Staff Resources, Education and Training

Resources, Education and Training
A major staff resource that is directly relevant to the reduction of violence relates to education and training. Some form of education and training is recognized as being necessary to adequality deal with potential violent situations. The need for education and training is highlighted especially in areas where violent incidents are more common or where there is an identified need to reduce the levels of violence in a particular location. Not many recent studies lay out the potential content of education or training programs, therefore some earlier key sources are included.

Herr, N.R, Jones, A.C., Cohn, D.M. and Weber, D.M. (2015). The impact of validation and invalidation on aggression in individuals with emotional regulation difficulties. Personality Disorders:Theory, Research and Treatment 2015, Vol. 6. No. 4, 310-314.

“Aggressive behavior is a problem for people who difficulty regulating their emotions. This experimental study manipulated validation and invalidation after an emotional experience (sad mood) with subsequent aggression being measured in an in-laboratory behavioral task. Results indicated that for those individuals who have difficulty regulating their emotions validation led to significantly less aggression than invalidation. Validation of emotional experiences may help prevent aggression among individuals who have difficulty regulating their emotions. The generalizability of the study is limited in that a nonclinical sample was used, being undergraduates that were used in the sample. However, it is suggested that validation may prevent aggressive behaviors therefore validation techniques should be taught to those who might work with potentially aggressive patients and self-validation should be encouraged among patients.”

Newbill, W.A., Marth, D., Coleman, J.C., Menditto, A.A., Carson, S.J. and Beck, N.C. (2010). Direct observational coding of staff who are the victims of assault. Psychological Services. 2010, Vol 7, No. 3, 177-189. DOI:10.1037/a0020005

“Validation turned out be a key theme in this long- term observation study on aversive interactions between staff and psychiatric patients in a state hospital. The results indicated the need to develop training strategies to prevent assault whilst recognizing that the ‘packaged” staff instruction usually provided may not be effective in decreasing the frequency of assaults on staff. Apart from the self-defense and de-escalation components of these training packages staff need to be taught that the risk of assault increases if the patient is asked to do something they do not want to do, are stopped from doing something they want to keep doing or are refused a request. It is suggested that being able to validate the emotional response of the patient and this form of validation should be part of staff training and include the ability to promote collaborative problem solving with the patient. Patients need to be offered reinforcement when responding appropriately to limit setting and need to be taught coping skills. The study looks at differences between assaulted and nonassualted staff and found that there were two possible explanations for the different rate of aversive interactions with patients. The first was that nonassaulted staff used a mixture of aversive and nonaversive limit-setting techniques, for example being aversive with a patient then using validation to help with goal setting. The second explanation focused on staff who gain immunity from assault in aversive situations by having built up a history of positive interactions with patients, for example by engaging in high levels of praise and recognition of adaptive behaviors and joining in social activities with the patient that provides “social capital”. It is suggested that this data should be used when teaching issues related to developing therapeutic relationships in clinical situations.”

Jones, N.T., Menditto, A.A., Geeson, L.R., Larson, E. and Sadewhite, L. (2001). Teaching social-learning procedures to paraprofessionals working with individuals with severe mental illness in a maximum-security forensic hospital. Behavioral Interventions. 16, 167-179. DOI: 10.1002/bin.090

“This study examined the benefits of teaching social-learning techniques to staff working in the forensic environment of a midwestern state hospital. Training led to improvement in the application of social-learning procedures as well as increases in staff activity and time spent interacting with patients. Staff trained in this approach were then available as mentors, tutors and models for peers. The study found evidence for the integrated/technical method of training with didactic instruction combined with observation and supervised application of social-learning techniques to be the most effective model of training. Caution was advised on the generalization of these findings outside of non-forensic units and due to the small sample size.”

