Positive Effects of an Anti-Aggression and De-Escalation Training on Ward Atmosphere and Subjective Safety May Depend on Previous Training Experience

Anti-aggression and de-escalation (ADE) trainings of health-care professionals working on psychiatric inpatient wards have been shown to increase staff knowledge and confidence, which could be connected with higher subjective safety. Additionally, a potential reduction of aggressive incidents could improve ward atmosphere. Thus, the current study aimed to investigate the effects of ADE training on ward atmosphere and subjective safety. In 2015, an ADE training was established at the Psychiatric University Clinics (UPK), University of Basel. Nursing staff from 22 wards received theoretical and practical training over the course of 5 days. Ward atmosphere and subjective safety were assessed using the Essen Climate Evaluation Schema (EssenCES). A total of 46 people had been assessed in 2012 before training implementation (baseline), and 45 persons in 2016 after implementation. In the 2016 group, 23 people had previously participated in an ADE training, and 22 were first-time participants. Patients’ coherence (p = 0.004), subjective safety (p = 0.004), and ward atmosphere (p = 0.001) were rated significantly higher by first-time ADE training participants compared to baseline, and patients’ coherence (p = 0.029) and ward atmosphere (p = 0.011) were rated significantly higher by first-time ADE training participants than by nurses with prior ADE training. There were no significant differences regarding any EssenCES ratings by nurses with prior ADE training compared to baseline. ADE training was exclusively connected with higher ratings on most EssenCES scales for first-time participants. This indicates that the positive effects of ADE training may depend on previous training experience.


Materials aND MethoDs
Beginning in February 2015, an ADE training adapted from the commercially available RADAR and ProDeMamethods (7) was established at the Psychiatric University Clinics (UPK), University of Basel (12). Nursing staff from 22 wards received theoretical and practical training over the course of 5 days in groups of between 12 and 15 participants. Data collected in 2012 (baseline, group A) and in 2016 (after ADE training) were analyzed in the current study. Baseline data on ward atmosphere on open and closed wards was rated by 46 members of the UPK nursing staff (43.5% female) between June and July 2012 (13). Between February and August 2015, 80 members of the nursing staff working on open and closed wards received ADE training and were followedup with via question naire in January 2016; 45 (56.3%) questionnaires were available for analysis. Of these, 23 were completed by people who had previously participated in an ADE training (group B), and 22 by persons who were firsttime participants (group C).
General "ward atmosphere, " along with its subdimensions of "patients, " "coherence, " "subjective safety, " and "therapeutic hold, " were examined using the Essen Climate Evaluation Schema (EssenCES), a wellestablished selfrating scale (10,13). The EssenCES contains five items per dimension, and each item is rated on a 5point Likert scale. The subscale "subjective safety" is highly correlated with the frequency of dangerous events (10,11), and patient ratings are generally similar to staff ratings (8).
Additionally, data on previous ADE training experience and gender were collected. To guarantee the participants' anonymity, no further information allowing for the potential identification of participants was collected (e.g., information on age or profes sional experience).
According to current regulations, no approval from an ethics committee was required for this evaluation. Study procedures were carried out in accordance with all local and national regula tions and with the Declaration of Helsinki in its latest revision. Data were analyzed using descriptive statistics, χ 2 tests, ttest, and ANOVAs with post hoc Scheffé tests, and pvalues < 0.05 were considered significant. resUlts Table 1 shows the overall effect of the ADE training.
There were no significant gender differences between the 2012 and the 2016 groups. Overall, nursing staff reported a significant increase in patients' coherence, subjective safety, and general ward atmosphere in the time after the ADE training, while there were no significant differences regarding therapeu tic hold. Table 2 shows a subgroup analysis comparing groups A (2012), B (2016 after ADE training, with prior ADE training experience), and C (2016 after ADE training, without prior ADE training experience) to examine the effect of prior ADE training on ward atmosphere ratings.
Again, there were no significant gender differences. ANOVAs In the post hoc tests, there were no significant differences regarding any EssenCES subscale between groups A and B. However, patients' coherence (p = 0.004), subjective safety (p = 0.004), and ward atmosphere (p = 0.001) were rated significantly higher by group C than by group A, and patients' coherence (p = 0.029) as well as ward atmosphere (p = 0.011) were rated significantly higher by group C than by group B.

DiscUssioN
The purpose of this study was to examine the effects of an ADE training on nursing staff ratings of patients' coherence, ward atmosphere, subjective safety, and therapeutic hold. Our results show that, overall, staff reported higher ratings for patients' coher ence, subjective safety, and ward atmosphere in the time follow ing ADE training. In particular, staff without previous training reported a significantly improved ward atmosphere, subjective safety, and patients' coherence with respect to baseline ratings. However, staff with previous training experience showed no significant differences in the subgroup analysis. This may explain the conflicting findings regarding the outcome of ADE trainings found in the previous literature. While there is evidence for improved selfconfidence as an effect of ADE trainings (7), some studies failed to find effects on nurses' perceptions toward patient aggression (14). Needham et al. showed that while the severity of aggressive incidents rema ined unchanged after an ADE training, the subjective severity as assessed by nursing staff declined (15), demonstrating primarily subjective effects of the training. In addition, Blaesi et al. showed that EssenCES scores increased on newly opened wards compared to permanently closed and open wards (13), suggesting subjective effects with respect to change. It is plausible that these effects depend on personal characteristics and previous staff experience.
Our study provides the first evidence for an association between ADE training effects and previous training experience. However, the small sample size, the relatively long time between assessments, and the crosssectional design limit the interpret ability of our findings. In particular, changes in the mix of patient cases, patients' characteristics, and structural changes in the hos pital from 2012 to 2016 may have influenced the present findings. Furthermore, only information on gender was available, and other potential confounding factors, for example, years of professional experience, could not be controlled for. Therefore, the current results should be interpreted with caution, and replication of the findings is needed.
In summary, our study indicates that the positive effects of an ADE training may depend on previous training experience. This information may help to disentangle conflicting results of previous studies, to optimize ADE trainings, and to better address the needs of healthcare professionals. Future studies are encour aged and should consider previous ADE training experience as a potential confounder.

Data aVailaBilitY stateMeNt
The datasets analyzed in this study can be obtained from the cor responding author on request.

ethics stateMeNt
According to current regulations, no approval from an ethics committee was required for this evaluation. Study procedures were carried out in accordance with all local and national regula tions and with the Declaration of Helsinki in its latest revision.
aUthor coNtriBUtioNs CH designed the study, and wrote the initial draft of the paper. FR and SS collected the data. DF, FR, SS, and CH analyzed and interpreted the data. CH, DF, FR, SB, SS and UL have contributed to, read, and approved the final version of the manuscript. DF had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

fUNDiNG
The authors declare that, except for income received from their primary employer, no financial support or compensation has been received from any individual or corporate entity over the past 12 months for research of professional service related to this study, and there are no personal financial holdings that could be perceived as constituting a potential conflict of interest.