Enhancing Patient Safety in Nursing Education through Patient Simulation of De-Escalation Techniques - Research Proposal Example

Simulation Project for De-escalation Techniques Name Institution Introduction In the face of increased competition among nursing students and practitioners for better placements in the mental health field, improved healthcare access courtesy of the Patient Protection Act, and the ever increasing number of mental health patients, the nursing fraternity face increasing pressure to implement more evidence based-innovative strategies of learning and practice (American Association of Colleges of Nursing, 2005, p.11; Sutphen, Benner, Day & Leonard, 2010, p.33). One of the strategies developed and taunted as results oriented is the standardized patients simulation and encounters as part of mental health courses learning outcomes. The use of full body highly efficient patient simulators otherwise referred to as high fidelity simulations or HFS has been used in various clinical courses. However, this modality had not been utilized as an important learning tool in the mental health faculties. This has been due to the notion that the patient simulators might not correctly reflect the reality in the context of mental health. This is partly attributable to the earlier versions of patient simulators that failed to provide for important non-verbal factors such as facial expressions, body language and physical movements. De-escalation techniques refer to a set of psychological skills applied at reducing or minimizing disruptive and violent behaviour likely to be exhibited by mentally ill patients. They basically are a variety of therapeutic interventions which are aimed at preventing or reducing aggression, usually witnessed in mental health-care facilities (NICE, 2005, p.36). The intention is to reduce the aggression especially during the escalation stage when the patient is very agitated for whatever reason. The use of these techniques has since become standard policy in managing aggression and violence in health facilities. However, despite the evidence that de-escalation techniques are often used by the nursing fraternity, a lot of evidence points to the fact that staff and patients think that the skills are quite inadequate and training not properly done (Evans et al., 2003, p.277). Moreover, research carried out also identifies that the patient-staff relationships and interactions are a common antecedent to attacks in mental health facilities and psychiatric wards (Duxbury & Whittington, 2005, p.471). This only means that developing and improving these skills will be fundamental to the process of reducing these violent behaviours (Zarola & Leather, 2006, p.61). However, research into these de-escalation techniques has further pointed out various limitations, which suggest that more trials will be required to determine and gauge the effectiveness and usefulness of the current training in these techniques. From Kolb’s theory touching on experiential learning, experience has been placed on a pedestal as the ultimate source of sustainable learning and development (Kolb, 1984, p.57). The application of SPs as a strategy of learning additionally helps nursing faculties to deal with the challenge of achieving objectives in limited time and the constant competition for ideal clinical sites (Lehr & Kaplan, 2013, p.426). Thus, Over the time, many authors have concurred that simulated scenarios in the mental health field can be adequately applied to replicate reality to a relatively high degree of accuracy, hence exposing students to standardized clinical experience and facilitate the successful implementation of learning objectives in mental health nursing courses (Robbinson-Smith, Meakim & Bradley, 2009, p.205) Background The application of simulation practices in nursing education provides a favourable platform for students to experience, practice and develop acute clinical skills in an appropriate, controlled and safe environment (National League for Nursing, 2006, p.19; Lehr & Kaplan, 2013, p.428). The unpredictability, stigma, violence and undesirability associated with mental problems creates unwanted anxiety about assessing and communicating with mental health patients, hence making it hard for nursing students to interact meaningfully with the patients and increasing likelihood of agitation and escalation (Kameg, Clochesy, Suresky & Mitchell, 2010, p.316; Stuart, 2009, p.43). The application of these simulated encounters in nursing comes in handy to complement other learning strategies by facilitating the students to encounter trained ‘patients’ who exhibit symptoms of mental illness in less threatening scenarios. The use of simulation enables learners to integrate key de-escalation techniques which can be used to calm violent patients. Thus, the students are now better placed to intervene by applying the learned therapeutic communication, planning and assessment which are the objectives of the particular nursing course. Moreover, the nursing students gain additional experience whilst working with highly trained SPs who can exhibit aggressive behaviours, which students might not have encountered elsewhere during clinical rotations (Kameg et al., 2010, p.321). An important aspect of SPs utilization is the fact that these encounters provide a suitable alternative in the likely absence of real clinical placement sites in the mental health field (Durham & Alden, 2008, p.77). Insufficient funding for mental health practitioners continues to cause reductions of inpatient hospital accommodation and huge decreases in the outpatient service. Moreover, the aspect of letting student nurses to come into contact with violent patients without a mastery of proper de-escalation skills is a dangerous affair. All these compounded with other factors, means that the availability of suitable clinical sites for training is reduced in the field of mental health. Drastic cuts for mental health funding have even seen some mentally ill patients seek treatments in emergency rooms (Unworth et al., 2012, p.66). All this presents unique challenges in the quest of imparting necessary skills and experiences to nursing students and most never get a good chance to practice and improve their de-escalation skills. There is relatively limited relevant research in the application of SPs for mental health nursing learning. Nonetheless, the recent evidence points to the importance of incorporating simulation methods into the learning strategy of nursing faculties (McAllister, 2008, p.427; Stuart, 2009, p.45; Mikasa et al., 2013, p.362). Most boards of nursing across the globe have also shown support for these methods and have outlined the intrinsic value of simulation. Moreover, a strong emphasis has been laid on the need for improvements in de-escalation techniques training, especially after numerous reports of attacks on medical personnel by agitated mentally ill patients. (May, Lee & Park, 2009, p.492). Many articles have reiterated the usefulness of de-escalation techniques in nursing and medical courses and have made it clear that simulation would otherwise be inefficient if the staff carrying out interviews is poorly trained in de-escalation techniques and procedure. Aims and Objectives The learning objectives of this simulation are: 1 To test whether the nurses are able to make correct and accurate judgments after training with regards to the tone, body language, as well as paying attention to what the patient is saying. 2 To evaluate the relationship between efficiency and simulation in the learning process 3 To critically analyze the extent to which simulation training assist in dealing with mentally ill patients. 4 To minimize the risk of harm or violence to the patients themselves, care providers and the training student nurses in real life situations. Target Population The selection and training of Simulation Patients (SPs) is based on established best practices for the same, so is the rehearsal and the ultimate implementation (Wallace, 2007, p.67). The educators should employ various criteria in selecting the SPs, such as the demographics specific to cases (two males aged around 18-24 and two females aged 18-24), the specific skill-set required for simulation (superb acting abilities and verbal feedback prowess), and the availability for training and rehearsal. The trainers should understand that the SPs need thorough training and rehearsals in exhibiting aggressive behaviour when provoked by their interviewers. They should also understand the de-escalation triggers that trained professionals use to calm patients in real life encounters. As such, the SPs should internalize when to feel agitated and when not to feel agitated, depending on the approach of their interviewers. Two other experienced SPs are chosen to complement those being trained. On the other hand, the interviewers will be composed of group A and group B. Group A is untrained in de-escalation techniques while group B is thoroughly trained in de-escalation techniques. Group A and Group composed of the same students, before and after training. Other personnel include the trainers, technical team, the educators from the nursing faculty and any other required personnel. Logistics and Implementation The SP educators will leverage their association with the local acting fraternity to audition for the SPs, hire the two experienced SPs and assemble all the required materials for training. With the SPs hired and necessary theatre equipment secured, the training will consist of three two-hour group training rehearsals conducted by the lead educators in conjunction with the assistant trainers. The training topics to be covered by standardized patients will include: Introduction to simulation facilities and orientation, overview, costumes and attire, simulated recall (video playback of encounters), verbal techniques, read-through of scenarios, role playing, feedback techniques, discussions and reviews of example videos and common errors encountered in simulation practice. The personnel responsible for training the students on de-escalation can follow the same training model as that of SPs, where the training consists of three two-hour group training rehearsals conducted by the lead educators in conjunction with the assistant trainers. The trainers will focus on a number of training strategies and de-escalation themes as follows: Theme 1: The character traits of an effective, efficient de-escalator The best de-escalators are honest, self-aware, non-judgmental, open, coherent and confident. They often will appear calm, non-threatening and will exhibit real concern for their patient. They must also exude a non-authoritarian aura. Such qualities and traits will ensure that the patient gain their trust hence the patient is likely to be well behaved during their encounters. The interviewer must be in a position to empathize with the patient as this is important in making the patients feel like they are well understood. This also validates the patient’s experiences and thus minimizes the need for them to be overly aggressive (Duperouzel, 2008, p.299). Theme 2: Ability to maintain self-control All studies point at the importance of a calm appearance when dealing with mentally ill patients, especially when aggression is witnessed. The best de-escalators can remain very calm even though their internal state is otherwise. This show on the part of the staff/interviewer has been proven to enable the patient manage their anger or agitation and is a clear indication that that person actually trusts them; hence the patient is compelled to not turn violent. Being calm also enables the interviewer make the correct therapeutic decisions during the entire experience, no matter what happens. Anxiety is easily controlled by focusing attention on the patient rather than on self (Duperouzel, 2008, p.304). Theme 3: Verbal skills and non-verbal skills The de-escalator should use a soft, gentle voice. The choice of word should be tactful and some humour may be incorporated though proper care must be taken to ensure that the patient doesn’t feel belittled or such. The de-escalator should have a straight posture, proper eye contact, respectful proximity, excellent facial cues and coordinated body movements. Basically, the body language should be that it expresses concern for the patient (Carlsson et al., 2000, p.534). The interview should also be a good listener to ensure that the patient knows they are listened to and understood. The use of physical touch should be utilized carefully depending on the patient and experience of the handler. The use of distraction can be applied selectively to distract the patient whenever necessary. Theme 4: Engaging the patient The de-escalator should seek to form strong bonds with patients that display violent behaviour in a bid to create a good sense of regard on the part of the patient. This will help in de-escalating the agitation (Carlsson et al., 2000, p.539). One should aim to demonstrate trust and show their humane side since this helps the patient to feel a sense of equality with the person engaging him/her. While the de-escalator must be always collected and calm, he/she must continually assess for potential violent behaviour by the patient. At all times, patients must be made to feel valued, respected and honoured. Violent behaviour is often as a result of lost dignity. The feeling of respect from those around him minimizes the need for violence. Theme 5: Just when should one intervene? Early intervention is recommended for successful de-escalation. However care must be taken against unnecessary interventions. Decision to intervene and not to intervene are anchored on: one’s knowledge of particular patients, the likely meaning of a certain behaviour, the danger posed by a certain behaviour, the patient’s deviation from usual/normal behaviour and the impact of behaviour on other people. From these and from the training received, one can then judge whether to intervene or not. Theme 6: Making sure the conditions are safe for de-escalation There should be an assessment done on the number of support staff required to safely and successfully de-escalate a subject. Care must be taken as a show of might and force might actually produce more violent behaviour, hence escalation. Other assessments should include a thorough check for concealed weaponry and any other dangerous material including un-prescribed medication. There should also be adequate exits incase flight be the only option left (Duperouzel, 2008, p.307). The patient might also be made to move to another location that is more quiet and comfortable. All the while, one must remember that the de-escalation process is a highly intuitive and instinctive undertaking that requires creativity, flexibility and an eye for non-verbal cues. Measurable outcomes The outcomes will be pegged on the learning objectives of the simulation project by gauging the effective of the learning i.e. Are the students able to make correct and accurate judgments after training? How efficient and useful is the training model? How fast can the students de-escalate a patient and how well do they apply the skills learnt? By how much will this training prepare the learner to face real patients and de-escalate them successfully? The de-escalation professionals will use the De-escalating Aggressive Behavior Scale to come up with statistical tests of significance which will then be computed for comparison of the results for all students before and after training. These results will be useful in gauging the performance of students before and after the training and this, together with other discussed measures will help in determining whether the outcomes are positive and gauge the performance of each student. It is also important to note that the object of the simulation exercise should also enable the learners to successfully de-escalate agitated patients and hence effectively prepare them for future clinical rotations and health work. An open ended evaluation of the exercise can be very revealing and helpful in analyzing the simulation outcomes. A further analysis of the content can be used to come up with broader, deeper themes which can categorically be used to gauge the outcomes of the exercise. Examples of Qualitative themes in this project can include: A lot of learning occurred Improved de-escalation ability Added confidence to de-escalate any patient Applied theoretical knowledge in de-escalation Recommendations The above qualitative themes can be used to deduce and classify student comments and hence help gauge the learning outcomes. Examples of how the themes match to student comments include: Qualitative Theme Comment Examples Improved de-escalation skills “The training has really helped me improve my de-escalation skills. Before the training, I was not sure what to do to de-escalate the patient.” A lot of learning occurred “The simulation exercise was very eye-opening. I have learnt so many ways to deal with patient escalation in an efficient way.” Increased confidence “I feel that this experience has tremendously increased my confidence in dealing with mentally ill patients. Before the training, I got so nervous when the patient got agitated. Now, I can easily contain my anxiety. ” Application of theoretical knowledge “After the training, I found that I was in a position to apply a lot of theoretical knowledge I learnt earlier which for some reason, I could not apply before the training.” Recommendations “I think we can use more training in de-escalation techniques.” “I am of the opinion that the de-escalation training should have been carried out earlier to enable students practice these skills at a much earlier stage.” Methods of debriefing and feedback 1. Asking open ended questions/ open sharing: Used to obtain more detailed information or responses from the learners and also enables the learners to critically analyze the subject matter. These questions are based on the behavioral, cognitive and technical objectives of the study. 2. Using reflection/ Journaling: By reflecting specific questions back to the group, deep discussion ensues. Learners can deeply analyze how they view the experience and develop new perspectives. The learners are in a position to compare their performance before and after the training. 