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Crisis intervention for adults using a trauma-informed approach: initial four weeks of management, third edition.

Registered Nurses Association of Ontario (RNAO). Crisis intervention for adults using a trauma-informed approach: initial four weeks of management, third edition. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017 Dec. 104 p. [61 references]

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

This guideline updates previous versions:

Registered Nurses Association of Ontario (RNAO). Crisis intervention. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Aug. 55 p. [46 references]

Registered Nurses Association of Ontario (RNAO). Crisis intervention supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2006 Mar. 6 p. [22 references]

This guideline meets NGC's 2013 (revised) inclusion criteria.

National Guideline Clearinghouse (NGC) has assessed this guideline's adherence to standards of trustworthiness, derived from the Institute of Medicine's report Clinical Practice Guidelines We Can Trust External Web Site Policy.

NEATS Assessment More about NGC's appraisal Standard of Trustworthiness
Yes Disclosure of Guideline Funding Source
Very Good Disclosure and Management of Financial Conflict of Interests
Guideline Development Group Composition
Yes Multidisciplinary Group
Unknown Methodologist Involvement
Good Patient and Public Perspectives
Use of a Systematic Review of Evidence
Very Good Search Strategy
Excellent Study Selection
Excellent Synthesis of Evidence
Evidence Foundations for and Rating Strength of Recommendations
Good Grading the Quality or Strength of Evidence
Excellent Benefits and Harms of Recommendations
Excellent Evidence Summary Supporting Recommendations
Poor Rating the Strength of Recommendations
Excellent Specific and Unambiguous Articulation of Recommendations
Excellent External Review
Excellent Updating

Major Recommendations

Definitions for the levels of evidence (Ia, Ib, IIa, IIb, III, IV, V) are provided at the end of the "Major Recommendations" field.

Practice Recommendations

Recommendation 1.1

Use brief intervention approaches with persons in crisis to reduce symptoms of crisis and increase motivation for change and other health improvements.

(Level of Evidence = Ib)

Recommendation 1.2

Support persons experiencing a crisis to engage meaningfully and safely in a critical incident stress debriefing process within 24 to 72 hours post-crisis in order to reduce distress and improve mental health.

(Levels of Evidence = Ib and V)

Recommendation 1.3

Create crisis plans in collaboration with persons experiencing crisis using strength-based approaches.

(Levels of Evidence = Ib and IV)

Recommendation 1.4

Facilitate access for persons experiencing crisis to community-based outreach support (including outreach visits and mobile crisis teams), as well as appropriate health-care providers, peer support workers, and mental health and substance use services.

(Levels of Evidence = Ia, IV and V)

Recommendation 1.5

Engage peers trained in evidence-based approaches such as psychological first aid to provide comfort and support to persons experiencing crisis.

(Levels of Evidence = Ia, Ib and V)

Recommendation 1.6

Encourage utilization of telecommunication- and technology-based solutions for people at risk for, or experiencing, crisis as a means for receiving:

  1. Emergency assessment, triage, and support
  2. Psycho-education and/or online skills and tools to support coping and self-management

(Levels of Evidence = Ia, Ib and V)

Recommendation 2.1

In collaboration with the person and when needed, provide or refer them to additional or continued supports and services.

(Level of Evidence = Ia)

Education Recommendations

Recommendation 3.1

Integrate interactive learning opportunities regarding trauma-informed approaches and support of persons experiencing crisis into curricula for all entry-level nursing and health-care programs.

(Levels of Evidence = Ia and IIb)

Recommendation 3.2

Engage in continuing education to enhance knowledge and skill to support persons experiencing crisis through trauma-informed approaches.

(Levels of Evidence = Ia, IIb, and IV)

System, Organization, and Policy Recommendations

Recommendation 4.1

Organizations identify and embed trauma-informed approaches directly within their policies and procedures to support:

  1. A framework for approaches to crisis intervention and service delivery
  2. A safe and supportive work environment for providers who have experienced critical incidents

(Levels of Evidence = IV and V)

Recommendation 4.2

Enhance collaboration between sectors through system-level integration between health systems, social services (e.g., housing and employment), education systems, the justice system, advocates, persons with lived experience, and families in order to improve system capacity to respond in a trauma-informed way to persons experiencing crisis.

