Objective:The project goal was to compare the effectiveness of strategies to prevent and de-escalate aggressive behaviors among psychiatric patients in acute care settings, including interventions for reducing use of seclusion and restraint.Methods:Relevant databases were systematically reviewed for comparative studies of violence prevention and de-escalation strategies involving adult psychiatric patients in acute care settings. Studies (trials and cohort studies) were required to report on aggression or seclusion or restraint outcomes. Both risk of bias, an indicator of quality of individual studies, and strength of evidence (SOE) for each outcome were independently assessed by two study personnel.Results:Seventeen primary studies met inclusion criteria. Evidence was limited for benefits and harms; information about characteristics that might modify the interventions’ effectiveness, such as race or ethnicity, was especially limited. All but one study had a medium or high risk of bias and thus presented ...

Preventing and De-escalating Aggressive Behavior Among Adult Psychiatric Patients: A Systematic Review of the Evidence

Background Agitation after general anaesthesia can lead to self-harm, violence against staff, and increased resource utilisation. We aimed to assess patient and procedural characteristics associated with this complication in adults. Methods We identified cases of agitation (Richmond Agitation–Sedation Scale score +3 or +4, or administration of haloperidol) in patients after general anaesthesia in the PACU from July 1, 2010 to September 30, 2016. The cases were matched 1:1 with control patients without agitation by age, sex, and procedure. Potential clinical associations were assessed with a multivariable analysis. Results We identified agitation in 510 patients [incidence: 2.5 cases/1000 patients; 95% confidence interval (CI): 2.3–2.7]. Variables associated with agitation were substance misuse [odds ratio (OR): 6.77; 95% CI: 1.23–37.2; P=0.03], cognitive impairment (OR: 4.66; 95% CI: 1.79–12.1; P=0.002), obesity (OR: 2.49; 95% CI: 1.66–3.73; P Conclusions Agitation after general anaesthesia was associated with postoperative indwelling catheters, tracheal intubation and patient features suggestive of pre-existing mental health problems. Anticipation of high-risk patients could allow allocation of staffing resources to provide a safe environment for anaesthetic recovery.

Agitation in adults in the post-anaesthesia care unit after general anaesthesia

Background
Staff members working on our nonmental health (non-MH) units (i.e., medical-surgical [MS] units) were not educated in recognizing or deescalating behavioral emergencies. Published evidence suggests a behavioral emergency response team (BERT) composed of MH experts who assist with deescalating behavioral emergencies may be beneficial in these situations. Therefore, we sought to implement a BERT on the inpatient non-MH units at our military treatment facility.

Aims
The objectives of this evidence-based practice process improvement project were to determine how implementation of a BERT affects staff and patient safety and to examine nursing staffs’ level of knowledge, confidence, and support in caring for psychiatric patients and patients exhibiting behavioral emergencies.

Methods
A BERT was piloted on one MS unit for 5 months and expanded to two additional units for 3 months. Pre- and postimplementation staff surveys were conducted, and the number of staff assaults and injuries, restraint usage, and security intervention were compared.

Results
The BERT responded to 17 behavioral emergencies. The number of assaults decreased from 10 (pre) to 1 (post); security intervention decreased from 14 to 1; and restraint use decreased from 8 to 1. MS staffs’ level of BERT knowledge and rating of support between MH staff and their staff significantly increased. Both MS and MH nurses rated the BERT as supportive and effective.

Linking Evidence to Action
A BERT can assist with deescalating behavioral emergencies, and improve staff collaboration and patient and staff safety.

Behavioral Emergency Response Team: Implementation Improves Patient Safety, Staff Safety, and Staff Collaboration

Aim: The aim of this study was to examine the social world of generalist nurses delivering mental healthcare in remote Australia.

Background: Of Australia's population of approximately 25 million, one in five will experience a mental illness during their lifetime. People who live in remote Australia are significantly more likely than those in urban areas to experience a mental illness or substance use disorder, or to commit suicide. Commentators have suggested that the higher prevalence of mental health problems in remote communities is a reflection of socioeconomic disadvantage, a harsher natural and social environment, loneliness and isolation. The more remote from metropolitan centres, the less specialised mental health services, investment, funding and infrastructure are available to care for the mentally ill. Correspondingly, the specialised mental health workforce, across all disciplines and professions, rapidly declines with remoteness. This workforce maldistribution results in a situation where the largest permanent health workforce in remote Australia are generalist nurses. Remote nurses work in isolated communities and are regularly exposed to stressful and dangerous conditions. They are oldest cohort of Australian nurses and work the longest hours per week. Research has reported that remote nurses have low self-perceived levels of competency, confidence and skills when caring for mental health patients, particularly when confronted by violent and aggressive mental health presentations.

