Crisis De-escalation Team

A lot change of initiatives have been developed over the years on different ways to manage escalating crisis in the psychiatric hospital wards and there are triggers to these violence, aggression and crisis that often escalate and end up resulting to using restrictive practices. In response to these violence and aggression from the service users on the ward and physical intervention used to manage the behaviour, Crisis de-escalation team change initiative proposal will aim at the triggers to violence, minimise rising behaviours from escalating, improving quality of care provided to the service users by healthcare professionals and ultimately meeting the needs of service users to reduces distress.

This intended change implementation initiative will draw references from Centre for the Advancement of Positive Behaviour Support on the organisation's crisis reduction strategy; references will also be drawn from Royal College of Nursing Consultation on guidance to the minimisation of and alternatives to restrictive practices in health and adult social care. The change initiative will recognise the fact that service users will engage in challenging behaviours because of their unmet needs, exposure to environment and interactions which they may disagree with or find challenging to their believes and often have generally less quality of life. Often times people's behaviour represent a desperate attempt to change the status quo, do things their own way or attempt to meet their own unmet needs.

Background

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There are rising incidents of aggression and violence from the service users on the ward. This report is based on accuracy observations incident reports on the ward and research/ data analysis carried out, which shows that about 9 in 10 of service users interviewed on the ward agreed that aggressive challenging behaviours from service users have increased and healthcare professionals unanimously agreed to that.

These are negative attitude and challenging behaviours that can better be managed if the ward has a plan to tackle the causes or better known as triggers. Change proposal to implement Crisis De-escalation Team in an intensive care unit (ICU) ward of a mental health hospital will challenge triggers of aggression and crisis from escalating and manage the situation. It will further help to limit the frequent use of restrictive practices and reduce isolation of service users that exhibited challenging and unmanageable behaviour.

Crisis De-escalation

Team is not about stopping any specific interventions, nor to have general overhaul of existing practices, but it is rather to have some ward based healthcare professionals specifically trained to identify potential crisis and the triggers, then be ready to step in at any escalating situation on the ward, engage with the situation and everyone involved and de-escalate the issue.

The change initiative was motivated through research studies that showed likely change implementation was successful in psychiatric hospital wards in Australia and home treatment team unit in an NHS trust in London.According a review carried out by Australian Mental health commission (2014) on evaluation studies of crisis escalation and restraint reduction programmes, it identified that increasing staff level and implementation of crisis de-escalation/resolution team is successful on reducing the regular and duration of seclusion and restraint use while maintaining safe environment on the ward.

Crisis de-escalation team should comply with all the policy protocols, ensures the ward and trust standard are maintained with regards to quality of services provided, work to ensure the safety of everyone on the ward, encourage other colleagues and ward management to consider their approach to resolving crisis. They will assess the situation and if necessary call for restrictive measures to be used which will be evidence based, reasonable and justified. The crisis de-escalation team will be part of the ward staff team and will be directly involved in the service user's care, they are also required to fulfil other functions on the ward as a full staff member as to dilute their abilities not focusing on deescalation team duties only.Employees that will be part of this crisis de-escalation team will receive training and on-going training on new proposed change while retaining their full time staff employment on the ward.

This is to ensure that ward does not lack the resources and understaffed while the training is on-going and change implementation is rolled out on the ward.Funding for this change initiative will come from the ward budget, manager being part of the change champions will facilitate the fund. It is important to note that the change does not call for more employment rather it asked for special training given to the staff implementing the change.

Encouragement to fund this change will be from the positive feedbacks from consultation of the ward management and healthcare professionals, and it was also the major drive towards the proposed change implementation strategy. Methodology The description and analysis of the research studies are evidence based which were rallied through qualitative data, detailed accounts of an actual experience and observations, also through implementation of ideas and resourcefulness from a success elsewhere in Australia, America and hospital ward in Scotland. The implementation was assimilated into a draft restructure practice strategy.

Fifteen of the research studies carried out was a retrospective analysis that examined incidents on the ward through incident reports and restrictive practices used, but in some cases additional information was obtained from descriptive statistics gotten from other sources. Nineteen research studies were rallied from questionnaires or data that are collected on a periodic basis to obtain information, and 10 of them are done through qualitative research methodology.

Twenty research studies were focused on the instances where less restrictive measures was used to deescalate challenging situations and the method that was applied. The research involved a comparison of outcomes on the more use of restrictive practices and less restrictive practices used on the ward to analyse the effectiveness of each these measures before, during and after it was applied. The research studies were conducted in 3 different Intensive Care Units (ICU) in a psychiatric hospital/ward.

Research studies were also done in an acute inpatient ward and early intervention unit within the psychiatric hospital. Definition of the change proposal Crisis de-escalation team is about having special trained staff on the ward that will be designated to manage the triggers of aggression and crisis, engage with service users in polite and calm manner to better understand their point of view and seek for possible alternatives to stop the crisis from escalating.

The team should employ empathy and compassion, know what to do and say at any situation, respecting the crisis circle, remained composed, cool and calm when dealing with crisis and try to resolve the situation without applying the use of restrictive practices.Violence can sometimes arise unexpectedly on the ward and overwhelmed everyone; it is true to say that when healthcare professionals are overwhelmed and understaffed they are likely to react in such a manner that may escalate the crisis.

