Abstract
There is a shortage of psychiatric nurses in hospitals around the world. In the US alone, understaffing of psychiatric wards is estimated between 11% and 28%, which is expected to only get worse in the future (Niu et al., 2019). Violence against nurses is one of the strongest predictors in leaving the profession, as psychiatric nurses are 20 times more likely to be exposed to verbal or physical violence (Niu et al., 2019). The rate of violent incidents is very high, standing at 0.55 incidents per patient bed in a month, which corresponds to the statistics of 82% of women and more than 50% of male nurses facing patient-incited violence at least once a year (Niu et al., 2019).
Such incidents greatly increase the likelihood of leaving the profession, contributing to the already enormous attrition rates. De-escalation techniques are some of the tools available to a nurse when dealing with a conflicting patient. Some of these methods involve physical or drug-based restraint, while others are milder and less invasive, including psychological techniques, such as speech, dance, and other cognitive-behavioral tools of influence. The proposed research of quasi-experimental design seeks to evaluate the existing levels of knowledge in psychiatric nurses, educate them in various forms of de-escalation, allow them to utilize the techniques in practice, and evaluate the effectiveness of various forms on nurse satisfaction as well as patient violence rates.
Introduction
Nurses working in psychiatric services are exposed to much greater degrees of verbal, emotional, and physical violence when compared to other nurses. Niu et al. (2019) report that, on average, nurses in psychiatric wards experience 0.55 incidents of patient-incited violence per bed per month, which is 20 times higher than in other nursing professions. The issue is magnified by the fact that patients cannot always control their violent impulses, and that nurses do not know how to appropriately diffuse the situation (van Leeuwen & Harte, 2017). Because of the high rates of violence, the potential for injury and trauma, and other related factors, turnover rates among healthcare workers in mental care facilities are significantly higher (Zhao et al., 2018).
These issues lead to a broad range of consequences for mental healthcare. In the US, to attract and retain nurses, healthcare providers are forced to pay psychiatric nurses about 1/3 more than the average RN earns per year, with paychecks exceeding 100,000 dollars per nurse versus 70,000 dollars per country average (Delaney, Drew, & Rushton, 2019). While the financial compensation is certainly warranted, it imposes additional costs on the system, which are, in turn, making psychiatric assistance less available to the poor and vulnerable populations.
High turnover rates also produce understaffing issues, forcing hospitals to impose overtime on their existing staff, potentially exacerbating burnout, apathy, and care fatigue in nurses (Hulme et al. 2019). All of these factors create a full circle, where nurses leave because of various stressors, which become more pronounced due to a lack of staff.
De-escalation techniques remain some of the very few tools in a nurse’s repertoire that he or she could use in order to prevent a violent incident from occurring (Kuivalainen et al., 2017). However, the information regarding the available techniques and their comparative effectiveness is scattered and incomplete (Kuivalainen et al., 2017). As such, it is difficult to make estimations and recommendations for situations in which particular methods would be effective. Together, all of these factors form a complex issue that reduces the effectiveness of mental care and increases the chances of negative outcomes for patients and nurses alike.
Overreliance on physical and pharmacological restraining methods as the most intuitive and readily available tools in a nurse’s arsenal has been causing short-term injuries in patients in 55% of all restraining cases (Juromski et al., 2018). In addition to this issue, the use of standard protocols is associated with long-term deterioration of trust between nurses and patients, making repeat incidents occur in the future (Vermeulen et al., 2019).
Therefore, several concerns are brought up in regards to violence towards nurses in wards. The first concern is the security of patients and nurses alike, with the overarching goal being to bring down the number of incidents and reduce the impact for all parties in those that do occur. The second concern is to reel in the economic impacts of such behavior on the mental healthcare system. The third concern is to identify the appropriateness and effectiveness of available de-escalation tools and techniques available to nurses. The gaps of knowledge do exist, as in the majority of available sources, there is a lack of a holistic approach to all of these issues, instead of seeking to provide an answer to a single piece rather than foresee the greater implications of their findings (Kuivalainen et al., 2017).
