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Using Nonviolent Crisis Intervention® Training to Prepare Nursing Students for the Job

By Celeste Waddy-Carlton, MSN Ed., RN | 0 comments
Using Nonviolent Crisis Intervention® Training to Prepare Nursing Students for the Job
Introduction
I led a research project to test the effectiveness of CPI’s Nonviolent Crisis Intervention® training program for the third semester Fall 2011 and Spring 2012 nursing students enrolled in a course titled Caring for Clients With Complex Alterations in Integrative Needs offered at the New York City College of Technology (City Tech). The rationale and justification for the research study was to test the effectiveness of the Program at City Tech. At the end of the research study in Spring 2012, the data collected was analyzed.

Subjects and Methods

Subjects
A total of 108 students of City Tech, undertaking the psychiatric course during the academic year, were invited to participate in this study. The course consists of two hours of lecture for 14 weeks and six hours of clinical practice on a psychiatric unit in several hospitals in Brooklyn, New York. Clinical rotation includes the inpatient psychiatric unit, psychiatric outpatient services, and the psychiatric emergency room.

Participants were asked to complete a pre-test before the training, and a post-test and an evaluation questionnaire at the completion of the training. No screening was done to identify the participants. The subjects’ privacy was de-identified without the ability to re-identify. The participants were clearly informed that their participation was voluntary and confidential and that their responses would not in any way impact their final grades for the course.

Subject Population
The subject group’s students enrolled in the psychiatric class of the City Tech nursing program in the Fall of 2011 and Spring of 2012. The total amount of students that participated in this one-year research project was 108. The sample size was the total amount of students that were registered in both Fall 2011 and Spring 2012 semesters.

Subject Identification and Recruitment
The student participants were recruited during orientation prior to the commencement of the training program, and an informed consent was obtained. Participation in the research study had no influence on their grades for the course and has no bearing on their university standing.

Conducting this research project helped nursing instructors and nursing students better understand the experience and the effectiveness of the Nonviolent Crisis Intervention®  training program at City Tech.

Potential Risks
The risks associated with participation in this research study were not greater than those associated with or encountered in their everyday lives or as nursing students at City Tech.

Potential Benefits for Subjects
There were no direct benefits to the participants of the research study. However, participating in the study improved the understanding of the experience as a nursing student participating in the training program. The results of the study would be used in nursing publications or presentations.

Research Design
A cross-sectional qualitative and quantitative non-experimental descriptive research design was used to conduct the study. Reference is made to a study by Alan Bryman, justifying and exploring the argument that there is considerable value in examining both the rationales that are given for combining quantitative and qualitative research and the ways in which they are combined in practice (Bryman, 2006).

Methods
The proposed research design was a cross-sectional design. The study used a pre-test, a post-test, and an evaluation method. The training program was a one-day training program. At the beginning of the training, participants were asked to complete a five-minute pre-test, and at the end of the training, they completed a post-test and also a participant evaluation form.

The five-item pre-test, the eight-item post-test, and the 11-item participant evaluation survey of the training were developed by CPI. CPI gave permission to the principal evaluator to use this survey in the research study.

The five items on the pre-test asked the participants to answer basic questions. The eight-item post-test asked questions pertaining to the training. The 11-item participant evaluation used a scale of 5 (strongly agree) through 1 (strongly disagree). The range of responses on the evaluation survey was as follows:
  • 5 = strongly agree
  • 4 = agree
  • 3 = neither agree nor disagree
  • 2 = disagree
  • 1 = strongly disagree

In addition, to evaluate the training program, the scales of the participant evaluation form requested the students to circle a number that appropriately expressed their opinion regarding the training, the Instructor, and the presentation. There were two additional sections whereby students were requested to comment on the training by writing a brief narrative regarding the results of their experience in the training program and any statements about the training program, teaching methods, course material, and/or the Instructor.

Statistical Analysis
The statistical analysis plan used Excel to analyze the data of the pre-test, post-test, and evaluation method. A paired T-test was used to analyze the total scores of the participants before and after the training program. Furthermore, each specific question was analyzed using the same methodology.

