During their training, psychiatry residents must learn to evaluate and manage agitated patients. Encounters with agitated patients are potentially volatile situations, which pose danger for both patients and staff. Inadequately-trained staff may put patients at risk by further escalating the situation, missing underlying medical causes of agitation, and inappropriately using sedation and restraints (1).
Many psychiatry residents do not feel adequately prepared to care for agitated patients (2). Several barriers may prevent trainees from becoming proficient in managing agitated patients. The frequency of exposure to agitated patients is variable, and, when such patients are seen, residents are most likely to be “on call,” where level of supervision is variable. Agitated patients are frequently initially treated by emergency physicians and are often calmer when seen by psychiatry consultants.
Experiential learning through simulation is frequently used for safety training in fields where high-risk decisions must be made rapidly (3). Therefore, simulation may be useful to train residents to work with agitated patients. Simulation may have advantages over informal role-playing in that trained actors, known as Simulated Patients (SPs), can produce reliable portrayals of complex patients, leading to a higher-fidelity experience (4, 5). Educators in other medical fields have demonstrated the effectiveness of using simulation to teach trainees to deal with crisis situations (6). In psychiatry settings, SPs were found to be realistic, and brief encounters of approximately 15 minutes adequately addressed skills required for junior residents (7).
Others have described using simulation to prepare trainees to work with agitated patients in the emergency department (8, 9), however little is known regarding the benefit and feasibility of simulation training for psychiatric residents. Therefore, we created an educational intervention to train junior psychiatric residents to evaluate and manage agitated patients, and then evaluated the intervention, using a survey including both closed- and open-ended questions.
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Overall Educational Program
The objectives of the training session were to enable residents to 1) evaluate patients to determine the cause of agitation; 2) use verbal de-escalation when appropriate; 3) select suitable pharmacotherapy for management of agitation; 4) maintain personal and patient safety. To investigate the benefit and feasibility of such an educational intervention, participants completed a questionnaire before and after the intervention.
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Participant Recruitment
All PGY-1 and -2 residents (N=22) in the McGill Psychiatry Residency Program were invited by e-mail to participate. Only junior residents were included for this pilot study, and attendance was not mandatory. Twelve residents (55%) participated. Those who did not participate included 5 who were out of town, 3 who replied late but attended as observers, and 2 who did not respond. This project was approved by the McGill University Research Ethics Board.
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Educational Intervention
The educational intervention began with a 1-hour plenary session that focused on safety, evaluating the etiology of agitation, using verbal de-escalation, and selecting appropriate pharmacotherapy. The plenary was based on reviews (e.g., Moore and Praff (10)) and expert guidelines (1).
Participants then participated in three 14-minute simulations with SPs, each followed by a 14-minute debriefing by an expert observer. Participants were informed that the simulation component was formative, and were instructed to conduct a focused psychiatric assessment and develop a provisional treatment plan, while managing any problem that arose. The three cases consisted of 1) a woman with mania, who fights with her boyfriend and pulls out a concealed bottle of pepper spray; 2) a patient who had a history of depression and presents with delirium, then escapes from the emergency department; and 3) a patient with a personality disorder, anxiety, and benzodiazepine dependence, who is seeking additional medication in an outpatient setting. The actors were instructed to simulate patients whose level of agitation was amenable to verbal de-escalation. SPs rehearsed scenarios with the first author (DZ) 1 week before the intervention.
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Evaluation of the Educational Intervention
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Pre-intervention questionnaire
Participants self-assessed their understanding of safety procedures, causes of agitation, verbal de-escalation, and pharmacotherapy on a 7-point scale (1: poor to 7: excellent). Also, they reported, on a 7-point scale (1: very low to 7: very high), their comfort and perceived competence in evaluating and managing agitated patients. Participants were asked to provide open-ended explanations for ratings of comfort and competence. We collected demographic information, and all identifying information was removed.
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Post-intervention questionnaire
Participants rated the change in understanding of safety procedures, causes of agitation, verbal de-escalation, and pharmacotherapy on a 7-point scale (1: much worse; 4: no change; and 7: much better). Participants also repeated self-assessments of comfort and competence, providing open-ended, supportive explanations.
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Evaluation of the intervention
Within the post-intervention questionnaire, participants rated the usefulness of the plenary session, the simulations, and the debriefings. Ratings were on a 7-point scale (1: very low to 7: very high).
Self-reported ratings were analyzed with repeated-measures analysis of variance (ANOVA), where the repeated measures were Time (pre-/post-), Question (competence/comfort), and Skill (evaluation/management), and the between-subjects variable was Training Year (PGY1/PGY2).
The open-ended explanatory responses were coded for thematic content. The themes were derived inductively from the data. For clarity, the responses to open-ended questions were amalgamated.
Twelve residents participated in the study. Six (50%) were PGY-1. The mean age was 29 (range: 25–36). The majority (9 of 12) had completed at least 1 month of emergency psychiatry participation.
