Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial.

Background: Containment (e.g. physical restraint and seclusion) is used frequently in mental health inpatient settings. Containment is associated with serious psychological and physical harms. De-escalation (psychosocial techniques to manage distress without containment) is recommended to manage aggression and other unsafe behaviours, for example self-harm. All National Health Service staff are trained in de-escalation but there is little to no evidence supporting training's effectiveness. Objectives: Objectives were to: (1) qualitatively investigate de-escalation and identify barriers and facilitators to use across the range of adult acute and forensic mental health inpatient settings; (2) co-produce with relevant stakeholders an intervention to enhance de-escalation across these settings; (3) evaluate the intervention's preliminary effect on rates of conflict (e.g. violence, self-harm) and containment (e.g. seclusion and physical restraint) and understand barriers and facilitators to intervention effects. Design: Intervention development informed by Experience-based Co-design and uncontrolled pre and post feasibility evaluation. Systematic reviews and qualitative interviews investigated contextual variation in use and effects of de-escalation. Synthesis of this evidence informed co-design of an intervention to enhance de-escalation. An uncontrolled feasibility trial of the intervention followed. Clinical outcome data were collected over 24 weeks including an 8-week pre-intervention phase, an 8-week embedding and an 8-week post-intervention phase. Setting: Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts. Participants: In-patients, clinical staff, managers, carers/relatives and training staff in the target settings. Interventions: Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) interventions included de-escalation training, two novel models of reflective practice, post-incident debriefing and feedback on clinical practice, collaborative prescribing and ward rounds, practice changes around admission, shift handovers and the social and physical environment, and sensory modulation and support planning to reduce patient distress. Main outcome measures: Outcomes measured related to feasibility (recruitment and retention, completion of outcome measures), training outcomes and clinical and safety outcomes. Conflict and containment rates were measured via the Patient-Staff Conflict Checklist. Clinical outcomes were measured using the Attitudes to Containment Measures Questionnaire, Attitudes to Personality Disorder Questionnaire, Violence Prevention Climate Scale, Capabilities, Opportunities, and Motivation Scale, Coercion Experience Scale and Perceived Expressed Emotion in Staff Scale. Results: Completion rates of the proposed primary outcome were very good at 68% overall (excluding remote data collection), which increased to 76% (excluding remote data collection) in the post-intervention period. Secondary outcomes had high completion rates for both staff and patient respondents. Regression analyses indicated that reductions in conflict and containment were both predicted by study phase (pre, embedding, post intervention). There were no adverse events or serious adverse events related to the intervention. Conclusions: Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome. Limitations: Uncontrolled design and self-selecting sample. Future work: Definitive trial determining intervention effects. Trial registration: This trial is registered as ISRCTN12826685 (closed to recruitment). Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/101/02) and is published in full in Health Technology Assessment; Vol. 28, No. 3. See the NIHR Funding and Awards website for further award information. Context: Conflict (a term used to describe a range of potentially unsafe events including violence, self-harm, rule-breaking, medication refusal, illicit drug and alcohol use and absconding) in mental health settings causes serious physical and psychological harm. Containment interventions which are intended to minimise harm from violence (and other conflict behaviours) such as restraint, seclusion and rapid tranquilisation can result in serious injuries to patients and, occasionally, death. Involvement in physical restraint is the most common cause of serious physical injury to National Health Service mental health staff in the United Kingdom. Violence to staff results in substantial costs to the health service in sickness and litigation payments. Containment interventions are also expensive (e.g. physical restraint costs mental health services £6.1 million and enhanced observations £88 million per annum). Despite these harms, recent findings indicate containment interventions such as seclusion and physical restraint continue to be used frequently in mental health settings. Clinical trials have demonstrated that interventions can reduce containment without increasing violence and other conflict behaviours (e.g. verbal aggression, self-harm). Substantial cost-savings result from reducing containment use. De-escalation, as an intervention to manage aggression and potential violence without restrictive practices, is a core intervention. 'De-escalation' is a collective term for a range of psychosocial techniques designed to reduce distress and anger without the need to use 'containment' interventions (measures to prevent harm through restricting a person's ability to act independently, such as physical restraint and seclusion). Evidence indicates that de-escalation involves ensuring conditions for safe intervention and effective communication are established, clarifying and attempting to resolve the patient's concern, conveyance of respect and empathy and regulating unhelpful emotions such as anxiety and anger. Despite featuring prominently in clinical guidelines and training policy domestically and internationally and being a component of mandatory National Health Service training, there is no evidence-based model on which to base training. A systematic review of de-escalation training effectiveness and acceptability conducted in 2015 concluded: (1) no model of training has demonstrated effectiveness in a sufficiently rigorous evaluation, (2) the theoretical underpinning of evaluated models was often unclear and (3) there has been inadequate investigation of the characteristics of training likely to enhance acceptability and uptake. Despite all National Health Service staff being trained in de-escalation there have been no high-quality trials evaluating the effectiveness and cost-effectiveness of training. Feasibility studies are needed to establish whether it is possible to conduct a definitive trial that can determine the clinical, safety and cost-effectiveness of this intervention.