Problem Statement
As it stands, there are several methodologies of de-escalation being implemented in contemporary psychiatry. The most traditional method involves physical de-escalation and tranquilization of the patient, which relies on immobilizing the aggressive person using physical force and specialized tools (Kuivalainen et al., 2017). Pharmacological tranquilization is another method of calming down the patient by either injecting tranquilizer agents into their bloodstream or spraying it in the air in aerosol form (Kuivalainen et al., 2017).
Both of these methods are invasive and threaten injury not only for the nurses attempting it but for the patient as well. In addition, these methods are considered controversial in the scope of not only the nursing community but also the society in general, coming very close to violating patient dignity and rights.
Alternative methods of de-escalation include unorthodox ways, such as verbal de-escalation, dance-based de-escalation, repeating motion techniques, hypnosis, etc. (Brewer, Beech, & Simbani, 2017). The effectiveness and acceptance of these means are unclear, especially when compared to traditional methods (Brewer, Beech, & Simbani, 2017). In addition, the state of knowledge among nurses in regards to de-escalation techniques remains unknown (Thompson, Thompson, Gaskin, & Plummer, 2019).
Therefore, the comparative viability of utilizing these techniques for nurses should be established. The proposed solution is to compare the effectiveness of various non-invasive de-escalation techniques (verbal, dance, replication) versus invasive ones (pharmacological, physical restraining) in reducing patient aggressiveness levels during various stages of conflict (verbal assaulting, general aggressive behavior, attempts at violence, etc.).
Background
Psychiatry is one of the most demanded fields of medicine in the US and the world. The number of US citizens that have experienced a mild mental disorder is 19.1% a year, with an additional 4.6% experiencing significant mental impairments (NAMI, 2019). Thus, roughly every 4th American requires short-term psychiatric assistance, and roughly 1 in 25 requires long-term psychiatric surveillance. The reasons for such an increase in mental health reliance are associated with the increased job-related stress, higher population mobility, the ever-shifting demands of the market, the development of addictive technology, and the atomization of the society, among various others. Therefore, the necessity for a well-developed psychiatric healthcare system in modern society is well-pronounced.
At the same time, the US and the world healthcare systems are experiencing a chronic shortage of nurses. With the increase in population numbers as well as the growth in geriatric patients, it is estimated that 11 million additional nurses would be required by 2040-2060, roughly 11% of which would need to be psychiatric nurses (Ong et al., 2017). At the same time, the overall growth of nurse numbers is very slow, roughly 0.5% a year, which is bound to be offset by a looming retirement of nearly 20% of nurses representing the baby boomer generation (Ong et al., 2017). This is especially threatening to the psychiatric segment of healthcare, where the number of new recruits has been historically low.
Low retention rates in psychiatric medicine have always been associated with increased physical and psychological pressure on nurses working with potentially dangerous patients (Niu et al., 2019). Whereas nearly all other areas of medicine can expect their patients to be actively interested in assisting nurses in their work, psychiatric nurses have to deal with individuals who are confused, disoriented, or openly hostile to their wards, leading to increased chances of violence escalation during various procedures, without much of a warning or provocation patients (Niu et al., 2019). Recent reports indicate that roughly 50% of men and 80% of women in the profession have been exposed to patient attacks at least once in the past year (Niu et al., 2019).
While recruitment and retention of nurses are a global issue that requires a multi-vectoral approach, one of the interventions that could be done to improve the immediate situation require the assessment and implementation of effective de-escalation techniques that would prevent nurses from being endangered, assaulted, and hurt by patients either through emotional, verbal, or physical confrontation. Vermeulen et al. (2018) report that the first serious threat of violence can result in a nurse leaving the profession, especially if any physical damage was taken as a result. The study also shows that the effects of violence have a bigger effect on nurses than patients, whereas physical de-escalation has a greater negative impact on patients as a result (Vermeulen et al., 2018).
Verbal aggression is another form of violence instigated by patients against nurses. In some cases, it is reciprocated, creating a power dynamic that is unfavorable towards patients, who are relying on nurses in order to continue daily functioning. A report by Oyelade, Smith, and Jarvis (2017) states that verbal aggression usually serves as a prelude to physical violence, leading to the deterioration of perception of hospitals as safe spaces and nurses – as individuals who are there to help out. Therefore, de-escalation of verbal aggression and the principles of nonaggression are considered primary in defusing such situations. Nevertheless, the repetitiveness and ease of delivery make verbal aggression an important detriment to nurse resilience (Oyelade et al., 2017).
