Implementing a re-structured response to behavioural disturbance in the emergency Department - A mixed methods evaluation

Abstract

BACKGROUND: The increasing prevalence of violence in Emergency Departments (EDs) globally emphasises that the early detection of behavioural disturbance, the skilful application of de-escalation techniques and as a last resort, patient restraint, are vital to the safety and wellbeing of staff and patients. The findings from our previous research led four EDs across three sites to form a working party consisting of clinicians, educators, IT specialists, researchers, and security officers to design and implement a restructured approach to managing behavioural emergencies. METHODS: This mixed methods study used surveys and interviews and the Theoretical Domains Framework (TDF) to evaluate the barriers and facilitators to implementing an intervention designed to manage behavioural emergencies. We collected 61 surveys and conducted 12 interviews with nurses, physicians and security staff. RESULTS: The qualitative and quantitative data collected using the TDF pinpointed six facilitators and nine barriers for the implementation of the Code Black intervention. We were able to identify environmental, systemic and cultural factors that inhibited its implementation. Staff felt confident in their ability to apply the Code Black knowledge and skills and appreciative of efforts being made to improve safety. However, some remain unconvinced that behavioural change of staff will lead to safer outcomes. CONCLUSIONS: The restructured approach is an effective containment of escalating aggression which ensures greater safety of patients and staff. However, the implementation of interventions in emergency care settings is complex. EDs have unique characteristics that influence sustainability and that need to be explored further to ensure the ongoing uptake of new practices. This paper demonstrates how to identify facilitators and barriers to change and provide evidence that may be used to drive implementation in the emergency care setting.