Perceived Barriers to Using De-Escalation Techniques to Approach the Agitated Patient

Purpose: Health care workplace violence is an underreported, ubiquitous, and persistent problem. 1 Despite its pervasiveness, medical students receive little training in how to respond to workplace violence, although they are frequently exposed to patients in high-risk settings such as the emergency department and psychiatric wards. 1 De-escalation training has been shown to improve provider confidence in managing these scenarios 2 and provider attitude and temperament when faced with aggressive patients. 3 For any training to be executed and used in real-world conditions, it is important to assess barriers to implementation. The purpose of this study was to identify medical students’ perceived barriers to using verbal de-escalation techniques when faced with an aggressive or agitated patient and to characterize gender-related differences in these perceived obstacles. We hypothesized that female students would be more likely to identify internal barriers to de-escalation. Methods: This study analyzed qualitative data collected as part of a required workplace violence online training module completed asynchronously by fourth-year medical students at the Michigan State University (MSU) College of Human Medicine in the fall of 2019. The module addressed the appropriate management of agitated patients in the health care setting, including verbal de-escalation. Students were required to answer multiple open-ended questions including this prompt about verbal de-escalation: “What barriers do you anticipate might make it challenging for you to use this technique with agitated patients in the future?” The authors then performed a qualitative analysis of de-identified student responses to this prompt. Using constant comparison, the barriers were sorted into internal or external loci of control. Disputes were resolved by iterative conversation among the researchers until consensus was achieved. The MSU institutional review board reviewed and approved this study. Results: The module was completed by 161 students who identified 337 barriers. This included 91 female students identifying 191 barriers and 70 male students identifying 146 barriers, for an average of 2.1 barriers per student, irrespective of gender. Two barriers were uncategorizable. The most common barrier cited overall was emotional, namely fear or anxiety felt by the student (40.7% of total). Female students cited emotional barriers most commonly (50% of female responses). Male students cited patient-based barriers most commonly, for example, the patient was too agitated or did not speak English (45% of male responses). We classified 155 total internal barriers (46%) and 180 external barriers (53.4%). 68.3% of the internal barriers were identified by female students, while only 46.1% of the external barriers were identified by female students, which is statistically significant (P < .02). Discussion: Workplace violence is unavoidable for health care workers. It is imperative that medical students are trained early to safely interact with agitated patients, and specifically, how to de-escalate them appropriately, including verbal de-escalation when possible and appropriate. Our data demonstrate that students anticipate multiple barriers to using verbal de-escalation techniques appropriately, ranging from “my attending will prefer using restraints” (male, external) to “more concerned for my own safety” (female, internal). The preponderance of female-identified internal barriers fits with literature that suggests that females are more likely to attribute failures to their own actions, as opposed to males, who will attribute them to external events. 4 Significance: Our data suggest that not only are students wary of putting these important skills into practice, but it may be beneficial to offer targeted reassurances to male and female medical students based on their perceived barriers. Even without a gender-based component to the training, the anticipated barriers themselves can help guide future instruction to keep our students feeling safe in their environments and confident in their abilities. Lindsey Ouellette for help with statistical analysis

De-escalation · Health care · Medical education · Medical emergency · Poison control · Qualitative research · Suicide prevention · Healthcare professionals’ stress and burnout · Human Factors and Ergonomics · Medicine · Nursing · Patient Safety and Medication Errors · Psychology · Workplace Violence and Bullying

• Workplace Violence against Health Care Workers in the United States

  James P Phillips, Dan L Longo•New England Journal of Medicine•2016

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