The set of guidelines for de-escalation as provided by NICE (2015) offers the official view on the issues of violence against psychiatric nurses. The guide provides information on main de-escalation techniques and recommends physical restraint as one of the safest ways of preventing violence. In addition, the guide refers to the interceptive nature of de-escalation, stating that predicting when violence would occur and avoiding it is much easier than dealing with the consequences of an attack (NICE, 2015).
These findings align with several other studies on the issue, namely the one by Halett (2018), which investigated the instances and effectiveness of conflict management techniques. According to the research, conflict avoidance is a viable strategy, especially in patients that are not in a constant fit of aggression. Knowing the triggers that provoke patients and leaving them alone for the anger to dissipate saves time, nerves, and money for both parties (Halett, 2018).
At the same time, the study indicates that the implementation of conflict avoidance is not always an option, as procedures that involve unpleasant feelings are often unavoidable, and tend to be the primary triggers for patients (Halett, 2018). The current situation in regards to the nursing shortage, the incidence of violence, and the general mood in psychiatric hospitals show that the existing guidelines are only partially effective in changing the trends.
With pharmacological and physical de-escalation techniques being considered too invasive and only focused on the short-term benefits, some researchers focused on milder and non-invasive approaches utilizing a variety of cognitive-behavioral methods, ranging from verbal de-escalation techniques to dancing and mimicking approaches (Biondo, 2017). The idea behind these methods is similar – to make the individual perceive the nurse as less of a threat or bring their minds in a state of confusion in order to prevent an impending attack.
Biondo (2017) evaluated the potential for dance therapy to not only help de-escalate violent behavior of nurses and patients but also act as a stress reliever for both parties. Brewer et al. (2017) provide a complex review of both types of approaches, comparing their effectiveness. While pharmacological and physical methods were deemed effective at preventing immediate aggression, the effectiveness of milder forms of restraint offered only conflicting information on the subject (Brewer et al., 2017).
The state of knowledge is one of the major indicators of nurse response towards aggression as well as the levels of the appropriateness of de-escalation. While psychiatric nurses as well as healthcare workers from other departments are given a course in de-escalation during their education, such knowledge tends to fade away or be replaced by realities of work. Therefore, it needs to be refreshed in order to increase nurse responsiveness, reduce care fatigue, and encourage mindfulness when dealing with patients. Thompson et al. (2019) indicate that educational intervention aimed at nurses has a largely positive response and offers great improvements in handling patients as well as increasing the overall morale of the participants involved in the study. These findings make educational interventions viable for implementation in the course of this study.
Purpose
The purpose of the study is to implement an educational intervention for psychiatric nurses, in order to improve their morale, knowledge, and handling of violent patients. In addition, the study wishes to provide a comparative analysis of situations and different methods of de-escalation in short-term and long-term perspectives. As such, it will answer the questions posed in several articles in one and provide a solid framework for future research.
The overarching purpose of the research includes improving the state of practice in psychiatric wards and giving guidance to other studies in order to improve the existing techniques and throw away ones that do not work as expected. While pharmacological and physical restraints are likely to remain in practice, the overreliance of nurses and wards on such can be put into question, especially in the light of new, less invasive methods being brought into practice. The issues of current levels of nursing knowledge of de-escalation techniques will also be brought into the light.
The broader implications of the research for the state of nursing and medicine are that, should the proposed intervention be successful, it could be replicated in other hospitals and at a larger scale, thus improving patient and nursing outcomes. Additional purposes include reducing turnover rate, violence rates towards nurses, ineffective or over-the-top responses from the psychiatric ward towards patient violence escalation, and highlighting various leadership and organizational challenges the study will encounter along the way, as well as ways of overcoming them.
The Nature of the Project
The proposed project is an educational and applicational intervention, that will use a quantitative design. Such a methodology is preferable in medical research, as it offers statistically-significant data that is difficult to misinterpret. The data of interest for this project is as follows: the state of knowledge of de-escalation techniques before and after the educational intervention, the implementation of such techniques during conflict situations, and the effectiveness of in different scenarios. Due to the relatively small estimated number of participants within a single ward, as well as the inability to create a control group, the project will follow a quasi-experimental design. The results will be compared to the baseline of patient-nurse conflict incidents in the past years as well as the country’s overall average.
