BE ALERT - Behavioral Excellence: Advancing Leadership and Education in Real Time

Objective: : The increasing prevalence of workplace violence (WPV) in the Emergency Department (ED) continues to be of growing concern across the country, with numerous negative consequences resulting from this epidemic. Recent studies show approximately 70% of ED nurses report some form of physical violence during their work shift. Outcomes associated with WPV include loss of workdays, high staff turnover, burnout, staff dissatisfaction, increased worker’s compensation claims, and poor patient quality of care.

De-escalation techniques and tools are widely used to decrease WPV in the healthcare setting. Although no “gold standard” currently exists regarding teaching de-escalation techniques, structured education that provides a standardized approach to address escalating or violent behavior effectively is optimal. This project aimed to evaluate the effectiveness of de-escalation techniques in simulation-based education (SBE).

EBP Model:: The IOWA Model of Evidence-Based Practice was utilized for this project. Identification of a practice problem was followed by ensuring there was sufficient evidence to support the change. This model served as a guide and assisted the team with the steps to help identify issues, research solutions, and implement changes.

Setting:: Teaching urban level 1 trauma center located in the West.

Participants:: ED nurses participated in this project.

Methods: : A comprehensive literature review was completed with guidance from our Research Nurse Scientist (RNS) to determine the most appropriate educational intervention for teaching techniques to address WPV. It was determined simulation strategies would be the most effective training to improve confidence among nurses managing these situations.

Using a simulated patient experience, the following methods were demonstrated: de-escalation management strategies, modeling appropriate behavior, utilizing empathetic communication, identifying inappropriate patient/family behavior, and strategizing to manage the encounter and self-reflection.

The simulation-based experience (SBE) consisted of three scenarios, each with a unique escalating patient/family member to interact with. Prior to the SBE the participants completed a pre-simulation survey to establish a baseline confidence level.

Following the first scenario, a debrief was conducted. Education regarding recognition and tools to de-escalate these situations was provided. Participants then progressed through the final two scenarios utilizing this education.

After the three scenarios, a final debrief was conducted, and a post-simulation survey was completed.

Outcomes:: The pre-and post-simulation survey administered utilized a 5-point Likert scale. Survey questions assessed confidence and competence in the following areas: Implementation of de-escalation techniques, identifying manipulative behaviors, setting boundaries and limits with a patient and/or family member, and providing care for a behaviorally challenging patient.

The results were analyzed by comparison of pre-simulation and post-simulation raw data. The results of the data indicate nurses answered with greater confidence in their skills when managing behaviorally challenging and aggressive patients.

Implications:: Simulation education was found to be a successful intervention in addressing WPV, de-escalation techniques, and identifying triggers that escalate behavior. Given these results, the delivery of SBE will be expanded to include a second cohort of staff from the ED, Critical Care, and Acute Care units to offer this simulation education to upwards of 400 additional nursing and provider staff.