Implementing the crisis de-escalation team is to also reduce tension, minimise any panic and frustration from staff members when they are face with circumstances beyond their control.When it come using restrictive practices to manage these ongoing rising challenging behaviours on the ward, healthcare professionals have often struggled to come up with explanations to justify what accounts to good practice on restrictive practice in the context of keeping everyone on the ward safe.

Barriers to change implementation Barriers to the change implementation were encountered mainly from three different areas, hospital management, what need to change and the employees. Before a successful change strategy can be developed, barriers to the change need to be identified.

1. Employees unwillingness to embrace change
2. Employees resistance to change
3. Ineffective communication strategy
4. Ward Financial shortfall and funding
5. Shortage of staff and shift patterns
6. Lack of understanding of what needs to change and knowledge of skills needed for the implementation
7. Employees fear of the unknown.
8. Overcoming the barriers to change implementation

Identifying the barriers to the proposed change and how to overcome them is a good step towards achieving successful implementation of planned change initiative.

Effective Communication Strategy

There should be a clear and honest communication to employees and the stakeholders about what need to change and why it needed to change. Employees should be explained probably benefits the change will bring to them and hospital ward.

Good Leadership

This is needed for the change implementation to be successful. Employees need to be carried along and be involved in the change process. As some employees are reluctant to embrace change, they should be made to understand why the change is better than status quo and why it is necessary.

Training should be provided to the volunteered employees that will . Help drive the change forward. Also awareness is very important because healthcare professionals on the ward need to understand the planned change goals, targets and the strategies of implementing the change. Provision of incentives and resources to help drive healthcare professionals towards the change, this will be a motivating strategy to get them on-board with the change.

Simplifying the planned change initiative: It should not be complex to understand and implement. The change should be localised, small but meaningful change that will not require a lot more staff than already existed. The implementation will not be made to result in big shakeups within the ward and should be phased.

Whom the proposed change initiative will benefit/affect Based on the index analysis, research studies and observations at the ward on the restrictive practices, the proposed change initiative (crisis deescalation team) will benefit everyone on the ward including the service users, employees and management.

How the proposed change will be implemented Identifying the barriers to proposed change initiative and overcoming the barriers is a good step towards the successful implementation of the change. The change implementation is planned and will happen by incremental change. Based on evidence, experts opinion and research analysis have proven that implementation of a successful change in a hospital ward is always difficult and challenging because of complex relationships that exists stakeholders, management, managers and healthcare professionals.

Despite these barriers, any small meaningful change that will bring about evidence based best practice to positively improve the quality of care provided the service users on the ward is worth implementing and evaluated to monitor the progress. Support and approval from the leadership for the change initiativeSometimes good change initiatives ended up not been implemented because there was no leadership support for it.

Getting the leadership support and the stakeholders on the board with the proposed change initiative is a huge step in the implementation stage of the proposed change initiative, the need for the change should to be properly communicated to the ward manager, and a case on need for the change to happen should be communicated to the manager.

Data analysis, surveys based on observations and research findings should be presented to the manager and the leadership team on the ward to get them involved in the change initiative plan.With the manager's approval for the change to happen, the manager will therefore help to resolve conflicts of interests and negotiate with the stakeholders to help make the case why the change initiative is needed to be implemented on the ward.

The manager as part of the agent for the change should appoint leaders of the change initiative, and will help provide the tools, skills and training, and possibly the funding for the change from the budget or increase in the budget.

Volunteers will be identified within the ward and it will be ward employees that will be trained to help champion the proposed change. They should be given the chance to decide on their own to become the change agents and will work closely with the ward manager for provision of information and resources needed to push forward with the change.

Communication and Awareness

The appointed leaders of the change will use all communication methods (Mass, interactive and face to face) to explain what need to change is an important step in change implementation. These involves

• Explaining the change initiative to the employees and everyone that will be impacted on the change initiative.
• There should be an open dialogue to entertain concerns, questions and individual opinions on the change initiative.
• There should be a constant reminder and follow-up of the planned change initiative.

Skills and Learning Required for the Implementation

Training will be provided to healthcare professionals that will champion the change initiative. There are private training institutions (BSI) that offers best training in crisis management planning, with the approval of the manager, the volunteered staff will undertake short course training. Also other trust provided practical courses on crisis resolution should be provided to enable them know when and to put their knowledge into action. This is to carry out best evidence based practice on de-escalate the triggers of violence and aggression from service users. Although the team members of this change initiative will be on voluntary basis, the ward manager will provide incentives to team members of this change as an encouragement and motivation.

Implementing change initiative through engaging employees and healthcare professionals at all level within the ward.All the change agents including the manager, stakeholders and volunteered champions of change will actively engage with every staff member on the ward. This will be to create a better understanding of why this change initiative is very important and how it is small necessary step towards resolving the rising violence and aggression from service users.

This change implementation is bottom-up approach and will require genuine interest and participation from the employees, employees are the ones that have been directly affected by the status quo and will be impacted more from the new change initiative. Healthcare professionals will to be motivated to participate fully in the change implementation timeline and initial goal plans.

Monitor the implementation, examine the results and recognise the success. Early stages of implementation will be closely monitored to assess strengths and challenges; there will be follow ups and reviews. There will be surveys and audits carried out to compare the status quo and change, this will be done to know if the change is having the expected outcome and also know if there are areas of the change that will require further improvement.

Change champions will be encouraged and motivated through celebration of change success. Momentum will be built on the change by rewarding the employees that are championing the change implementation. Other staffs will be encouraged to become part of the change team; this is to reduce any change resistance that may exist within the employees and create way for successful change implementation.

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