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Self-reported ratings of knowledge (Pre-intervention)
Participants rated their understanding of key topics. Mean (standard deviation [SD]) ratings for verbal de-escalation, safety procedures, causes of agitation, and pharmacotherapy were 3.9 (1.7), 4.7 (1.1), 5.3 (1.4), and 4.8 (1.7), respectively.
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Self-assessed change in knowledge (Post-intervention)
After the intervention, participants self-reported changes in understanding of the same topics. Mean (SD) scores for verbal de-escalation, safety procedures, causes of agitation, and pharmacotherapy were 5.7, (0.75), 5.1 (0.90), 5.0 (0.85), 4.9 (1.32), respectively. Therefore, participants felt that their knowledge improved across all topics (all responses were >4).
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Self-reported ratings of competence and comfort (Pre- and Post-intervention)
Mean (SD) Pre- ratings of comfort in evaluating and managing agitated patients were 3.0 (1.2) and 2.9 (1.4), respectively. Post- ratings of comfort evaluating and managing agitated patients were 4.7 (1.2) and 4.6 (1.0), respectively. Mean Pre- ratings of perceived competence evaluating and managing agitated patients were 3.5 (1.1) and 3.3 (1.4); Post- ratings of perceived competence evaluating and managing agitated patients were 4.7 (1.1) and 4.5 (1.1). Therefore, participants reported increases in all measures after the intervention (F[1,10]=16.53; p<0.005).
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Evaluation of the intervention
Participants rated the usefulness of the plenary session, the simulations, and the feedback sessions highly (means [SD]: 6.2 (0.94), 6.4 (1.0), and 6.5 (0.67), respectively, on a 7-point scale).
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Open-ended explanations of competence and comfort (Pre-intervention)
Five themes were derived from responses to the open-ended questions completed before the intervention. These were 1) a lack of experience (only a theme in PGY-1 participants); 2) anxiety; 3) doubting their abilities; 4) knowing what to do, but having trouble implementing it; and 5) high baseline confidence (only one person reported feeling very comfortable in his ability to manage agitated patients and ascribed this to training in a specific hospital).
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Open-ended explanations of competence and comfort (Post-intervention)
After the intervention, eight themes were derived from explanations of improvement in competence, and comfort: 1) better understanding of concepts; 2) more comfort with skills practiced; 3) feeling more confident; 4) having enjoyed the experience or found it helpful; 5) having identified issues to work on; 6) having found the feedback useful; 7) anxiety remaining problematic; and 8) needing more practice.
Before the pilot intervention, many participants suggested that a lack of experience and their anxiety affected both their comfort and perceived competence in evaluating and managing agitated patients. Ratings of comfort and self-assessed competence increased after the intervention. Participants reported a better understanding of key concepts and were more comfortable with skills; however, some reported lingering anxiety and suggested that more supervised practice with real patients might alleviate barriers to feeling comfortable and competent. It is worth noting that most residents had completed their emergency psychiatry rotation, yet still found the intervention beneficial.
There are several limitations to this study. First, this was a pilot study, involving a small number of junior residents from a single training program, and this may limit the generalizability of these findings. Also, several residents did not attend, and it is possible that the intervention missed both the least prepared and those who self-assessed as prepared. Second, the current study relied on self-reported of understanding and self-perceived competence. It remains to be seen whether and how objective measures of competence relate to residents’ self-evaluations. Third, it is possible that response expectancy may account for a portion of the reported improvements.
Some participants reported that, despite the intervention, they remained anxious and still lacked real clinical experience. This is not unexpected, considering that the activity only lasted 2.5 hours. Future studies should include an investigation into whether trainees continue to become more comfortable and competent after they have the opportunity to apply their learning in the clinical environment. Ultimately, future work should investigate whether learning to evaluate and manage agitated patients through simulation leads to changes in patient care, patient outcomes, and physician and trainee safety.
The feasibility of implementing a similar program will always depend on local resources available. Our intervention required 6 de-briefers, 10 SPs, and 2 SP trainers, for approximately 4 hours of simulation time, to accommodate 12 residents. Our de-briefers expressed the opinion that additional training in simulation de-briefing would be beneficial. Distributed residency training, vacation, and other leave may interfere with residents’ ability to participate.
Considering these challenges, it is vital to determine which learning outcomes are best suited for a simulation environment. We propose that, in addition to highly technical procedural skills, simulation is most useful when training learners to manage clinical scenarios that are of low frequency and high importance.
In summary, residents found that participating in a simulation-based activity was useful and reported increased knowledge as well as improved comfort and perceived competence both evaluating and managing agitated patients. This intervention was feasible and appears to be particularly well suited for helping residents learn to apply verbal de-escalation techniques. More research is needed to determine the long-term impact of similar activities as well as whether these educational interventions may lead to changes in patient care.