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

Owen Price, Cat Papastavrou Brooks, Isobel Johnston, Peter McPherson, Helena Goodman, Andrew Grundy, Lindsey Cree, Zahra Motala , Jade Robinson, Michael Doyle, Nicholas Stokes, C J Armitage, Elizabeth A Barley, Helen Brooks, Patrick Callaghan, Lesley-Anne Carter, Linda Davies, Richard Drake, Karina Lovell, Penny Bee

Research output: Contribution to journalArticlepeer-review

Abstract

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 e.g., self-harm. All NHS 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; 4) 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 Experienced-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 eight-week pre-intervention phase, an eight-week embedding and an eight-week post-intervention phase.
Setting
Ten inpatient wards (including acute, psychiatric intensive care, low, medium, and high secure forensic) in two UK Mental Health Trusts.
Participants
In-patients, clinical staff, managers, carers/relatives, and training staff in the target settings.
Interventions
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 (PCC-SR) were very good (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. The follow up phases of the study were associated with statistically significant 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.
Study registration
ISRCTN12826685 (closed to recruitment).
Funding details
Funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (ref: 16/101/02).
Original languageEnglish
Pages (from-to)1-218
Number of pages218
JournalHealth Technology Assessment
Volume28
Issue number3
Publication statusPublished - 30 Jan 2024

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