Method: A single, explanatory, revelatory case study design, utilising a holistic approach, was employed in this study. Qualitative data were collected in semi-structured interviews conducted face-to-face or via telephone (n = 30). The data were subjected to interpretive thematic analysis. Findings from the thematic analysis were combined with secondary data sources relevant to the case and subjected to situational analysis (Clarke, 2005) using messy, ordered and relational maps to construct a social world/arena map of the remote nurses' social world in delivering mental healthcare. Actor-network theory was employed to analyse the relationships between actors (human and non-human), which consisted of both individuals and groups within the remote nurses' social world.

Findings: Three major findings arose from the study. First, under the actor-network analysis, when delivering mental healthcare, remote nurses assume the role of the obligatory passage point; second, remote nurses have low self-perceived levels of mental healthcare skills, abilities and confidence; and remote nurses possess unique characteristics that enable them to stay and function in the case environment.

Conclusion: There exists substantial demand for mental health services in remote Australia. The delivery of such services must overcome many barriers. Central to the success of mental healthcare delivery are remote generalist nurses. This study revealed new insights into the complex and fluid social worlds of remote generalist nurses delivering mental healthcare. The study also found that remote nurses have unique characteristics, both individually and as a group, that enable them to remain in their social world and deliver front-line services.

Generalist registered nurses caring for mental health clients in remote areas of Australia: an interpretive case study

Disruptive behaviors are common among hospitalized patients with psychiatric and substance abuse behaviors. Nurses working on nonpsychiatric units, however, may lack competencies to care for patients with such behaviors. A survey was developed and administered to 844 nurses across three hospital settings that revealed a lack of nurse confidence to intervene in situations that require de-escalation techniques and crisis communication. This study provides direction for further research and interventions in hospital settings with similar professional development needs.

Hospital staff nurse perceptions of competency to care for patients with psychiatric or behavioral health concerns.

https://www.calhospital.org/sites/main/files/file-attachments/rapidresponse.pdf

Rapid response team for behavioral emergencies.

Aim. To report the development and psychometric testing of the Behavioral Health Care Competency survey, designed to measure hospital nurse perceptions of behavioral healthcare competency. Background. Hospital nurses working in general or other non-psychiatric units may lack behavioral healthcare competency to manage disruptive behaviours associated with mental illnesses. Design. Instrument development. Method. A nurse study team including clinical experts and nurse researchers from three community hospitals in southern California (USA) reviewed content validity of each item and the 31-item instrument and created a behavioral health care competency conceptual model based on the nursing process. Separate institutional review board permissions were obtained from each hospital. The study team collaborated in the timing of survey administration (November 2010), analysis of the results and survey validation. Results. A total of 844 nurses completed the survey, representing approximately 23–41% of eligible nurses from each hospital. Using principal component analysis with varimax rotation, 23 items led to a factor structure with four components. Four subscales with adequate alpha coefficients were formed: Resource Adequacy, Patient Assessment, Practice/Intervention Competency, and Psychotropic Recommendation. Conclusion. The 23-item hospital nurse Behavioral Health Care Competency survey is an adequate and valid newly developed instrument. Further testing with diverse samples is needed to strengthen generalizability and address unique and specialized nursing care needs.

Instrument validation: hospital nurse perceptions of their Behavioral Health Care Competency

https://www.jenonline.org/article/S0099-1767(17)30269-6/pdf

Use of a Standardized Procedure to Improve Behavioral Health Patients’ Care: A Quality Improvement Initiative

With the advent of new psychotherapeutic agents, many individuals with mental illness are living successfully in communities. However, they may become involved in situations with law enforcement officers, which may lead to potentially negative experiences. During police academy training, new officers may receive training focused on optimizing interactions with people with physical/mental disabilities; however, this may be inadequate to enable effective communication between officers and individuals with mental illness. Given the growing prevalence of mental illness, it is increasingly likely that officers will encounter such individuals. An exemplar educational program geared to staff police officers in the city of Orange, California is described. This program provides law enforcement officers with training about psychiatric disorders and affected individuals, effective communication skills, and interventions that may assist in management of field contacts with individuals with mental illness.

Jeannine Loucks

Papers

Rapid response team for behavioral emergencies.

Hospital staff nurse perceptions of competency to care for patients with psychiatric or behavioral health concerns.

Instrument validation: hospital nurse perceptions of their Behavioral Health Care Competency

Use of a Standardized Procedure to Improve Behavioral Health Patients’ Care: A Quality Improvement Initiative

Educating law enforcement officers about mental illness: nurses as teachers.