(Level of Evidence: V)

Recommendation 4.3

Health, social service, and law enforcement organizations collaborate to ensure that crisis intervention services are accessible to persons experiencing crisis through the establishment of:

  1. Mobile crisis teams
  2. Outreach visits
  3. Telephone triage and helplines

(Levels of Evidence = Ia, IIb, Ib, and IV)

Recommendation 4.4

Police agencies integrate comprehensive crisis training:

  1. To enhance police officers' interaction with persons experiencing crisis
  2. To encourage police officers to make informed decisions about helping persons access appropriate services

(Levels of Evidence = Ia, IIb, and IV)

Definitions

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials, and/or synthesis of multiple studies primarily of quantitative research.

Ib Evidence obtained from at least one randomized controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomization.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization.

III Synthesis of multiple studies primarily of qualitative research.

IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studies or descriptive studies, and/or qualitative studies.

V Evidence obtained from expert opinion or committee reports, and/or clinical experiences of respected authorities.

Clinical Algorithm(s)

None provided

Disease/Condition(s)

Crisis

Note: The expert panel has chosen to use the term "crisis" as a time-limited response to a life event that overwhelms a person's usual coping mechanisms in response to situational, developmental, biological, psychological, sociocultural, and/or spiritual factors.

Guideline Category

Counseling

Management

Prevention

Treatment

Clinical Specialty

Family Practice

Nursing

Psychiatry

Psychology

Intended Users

Advanced Practice Nurses

Emergency Medical Technicians/Paramedics

Health Care Providers

Nurses

Other

Physician Assistants

Physicians

Psychologists/Non-physician Behavioral Health Clinicians

Social Workers

Guideline Objective(s)

To provide evidence-based best practice recommendations on effective crisis intervention using trauma-informed approaches for adults (18 years and older) experiencing crisis (i.e., developmental, situational, community, environmental, or mental health crisis) and to prevent future crises

Target Population

Adults (18 years and older) experiencing or have experienced crisis

Interventions and Practices Considered

  1. Use of brief interventions
  2. Support of persons experiencing a crisis to engage in a stress debriefing process
  3. Development of crisis plans collaboratively with persons experiencing crisis
  4. Facilitation of access to community-based outreach support
  5. Engage peers trained in evidence-based approaches such as psychological first aid
  6. Utilization of telecommunication- and technology-based solutions for:
    • Emergency assessment, triage, and support
    • Psycho-education and/or online skills and tools
  7. Referral for continued support and services
  8. Integration of trauma-informed crisis approaches into curricula
  9. Continuing education
  10. Identification and embedding trauma-informed approaches directly within organization policies and procedures
  11. Enhanced collaboration between sectors through system-level integration between health systems, social services, education systems, the justice system, advocates, persons with lived experience, and families

Major Outcomes Considered

  • Rapid resolution of the crisis to achieve at least a pre-crisis level of functioning
  • Use and enhancement of coping skills
  • Promotion of a sense of control and self-efficacy
  • Provision of support for problem-solving and access to required services and supports

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Guideline Review

The Registered Nurses' Association of Ontario (RNAO) Best Practice Research and Development Team's project coordinator searched an established list of Web sites for guidelines and other relevant content published between January 2011 and June 2016. The resulting list was compiled based on knowledge of evidence-based practice Web sites and recommendations from the literature. Expert panel members were also asked to suggest additional guidelines (see Figure D1 in the original guideline document). Detailed information about the search strategy for existing guidelines, including the list of Web sites searched and inclusion criteria, is available in the search strategy document (see the "Availability of Companion Documents" field).

Systematic Review

A comprehensive search strategy was developed by RNAO's Best Practice Research and Development Team and a health sciences librarian based on inclusion and exclusion criteria created with the RNAO expert panel. A search for relevant articles published in English between January 2011 and November 2016 was applied to the following databases: Cumulative Index to Nursing and Allied Health (CINAHL), MEDLINE, MEDLINE In-Process, Cochrane Library (Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials), EMBASE, and PsycINFO. Education Resources Information Centre (ERIC) was only used for Question Three. In addition to this systematic search, panel members were asked to review personal libraries for key articles not found through the above search strategies.

Detailed information about the search strategy for the systematic review, including the inclusion and exclusion criteria and search terms, is available in the guideline search strategy document (see the "Availability of Companion Documents" field).

Once articles were retrieved, two RNAO nursing research associates (registered nurses holding master's degrees) independently assessed the eligibility of the studies according to established inclusion and exclusion criteria. Any disagreements at this stage were resolved through tie-breaking by a guideline development co-lead.

Hand Search

Panel members were asked to review personal libraries to identify key articles not found through the above search strategies. Articles identified by panel members were included in the search results if two nursing research associates independently determined the articles had not been identified by the literature search and met the inclusion criteria.

Number of Source Documents

One guideline and 130 studies were selected to inform the recommendations and discussions of evidence. See the flow diagrams in Appendix D in the original guideline document for more information on the review process and the bibliography of all included studies (see the "Availability of Companion Documents" field).

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials, and/or synthesis of multiple studies primarily of quantitative research.

Ib Evidence obtained from at least one randomized controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomization.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization.

III Synthesis of multiple studies primarily of qualitative research.

IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studies or descriptive studies, and/or qualitative studies.

V Evidence obtained from expert opinion or committee reports, and/or clinical experiences of respected authorities.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Guideline Review

The guideline development co-leads appraised seven international guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE) II. Guidelines with an overall score of four or below were considered to be weak and were excluded. Guidelines with an overall score of five were considered to be moderate, and guidelines with a score of six or seven were considered to be strong. The following guideline, rated moderate, was selected to inform the recommendations and discussions of evidence:

World Health Organization. (2013). Guidelines for the management of conditions specifically related to stress. Geneva, Switzerland: Author.

Systematic Review

Quality appraisal scores for 27 articles (a random sample of approximately 20 per cent of the total articles eligible for data extraction and quality appraisal) were independently assessed by the Registered Nurses' Association of Ontario (RNAO) nursing research associates. Quality appraisal was assessed using AMSTAR (A Measurement Tool to Assess Systematic Reviews) and RNAO's scoring system, which rates reviews as low, moderate, or high. The nursing research associates reached acceptable inter-rater agreement (kappa statistic, K = 0.855), which justified proceeding with quality appraisal and data extraction for the remaining studies. The remaining studies were divided equally between the two research associates for quality appraisal and data extraction. A final narrative summary of literature findings was completed. The comprehensive data tables and narrative summaries were provided to all expert panel members for review and discussion.

A complete bibliography of all full screened for inclusion and their quality appraisal scores is available (see the "Availability of Companion Documents" field).

Methods Used to Formulate the Recommendations

Expert Consensus (Delphi)

Description of Methods Used to Formulate the Recommendations

Guideline Development Process

For this guideline, the Registered Nurses' Association of Ontario (RNAO) assembled a panel of experts who represent a range of sectors and practice areas. A systematic review of the evidence was based on the purpose and scope of this guideline, supported by the four research questions listed below. The systematic review captured relevant peer-reviewed literature published between January 2011 and November 2016. The following research questions were established to guide the systematic review:

  1. What are effective and trauma-informed interventions that can be utilized by nurses and the interprofessional team with adults experiencing crisis?
  2. What are effective and trauma-informed interventions that can be utilized by nurses and the interprofessional team to mitigate or prevent future crisis in adults?
  3. What content and educational strategies are necessary to educate nurses and the interprofessional team effectively regarding crisis and trauma-informed approaches?
  4. What organization- and system-level supports are needed by nurses and the interprofessional team to implement best practices effectively using trauma-informed approaches to crisis?

The RNAO Best Practice Research and Development Team and expert panel worked to integrate the most current and best evidence, and to ensure the appropriateness and safety of the guideline recommendations with supporting evidence and/or expert panel consensus.

