captures attitudes immediately following the training. No demographic data was collected from participants. The entire training program happened over a single day. The present research occurred entirely within the UK, limiting generalizability to other populations.
The authors conclude:
“We recommend co-production models for designing and delivering training to mental health professionals. While the training was acceptable and impactful, further research is needed to demonstrate whether it is clinically and cost-effective.”
Past research has highlighted abuses suffered by service users in inpatient psychiatric settings. This problem is especially pronounced for minorities. Research has also found that inpatient care does not reduce suicide risk and may actually increase it.
Experts have commented that the focus on the biomedical model within the psy-disciplines has led to troubling mental health nurse education. Research has shown that trauma-informed care can reduce self-harm and restrictive practices (restraint and seclusion) in inpatient settings. However, some service users have had poor experiences with trauma-informed care.
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Grundy, A. C. et. al. (2024). Evaluation of a novel codesigned and co-delivered training package to de-escalate violence and aggression in UK acute inpatient, PICU, and forensic mental health settings. Journal of Psychiatric and Mental Health Nursing. (Link)