Somani, R., Muntaner, C., Hillan, E., Velonis, A.J., and Smith, P (2021). A Systematic Review: Effectiveness of Interventions to De-escalate Workplace Violence against Nurses in Healthcare Settings. Safety and Health at Work. https://doi.org/10.1016/j.shaw.2021.04.004

“A PRISMA systematic review of the literature was conducted to gauge the effectiveness of various interventions taught to staff to reduce workplace violence in healthcare institutions, commonly perpetrated by patients, their relatives/visitors and coworkers. Twenty six studies, mostly from developed countries were included in the review. The interventions were grouped into three categories: stand-alone training used to educate nurses; more structured, broader education programs with the opportunity to practice skills and ; and multi component interventions which include often include organizational changes. Ten of the studies implemented stand-alone training sessions/workshops for nurses to counter workplace violence. The sessions were over various time frames such as three to four hour or eight hours. Nurses reported afterwards of feeling more confident in their ability to deal with violent situations and in their ability to assess violent situations. However, one study pointed out that although nurses might feel more confident in handling workplace violence training does not alter the fundamental safety concerns regarding workplace violence. Eleven of the studies used structured programs with the focus mostly being on workplace bullying/lateral violence /incivility. These structured programs included specific techniques such as a Cognitive Rehearsal Program (CRP) which involves role play facilitated by professionals; Culture of Civility, Respect, and Engagement in the Workplace (CREW); train-the –trainers promoting champions who will train colleagues; and the Management of Clinical aggression – Rapid Emergency Department Interventions (MOCA-REDI) an education program led by trained facilitators. Five of the studies were multi component interventions with a multi pronged approach usually involving relevant stakeholders to shape the format of multicomponent interventions. Training for nurses featured in almost all of the interventions and yielded positive changes with nurses reporting increased confidence and communications skills although the training interventions were recognized as being ineffective at decreasing workplace violence. It is pointed out that the training interventions do not address the behavior of the person instigating the violence, they are not the person who has received the training. However, multicomponent interventions were judged to be the most effective approach to impact the rates of workplace violence.”

Arnetz, J. E., Hamblin, L., Russell, J., Upfal, M.J., Luborsky, M., Janisse, J., and Essenmacher, L. (2017). Preventing patient-to-worker violence in hospitals: outcome of a randomized controlled intervention. J Occup Environ Med. 2017 Jan; 59(1): 18–27.

“This was a long-term action research study using a randomized control intervention across a multi-site hospital system in Michigan, USA. The intervention used was the use of an Action Plan developed from walkthroughs with stakeholder representatives such as unit supervisors in selected units. During the walkthrough possible risk factors relating to violence were identified using a checklist of Administrative, Behavioral and Environmental strategies. Sixteen of the intervention units developed action plans that were implemented and evaluated at 6 month and 24 month follow up intervals. Among the Behavioral Strategies implemented in acute care nursing settings were de-escalation training for staff, behavior management classes and strategies such as educating staff to stay calm. There were no statistically significant decreases in event and injury rates in the intervention group although that group and significantly lower risks for both events and injuries over time as compared to controls and over a 24 month post-intervention period rates of violence-related injuries were significantly lower, suggesting heightened awareness. The benefits of bringing the issue workplace violence to unit level was emphasized, suggesting that the intervention may have motivated unit supervisors and staff to assume ownership and responsibility for their problems. The authors point out that previous attempts at violence reduction in hospitals has been workplace specific whereas this study attempted to provide a standardized approach to workplace violence reporting, risk and hazard appraisal and intervention. A population approach using epidemiological analysis rather that case-based surveillance is suggested where epidemiological risk analysis can be translated into fact-based prevention practices that can be prospectively evaluated for effectiveness. The study is limited in that it was conducted in one geographical site, was time consuming for staff and contamination could have occurred over time between the control and intervention sites.”

Urheim, R., Palmstiera, T., Rypdal, K.,Gjestad, R., Senneseth, M., and Mykletun, A. (2020). Violence rate dropped during a shift to individualized patient-oriented care in a high security forensic psychiatric ward. BMC Psychiatry. May 05; Vol20(1), 200-224.

“This was a long-term study conducted over a seventeen year period in a psychiatric forensic unit in Norway employing a quasi-experimental method. The study sought to ascertain which variables contributed to a drop in the level of violence during the period of the study. During the study period there were arrange of changes made to care and organizational variables. One of the most important changes highlighted was the shared staff and patient review after a violent incident that reflected on the perspective of the staff and the patient. Forensic patients reported feeling safe and understood and trusting of staff was crucial to their recovery. An increase in the number of educated staff and in the number of female staff were also seen as being important variables in the reduction in the levels of violence. The introduction of less coercive approaches to care such as increased patient autonomy, unescorted leave, reduced use of sedating antipsychotic medication were thought to reduce violence whilst the restrictions placed on patients, loss of freedom in relation to every-day frustrations may have increased levels of violence. There was more violence found amongst newly admitted patients. The only individual patient characteristic that was noted was unstable personality disorder and it was thought this patient diagnosis might be over represented in the forensic setting and linked to higher rates of aggression. It was reported that overall most of the changes brought in during the 17 year time period of the study had helped to produce a decline in the occurrence of violent incidents. These included new treatment and care routines, an increased proportion of female staff and higher education levels for staff. A rival hypothesis was put forward that was not examined was that perhaps patients admitted later in the study period were less violent and it was pointing out that the clustering of variables to prove causality can be problematic. However, the study found overall that a shift towards individualized –orientated care delivered by a well-educated nursing staff with a balanced gender proportion, was related to a reduced rate of violent incidents in a high secure forensic unit.”

Searby ,A., Snipe, J., and Maude, P. (2019). Aggression management training in undergraduate nursing students: A scoping review. Issues in Mental Health Nursing, 2019 June; Vol. 40 (6) 503 – 510.

“The need for nurses to be able to manage aggression and violence as they begin their nursing careers was highlighted in this review carried out in Australia. The feasibility of dealing with workplace aggression and violence was shown to be a topical issue related to job satisfaction, attrition and higher rates of turnover. It is important to retain and support newly qualified healthcare staff such as nurses. It was postulated that providing aggression management training to undergraduate nursing students would better prepare them for the work force. The review focused on seven studies that had employed a range of approaches utilizing different formats, content and fashions to provide aggression management training to undergraduate students. The efficacy of the training provided was usually determined through the use of pre-test and post-test. These results indicated improvements in competence and attitudes in the students but it is suggested that to really determine the efficacy of the training programs additional measures have to be made beyond the pre-test/post-test approach. For example, the use of more up-to-date approaches to training such as the use of simulation should be considered. Overall it was recommended that aggression management training should be considered as essential in the nursing curriculum to provide neophyte nurses with the skills and capabilities to manage aggression and violence in their future workplace. However, no mention was made on the impact this training would have on the potential overconfidence of these newly qualified nurses or ability to select appropriate strategies to combat aggression and violence in the workplace.”

Feinstein, R. E., and Yager, J. (2018). A Live Threat Violence Simulation Exercise for Psychiatric Outpatient Departments: A Valuable Aid to Training in Violence Prevention. Academic Psychiatry volume 42, 598–604.

“The use of simulation in training to prevent violence was investigated in this long term study in Colorado. There was concern regarding the potential of violence towards staff in psychiatric outpatient settings. A violence simulation exercise was developed, implemented and evaluated to help reduce the risk of future outpatient violence and minimize and effects of future violence on staff. As a companion to a seven hour violence prevention program a four hour live violence threat simulation exercise was provided. The simulation included an orientation and two threat simulation scenarios. Each simulation was followed by debriefings, satisfaction surveys, problem identification, action plans and annual safety and process involvements. During a five year period the authors collected survey data on the simulation exercise and respondents who responded (more than 52%) reported the simulation to be “very helpful/helpful, and they were “:much better/better” prepared to deal with violent episodes. The actual impact on reducing the level of aggression and violence in outpatient settings is difficult to ascertain but during the five years of the study there were four major violent incidents and thirty-six potential violent incidemts but there were no staff injuries and only one staff meaner who suffered minimal psychological sequalae. It was also reported that following the simulation a small number, less than 2%, of the participants experienced post-simulation side effects such as worries about past trauma; anxiety; sleep problems; and increase in workplace concerns. Overall, the participants in the simulation felt found the simulations to be helpful and they felt better prepared to manage violence. Following the simulation exercises changes were initiated in the outpatient settings including staff safety behavioral changes, physical space layout and improvements to safety processes. The authoress reported that the use of the simulation exercises over a prolonged period had promoted excellent relationships between staff and police and had help produce a consistent safety record.”

