McLean nurses and mental health specialists pride themselves on their ability to help patients through difficult times during their care. The verbal and non-verbal communication skills employed by staff are commonly referred to as de-escalation strategies. These skills and strategies are critical to promote patient engagement and facilitate least-restrictive care. McLean’s nursing department has a small group of dedicated instructors who train their peers in these strategies, utilizing the Crisis Prevention Institute (CPI) program as the base for the education. The instructors group is composed of twelve staff, including registered nurses, advanced practice nurses, and mental health specialists from across the hospital. This group trains the nursing department new hires, current staff, security, and others in the skills needed to de-escalate situations before a crisis occurs. The education occurs throughout the year with classes offered at both the Belmont campus and at McLean SouthEast in Middleborough. Of the 620 staff trained in 2017, 230 were newly hired staff at McLean who were taught over 13 classes throughout the year. This impressive undertaking has helped shape the care and support staff members provide to patients in crisis.
New staff members who attend the full-day course are introduced to the factors that could cause a patient to become escalated at an inpatient program, how to recognize when a situation is escalating, and approaches to engage and calm patients at different stages of a crisis. These strategies include empathetic listening, non-judgmental support, providing alternatives, and clear, direct communication. With verbal de-escalation, a focus is placed on the staff member’s tone, volume, and cadence as crucial in communicating respect and support during verbal de-escalation. In addition to verbal strategies, non-verbal strategies are taught, including body posture and personal space. Current employees attend a yearly review class and complete an online learning module to reinforce the concepts taught in class. This annual refresher helps staff maintain their skills and learn new concepts that are being taught to the new hires.
Shortly after joining McLean last summer, nursing professional development specialist Kristen Kichefski, MSN, MBA, RN-BC, took the lead in coordinating the CPI program. In August, she met with the group of instructors to introduce herself and learn more about the program’s needs. The result of the meeting was an exciting exchange of ideas to strengthen the program and enhance the skills taught to our staff so that they can best support the individuals at our inpatient programs. Kichefski recalled her first meeting with the group as impressive and remarked that she “found the group to be comprised of engaged, dedicated professionals who believe that early, patient-centered interventions are the key to help individuals build their coping skills while maintaining safety at the programs.” This meeting was the first of what is now regular monthly meetings to advance best practices in the education and deployment of our de-escalation training.
The first accomplishment came with the integration of de-escalation concepts early in the new hire orientation. At the initial meeting, the instructors all felt that new hires should have a baseline understanding of the concepts in the CPI curriculum before attending their certification class. Because of their recommendation, the orientation materials were re-ordered so that new hires would receive additional de-escalation education a week prior to attending the CPI class, allowing them to identify and recognize the strategies used by their preceptors and better apply the concepts discussed in class.
The staff debriefs were noted as an area the instructors were committed to strengthening. Staff debriefs are recognized as a critical tool to reflect upon contributing factors of escalation, the effects on patients and staff, and to identify patients’ future needs to prevent escalation from reaching the point of crisis. In January 2018, the instructor group assumed the duty of reviewing staff debriefs to identify the trends and needs of both patients and staff. The group is currently exploring a redesign of the staff debrief form to more effectively capture pertinent information that may assist in identifying additional ways to support patients and staff in times of crisis.
The instructors are passionate about the education they provide to staff. “I really enjoy being a CPI instructor because I get to meet the majority of new staff coming to the hospital. It’s an amazing opportunity being able to introduce them to all of the programs we offer and help them prepare for their roles as care providers,” said Cassandra Godzick, NP. Godzick added, “I hope our group can reduce restraints even more. I know we can do it because we’re training our front-line staff to be prepared to treat every patient with understanding and respect.”
The group’s goals for 2018 include continuing to evaluate and improve the way staff engage and assist patients in dealing with challenging moments. This will be accomplished through collaboration with colleagues from other institutions to exchange best practices, through evaluation of the effectiveness of training, and through connecting with staff and patients to assess the translation of de-escalation training into practice.
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