Simulation-based education for staff managing aggression and high-risk behaviors in children with autism spectrum disorder in the hospital setting: A pilot and feasibility cluster randomized controlled trial

Background and objective: Aggression and high-risk behaviors, which can result in behavioral emergencies, are common in children with autism and can be magnified in the hospital environment. Children with autism, with or without intellectual disability, have complex communication needs which require a sophisticated level of knowledge, understanding and skill from health care professionals. Pediatric acute care nursing staff are often not trained and lack confidence in managing children with autism. The purpose of this study was to conduct a pilot and feasibility cluster randomized controlled trial (RCT) of simulation-based education for staff in managing behavioral emergencies with autism spectrum disorder (ASD) in the hospital setting. Methods: This study used a mixed method, to explore the acceptability and feasibility of delivering a large-scale cluster RCT and assess trial processes including recruitment, completion rates, contamination, and outcome measures. The simulation-based training format comprised two scenarios involving an adolescent with autism, intellectual disability and aggressive behaviors. Two pediatric wards of similar size and patient complexity were selected to participate in the study and randomized to receive either simulation-based education plus web-based education materials or web-based education materials only.   Results: The RCT design is feasible with recruitment, acceptability and completion rates reaching target. Self-perceived baseline levels of confidence in managing aggression in children were mid-range and lower for children with autism and intellectual disability. Forty to fifty percent of intervention participants rated the training highly in terms of developing skills and knowledge respectively. The mean group score for observer ratings of de-escalation across four simulations was 20 out of a possible 35. Data for ward aggression were not collected. Conclusions: Simulation-based education is an acceptable training format for acute care pediatric nurses. This study is feasible to conduct as a cluster RCT with some modifications to this protocol including assessment of baseline differences in confidence. Observer ratings of de-escalation skills indicated that more than one episode of training may be required for acute care pediatric staff to successfully de-escalate aggressive incidents. As such, we will use repeated simulation scenario exercises for each intervention group in the next trial.