Acad Psychiatry (2015) 39:94–98 DOI 10.1007/s40596-014-0212-x
IN BRIEF REPORT
How Do We Keep Our Residents Safe? An Educational Intervention Tobias D. Wasser
Received: 12 March 2014 / Accepted: 17 July 2014 / Published online: 7 August 2014 # Academic Psychiatry 2014
Abstract Objective Recent evidence suggests that 25–64 % of psychiatry residents are the victims of assault by patients; only a minority, however, feel they receive adequate safety and violence training during residency. To address this disparity, the author designed, implemented, and assessed the effectiveness of a brief educational intervention focused on improving the residents’ ability to recognize violence risk and increase attention to safety in the psychiatric interview. Methods The subjects were 13 second-year psychiatry residents. Effectiveness was evaluated via the assessment of the residents’ written responses describing their first clinical intervention after hearing a case vignette of a potentially violent patient (before and 1 month following the intervention). Responses were evaluated for any evidence of concerns for safety. Results The number of residents citing safety concerns increased (38 to 92 %), as did the level of sophistication in their proposed interventions. Conclusions A brief educational intervention focused on violence risk and interview safety may be effective in increasing residents’ attention to safety concerns in their clinical care, and further work will be beneficial to confirm and expand upon these findings. Keywords Psychiatry residents . Forensic psychiatry . Teaching methods Although psychiatric training programs devote a great deal of focus to teaching residents how to assess a patient’s risk of suicide, often there is significantly less attention paid to training residents how to assess a patient’s risk of violence. Most T. D. Wasser (*) Yale University School of Medicine, New Haven, CT, USA e-mail: [email protected]
individuals with mental illness do not act out violently [1], and the severely mentally ill are significantly more likely to be victims of violent crime than they are to be perpetrators [2, 3]. Having even one resident become the victim of assault by their patient, however, is too many to tolerate. Thus, we must prepare trainees for this possibility in hopes of preventing it. Unfortunately, too few are sufficiently trained in violence risk assessment and management. In a 1999 national survey, one third of psychiatry residents reported receiving no training in this area, and another third described their training as inadequate [4]. This finding is particularly concerning given that 73 % of these residents had been threatened and 36 % had been physically assaulted by a patient [4]. More recent evidence suggests that this trend is not improving and psychiatric trainees are not alone, although they may be the most affected. A 2012 review by Kwok et al. [5] on the prevalence of patient assaults on residents found that 38 % of surgery, 26 % of emergency medicine, 16–40 % of internal medicine, and 25–64 % of psychiatry residents reported a history of patient assault. And although the proportion of psychiatry residents receiving violence management training appeared to be increasing, only a minority felt this training was adequate [5]. From a resident health and well-being perspective, one area for concern is the significant psychological impact that patient assaults have on trainees [6]. The adverse psychological consequences include anger, fear, anxiety, posttraumatic stress symptoms, guilt, self-blame, shame, believing that being assaulted is inherent to the profession, and a change in career interest [5, 7, 8]. Equally concerning is that these events often are underreported [5, 7, 8], leading to further potentially unrecognized psychological harm, particularly because only one third receive supportive counseling following an assault [5]. This is especially concerning given that residents are a group already faced with the challenges of long work hours, sleep deprivation, and loss of autonomy and subsequently are more vulnerable to depression [9].
Acad Psychiatry (2015) 39:94–98
Given the insufficient safety training for residents, it is crucial to refocus our attention on this issue. Numerous efforts have been made to delineate how we might improve resident education in this area. In 1993, the American Psychiatric Association (APA) published an outline for residency training in managing patient violence, consisting of training on the antecedents of violence; evaluation of violent patients; use of verbal, mechanical, and pharmacological interventions; and the psychodynamics of aggression [10]. Kwok et al. added that this education should occur early in training, include information on the prevalence of patient assaults and their adverse psychological consequences, and address attitudinal and institutional barriers to reporting such incidents [5]. Schwartz and Park went one step further in outlining recommendations for a 10-h training in the first year of residency, consisting of didactic seminars on the assessment and management of violent patients [4]. These seminars covered several topics, including diagnosis and pharmacological interventions, seclusion and restraint methods, environmental safety, forensic issues, and self-defense techniques, followed by practical training in simulated situations with suggestions for supplemental reading materials [4]. In the second phase of their program, trainees would attend 2-h seminars in each of the following years of residency to reinforce their knowledge and skills [4]. Although the guidelines referenced above recommend how to structure such safety and violence training, little work has been done to assess its effectiveness in improving clinical practice. A previous work has demonstrated that training psychiatry residents and clinical psychology interns in evidencebased risk assessment can enhance their documentation in the assessment and management of violence risk [11]. However, there is little available evidence regarding whether this enhancement will translate into safer clinical care. Toward this end, and given the evidence supporting the use of brief interventions in a variety of disciplines [12, 13], we designed and implemented a brief (2 h) educational intervention at our institution focused on improving residents’ ability to recognize violence risk and increase their attention to safety in the psychiatric interview. Our core learning objectives were that residents would recognize the characteristics of patients and situations that elevate the risk for violence, increase their efforts to be cognizant of their own internal state while sitting with patients, and make appropriate adjustments to the interview milieu to attend to their safety. We then assessed whether such a brief intervention could be effective in increasing the residents’ attention to safety in their clinical care, given that previously outlined trainings were much longer (5–10 h).
Methods The course participants were a group of 13 psychiatry residents in postgraduate year (PGY) 2. The course was divided
95
into two sessions, the first of which was 2 h in duration and the second was 1 h, both taught by the author of this article. At the start of the first session, residents were presented with a case vignette of a potentially violent patient and asked to write down what their first intervention would be with the patient. Their anonymous written responses were collected as a “pretest.” Each participant was then asked to present their intervention as part of a larger discussion of the safety concerns in this particular clinical vignette. The remainder of the first session was spent engaging in didactics covering several topic areas (Table 1). The first topic focused on teaching residents how to identify and distinguish between acute and chronic violence risk factors in a variety of treatment settings. The second centered on increasing residents’ awareness of safety concerns related to both physical and emotional aspects of the psychiatric interview. The final topic introduced trainees to warning signs for acute aggression (the “violence prodrome”) and a step-wise approach for responding to patients with signs of escalating aggression. The second session occurred 1 month later. Residents were not told in advance that this second session was related to the previous session, and the author was not present at the start of the second session, so as to avoid priming the participants to the topics of violence and safety, given that the author had also taught the previous session. A similar format was then followed in which residents were presented with the case of a potentially violent patient and asked to write down their first intervention, with responses again collected and discussed (the “posttest”). The case vignettes for each session were designed to clearly elicit safety concerns from the participants and were almost identical, both including multiple violence risk factors, with only minor changes in details. Following the collection of the responses, the author joined the group, and the class then engaged in a discussion regarding if or how their approach to interviewing patients had changed since the previous session. Participants were then given the opportunity to present their own clinical cases where violence and/or safety had been a concern for discussion with the group. Residents’ written responses to the case vignettes were examined for any indication of concern for violence or safety. Residents were deemed to have considered safety as a component of their intervention if in their written response they used the words safety or violence or described any action that indicated a consideration for their own safety (e.g., “request security”). Given the small sample size and inability to control for multiple variables, no formal statistical analyses were utilized to evaluate the results. The Yale University Institutional Review Board Human
96
Acad Psychiatry (2015) 39:94–98
Table 1 Summary of the didactic session Learning objectives
Outline of topic areas presented Recognizing the risky patient and the risky situation
As a direct result of this class, participants will 1. Demonstrate the ability to recognize characteristics of patients and situations which elevate the risk for violence. 2. Increase their efforts to be cognizant of their own internal state while sitting with patients and take action based on their observations. 3. Make appropriate adjustments to the interview milieu in all clinical encounters to attend to their safety and that of their patients.
1. Identifying and differentiating static and dynamic risk factors 2. Key principles in understanding the risk of violence in mentally ill individuals 3. Risk factors for violence in different psychiatric settings
Attending to safety in the psychiatric interview
1. Making safety the first priority 2. Recognizing one’s own emotional state 3. Safety of the physical space 4. High risk clinical scenarios 5. Setting-specific safety features 6. Establishing boundaries of the interview
Approach to and management of the escalating patient
1. Awareness of one’s own internal emotional state 2. Recognizing the violence prodrome 3. How to address the escalating patient (a) Practical tips about one’s own physical conduct (b) De-escalation techniques
Subjects Committee granted our study exemption from review as research conducted in a commonly accepted educational setting.
patient, calling for security personnel, offering medication, attempting verbal de-escalation, and giving the patient time to calm down. Discussion
Results The results of the pretest demonstrated that 38 % of residents (5 of 13) cited safety concerns as a component of their initial intervention (Table 2). These five responses included taking actions that indicated a consideration of safety concerns, although no response actually included the words safety or violence. These responses included asking the patient to calm down before he could be further evaluated, setting limits with patient and staff, validating the patient’s concerns, having both the patient and resident sit down with the resident having his or her back to the door, and offering the patient medications to try and help him calm down. The results of the posttest showed an increase with 92 % of residents (12 of 13) citing safety concerns, with nine residents specifically citing the word safety as a component of their initial intervention (Table 2). Other prominent themes in their responses included assessing for the immediate risk of violence, allowing adequate distance between the resident and
These preliminary results appear to indicate that a brief educational intervention focused on promoting resident safety awareness may be effective. Following the intervention, there was a remarkable increase in the number of residents who raised safety concerns in the case of a patient with numerous risk factors for violence. Additionally, the nature of the residents’ concerns appeared more direct following the intervention, with far more residents indicating they would consider safety as a primary concern, conduct an acute risk assessment, or request the presence of security personnel. This finding suggests that the residents were more alert for safety-related issues and ready to act in a way that would ensure their safety. Further, the resident responses citing safety concerns following our intervention increased not only in number but also in their level of sophistication. The posttest responses clearly demonstrate a more nuanced understanding of the topic, with many residents outlining a multistep or tiered approach to maintaining their safety, which is notably absent in the pretest responses.
Acad Psychiatry (2015) 39:94–98
97
Table 2 Residents’ written responses citing safety concerns Pretest
Posttest
1. “I would explain to the patient that based on his presentation he has to remain calm and he will be further evaluated. Offer some po” 2. “Avoid setting limits explicitly, but be very clear to myself and to staff I’m working with what these might be” 3. “Validate” 4. “Try to get both of you sitting, back to the door” 5. “Offer po Haldol or Ativan to help him calm down prior to proceeding”
1. “Ensure safety” 2. “Safety – Allow adequate distance, inform staff, call for security” 3. “Safety – de-escalate, request security, medicate, give him time to cool down, re-evaluate” 4. “Leave the room, state you’ll be back when patient has calmed down” 5. “Safety – assess need for 1:1, withdrawal symptoms, meds for agitation, collateral from family or treaters” 6. “Safety – First try de-escalating verbally, then offering him some po meds to calm down” 7. “Assess immediate risk for safety/violence and withdrawal. Treat emergent symptoms, e.g. agitation” 8. “Get security, offer meds” 9. “Safety – manage acute agitation, collateral, med history, labs, Utox, risk assessment, dispo – placement?” 10. “Safety, reassure, identify needs, Utox” 11. “Obtain security for personal protection, verbal de-escalation vs. prn” 12. “Safety first, call security, offer po meds and if refuses, give injectable”
Our intervention differed from those previously described in the literature in a number of key ways, most notably the duration and goals of the training. Whereas others have suggested significantly lengthier and more extensive training sessions for residents in violence and safety management [4, 10], we utilized a brief, 2-h session to introduce participants to key topics in violence and safety, with specific and limited goals. Our efforts were purposefully limited in scope due to experiences in our institution that lengthier trainings involving practical skills teaching and simulation do not lead to lasting changes in learning or behavior. Instead, in our experience, these skills are rarely used and soon forgotten. If the goal of violence and safety training is to decrease the frequency of resident assaults and increase residents’ understanding of safe clinical practice, one must consider the means by which we achieve this end. If we attempt to accomplish this goal by teaching residents to be experts in risk assessment or restraint utilization, we are unlikely to be successful without many more months of extensive training and repeated opportunities to practice and hone these skills. Thus, the scope of our teaching was quite focused, with specific and achievable goals. Our aim was to move toward the goal of safer clinical practice by effecting an attitudinal change via making residents more attuned to safety considerations and providing them with a basic framework to take appropriate actions. Our hope was that focusing on simple principles that engender safer practice would be more successful than extended sessions attempting to teach a multitude of skills that our residents
were unlikely to use on a regular basis in their clinical practice. Though only preliminary, our results seem to indicate that such an experience may be successful in reaching this endpoint. Though promising, these findings should be considered in light of clear limitations. The percentage of residents citing safety concerns following our intervention certainly increased, but it is unclear if these results are truly statistically significant, given our lack of formal statistical analyses. The small sample size and anonymous results, which reduce our ability to control for confounding variables, make it difficult to perform such an analysis. Also, although our results suggest an increase in safety awareness at a 1-month follow-up, it is unclear if such improvement would be sustained at longer intervals. Additionally, our measures did not directly address whether we were successful in achieving all of our specific learning objectives, and we were unable to assess whether this intervention did in fact translate into a reduction in resident assaults. Finally, we cannot exclude the possibility that the improvement seen may in part be accounted for by differences in the case vignettes themselves. Certain aspects of this work require additional consideration and future study. For example, it is unclear when in residency training it would be most beneficial to provide this type of training and whether it would be helpful to have refresher courses in subsequent years of residency, as others have suggested [4]. Additionally, the ideal duration, content, and format of such training is, as of now, still unclear. Further work in this area with larger samples, variable duration of training, longer follow-up, and more specific assessment of
98
resident knowledge and rates of resident assaults will be crucial to determine the effectiveness of such interventions. Despite the finding that people with mental illness are more likely to be victims of violent crime than perpetrators of it, there is evidence that 25–64 % of psychiatry residents are the victims of assault by their patients [5]. Having an appreciation for how to conduct psychiatric interviews safely and identify those individuals at higher risk for violence should help residents decrease their chance of being physically harmed by patients. Residency training in violence assessment and management tends to be lengthy, and there is little evidence demonstrating whether current practices are effective. Our results indicate that a brief educational intervention focused on improving residents’ ability to recognize the risk of violence and increase their attention to safety may be effective. Given the limitations described above, however, further work with larger samples and more formal statistical analyses will be required to show whether such an intervention can indeed keep our residents safe. Implications for Educators • Recent evidence suggests that 25–64 % of psychiatry residents are the victims of assault by their patients, with numerous potential adverse psychological consequences, indicating a need to refocus our attention on the duration and efficacy of residents’ violence and safety training. • Our results indicate that a brief educational intervention focused on improving residents’ ability to recognize violence risk and increase their attention to interview safety may be effective. Acknowledgments The author thanks Madelon Baranoski, Ph.D., and David Ross, M.D., Ph.D., for their creative and editorial assistance with this article. Disclosures The corresponding author states that there is no conflict of interest.
Acad Psychiatry (2015) 39:94–98
References 1. Stuart H. Violence and mental illness: an overview. World Psychiatry. 2003;2(2):121–4. 2. Hiroeh U, Appleby L, Mortensen PB, Dunn G. Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study. Lancet. 2001;358(9299):2110–2. 3. Teplin LA, McClelland GM, Abram KM, Weiner DA. Crime victimization in adults with severe mental illness: comparison with the national crime victimization survey. Arch Gen Psychiatry. 2005;62(8):911–21. 4. Schwartz TL, Park TL. Assaults by patients on psychiatric residents: a survey and training recommendations. Psychiatr Serv. 1999;50(3): 381–3. 5. Kwok S, Ostermeyer B, Coverdale J. A systematic review of the prevalence of patient assaults against residents. J Grad Med Educ. 2012;4(3):296–300. 6. Coverdale J, Gale C, Weeks S, Turbott S. A survey of threats and violent acts by patients against training physicians. Med Educ. 2001;35(2):154–9. 7. Dvir Y, Moniwa E, Crisp-Han H, Levy D, Coverdale JH. Survey of threats and assaults by patients on psychiatry residents. Acad Psychiatry. 2012;36(1):39–42. 8. Antonius D, Fuchs L, Herbert F, Kwon J, Fried JL, Burton PR, et al. Psychiatric assessment of aggressive patients: a violent attack on a resident. Am J Psychiatry. 2010;167(3):253–9. 9. Sen S, Kranzler HR, Krystal JH, Speller H, Chan G, Gelernter J, et al. A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry. 2010;67(6):557–65. 10. Dubin WR, Lion JR, editors. Clinician safety: report of the American Psychiatric Association task force on clinician safety. Washington: American Psychiatric Press; 1993. 11. McNiel DE, Chamberlain JR, Weaver CM, Hall SE, Fordwood SR, Binder RL. Impact of clinical training on violence risk assessment. Am J Psychiatry. 2008;165(2):195–200. 12. Vasilaki EI, Hosier SG, Cox WM. The efficacy of motivational interviewing as a brief intervention for excessive drinking: a metaanalytic review. Alcohol Alcohol. 2006;41(3):328–35. 13. Walton GM, Cohen GL. A brief social-belonging intervention improves academic and health outcomes of minority students. Science. 2011;331:1447–51.
IN BRIEF REPORT
How Do We Keep Our Residents Safe? An Educational Intervention Tobias D. Wasser
Received: 12 March 2014 / Accepted: 17 July 2014 / Published online: 7 August 2014 # Academic Psychiatry 2014
Abstract Objective Recent evidence suggests that 25–64 % of psychiatry residents are the victims of assault by patients; only a minority, however, feel they receive adequate safety and violence training during residency. To address this disparity, the author designed, implemented, and assessed the effectiveness of a brief educational intervention focused on improving the residents’ ability to recognize violence risk and increase attention to safety in the psychiatric interview. Methods The subjects were 13 second-year psychiatry residents. Effectiveness was evaluated via the assessment of the residents’ written responses describing their first clinical intervention after hearing a case vignette of a potentially violent patient (before and 1 month following the intervention). Responses were evaluated for any evidence of concerns for safety. Results The number of residents citing safety concerns increased (38 to 92 %), as did the level of sophistication in their proposed interventions. Conclusions A brief educational intervention focused on violence risk and interview safety may be effective in increasing residents’ attention to safety concerns in their clinical care, and further work will be beneficial to confirm and expand upon these findings. Keywords Psychiatry residents . Forensic psychiatry . Teaching methods Although psychiatric training programs devote a great deal of focus to teaching residents how to assess a patient’s risk of suicide, often there is significantly less attention paid to training residents how to assess a patient’s risk of violence. Most T. D. Wasser (*) Yale University School of Medicine, New Haven, CT, USA e-mail: [email protected]
individuals with mental illness do not act out violently [1], and the severely mentally ill are significantly more likely to be victims of violent crime than they are to be perpetrators [2, 3]. Having even one resident become the victim of assault by their patient, however, is too many to tolerate. Thus, we must prepare trainees for this possibility in hopes of preventing it. Unfortunately, too few are sufficiently trained in violence risk assessment and management. In a 1999 national survey, one third of psychiatry residents reported receiving no training in this area, and another third described their training as inadequate [4]. This finding is particularly concerning given that 73 % of these residents had been threatened and 36 % had been physically assaulted by a patient [4]. More recent evidence suggests that this trend is not improving and psychiatric trainees are not alone, although they may be the most affected. A 2012 review by Kwok et al. [5] on the prevalence of patient assaults on residents found that 38 % of surgery, 26 % of emergency medicine, 16–40 % of internal medicine, and 25–64 % of psychiatry residents reported a history of patient assault. And although the proportion of psychiatry residents receiving violence management training appeared to be increasing, only a minority felt this training was adequate [5]. From a resident health and well-being perspective, one area for concern is the significant psychological impact that patient assaults have on trainees [6]. The adverse psychological consequences include anger, fear, anxiety, posttraumatic stress symptoms, guilt, self-blame, shame, believing that being assaulted is inherent to the profession, and a change in career interest [5, 7, 8]. Equally concerning is that these events often are underreported [5, 7, 8], leading to further potentially unrecognized psychological harm, particularly because only one third receive supportive counseling following an assault [5]. This is especially concerning given that residents are a group already faced with the challenges of long work hours, sleep deprivation, and loss of autonomy and subsequently are more vulnerable to depression [9].
Acad Psychiatry (2015) 39:94–98
Given the insufficient safety training for residents, it is crucial to refocus our attention on this issue. Numerous efforts have been made to delineate how we might improve resident education in this area. In 1993, the American Psychiatric Association (APA) published an outline for residency training in managing patient violence, consisting of training on the antecedents of violence; evaluation of violent patients; use of verbal, mechanical, and pharmacological interventions; and the psychodynamics of aggression [10]. Kwok et al. added that this education should occur early in training, include information on the prevalence of patient assaults and their adverse psychological consequences, and address attitudinal and institutional barriers to reporting such incidents [5]. Schwartz and Park went one step further in outlining recommendations for a 10-h training in the first year of residency, consisting of didactic seminars on the assessment and management of violent patients [4]. These seminars covered several topics, including diagnosis and pharmacological interventions, seclusion and restraint methods, environmental safety, forensic issues, and self-defense techniques, followed by practical training in simulated situations with suggestions for supplemental reading materials [4]. In the second phase of their program, trainees would attend 2-h seminars in each of the following years of residency to reinforce their knowledge and skills [4]. Although the guidelines referenced above recommend how to structure such safety and violence training, little work has been done to assess its effectiveness in improving clinical practice. A previous work has demonstrated that training psychiatry residents and clinical psychology interns in evidencebased risk assessment can enhance their documentation in the assessment and management of violence risk [11]. However, there is little available evidence regarding whether this enhancement will translate into safer clinical care. Toward this end, and given the evidence supporting the use of brief interventions in a variety of disciplines [12, 13], we designed and implemented a brief (2 h) educational intervention at our institution focused on improving residents’ ability to recognize violence risk and increase their attention to safety in the psychiatric interview. Our core learning objectives were that residents would recognize the characteristics of patients and situations that elevate the risk for violence, increase their efforts to be cognizant of their own internal state while sitting with patients, and make appropriate adjustments to the interview milieu to attend to their safety. We then assessed whether such a brief intervention could be effective in increasing the residents’ attention to safety in their clinical care, given that previously outlined trainings were much longer (5–10 h).
Methods The course participants were a group of 13 psychiatry residents in postgraduate year (PGY) 2. The course was divided
95
into two sessions, the first of which was 2 h in duration and the second was 1 h, both taught by the author of this article. At the start of the first session, residents were presented with a case vignette of a potentially violent patient and asked to write down what their first intervention would be with the patient. Their anonymous written responses were collected as a “pretest.” Each participant was then asked to present their intervention as part of a larger discussion of the safety concerns in this particular clinical vignette. The remainder of the first session was spent engaging in didactics covering several topic areas (Table 1). The first topic focused on teaching residents how to identify and distinguish between acute and chronic violence risk factors in a variety of treatment settings. The second centered on increasing residents’ awareness of safety concerns related to both physical and emotional aspects of the psychiatric interview. The final topic introduced trainees to warning signs for acute aggression (the “violence prodrome”) and a step-wise approach for responding to patients with signs of escalating aggression. The second session occurred 1 month later. Residents were not told in advance that this second session was related to the previous session, and the author was not present at the start of the second session, so as to avoid priming the participants to the topics of violence and safety, given that the author had also taught the previous session. A similar format was then followed in which residents were presented with the case of a potentially violent patient and asked to write down their first intervention, with responses again collected and discussed (the “posttest”). The case vignettes for each session were designed to clearly elicit safety concerns from the participants and were almost identical, both including multiple violence risk factors, with only minor changes in details. Following the collection of the responses, the author joined the group, and the class then engaged in a discussion regarding if or how their approach to interviewing patients had changed since the previous session. Participants were then given the opportunity to present their own clinical cases where violence and/or safety had been a concern for discussion with the group. Residents’ written responses to the case vignettes were examined for any indication of concern for violence or safety. Residents were deemed to have considered safety as a component of their intervention if in their written response they used the words safety or violence or described any action that indicated a consideration for their own safety (e.g., “request security”). Given the small sample size and inability to control for multiple variables, no formal statistical analyses were utilized to evaluate the results. The Yale University Institutional Review Board Human
96
Acad Psychiatry (2015) 39:94–98
Table 1 Summary of the didactic session Learning objectives
Outline of topic areas presented Recognizing the risky patient and the risky situation
As a direct result of this class, participants will 1. Demonstrate the ability to recognize characteristics of patients and situations which elevate the risk for violence. 2. Increase their efforts to be cognizant of their own internal state while sitting with patients and take action based on their observations. 3. Make appropriate adjustments to the interview milieu in all clinical encounters to attend to their safety and that of their patients.
1. Identifying and differentiating static and dynamic risk factors 2. Key principles in understanding the risk of violence in mentally ill individuals 3. Risk factors for violence in different psychiatric settings
Attending to safety in the psychiatric interview
1. Making safety the first priority 2. Recognizing one’s own emotional state 3. Safety of the physical space 4. High risk clinical scenarios 5. Setting-specific safety features 6. Establishing boundaries of the interview
Approach to and management of the escalating patient
1. Awareness of one’s own internal emotional state 2. Recognizing the violence prodrome 3. How to address the escalating patient (a) Practical tips about one’s own physical conduct (b) De-escalation techniques
Subjects Committee granted our study exemption from review as research conducted in a commonly accepted educational setting.
patient, calling for security personnel, offering medication, attempting verbal de-escalation, and giving the patient time to calm down. Discussion
Results The results of the pretest demonstrated that 38 % of residents (5 of 13) cited safety concerns as a component of their initial intervention (Table 2). These five responses included taking actions that indicated a consideration of safety concerns, although no response actually included the words safety or violence. These responses included asking the patient to calm down before he could be further evaluated, setting limits with patient and staff, validating the patient’s concerns, having both the patient and resident sit down with the resident having his or her back to the door, and offering the patient medications to try and help him calm down. The results of the posttest showed an increase with 92 % of residents (12 of 13) citing safety concerns, with nine residents specifically citing the word safety as a component of their initial intervention (Table 2). Other prominent themes in their responses included assessing for the immediate risk of violence, allowing adequate distance between the resident and
These preliminary results appear to indicate that a brief educational intervention focused on promoting resident safety awareness may be effective. Following the intervention, there was a remarkable increase in the number of residents who raised safety concerns in the case of a patient with numerous risk factors for violence. Additionally, the nature of the residents’ concerns appeared more direct following the intervention, with far more residents indicating they would consider safety as a primary concern, conduct an acute risk assessment, or request the presence of security personnel. This finding suggests that the residents were more alert for safety-related issues and ready to act in a way that would ensure their safety. Further, the resident responses citing safety concerns following our intervention increased not only in number but also in their level of sophistication. The posttest responses clearly demonstrate a more nuanced understanding of the topic, with many residents outlining a multistep or tiered approach to maintaining their safety, which is notably absent in the pretest responses.
Acad Psychiatry (2015) 39:94–98
97
Table 2 Residents’ written responses citing safety concerns Pretest
Posttest
1. “I would explain to the patient that based on his presentation he has to remain calm and he will be further evaluated. Offer some po” 2. “Avoid setting limits explicitly, but be very clear to myself and to staff I’m working with what these might be” 3. “Validate” 4. “Try to get both of you sitting, back to the door” 5. “Offer po Haldol or Ativan to help him calm down prior to proceeding”
1. “Ensure safety” 2. “Safety – Allow adequate distance, inform staff, call for security” 3. “Safety – de-escalate, request security, medicate, give him time to cool down, re-evaluate” 4. “Leave the room, state you’ll be back when patient has calmed down” 5. “Safety – assess need for 1:1, withdrawal symptoms, meds for agitation, collateral from family or treaters” 6. “Safety – First try de-escalating verbally, then offering him some po meds to calm down” 7. “Assess immediate risk for safety/violence and withdrawal. Treat emergent symptoms, e.g. agitation” 8. “Get security, offer meds” 9. “Safety – manage acute agitation, collateral, med history, labs, Utox, risk assessment, dispo – placement?” 10. “Safety, reassure, identify needs, Utox” 11. “Obtain security for personal protection, verbal de-escalation vs. prn” 12. “Safety first, call security, offer po meds and if refuses, give injectable”
Our intervention differed from those previously described in the literature in a number of key ways, most notably the duration and goals of the training. Whereas others have suggested significantly lengthier and more extensive training sessions for residents in violence and safety management [4, 10], we utilized a brief, 2-h session to introduce participants to key topics in violence and safety, with specific and limited goals. Our efforts were purposefully limited in scope due to experiences in our institution that lengthier trainings involving practical skills teaching and simulation do not lead to lasting changes in learning or behavior. Instead, in our experience, these skills are rarely used and soon forgotten. If the goal of violence and safety training is to decrease the frequency of resident assaults and increase residents’ understanding of safe clinical practice, one must consider the means by which we achieve this end. If we attempt to accomplish this goal by teaching residents to be experts in risk assessment or restraint utilization, we are unlikely to be successful without many more months of extensive training and repeated opportunities to practice and hone these skills. Thus, the scope of our teaching was quite focused, with specific and achievable goals. Our aim was to move toward the goal of safer clinical practice by effecting an attitudinal change via making residents more attuned to safety considerations and providing them with a basic framework to take appropriate actions. Our hope was that focusing on simple principles that engender safer practice would be more successful than extended sessions attempting to teach a multitude of skills that our residents
were unlikely to use on a regular basis in their clinical practice. Though only preliminary, our results seem to indicate that such an experience may be successful in reaching this endpoint. Though promising, these findings should be considered in light of clear limitations. The percentage of residents citing safety concerns following our intervention certainly increased, but it is unclear if these results are truly statistically significant, given our lack of formal statistical analyses. The small sample size and anonymous results, which reduce our ability to control for confounding variables, make it difficult to perform such an analysis. Also, although our results suggest an increase in safety awareness at a 1-month follow-up, it is unclear if such improvement would be sustained at longer intervals. Additionally, our measures did not directly address whether we were successful in achieving all of our specific learning objectives, and we were unable to assess whether this intervention did in fact translate into a reduction in resident assaults. Finally, we cannot exclude the possibility that the improvement seen may in part be accounted for by differences in the case vignettes themselves. Certain aspects of this work require additional consideration and future study. For example, it is unclear when in residency training it would be most beneficial to provide this type of training and whether it would be helpful to have refresher courses in subsequent years of residency, as others have suggested [4]. Additionally, the ideal duration, content, and format of such training is, as of now, still unclear. Further work in this area with larger samples, variable duration of training, longer follow-up, and more specific assessment of
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resident knowledge and rates of resident assaults will be crucial to determine the effectiveness of such interventions. Despite the finding that people with mental illness are more likely to be victims of violent crime than perpetrators of it, there is evidence that 25–64 % of psychiatry residents are the victims of assault by their patients [5]. Having an appreciation for how to conduct psychiatric interviews safely and identify those individuals at higher risk for violence should help residents decrease their chance of being physically harmed by patients. Residency training in violence assessment and management tends to be lengthy, and there is little evidence demonstrating whether current practices are effective. Our results indicate that a brief educational intervention focused on improving residents’ ability to recognize the risk of violence and increase their attention to safety may be effective. Given the limitations described above, however, further work with larger samples and more formal statistical analyses will be required to show whether such an intervention can indeed keep our residents safe. Implications for Educators • Recent evidence suggests that 25–64 % of psychiatry residents are the victims of assault by their patients, with numerous potential adverse psychological consequences, indicating a need to refocus our attention on the duration and efficacy of residents’ violence and safety training. • Our results indicate that a brief educational intervention focused on improving residents’ ability to recognize violence risk and increase their attention to interview safety may be effective. Acknowledgments The author thanks Madelon Baranoski, Ph.D., and David Ross, M.D., Ph.D., for their creative and editorial assistance with this article. Disclosures The corresponding author states that there is no conflict of interest.
Acad Psychiatry (2015) 39:94–98
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