Reviewing the evidence base for de-escalation training: a rapid evidence assessment
De-escalation training for NHS staff may not in itself reduce the number of violent or aggressive incidents, but it has been shown to contribute to a significant reduction in lost workdays, improved staff retention, reduced complaints, and reduced overall expenditure, and it may help staff to manage patient violence and aggression.
However, using comprehensive approaches to managing violence in NHS settings may be more effective than de-escalation training alone.
Violence in the workplace is a major issue for healthcare providers. Estimates suggest that around 15 per cent of NHS staff in England experienced physical violence in 2017. Those running healthcare services have a duty of care to their staff to prevent and minimise workplace violence, but complete eradication of violence is not always possible given the types of work that some healthcare professionals do and the patients with whom they work.
As a way to help staff manage, reduce or prevent violence from occurring in the first place, NHS England and NHS Improvement asked RAND Europe to conduct an analysis of de-escalation training to support the development of this type of training within health settings.
The study focused on individual skills-based training to help reduce workplace violence and addressed four overarching research questions:
- Is de-escalation training effective in managing violence towards NHS staff?
- What are the benefits and key methods used to provide the training?
- What are the key types of training and content within the evidence base?
- What are the factors of success in deploying training from the evidence base?
To answer the research questions the team conducted a rapid evidence assessment (REA) of de-escalation training literature. REAs allow for a systematic and critical assessment of the scope and quality of the evidence available. Given that there were several existing reviews evaluating the efficacy of de-escalation training in healthcare settings, the researchers' approach to the REA was to perform a review of existing de-escalation training reviews and other individual skills-based approaches to aggression management within the last 10 years (March 2009-March 2019).
Training may help staff to manage patient violence and aggression.
When staff have the appropriate knowledge, confidence and skills for handling aggressive or violent patients they may be less likely to experience negative outcomes such as injuries.
De-escalation training may not in itself reduce the number of violent or aggressive incidents.
Evidence on whether de-escalation training is effective at reducing violent incidents is mixed, with few studies evaluating long-term effects of training. When reductions in violence were reported, they were not always sustained throughout a given study period, which may indicate there is a need for periodic interventions.
De-escalation training has been shown to contribute to a significant reduction in lost workdays, improved staff retention, reduced complaints, and reduced overall expenditure.
Key individual benefits from the training additionally show improved knowledge and confidence in identifying and handling aggressive patients. Providing staff with the tools to handle violent situations when they do occur is suggested to limit the negative impact of aggression and violence.
Using comprehensive approaches to managing violence in NHS settings may be more effective than de-escalation training alone.
The limited evidence on the efficacy of individual skills-based training suggest that a combination of factors such as security measures, environmental design and policy interventions, in addition to individual skills-based training, may provide increased benefit.
Providing staff with the tools to handle violent situations potentially limits the negative impact of aggression and violence within those situations. The key benefits of this include:
- a reduction in lost workdays;
- a reduction in complaints; and
- improved staff confidence and retention.
Very few of the included reviews actually report on the methods used to provide the training, making it difficult to find common approaches and lessons learned. However there are indications that participants benefit from frequent provision of training, a culturally embedded programme of change to support the training and periodic refresher courses.
There are relatively few rigorous evaluation studies that provide for robust comparison and the quality of available evidence is limiting. Any efforts towards implementing de-escalation training would benefit from the inclusion of evaluation in their design. This would inform the development of the programme as well as support the knowledge base in general for de-escalation training.