The first part of the intervention would involve examining the theoretical and practical knowledge of all nurses that expressed the desire to participate. This will be done using a custom test that will be based on those used in the examination of nurses to fit for registration, in order to learn how much knowledge was retained during the years of practice. The scores would present quantitative data to be compared later with similar tests administered after the training. It would help evaluate the improvements and the immediate effects of the intervention on the knowledge levels of the nurses. Finally, the third test would be held after they are given the opportunity to use their newfound and rediscovered knowledge in a practical setting.
After training was administered, nurses would be allowed to return to their duties. For the duration of the practical part of the study, they would be required to fill out special forms whenever a potential event of violence occurred, including a brief description of what happened, the type of de-escalation technique implemented, and its effectiveness in resolving the situation. This would provide additional qualitative and quantitative data that would help evaluate the effectiveness and frequency of use of different de-escalation techniques in the setting, allowing for comparative analysis.
The results will allow creating a correlation between different de-escalation methods, success/unsuccess rates, and frequency of use. The total number of successful and unsuccessful incidents will be compared with data from previous years, in order to understand whether the intervention managed to reduce the number of violent attacks on nurses.
Finally, the third batch of tests would involve the evaluation of nurse burnout and care fatigue before and after the intervention. It will be done using the Maslach Burnout Inventory, which contains 26 items that could be used to determine the levels of burnout in individual nurses. It is theorized that with the improved effectiveness as a result of the educational intervention and greater understanding of the mechanisms behind patient aggression, the levels of burnout are bound to go down, associated with greater safety of the working environment.
Research Questions
Based on the background studies and evaluations of the existing problem, the research questions to be addressed in the scope of this research are as follows:
- Evaluate the existing state of knowledge of de-escalation techniques in nurses working in a psychiatric ward.
- Evaluate the existing levels of burnout as a result of patient violence as well as other conjoining factors.
- Evaluate the improvements (or lack thereof) on both the knowledge and burnout rates as a result of the intervention.
- Test out the effectiveness of various de-escalation methods on patients as well as their applicability to various situations.
The PICO framework for the research is as follows:
- P= Patient violence against psychiatric nurses;
- I= Education in de-escalation techniques;
- C= Baselines for patient violence incidents from previous years;
- O= Decreases in patient violence incidents, burnout rates, increases in knowledge levels and nurse satisfaction.
The complete PICO question, thus, is as follows: In psychiatric nurses (P), does education in de-escalation techniques (I), when compared to baselines for patient violence incidents from previous years (C), result in decreases in violence, burnout rates, and increases in nurse satisfaction and knowledge levels (O)?
Summary
Nurse psychiatrists are in very high demand due to increasing rates of mild and significant psychiatric disorders in the US and the world in general. At the same time, it is one of the most dangerous and exhausting professions due to the constant physical and emotional stress as well as the potential for violence. One of the ways of mitigating these issues is to engage in de-escalation techniques that seek to prevent a violent incident early on or reduce the damage dealt with by the nurse by the patient.
There are different types of violence, including verbal, psychological, and physical. While physical violence is typically handled using physical restraints or medicaments, verbal and emotional violence has a broader variety of potential responses. Some of the de-escalation techniques that recently attracted attention include verbal de-escalation measures, dance-based de-escalation, and cognitive-behavioral instruments.
The proposed research seeks to improve the quality of life in nurses, reduce the number of violent incidents with patients, and increase their knowledge of de-escalation techniques. This is proposed to be done via an educational intervention of quasi-experimental design. Quantitative data will be gathered by using tests, self-report cards, and the Maslach 26-item burnout inventory. The research has a broad range of implications for the nursing profession and psychiatric medicine in general, as positive results would suggest its viability to be implemented in larger settings.
Reduction of violent incidents in patients would not only benefit nurses, but patients as well, by protecting them from the ability to cause damage, improving nurse behavior, reducing burnout, and facilitating better patient outcomes in both the short-term and long-term perspectives.
References
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