Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

A quantitative systematic review of the effects of training interventions on enhancing the competence of nursing staff in managing challenging patient behaviour

Authors: Sirpa Tolli, Pirjo Partanen, Raija Kontio, Arja Häggman‐Laitila

Journal: Journal of Advanced Nursing (2017); 73(12):2817–2831

DOI: 10.1111/jan.13351

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✅ PICO Analysis

Type of Study:

Quantitative systematic review of 17 studies (4 RCTs, 2 CBA, 11 ITS designs)

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P – Population

• Setting:Healthcare settings including:
  • Psychiatric units
  • Emergency departments
  • Dementia care
  • Neuroscience units
  • Community nursing
• Participants:
  • Nursing staff working in hospitals, residential aged care, and home care
  • Included RNs, ENs, nursing assistants, and unqualified personnel
  • Some studies included patients’ perspectives (e.g., Björkdahl et al.)

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I – Intervention

Training interventions aimed at improving staff competence in managing challenging behaviour, classified into four types:

1. Disengagement techniques: Physical breakaway skills
2. Communication skills: Verbal de-escalation, therapeutic engagement
3. Controlling behavioural symptoms: Education + behavioural care planning
4. Restrictive measures: Use of physical/mechanical restraints and seclusion

Training methods included classroom instruction, eLearning, and hybrid models. Duration ranged from <2 hours to multi-day courses (up to 120 hours) .

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C – Comparison

• Pre–post comparisons with or without control groups
• Study designs included:
  • Randomised controlled trials (RCTs)
  • Controlled before–after (CBA) studies
  • Interrupted time series (ITS) studies

Outcomes measured before and after training interventions.

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O – Outcomes

Person-Centred Outcomes:

• Patient safety and well-being were rarely directly measured, despite being a core rationale for interventions
• No studies systematically evaluated patients’ experiences of restrictive interventions 

Process Outcomes:

1. Staff competence (primary focus):
   • Confidence: Most commonly and positively impacted (e.g., Oostrom & Van Mierlo, 2008; Davies et al., 2015)
   • Attitudes: Mixed evidence—some change, particularly in communication-based programs (e.g., Gerdtz et al., 2013)
   • Knowledge: Improvements were limited and inconsistently measured
2. Use of violence prevention tools:
   • Measurement tools varied widely; 11 self-report scales used
   • Competence generally evaluated unilaterally with few comprehensive or validated tools
   • No studies defined an optimal or minimal level of required competence 
3. Restraint use:
   • Only one RCT (Testad et al., 2005) showed a significant reduction in restraint use 7 months post-intervention (p = 0.017)
4. Violent incident rates:
   • Decreased in some ITS studies (e.g., Narevic et al., 2011; Swain & Gale, 2014)
   • Evidence generally weak due to design limitations 

System Outcomes:

• Few interventions measured cost-effectiveness, time impact, or long-term behavioural change
• Staff felt more confident but concerns persisted over skill retention and safety risks
• Shorter interventions (<1 day) sometimes yielded better results than extended ones

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Summary Conclusion

This systematic review found that training interventions—especially those targeting communication and behavioural symptom control—can improve nursing staff confidence in managing challenging behaviours. However, most interventions failed to demonstrate consistent improvements in attitudes, knowledge, or patient outcomes. Only a minority of studies showed reductions in restraint use or violent incidents, and few employed robust evaluation tools. The review highlights the urgent need for validated, comprehensive scales of staff competence, and recommends future interventions should directly incorporate patient safety and ethical practice considerations .

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