Promoting patient and nurse safety: testing a behavioural health intervention in a learning healthcare system: results of the DEMEANOR pragmatic, cluster, cross-over trial

Michele Hasselblad, Jay Morrison, Ruth Kleinpell, Reagan Buie, Deborah Ariosto, Erin Hardiman, Stephen W Osborn, Samuel K Nwosu, Christopher Lindsell, Michele Hasselblad, Jay Morrison, Ruth Kleinpell, Reagan Buie, Deborah Ariosto, Erin Hardiman, Stephen W Osborn, Samuel K Nwosu, Christopher Lindsell

Abstract

Background: Based on clinical staff safety within a learning healthcare system, the purpose of this study was to test an innovative model of care for addressing disruptive behaviour in hospitalised patients to determine whether it should be scaled up at the system level.

Methods: The Disruptive bEhaviour manageMEnt ANd prevention in hospitalised patients using a behaviOuRal (DEMEANOR) intervention team was a pragmatic, cluster, cross-over trial. A behavioural intervention team (BIT) with a psychiatric mental health advanced practice nurse and a social worker, with psychiatrist consultation, switched between units each month and occurrences of disruptive behaviours (eg, documented violence control measures, violence risk) compared. Nursing surveys assessed self-perceived efficacy and comfort managing disruptive patient behaviour.

Results: A total of 3800 patients hospitalised on the two units met the criteria for inclusion. Of those, 1841 (48.4%) were exposed to the BIT intervention and 1959 (51.6%) were in the control group. A total of 11 132 individual behavioural issues associated with 203 patient encounters were documented. There were no differences in the use of behavioural interventions, violence risk or injurious behaviour or sitter use between patients exposed to BIT and those in the control group. Tracking these data did rely on nursing documentation of such events. Nurses (82 pre and 48 post) rated BIT as the most beneficial support they received to manage patients exhibiting disruptive, threatening or acting out behaviour.

Conclusions: The BIT intervention was perceived as beneficial by nurses in preparing them to provide care for patients exhibiting disruptive, threatening or acting out behaviour, but documented patient behaviour was not observed to change.

Trial registration number: NCT03777241.

Keywords: cluster trials; nurses; patient safety; safety culture.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

References

    1. Stine EB. Effectiveness of de-escalation education on nurses’ confidence and aggressive patient outcomes. Doctor of Nursing Practice Project, Department of Nursing at Mount St Joseph University, 2020.
    1. de la Fuente M, Schoenfisch A, Wadsworth B, et al. . Impact of Behavior Management Training on Nurses’ Confidence in Managing Patient Aggression. Journal of Nursing Administration 2019;49:73–8. 10.1097/NNA.0000000000000713
    1. The Joint Commission, Division of Healthcare Improvement . Quick safety: De-Escalation in healthcare, 2019. Available: [Accessed 10 Sep 2021].
    1. Morrison J, Hasselblad M, Kleinpell R, et al. . The disruptive bEhavior manageMEnt and prevention in hospitalized patients using a behaviORal intervention team (DEMEANOR) study protocol: a pragmatic, cluster, crossover trial. Trials 2020;21:417. 10.1186/s13063-020-04278-2
    1. Chellew S. Managing disruptive patient behavior. healthcare Whitepaper, 2017. Available: [Accessed 03 Sep 2021].
    1. Brous E. Workplace violence: how it affects health care, which providers are most affected, and what management and staff can do about it. Am J Nurs 2018;118:51–5. 10.1097/01.NAJ.0000546381.04422.55
    1. Gaynes BN, Brown CL, Lux LJ, et al. . Preventing and De-escalating aggressive behavior among adult psychiatric patients: a systematic review of the evidence. Psychiatr Serv 2017;68:819–31. 10.1176/appi.ps.201600314
    1. Hallett N, Dickens GL. De-escalation of aggressive behaviour in healthcare settings: concept analysis. Int J Nurs Stud 2017;75:10–20. 10.1016/j.ijnurstu.2017.07.003
    1. Harris PA, Taylor R, Thielke R, et al. . Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81. 10.1016/j.jbi.2008.08.010
    1. Loucks J, Rutledge DN, Hatch B, et al. . Rapid response team for behavioral emergencies. J Am Psychiatr Nurses Assoc 2010;16:93–100. 10.1177/1078390310363023
    1. Rutledge DN, Wickman M, Drake D, et al. . Instrument validation: Hospital nurse perceptions of their behavioral health care competency. J Adv Nurs 2012;68:2756–65. 10.1111/j.1365-2648.2012.06025.x
    1. Arnup SJ, McKenzie JE, Hemming K, et al. . Understanding the cluster randomised crossover design: a graphical illustraton of the components of variation and a sample size tutorial. Trials 2017;18:381. 10.1186/s13063-017-2113-2
    1. The American Nurses Association . Workplace violence. Available: [Accessed 03 Sep 2021].
    1. Dermenchyan A. Addressing workplace violence. Crit Care Nurse 2018;38:81–2. 10.4037/ccn2018389
    1. Du M, Wang X, Yin S, et al. . De-escalation techniques for psychosis-induced aggression or agitation. Cochrane Database Syst Rev 2017;4:CD009922. 10.1002/14651858.CD009922.pub2
    1. Casey C. Management of aggressive patients: results of an educational program for nurses in non-psychiatric settings. MEDSURG Nursing 2019;8:9–21
    1. Ferrara KL, Davis-Ajami ML, Warren JI, et al. . De-Escalation training to medical-surgical nurses in the acute care setting. Issues Ment Health Nurs 2017;38:742–9. 10.1080/01612840.2017.1335363
    1. Gerhart JI, Sanchez Varela V, Burns JW. Brief training on patient anger increases oncology providers' self-efficacy in communicating with angry patients. J Pain Symptom Manage 2017;54:355–60. 10.1016/j.jpainsymman.2017.07.039
    1. Lee H. Yale behavioral intervention team (bit) model study: results from the two-year implementation of a proactive Cl psychiatric service at the Yale new Haven Hospital. J Psychosom Res 2017;97:157–8. 10.1016/j.jpsychores.2017.03.260
    1. Sledge WH, Gueorguieva R, Desan P, et al. . Multidisciplinary proactive psychiatric consultation service: impact on length of stay for medical inpatients. Psychother Psychosom 2015;84:208–16. 10.1159/000379757
    1. Sledge WH, Bozzo J, White-McCullum BA. The cost-benefit from the perspective of the hospital of a proactive psychiatric consultation service on inpatient general medicine services. Health Econ Outcome Res 2016;2:122. 10.4172/2471-268X/1000122
    1. Desan PH, Zimbrean PC, Weinstein AJ, et al. . Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team. Psychosomatics 2011;52:513–20. 10.1016/j.psym.2011.06.002

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe