PDF(Pubmed)
Abstract：
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts.
UNASSIGNED: In-patients, clinical staff, managers, carers/relatives and training staff in the target settings.
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome.
UNASSIGNED: Uncontrolled design and self-selecting sample.
UNASSIGNED: Definitive trial determining intervention effects.
UNASSIGNED: This trial is registered as ISRCTN12826685 (closed to recruitment).
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts.
UNASSIGNED: In-patients, clinical staff, managers, carers/relatives and training staff in the target settings.
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome.
UNASSIGNED: Uncontrolled design and self-selecting sample.
UNASSIGNED: Definitive trial determining intervention effects.
UNASSIGNED: This trial is registered as ISRCTN12826685 (closed to recruitment).
UNASSIGNED: 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.
UNASSIGNED: 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.
摘要：
■在心理健康住院环境中经常使用遏制（例如，身体约束和隔离）。遏制与严重的心理和身体伤害有关。降级（在没有遏制的情况下管理痛苦的心理社会技术）建议管理侵略和其他不安全行为，比如自我伤害。所有国家卫生服务人员都接受过降级培训，但几乎没有证据支持培训的有效性。
■目标是：（1）定性调查降级，并确定在成人急性和法医精神健康住院环境中使用的障碍和促进者；（2）与相关利益相关者共同制定干预措施，以增强在这些环境中的降级；（3）评估干预措施对冲突发生率的初步影响（例如暴力，自我伤害）和遏制（例如隔离和身体约束），并了解干预效果的障碍和促进者。
■基于经验的共同设计和不受控制的前后可行性评估的干预开发。系统评论和定性访谈调查了使用中的上下文差异和降级效果。综合这些证据为共同设计干预措施以加强降级提供了信息。随后进行了不受控制的干预可行性试验。在24周内收集临床结果数据，包括8周的干预前阶段，8周的嵌入和8周的干预后阶段。
■十个住院病房（包括急性，精神病重症监护,低,中等和高安全性法医）在两个英国精神健康信托中。
■住院患者，临床工作人员,经理,照顾者/亲属和目标设置中的培训人员。
■增强成人急性和法医单位的降级技术：开发和评估基于证据的培训干预措施（EDITION）干预措施包括降级培训，两种新颖的反思实践模式，事件后的情况汇报和临床实践反馈，协作开处方和查房，围绕入学实践变化，转移移交以及社会和物理环境，以及感官调节和支持计划，以减少患者的痛苦。
■与可行性相关的衡量结果(招聘和保留，完成成果措施)，培训结果以及临床和安全性结果。通过患者-工作人员冲突检查表测量冲突和遏制率。使用遏制措施态度问卷测量临床结果，对人格障碍的态度问卷，暴力预防气候量表，能力,机遇,和动机量表，员工量表中的强迫体验量表和感知表达情绪。
■建议的主要结果的完成率非常好，总体为68％（不包括远程数据收集），在干预后期间增加到76%(不包括远程数据收集)。工作人员和患者受访者的次要结局均具有较高的完成率。回归分析表明，冲突和遏制的减少都是通过研究阶段预测的(前，嵌入,干预后)。未发生与干预相关的不良事件或严重不良事件。
■干预和数据收集程序是可行的，并且有一个信号表明对拟议的主要结果有影响。
■不受控制的设计和自选样品。
■确定干预效果的明确试验。
■该试验注册为ISRCTN12826685（已停止招募）。
■该奖项由美国国家卫生与护理研究所（NIHR）卫生技术评估计划（NIHR奖编号：16/101/02）资助，并在《卫生技术评估》中全文发布。28号3.有关更多奖项信息，请参阅NIHR资助和奖励网站。
■冲突（一个术语，用于描述一系列潜在的不安全事件，包括暴力，自我伤害,打破规则,拒绝用药,在心理健康环境中使用非法药物和酒精和潜逃）会造成严重的身体和心理伤害。遏制干预措施旨在尽量减少暴力(和其他冲突行为)造成的伤害，如克制、隔离和快速镇静可能会对患者造成严重伤害，偶尔,死亡。参与身体约束是英国国家卫生服务精神卫生工作人员严重身体伤害的最常见原因。对工作人员的暴力行为导致医疗服务在疾病和诉讼付款方面的巨额费用。遏制干预措施也很昂贵（例如，身体约束每年花费610万英镑的精神卫生服务和8800万英镑的增加观察费用）。尽管有这些危害,最近的发现表明，隔离和身体约束等遏制干预措施继续在心理健康环境中经常使用。临床试验表明，干预措施可以在不增加暴力和其他冲突行为的情况下减少遏制（例如，言语攻击，自我伤害)。由于减少了安全壳的使用，因此节省了大量成本。降级,作为在没有限制性做法的情况下管理侵略和潜在暴力的干预措施，是核心干预。“降级”是一系列心理社会技术的统称，旨在减少痛苦和愤怒，而无需使用“遏制”干预措施（通过限制一个人的独立行动能力来防止伤害的措施，如身体约束和隐居)。证据表明，降级涉及确保安全干预和建立有效沟通的条件，澄清并试图解决患者的担忧，传递尊重和同理心，调节焦虑和愤怒等无用的情绪。尽管在国内外临床指南和培训政策中占有重要地位，并且是强制性国家卫生服务培训的组成部分，没有基于证据的模型作为训练的基础。2015年对降级培训的有效性和可接受性进行了系统审查，得出结论：（1）在足够严格的评估中，没有任何培训模式证明了有效性。（2）评估模型的理论基础通常不清楚，（3）对可能增强可接受性和可吸收性的培训特征的调查不足。尽管所有国家卫生服务人员都接受了降级培训，但还没有高质量的试验来评估培训的有效性和成本效益。需要进行可行性研究，以确定是否有可能进行确定性试验，以确定临床，这种干预措施的安全性和成本效益。
心理健康医院对患者和工作人员来说都是压力很大的地方。病人经常被违背他们的意愿拘留，在嘈杂的地方，陌生和可怕。暴力和自我伤害经常发生。有时工作人员身体约束患者或将患者隔离在锁着的房间里（称为隔离）。虽然这些措施有时可能是必要的，以保持安全，它们在心理和身体上都是有害的。为了帮助减少这些不安全措施的使用，员工接受沟通技巧培训，旨在减少愤怒和痛苦，而无需使用武力。专业人士称这些技能为“降级”。尽管降级培训是强制性的，没有很好的证据表明它是否有效，或者应该培训哪些特定的技术人员。加强成人急性和法医单位的降级技术：开发和评估基于证据的培训干预（EDITION）项目，旨在开发和评估基于研究证据的降级培训计划。我们采访了一百多名在精神病院工作或接受治疗的人。这些人很清楚，培训应针对人际关系和环境压力的关键来源，以防止工作降级。我们还回顾了所有关于降级和训练的科学研究，旨在确定最有可能增加降级使用的培训要素。然后，与目前的精神卫生服务用户和临床工作人员合作，我们制定了培训计划。向在精神健康医院10个不同病房工作的270多名工作人员提供了培训。我们测量了暴力的发生率，在员工接受培训前8周和接受培训后16周（总共24周的数据收集），自我伤害和使用身体约束和隔离。对这些数据的分析表明，这些不安全事件在训练后发生的频率明显低于训练前，这增加了培训有助于减少伤害的可能性。
■目标是：（1）定性调查降级，并确定在成人急性和法医精神健康住院环境中使用的障碍和促进者；（2）与相关利益相关者共同制定干预措施，以增强在这些环境中的降级；（3）评估干预措施对冲突发生率的初步影响（例如暴力，自我伤害）和遏制（例如隔离和身体约束），并了解干预效果的障碍和促进者。
■基于经验的共同设计和不受控制的前后可行性评估的干预开发。系统评论和定性访谈调查了使用中的上下文差异和降级效果。综合这些证据为共同设计干预措施以加强降级提供了信息。随后进行了不受控制的干预可行性试验。在24周内收集临床结果数据，包括8周的干预前阶段，8周的嵌入和8周的干预后阶段。
■十个住院病房（包括急性，精神病重症监护,低,中等和高安全性法医）在两个英国精神健康信托中。
■住院患者，临床工作人员,经理,照顾者/亲属和目标设置中的培训人员。
■增强成人急性和法医单位的降级技术：开发和评估基于证据的培训干预措施（EDITION）干预措施包括降级培训，两种新颖的反思实践模式，事件后的情况汇报和临床实践反馈，协作开处方和查房，围绕入学实践变化，转移移交以及社会和物理环境，以及感官调节和支持计划，以减少患者的痛苦。
■与可行性相关的衡量结果(招聘和保留，完成成果措施)，培训结果以及临床和安全性结果。通过患者-工作人员冲突检查表测量冲突和遏制率。使用遏制措施态度问卷测量临床结果，对人格障碍的态度问卷，暴力预防气候量表，能力,机遇,和动机量表，员工量表中的强迫体验量表和感知表达情绪。
■建议的主要结果的完成率非常好，总体为68％（不包括远程数据收集），在干预后期间增加到76%(不包括远程数据收集)。工作人员和患者受访者的次要结局均具有较高的完成率。回归分析表明，冲突和遏制的减少都是通过研究阶段预测的(前，嵌入,干预后)。未发生与干预相关的不良事件或严重不良事件。
■干预和数据收集程序是可行的，并且有一个信号表明对拟议的主要结果有影响。
■不受控制的设计和自选样品。
■确定干预效果的明确试验。
■该试验注册为ISRCTN12826685（已停止招募）。
■该奖项由美国国家卫生与护理研究所（NIHR）卫生技术评估计划（NIHR奖编号：16/101/02）资助，并在《卫生技术评估》中全文发布。28号3.有关更多奖项信息，请参阅NIHR资助和奖励网站。
■冲突（一个术语，用于描述一系列潜在的不安全事件，包括暴力，自我伤害,打破规则,拒绝用药,在心理健康环境中使用非法药物和酒精和潜逃）会造成严重的身体和心理伤害。遏制干预措施旨在尽量减少暴力(和其他冲突行为)造成的伤害，如克制、隔离和快速镇静可能会对患者造成严重伤害，偶尔,死亡。参与身体约束是英国国家卫生服务精神卫生工作人员严重身体伤害的最常见原因。对工作人员的暴力行为导致医疗服务在疾病和诉讼付款方面的巨额费用。遏制干预措施也很昂贵（例如，身体约束每年花费610万英镑的精神卫生服务和8800万英镑的增加观察费用）。尽管有这些危害,最近的发现表明，隔离和身体约束等遏制干预措施继续在心理健康环境中经常使用。临床试验表明，干预措施可以在不增加暴力和其他冲突行为的情况下减少遏制（例如，言语攻击，自我伤害)。由于减少了安全壳的使用，因此节省了大量成本。降级,作为在没有限制性做法的情况下管理侵略和潜在暴力的干预措施，是核心干预。“降级”是一系列心理社会技术的统称，旨在减少痛苦和愤怒，而无需使用“遏制”干预措施（通过限制一个人的独立行动能力来防止伤害的措施，如身体约束和隐居)。证据表明，降级涉及确保安全干预和建立有效沟通的条件，澄清并试图解决患者的担忧，传递尊重和同理心，调节焦虑和愤怒等无用的情绪。尽管在国内外临床指南和培训政策中占有重要地位，并且是强制性国家卫生服务培训的组成部分，没有基于证据的模型作为训练的基础。2015年对降级培训的有效性和可接受性进行了系统审查，得出结论：（1）在足够严格的评估中，没有任何培训模式证明了有效性。（2）评估模型的理论基础通常不清楚，（3）对可能增强可接受性和可吸收性的培训特征的调查不足。尽管所有国家卫生服务人员都接受了降级培训，但还没有高质量的试验来评估培训的有效性和成本效益。需要进行可行性研究，以确定是否有可能进行确定性试验，以确定临床，这种干预措施的安全性和成本效益。
心理健康医院对患者和工作人员来说都是压力很大的地方。病人经常被违背他们的意愿拘留，在嘈杂的地方，陌生和可怕。暴力和自我伤害经常发生。有时工作人员身体约束患者或将患者隔离在锁着的房间里（称为隔离）。虽然这些措施有时可能是必要的，以保持安全，它们在心理和身体上都是有害的。为了帮助减少这些不安全措施的使用，员工接受沟通技巧培训，旨在减少愤怒和痛苦，而无需使用武力。专业人士称这些技能为“降级”。尽管降级培训是强制性的，没有很好的证据表明它是否有效，或者应该培训哪些特定的技术人员。加强成人急性和法医单位的降级技术：开发和评估基于证据的培训干预（EDITION）项目，旨在开发和评估基于研究证据的降级培训计划。我们采访了一百多名在精神病院工作或接受治疗的人。这些人很清楚，培训应针对人际关系和环境压力的关键来源，以防止工作降级。我们还回顾了所有关于降级和训练的科学研究，旨在确定最有可能增加降级使用的培训要素。然后，与目前的精神卫生服务用户和临床工作人员合作，我们制定了培训计划。向在精神健康医院10个不同病房工作的270多名工作人员提供了培训。我们测量了暴力的发生率，在员工接受培训前8周和接受培训后16周（总共24周的数据收集），自我伤害和使用身体约束和隔离。对这些数据的分析表明，这些不安全事件在训练后发生的频率明显低于训练前，这增加了培训有助于减少伤害的可能性。
