Development of an evidence-based training intervention for mental health staff in de-escalation techniques for the management of violence and aggression: evidence identification and theory development

Abstract

BackgroundViolence and aggression occur commonly in mental health settings. De-escalation techniques, a range of verbal and nonverbal skills aiming to reduce aggression, are recommended yet the evidence-base for use and training impact is limited. There is, therefore, a need for the development of new, evidence-based interventions to establish effectiveness and increase safety.AimsTo provide the preparatory work necessary to develop an intervention to improve de-escalation techniques and reduce harms to service users and staff.MethodsA two phase design based on the Medical Research Council framework for complex interventions was adopted. This consisted of a systematic review of evaluated training interventions and semi-structured interviews and framework analysis with mental health staff and service users. Data was synthesised with the results of a qualitative review of the techniques completed prior to the PhD.ResultsThe systematic review identified no RCT-supported training intervention and limited acceptability data. The service user interviews revealed factors barring, reducing and enhancing the effective use of de-escalation techniques. Factors barring use included: failure to investigate aggression causes and use containment as last resort. Factors reducing effectiveness related to disrespect, ward rules and individual service user factors. Factors enhancing effectiveness related to: reducing social distance, rule subversion and authenticity. Staff interviews revealed a continuum of 14 interventions used in response to escalating aggression ranging between 'support' and 'control.' The cognitive, affective and organisational influences on where staff intervened along this continuum revealed important pointers for intervention. The synthesis revealed six clear mechanisms through which de-escalation techniques may be improved. These were: enhancing staff emotional regulation skills; increasing accountability for non-last-resort containment use; providing an alternative framework of routines to use in response to aggression; promoting greater respect for service users; harnessing service user-specific knowledge to inform individualised interventions; promoting de-escalation-focused regimes.Conclusion Results revealed important mechanisms through which a more effective, evidence-based and acceptable intervention may function.

Date of Award	31 Dec 2016
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Karina Lovell (Supervisor) & John Baker (Supervisor)