3. Maintaining silence: This can be necessary in trying to force students to start conversation between them. It also gives space for meaningful reflection of what happened before and after training. 4. Use of video recordings: Is very beneficial in the portrayal of the entire experience and offers a great opportunity for all involved parties to view themselves from a new perspective. It is a great source of data to be used for farther analyses. Thus the students will observe themselves as they de-escalate the patient, before and after training. 5. Dumping or concept map (Data Manipulation Language for generic data compilation) 6. Observer participation/ de-escalation professionals’ diagnosis 7. Student Led (Student led discussions) 8. SIRC Template (Using the scenario simulation template to analyze the experience and get feedback) APPENDIX 1 1. Case Scenarios The simulation model here will involve nurses before and after training. Nurses will be exposed to two distinct scenarios, labeled Scenario X and Scenario Y. In scenario X, untrained nurses will meet the standardized patients and handle them the best way they know how, while the technical team records the entire experience in video and audio modes. After this first SP-students encounter, preparations will start for training in de-escalation techniques. Upon training, the students are then ready for scenario Y. Scenario Y involves the same students repeating their encounter with the standardized patients while the technical team takes detailed video and audio recordings of the experience. These videos will then be taken for assessment by de-escalation professionals who are unaware of the two scenarios. By use of De-escalating Aggressive Behavior Scale, statistical tests of significance will then be computed for comparison of the results. Further assessments can be done through comparing the effectiveness in which the nurses handle their patients. The gist of the two scenarios is to show the significance and importance of training in de-escalation techniques. 2. Tools, Measuring items & Equipment Gowns/costumes Video and sound recorders Computerized simulation manikin Clinical evaluation tools Audio-visual simulation management equipment Computerized Monitors Web-based simulation programs Error disclosure toolkit Mechanical restraints Basic nursing tool kit Response trackers Likert scale charts Lasater Clinical Judgment Rubric Standard Safety Clinical equipment Any other simulation training equipment References American Association of Colleges of Nursing. (2005). Faculty shortages in baccalaureate and graduate nursing programs: Scope of the problem and strategies for expanding the supply.Washington, DC: Author. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. Stanford, CA: Jossey-Bass Publishers. Carlsson, G., Dahlberg, K. & Drew, N. (2000). Encountering violence and aggression in mental health nursing: A phenomenological study of tacit caring knowledge. Issues in Mental Health Nursing, 21, 533–545. Duxbury, J. & Whittington, R. (2005). Causes and management of patient aggression and violence: Staff and patient perspectives. Journal of Advanced Nursing, 50 (5), 469–478. Durham, C. F., & Alden, K. R. (2008). Enhancing patient safety in nursing education through patient simulation. In R.G. Hughes (Ed.), Patient safety and quality: An evidence based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality (US). Retrieved November 3 2014 from Duperouzel, H. (2008). ‘It’s OK for people to feel angry’: The exemplary management of imminent aggression. Journal of Intellectual Disabilities, 12, 295–307. Evans, D., Wood, J. & Lambert, L. (2003). Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing, 41, 274–282. Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Edgewood Cliffs, NJ: Prentice-Hall. Kameg, K., Howard, V. M., Clochesy, J., Mitchell, A. M., & Suresky, J.M. (2010). The impact of high fidelity human simulation on self-efficacy of communication skills. Issues in Mental Health Nursing, 31, 315–323. Lehr, S. T., & Kaplan, B. (2013). A mental health simulation experience for baccalaureate student nurses. Clinical Simulation in Nursing, 9, 425–431. Retrieved November 3 2014 from McAllister, M. (2008). Looking below the surface: Developing critical literacy skills to reduce the stigma of mental disorders. Journal of Nursing Education, 47, 426–430. Mikasa, A. W., Cicero, T. F., & Adamson, K. A. (2013). Outcome-based evaluation tool to evaluate student performance in high-fidelity simulation. Clinical Simulation in Nursing, 9(9), 361–367. Retrieved from http://dx.doi.org/10.1016/j.ecns.2012.06.001 May, W., Park, J. H., & Lee, J. P. (2009). A ten-year review of the literature on the use of standardized patients in teaching and learning: 1996–2005. Medical Teacher, 31, 487–492. National League for Nursing. (2006). Designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: A national, multi-site, multi-method study. New York, NY: Author. NICE (2005). Clinical Practice Guidelines for Violence. The Short-Term Management of Disturbed/Violent Behaviour in Psychiatric In-patient and Emergency Departments Guideline. NJ: Prentice Hall Robinson-Smith, G., Bradley, P. K., & Meakim, C. (2009). Evaluating the use of standardized patient in undergraduate mental health nursing experiences. Clinical Simulation in Nursing, 5, 203–211. Stuart, G. W. (2009). Principles and practice of mental health nursing (9th ed.). St. Louis, MO: Mosby. Unworth, J., McKeever, M., & Kelleher, M. (2012). Recognition of physical deterioration in patients with mental health problems: The role of simulation in knowledge and skill development. NJ: Prentice-Hall. Wallace, P. (2007). Coaching standardized patients for use in the assessment of clinical competence. New York, NY: Springer. Zarola, A. & Leather, P. (2006). Violence and Aggression Management Training for Trainers and Managers: A National Evaluation of the Training Provision in Healthcare Settings. Nottingham: University of Nottingham. Read More