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.
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
Unit 2093, University of Connecticut, Storrs, Connecticut 06269-2093.
They can be reached electronically at firstname.lastname@example.org