Statistical Analysis Plan
There were 46 nursing students enrolled in the Fall 2011 semester and 62 nursing students enrolled in the Spring 2012 semester. Both cohorts participated in this research project. Excel was used to conduct the statistical analysis of the pre-test, the post-test, and the evaluation method. The purpose of the statistical analysis plan was to measure City Tech students’ pre-nursing knowledge and compare it to the post-training knowledge. The goal was to summarize the students’ evaluation of the training program.

Limitations of the Study
In line with most research studies, this study had limitations that may impact or influence the generalizability of the findings. One limitation is that it was conducted in a single institution with internal controls rather than comparison controls. If the study included participants from other similar institutions, internal comparison might have added weight to the study. As such, the responses of students are open to prejudicial treatment if respondents believed that their respective responses were desirable or more socially acceptable. A further limitation was that there was no measurement of skills transfer to the clinical environment post-intervention.

Results

Demographics
A total of 108 male and female matriculated City Tech students from the Fall 2011 and Spring 2012 semester completed both the pre-test and post-test. This gave an overall rate of 100%. The pre-test and the post-test results showed a major difference between the pre-test and post-test responses.

Findings

Participant Evaluation Questions
As a result of completing this program, I believe that I have learned to:
Use nonverbal techniques to prevent acting-out behavior.
  • 63% of the participants strongly agreed
  • 29% of the participants agreed

Implement verbal de-escalation strategies, such as limit setting.
  • 62% of the participants strongly agreed
  • 31% of the participants agreed

Use safe physical intervention procedures as a last resort when a person is a danger to self or others.
  • 76% of the participants strongly agreed
  • 18% of the participants agreed

Build Therapeutic Rapport with acting-out individuals after a crisis is over.
  • 64% of the participants strongly agreed
  • 32% of the participants agreed

Questions About the Instructor
During the program, the Instructor:
Applied the course content to variety of examples.
  • 85% of the participants strongly agreed
  • 12% of the participants agreed

Stimulated interest in the subject matter.
  • 83% of the participants strongly agreed
  • 15% of the participants agreed

Created an enjoyable learning atmosphere.
  • 85% of the participants strongly agreed
  • 12% of the participants agreed

Emphasized the philosophy of Care, Welfare, Safety, and Security℠.
  • 85% of the participants strongly agreed
  • 11% of the participants agreed

Questions About the Program Content
(5 = highest; 1 = lowest)

The program content was relevant to my needs.
  • 69% of the participants think the program content was very relevant to their needs
  • 26% of the participants think the program content was relevant to their needs

How would you rate the program overall?
  • 67% of the participants strongly agreed
  • 28% of the participants agreed

Results of this research study showed that 95% of the participants agreed that Nonviolent Crisis Intervention® training is effective.

Discussion
Given the importance of training, enhanced patient rights, increased litigation, and the use of evidence-based practice in the prevention and management of aggressive incidents, health services, both nationally and internationally, have initiated training programs to educate nurses in the prevention and management of violence and aggression to reduce and mitigate such behaviors, including their impact on health care facilities, staff, and patients.

Historically, interventions used to manage violent and aggressive patients in mental health inpatient units were haphazard and unstructured (Duxbury & Paterson, 2005). Appropriate training has reduced the need for coercive practices and reduced the rate, severity, and negative outcomes due to the application of de-escalation strategies (Abderhalden et al, 2004).

Many training programs emerged from the prison system in the US and UK. Formerly known in the UK as “Control and Restraint,” the programs were later modified and implemented in the health service industry, but despite efforts to adapt techniques to suit the needs of the health industry, early training programs concentrated only on the physical skills relating to restraint (Wright, 1999).

Calabro, Mackey, and Williams studied a training program designed to prevent and manage violent and aggressive patients in the US in an acute psychiatric hospital consisting of 12 inpatient units. The focus was to evaluate the course in the areas of “knowledge, attitudes, self-efficacy, and behavioral intention.”

95 percent responded positively that the training was effective. Five percent of respondents were neutral or indicated not applicable.

A five-point Likert scale was used to evaluate the areas of attitude, self-efficacy, and behavioral intention. All outcomes showed a significant improvement immediately after the one-day course. The researcher suggested that participants were more likely to engage with aggressive patients and felt more confident and willing to use the skills taught on the psychiatric unit.

