Title: Enhancing de-escalation techniques in adult acute and forensic units: development and evaluation of an evidence-based training intervention. (EDITION)
Funder: Department of Health and Social Care

Abstract: Design: Our study aims to develop and evaluate a feasible, acceptable, evidence-based intervention to enhance the implementation and effectiveness of de-escalation techniques in clinical practice. Informed by the MRC Framework for Complex Interventions (10), 3 separate but interrelated Work-Packages (WPs) are proposed. WP1 will, through systematic review updates and qualitative research, investigate contextual variation in the use and effectiveness of de-escalation when applied in different settings and to different subgroups. WP2 will synthesise WP1 learning, identify behaviour change targets and co-develop, with multiple stakeholders, a feasible and acceptable training intervention. WP3 will implement the training package in a diverse range of clinical settings and using case study methodology, evaluate its feasibility and impact. Settings: 10 inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two UK Mental Health Trusts. Strategy for reviewing literature: We will update our systematic review of de-escalation training effectiveness and acceptability (2). Searches will be conducted from August 2014, results screened for relevance, data extracted then appraised by Cochrane Risk of Bias Tool (RCTs), Cochrane guidance for non-randomised designs and COREQ criteria (qualitative acceptability data). We will update our review of staff and patient perspectives on effective de-escalation techniques components, searching from June 2010, assessing quality via COREQ and synthesising data by Thematic Synthesis. Target population: Adult acute and forensic: in-patients, frontline clinical staff, managers, carers, relatives and Prevention and Management of Violence and Aggression (PMVA) training staff. Health technology being assessed: A training package for mental health staff to enhance the delivery and effectiveness of de-escalation techniques adaptable to adult forensic and acute settings and different patient groups. Measurement of costs and outcomes: Feasibility outcomes include recruitment and retention, training uptake and engagement, outcome measure completion and the appropriate primary outcome for a full trial. We will assess the potential impact of the training on: de-escalation performance, rates of conflict and restrictive practices, staff attitudes to restrictive practices and to personality disorder, patient experience of coercion and perceived expressed emotion in staff. Service use data associated with current and new training will be collected by survey. Cost data will be summarised descriptively to inform the costing methods for a full trial. Sample size: We will collect outcome data in ten mental health wards to inform the parameters of a fully-powered trial, including identifying the primary outcome measure for sample size. Project timetable: Project duration: 30 months. Completion milestones: WP1 qualitative study and systematic review updates (month 10); WP2 synthesis and intervention development (month 16); WP3 training implementation and evaluation (month 24); WP3 data analysis and dissemination (month 30). Expertise in team: Experienced multi-disciplinary team of service users, mental health nurses, psychiatrists, psychologists and health services researchers with expertise in: lived experience, PPI, trials and qualitative methodology, biomedical statistics, behaviour-change, implementation science and health economics.

Lay abstract: Aims of the research Users of mental health services have told us that the way that mental health staff respond to patient anger and distress should be improved. We want to develop and test a new training package that will provide staff with skills (called de-escalation techniques) to help to safely reduce anger and distress. Background In-patient wards can be stressful places for service users, carers and staff and incidence of violence and self-harm are not uncommon. Previous research has shown that self-harm, suicide, aggression and violence are less likely in-patient services that protect patient rights, manage conflict between patients, have clean, comfortable, spacious and well-maintained wards and systems in place to support patients when they receive bad news and have highly skilled staff that are well supported by managers. The skills that staff use in response to early signs of aggression and self-harm (de-escalation techniques) are known to be very important, both in terms of safely reducing the behaviour/s and avoiding the need for potentially harmful practices such as physical restraint. Although all NHS staff are trained in de-escalation techniques, recent research has shown that practices such as restraint continue to be used more often than they should be. One possible reason for this is that there is no current model of training proven by research to be effective. Developing and evaluating a new type of training is therefore urgently needed to improve safety and the ward environment. Design and methods used This project will use a variety of approaches. All available scientific evidence on de-escalation techniques will be gathered. We will also speak to service users, carers and relatives, staff, hospital managers and training staff to gather views on the best ways of helping to calm people who are distressed without using practices like physical restraint and forced medicines. We will use this understanding to develop new training. We will test whether the training improves the way staff communicate with distressed people in role-plays. Then test whether it reduces violence, aggression and use of restraints and isolation rooms in practice. Patient and public involvement Our team of researchers includes both current service users and carers. Service users had leading roles in the design of the project, including selecting the outcomes of training that will count as success. Current service users and carers will have leading roles in the development and delivery of training, in writing articles for academic journals and presenting our findings at national and international conferences. Dissemination We plan to roll-out the training throughout the NHS. We will publish findings in academic journals and present our findings at national and international conferences.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH