Management if Aggressive and Disruptive Behavior in the Emergency Department Using De-Escalation Techniques and Simulation: A Quality Improvement Project to Improve the Knowledge and Confidence of Emergency Department Nurses and Clinical Staff

Abstract Approximately 40% of all healthcare workers have reported episodes of violence by patients over the last 2 years. This Veteran’s Health Agency reported 824 disruptive events reported in the last 5 years, of which 56 occurred in the emergency department. Research shows that interventions are not always timely, resulting in the clinical staff requesting the Veteran’s Health Agency Police to intervene when a veteran’s level of stress is escalating. The gap in practice is shown to be related to a lack of knowledge in the clinical staff in managing high stress levels exhibited by some veterans, limited knowledge of de-escalation techniques, and a lack of clear delineation of roles of the hospital police and clinical staff when mitigating a disruptive event. This project is a quality improvement project focused on de-escalation skill training to address workplace violence using simulation. The goal was to improve staff knowledge and confidence and reduce staff injury when interacting with an aggressive, disruptive patient. The project included de-escalation training and simulated scenarios of veterans presenting to the emergency department with a mental health emergency. The project focused on the identification of signs and symptoms of increased stress levels, verbal and nonverbal behavior the patient exhibits that identifies an increased risk of a violent event, and appropriate interventions. De-escalation techniques were assessed with the English Modified De-escalating Aggressive Behavior Scale. Staff confidence levels were measured before and after the training using the Confidence in Coping with Patient Aggression Scale. Keywords: de-escalation training, aggressive behavior, disruptive behavior management, violence against nurses, violence against physicians, violence emergency department, older adult emergency department, agitation aggression veterans