Asikainen, J.,Vehvilainen-JulKunen, K., Repo-Tilhonen, E., and Louheranta, O. (2020) Violence factors and debriefing in psychiatric inpatient care: A review. Journal of Psychosocial Nursing & Mental Healthy Services, 58(5) 39-49.

“This review from Finland examined thirty nine publications relating to violence factors in psychiatric care. The potential for using debriefing to reduce the incidence of violence was then explored. There were a range of influencers that were thought may trigger violent incidents, these included patient characteristics, management, staff approaches, and the unit environment. The most effective ways of reducing violence in psychiatric care centered on three areas where nurses have a major input: nursing communication; leadership; and debriefing. Debriefing plays an important role in helping reduce violence, that along with nursing communication and aspects of leadership are areas where training is important.”

Tuente, S.K., Bogaert, S., Bulten, E., Keulen-de Vos, M., Vos, M., Bokern, H., van Ijzendoorn S., Garaets, C.N.W., and Veling, W. (2018). Virtual reality aggression prevention therapy (VRAPT) versus waiting list control for forensic psychiatric inpatients: A multicenter randomized controlled trial. Journal of Clinical Medicine, 2020 Jul; 9(7): 2258. Published online 2020 Jul 16. doi: 10.3390/jcm9072258

“This is a multi-cite study from the Netherlands piloting a new form of simulation for patients using virtual reality scenarios to train forensic psychiatric patients in preventing aggression. Interestingly, the onsite training was focused on the patient rather than the staff. Patients were divided into two groups; those receiving the Virtual Reality Aggression Therapy (VRAPT), or those on the “waiting group” (who did not receive VRAPT). The VRAPT was delivered via sixteen bi-weekly sessions that lasted on average for one hour. During the session the patient worked through exercises to practice new and adaptive behavior the Social Information Processing Model (SIP). The SIP helps people respond to social situations, such as those that can lead to aggressive behavior, using six cognitive-emotional steps. The outcomes were measures using a range of tools primarily focused on the level of aggression post-treatment. The study rather disappointingly found that no significant improvements in aggressive behavior were found after VRAPT compared to the waiting list patients. The authors point out the previously documented fact that aggressive behavior in forensic patients is not easily changed. Also, treatment effects in forensic psychiatry might be impacted by the comorbidities often associated with this patient group. Although it was difficult to establish treatment effects and change behavior in psychiatric patient, it is suggested that VR treatment should be investigated with other populations with aggressive behavior problems.”

Lantta, T., Anttila, M., Kontio, R., Adams, C.E. and Valmaki, M. (2016). Violent events, ward climate and ideas for violence prevention among nurses in psychiatric wards: a focus group study. International Journal of Mental Health Systems, 2016; 10: 27. Published online 2016 Apr 5. doi: 10.1186/s13033-016-0059-5

“This descriptive, exploratory study discussed some interesting concepts in relation to the education and training of nurses in psychiatric units in relation to violence. The study used focus groups in three in-patient psychiatric units in one hospital in Finland to explore nurses’ experience of violent events and provide insight into ward climate and violence prevention. The importance of the nurses’ experiences was highlighted and it was pointed out that experience of violent events provided warning signs which helped predict forthcoming violence which often had complicated circumstances involving both nurses and patients. A key suggestion for violence prevention was a more skilled interaction between nurses and patients and an increase in contact between nurses and patients on the unit. Violent events have implications on training, administration and policy with the participants suggesting four areas to improve the effectiveness of violence prevention. These were in-service training, competent interaction, presence of nurses and security improvements. It was suggested that training should include more comprehensive observation skills related to the interpretation of signs or triggers. It was recognized that some nurses have a natural way of engaging with patients, but knowing that the behavior of a nurse can provoke a patient most nurses need training in patient engagement. Pointing out the deficiencies of de-escalation training focused on physical restraint introduced in Finland in the 1990’s, the authors suggest that training should focus more on promoting competent interactions by nurses respecting patients’ perspectives.”