The training program has several purposes and was designed for a variety of settings such schools, health care facilities, and correctional facilities. The training program is a safe, nonharmful behavior management system designed to aid staff members in maintaining the best possible Care, Welfare, Safety, and Security℠ for agitated or out-of-control individuals even during their most violent moments.

This training is effective in teaching individuals to safely manage aggressive behaviors not only because of its content, but due to the environment in which the program is taught (CPI, 2010). One of the goals of the training program is to find positive ways of dealing with crises so they are not traumatic. A crisis can be a learning experience for everyone involved, and the result can lead to growth and change (CPI, 2010).

Dr. Donald Kirkpatrick’s Learning Evaluation Model shows  that Level 1 deals with Reaction Evaluation. In this level, an individual describes how they felt about the training or learning experience. Level 2 is Learning Evaluation, which measures the increase in knowledge before and after the training. Level 1 and Level 2 evaluation methods are similar to the evaluation methods of the Nonviolent Crisis Intervention® training program. The evaluation results of this research study identified with Dr. Kirkpatrick’s theory of learning (Kirkpatrick, 1996).

Participants were asked if the Training Program was relevant to their needs, and 95 percent reported that it was. They were also asked to rate the program overall, and 95 percent strongly agreed that it was beneficial. They reported that it increased their knowledge in dealing with individuals experiencing a mental illness in the hospital setting and in the community. They also strongly recommended that the training be a part of every nursing curriculum in the country since it effectively prepares nursing students to embark upon their clinical nursing experiences in various psychiatric settings.

Conclusion
The study showed that nursing students had more favorable attitudes toward the Nonviolent Crisis Intervention® training program after the completion of training. The training helped them decrease their fears and become better prepared for their future psychiatric clinical experiences. Implementing the training program in nursing schools as part of the nursing curriculum can assist with providing better learning outcomes for nursing students, and ultimately better Care, Welfare, Safety, and Security℠ for patients as well.

Significance of the Study
The study will add to the body of knowledge regarding nursing students’ attitudes toward psychiatry and the impact of their attitude on their clinical practice experience. Knowledge gained from this study will help curriculum designers develop future sound educational programs for nursing students undertaking psychiatric nursing courses.

References
Abderhalden, C., Duxbury, J.A.D., Hahn, S., Halfens, R.J.G., & Needham, I. (2006). The effect of a training course on the mental health nurses’ attitudes on the reasons of patient aggression and its management. Journal of Psychiatric and Mental Health Nursing, 13, 197–204.

Bryman, Alan. (2006). Integrating quantitative and qualitative research: how is it done? Qualitative Research. Retrieved from http://www.socsci.uci.edu/ssarc/sshonors/webdocs/ Integratingqualandquant.pdf

Calabro, K., Mackey, T.A. & Williams, S. (2002). Evaluation of training designed to prevent and manage patient violence. Issues in Mental Health Nursing, 23, 3–15.

Duxbury, J. & Paterson, B. (2005). The use of physical restraint in mental health nursing: An examination of principles, practice and implications for training. The Journal of Adult Protection, 7(4), 13–24.

Kirkpatrick, D. L. (1994). Evaluating training programs: The four levels. San Francisco: Emeryville, CA: Berrett-Koehler.

Wright, S. (1999). Physical restraint in the management of violence and aggression in in-patient settings: A review of issues. Journal of Mental Health, 8(5), 459–472.

Acknowledgements
The author extends her gratitude to the students who shared their thoughts in the aim of helping the author and other professionals better understand the experience and challenges of nursing students participating in a clinical within a mental health inpatient or outpatient facility. Special thanks to Dr. Rafferty of City Tech Nursing Department for reading the recruitment script and to consent the participants.

About the Author
Celeste Waddy-Carlton is an assistant professor at the New York City College of Technology in Brooklyn, NY and a Nonviolent Crisis Intervention® Certified Instructor.

Originally published in the Journal of Safe Management of Disruptive and Assaultive Behavior (JSM), Fall 2013. © 2013 CPI.

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