Spring 2003 Newsletter Section 7

Most of the literature on behavioral emergencies in the last decade has consisted of empirical studies, whose foundation is clinical data, and conceptual papers that are theoretical in nature (such as reviews and practice guidelines). In contrast to these scholarly products stands a strategy that investigates what clinicians actually do to address behavioral emergencies. This approach to clinical inquiry has emerged in recent years and has complemented empirical approaches by focusing professional learning on the adaptation of general intervention strategies and models to the contexts in which they are implemented.

Establishing the consensus of expert clinicians (Kahn, Docherty, & Carpenter, 1997) is a current method that aims to describe systematically the practices and thinking processes in use. For instance, Allen, Currier, Hughes, Reyes-Harde, & Docherty (2001) generated an Expert Consensus on the treatment of behavioral emergencies by surveying 50 clinicians/scholars in emergency psychiatry and identifying commonalities in their reported handling of clinical emergencies. A similar strategy was employed in Connecticut to engage a state-wide group of senior mental health clinicians in learning conversations about current practices in the handling of behavioral emergencies and about how to improve practice by enhancing clinical skill acquisition. The design of the learning intervention was based on three assumptions: professionals have access to a vast amounts of information, but a shortage of time to make sense of the information in the context of their work; organizations benefit when knowledgeable employees share and construct knowledge that is context specific; and clinical decision making relies on the effective use of both accessible explicit knowledge and tacit knowledge that is critical but more difficult to articulate. The purpose of this paper is to describe our learning process.

Twenty senior clinicians from the various state-funded agencies involved in the delivery of clinical services participated in a four half-day sessions entitled Critical Decision Making Models for Managing Behavioral Emergencies. The objectives of the sessions were to engage expert practitioners in learning conversations that would lead to strategy development regarding the articulation and implementation of sound clinical decision making in behavioral emergencies, and to develop "products" to support efforts to improve clinical decision making in behavioral emergencies in their worksites. Learning conversations (Baker, Jensen, & Kolb, 2002) are group training tools aimed at converting experiences to knowledge, articulating themes and connections, and constructing collective models by engaging in group activities that entail 'thinking out loud together".

The first two sessions were devoted to identifying key components of clinical decision-making and context-specific variations in implementation. In one activity, small groups of participants listened to one group member „think aloud‰ about all aspects of a recent critical incident and captured the components of the clinical decision-making process in action. The small groups then collaborated on listing the themes they identified and mapped them on several flip chart papers, placing related components in physical proximity. The resulting clusters of key components of clinical decision making included all the components that are well known (e.g., precursors) but also many components that are seldom addressed in the literature yet that clinicians encounter daily: staff emotional reactions, patients' rights, institutional politics, JCAHO and CMMS rules, communication among treaters, accountability to management, clinical resources, professional ethics (including discrepancies among the ethical codes of the various professional groups that collaborate in managing clinical emergencies), recovery time, feedback processes (use of learning from this emergency influence our practice guidelines), etc. A fascinating discussion ensued, resulting in deeper recognition of the complex problem background in which the management of behavioral emergencies occurs and its impact on practice, several context-specific „ideal‰ intervention models, and an agreed-upon description of knowledge, skills, and attitudes that are critical to effective clinical decision making.

The third session shifted the focus to improving the quality of decision-making in behavioral emergencies by leveraging informal learning opportunities in the workplace. Participants focused on describing the novice-to-expert continuum (Dreyfus, 1996) for critical skills, exploring informal learning practices that build decision making skills, and identifying existing opportunities for informal learning that could be used as vehicles for building behavioral intervention proficiency. Debriefing sessions following critical incidents emerged are prime opportunities for senior clinicians to role model and "walking" the trainees through their thought processes as the event unfolded. A recurring theme was the role of emotion in learning and the ways in which the emotional context of behavioral intervention can facilitate or hinder learning and skill development.
The last session focused on enhancing informal learning. The participants came to the consensus that much knowledge about the management of behavioral emergencies is acquired, not from books, lectures, or formal training sessions, but from informal learning –- direct clinical experience, trial and error learning, observation of senior colleagues, traditional supervision, peer-supervision, and critical reflection. Improving the quality of how clinicians handle behavioral emergencies requires maximizing informal learning opportunities by working with supervisors to establish or enhance informal learning in the workplace, and exploring, identifying, and modifying mental models, organizing structures, and institutional cultures that shape current practices.

References
Allen, M. H., Currier, G. W., Hughes, D. H., Reyes-Harde, M., & Docherty, J. P. (2001). The Expert Consensus Guideline Series: Treatment of behavioral emergencies. Postgraduate Medicine, May, 1-88.

Baker, A. C., Jensen, P. J., & Kolb,, D. A. (2002). Conversational Learning: An Experiential Approach to Knowledge Creation. Westport, CT: Quorum Books.

Dreyfus, H. (1996). Intuitive, deliberative, and calculative models of expert performance. In C. E. Zsambok & G. Klein (Eds.) Naturalistic Decision Making. Mahwah, NJ: Erlbaum & Associates.

Kahn, D. A., Docherty, J. P., & Carpenter, D. (1997). Consensus methods in practice guideline development: A review and description of a new method. Psychopharmacology Bulletin, 33, 631-639.

Marc Hillbrand, Ph.D., is Psychology Discipline Chair, Connecticut Valley Hospital, and Assistant Clinical Professor of Psychiatry, Yale University School of Medicine.

Marijke Kehrhahn, Ph.D., is an Associate Professor of Adult Learning in the Neag School of Education, University of Connecticut.

Address correspondence to Dr. Hillbrand at CVH, Box 70, Middletown CT 06457, or Dr. Kehrhahn at 249 Glenbrook Rd.
Unit 2093, University of Connecticut, Storrs, Connecticut 06269-2093. They can be reached electronically at marc.hillbrand@po.state.ct.us or marijke.kehrhahn@uconn.edu.