Mental health hospitals are stressful places for patients and staff. Patients are often detained against their will, in places that are noisy, unfamiliar and frightening. Violence and self-injury happen quite frequently. Sometimes staff physically restrain patients or isolate patients in locked rooms (called seclusion). While these measures might sometimes be necessary to maintain safety, they are psychologically and physically harmful. To help reduce the use of these unsafe measures, staff are trained in communication skills designed to reduce anger and distress without using physical force. Professionals call these skills 'de-escalation'. Although training in de-escalation is mandatory, there is no good evidence to say whether it works or not, or what specific techniques staff should be trained in. The Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) project aimed to develop and evaluate a de-escalation training programme informed by research evidence. We interviewed over one hundred people who either worked in or received treatment in a mental health hospital. These people were clear that the training should target key sources of interpersonal and environmental stress that prevent de-escalation from working. We also reviewed all the scientific studies on de-escalation and training, aiming to identify the elements of training that are most likely to increase use of de-escalation. Then, in partnership with current mental health service users and clinical staff, we developed the training programme. Training was delivered to more than 270 staff working in 10 different wards in mental health hospitals. We measured rates of violence, self-injury and use of physical restraint and seclusion 8 weeks before staff received training and 16 weeks after they received training (24 weeks of data collection in total). Analysis of these data showed that these unsafe events were occurring significantly less frequently after training than they were before training, which raised the possibility that the training was helping to reduce harm.

The Impact of the COVID-19 Pandemic on Forensic Mental Health Services and Clinical Outcomes: A Longitudinal Study.

BACKGROUND: The COVID-19 pandemic has had a substantial impact on forensic mental health service provision and implementation. This study aimed to provide an analysis of the impact of COVID-19 related restrictions on routine outcomes within a large forensic mental health service in London, UK. METHOD: We conducted a longitudinal cohort study using data collected routinely prior to the COVID-19 pandemic (April 2018-March 2020) and then stages thereafter (March 2020-March 2021; analyzed as March-May 2020, June-September 2020, October-December 2020, January-March 2021). We used causal impact models (Bayesian structural time-series) to examine the effect of COVID-19 related changes on routine outcomes related to service provision and implementation. RESULTS: There was an overall increase in long-term segregation (LTS) hours during the pandemic; 140%, (95% Cl 107, 171%) during Lockdown 1; 113%, (159% Cl 127, 192%) during post-Lockdown 1; 45% (95% Cl 23, 68%) during Lockdown 2 and, finally, 90% (95% Cl 63, 113%) during Lockdown 3. The most negative outcomes were evident during Lockdown 3. Incidents of violence were significantly more frequent during Lockdown 3 than would have been predicted based on pre-pandemic data, including physical assaults to service users (206%, 95% CI 57%, 346%), non-physical assaults to service users (206%, 95% CI 53%, 339%), and self-harm (71%, 95% CI 0.4%, 135%). Use of enforced medication also increased during Lockdown 3 (317%, 95% CI 175%, 456%). CONCLUSION: The pandemic and its related restrictions negatively affected some service outcomes. This resulted in increased incidents of violence and increased use of restrictive interventions, beyond what would have been expected had the pandemic not occurred.

Towards ultra-thin plasmonic silicon wafer solar cells with minimized efficiency loss.

The cost-effectiveness of market-dominating silicon wafer solar cells plays a key role in determining the competiveness of solar energy with other exhaustible energy sources. Reducing the silicon wafer thickness at a minimized efficiency loss represents a mainstream trend in increasing the cost-effectiveness of wafer-based solar cells. In this paper we demonstrate that, using the advanced light trapping strategy with a properly designed nanoparticle architecture, the wafer thickness can be dramatically reduced to only around 1/10 of the current thickness (180 µm) without any solar cell efficiency loss at 18.2%. Nanoparticle integrated ultra-thin solar cells with only 3% of the current wafer thickness can potentially achieve 15.3% efficiency combining the absorption enhancement with the benefit of thinner wafer induced open circuit voltage increase. This represents a 97% material saving with only 15% relative efficiency loss. These results demonstrate the feasibility and prospect of achieving high-efficiency ultra-thin silicon wafer cells with plasmonic light trapping.

Enhanced light trapping in the silicon substrate with plasmonic Ag nanocones.

Ag nanocone enhanced light trapping in the silicon substrate is numerically investigated. For a wide range of the dielectric spacer thickness, the normalized scattering cross section of the rear located particles is higher than that of the front located particles, which is contrary to previous reports. This design not only avoids the conflict with the detrimental Fano effect but is also beneficial to the rear located particles. The fraction of the incident light scattered into silicon is calculated. The path length enhancement is assessed. The Ag nanocone shows highly competitive light-trapping potential.

Broadband enhancement in thin-film amorphous silicon solar cells enabled by nucleated silver nanoparticles.

Recently plasmonic effects have gained tremendous interest in solar cell research because they are deemed to be able to dramatically boost the efficiency of thin-film solar cells. However, despite of the intensive efforts, the desired broadband enhancement, which is critical for real device performance improvement, has yet been achieved with simple fabrication and integration methods appreciated by the solar industry. We propose in this paper a novel idea of using nucleated silver nanoparticles to effectively scatter light in a broadband wavelength range to realize pronounced absorption enhancement in the silicon absorbing layer. Since it does not require critical patterning, experimentally these tailored nanoparticles were achieved by the simple, low-cost and upscalable wet chemical synthesis method and integrated before the back contact layer of the amorphous silicon thin-film solar cells. The solar cells incorporated with 200 nm nucleated silver nanoparticles at 10% coverage density clearly demonstrate a broadband absorption enhancement and significant superior performance including a 14.3% enhancement in the short-circuit photocurrent density and a 23% enhancement in the energy conversion efficiency, compared with the randomly textured reference cells without nanoparticles. Among the measured plasmonic solar cells the highest efficiency achieved was 8.1%. The significant enhancement is mainly attributed to the broadband light scattering arising from the integration of the tailored nucleated silver nanoparticles.