A modified Delphi technique was employed to obtain panel consensus on the recommendations.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

  • Critical incident stress debriefing (CISD) has been shown to be reproducible, easily implemented, and cost-effective for reducing psychological distress and the perception of stress.
  • Telecommunication- and technology-based solutions are also less stigmatizing than seeking help in person, more cost-effective, less time-consuming, not limited to business hours or geographical boundaries, and more likely to maintain person–provider confidentiality.

Method of Guideline Validation

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

Stakeholder reviewers for Registered Nurses' Association of Ontario (RNAO) best practice guidelines (BPG) are identified in two ways. First, stakeholders are recruited through a public call issued on the RNAO Web site External Web Site Policy. Second, individuals and organizations with expertise in the guideline topic area are identified by the RNAO Best Practice Research and Development Team and the expert panel, and they are directly invited to participate in the review.

Reviewers are asked to read a full draft of the guideline and to participate in the review prior to its publication. Stakeholder feedback is submitted online by completing a survey questionnaire. The stakeholders are asked the following questions about each recommendation:

  1. Is this recommendation clear?
  2. Do you agree with this recommendation?
  3. Is the discussion of evidence thorough and does the evidence support the recommendation?

The survey also provides an opportunity to include comments and feedback for each section of the guideline. Survey submissions are compiled and feedback is summarized by the RNAO Best Practice Research and Development Team. Together with the expert panel, RNAO reviews and considers all feedback and, if necessary, modifies the guideline content and recommendations prior to publication to address the feedback received.

Stakeholder reviewers have given consent to the publication of their names and relevant information in this guideline.

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Potential Benefits

  • In addition to the benefits of creating crisis plans outlined in the "Evidence Summary" for recommendation 1.3, health-care providers are able to understand the person's unique situation, can assess the person's risk more effectively and are able to provide early interventions to prevent future crisis.
  • In addition to the benefits of outreach teams outlined in the "Evidence Summary" for recommendation 1.4, outreach teams also have the potential to reduce visits to the emergency department for psychiatric crisis situations.
  • Benefits of utilizing telecommunication- and technology-based solutions with people at risk for, or experiencing, crisis include working with media to avoid sensationalization of the crisis event (e.g., natural disaster or mass suicide event) among the wider public. It also allows coordination with police in high-risk areas to provide around-the-clock vigilance and support and to create awareness campaigns for the wider public (e.g., raising awareness of signs and symptoms of crisis, and creating early identification messaging and media campaigns to promote awareness of the telephone service). Telecommunication- and technology-based solutions are also less stigmatizing than seeking help in person, more cost-effective, less time-consuming, not limited to business hours or geographical boundaries, and more likely to maintain person-provider confidentiality.
  • The benefit of receiving services four weeks post-crisis is mitigation of future crises and/or other associated mental and physical harms. Research demonstrates that persons living with mental illness that receive long-term interventions recover from the crisis.

Potential Harms

  • The urgency for follow-up and referral is heightened when enacting brief interventions (BI) to manage crisis leading to or following a suicide attempt. The provider needs to screen for suicide risk, create safety plans, and connect the person to appropriate resources and/or providers.
  • The Registered Nurses' Association of Ontario (RNAO) expert panel notes that debriefing a crisis situation may trigger negative emotional outcomes and temporarily impede a person's ability to reach a pre-crisis state. When this occurs, health-care providers should offer the person the choice to stop this intervention. Before using this approach, an evaluation of critical incident stress debriefing (CISD) specific to the person's situation is advisable in order to weigh the benefits and harms that may occur from debriefing.
  • Potential harms of creating crisis plans may be anxiety among persons who have experienced crisis that stems from being unable to meet expectations outline in the crisis plan.
  • Peer support workers trained in psychological first aid (PFA) should only assist in the provision of basic care, comfort, and support to persons experiencing crisis. Exceeding these boundaries may cause clear harm to persons experiencing crisis. Organizations should create clear distinctions of roles and develop policies that support distinction between roles.
  • The literature has demonstrated that telecommunication- and technology-based solutions used as part of psycho-education and/or skill development may pose harm to those who live in geographically remote or isolated areas (such as rural and remote regions or areas where telecommunications are inoperative or limited) when those persons need urgent post-conflict or post-disaster face-to-face treatment but are some distance from their care providers. As such, health-care providers and other interprofessional team members must be cognizant that these strategies are not exclusive treatment forms, and that they do not replace face-to-face interventions, but that they can provide a first step into the health-care system.
  • Although there are benefits of police presence in ensuring safety and stabilization for persons experiencing crisis, the panel also recognizes that a police presence during a crisis intervention may trigger negative emotional outcomes in some persons. Considerations (such as not wearing a police uniform) should be taken for reducing the potential for emotional harm.

Qualifying Statements

  • These guidelines are not binding on nurses, other providers of the interprofessional team, or the organizations that employ them. The use of these guidelines should be flexible, and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury, or expense arising from any such errors or omission in the contents of this work.
  • This best practice guideline (BPG) is a comprehensive document that provides resources for evidence-based practice. It is not intended to be a manual or how-to guide; rather, it is a tool to guide best practices and enhance decision-making for nurses, other health-care providers, social service providers, and police officers working with adults (18 years and older) who are experiencing or have experienced crisis. This guideline should be reviewed and applied in accordance with the needs of individual organizations or practice settings and with the needs and preferences of the persons experiencing crisis and their families who are accessing the health system for care and services. In addition, this guideline offers an overview of appropriate structures and supports for providing the best possible evidence-based care.

Description of Implementation Strategy

Implementing guidelines at the point of care is multi-faceted and challenging; it takes more than awareness and distribution of guidelines for practice to change. Guidelines must be adapted for each practice setting in a systematic and participatory way in order to ensure recommendations fit the local context. The Registered Nurses' Association of Ontario's (RNAO's) Toolkit: Implementation of Best Practice Guidelines (2012) provides an evidence-informed process for doing this (see the "Availability of Companion Documents" field).

The Toolkit is based on emerging evidence that successful uptake of best practice in healthcare is more likely when:

  • Leaders at all levels are committed to supporting guideline implementation.
  • Guidelines are selected for implementation through a systematic, participatory process.
  • Stakeholders for whom the guidelines are relevant are identified and engaged in the implementation.
  • Environmental readiness for implementing guidelines is assessed.
  • The guideline is tailored to the local context.
  • Barriers and facilitators to using the guideline are assessed and addressed.
  • Interventions to promote use of the guideline are selected.
  • Use of the guideline is systematically monitored and sustained.
  • Evaluation of the guideline's impact is embedded in the process.
  • There are adequate resources to complete all aspects of the implementation.

The Toolkit uses the "Knowledge-to-Action" framework to demonstrate the process steps required for knowledge inquiry and synthesis (see Figure 2 in original guideline document). It also guides the adaptation of the new knowledge to the local context and its implementation. This framework suggests identifying and using knowledge tools, such as guidelines, to identify gaps and begin the process of tailoring the new knowledge to local settings.

RNAO is committed to widespread deployment and implementation of its Best Practice Guidelines (BPGs.) RNAO uses a coordinated approach to dissemination that incorporates a variety of strategies, including:

  1. The Nursing Best Practice Champion Network®, which develops the capacity of individual nurses to foster awareness, engagement, and adoption of BPGs.
  2. Nursing order sets, which provide clear, concise, and actionable intervention statements derived from the BPGs' practice recommendations that can be readily embedded within electronic medical records (although they may also be used in paper-based or hybrid environments).
  3. The Best Practice Spotlight Organization® (BPSO®) designation, which supports implementation at the organization and system levels. BPSOs® focus on developing evidence-based cultures with the specific mandate to implement, evaluate, and sustain multiple RNAO BPGs.

In addition, RNAO offers annual capacity-building learning institutes on specific BPGs and their implementation. Information about our implementation strategies can be found at:

Implementation Tools

Chart Documentation/Checklists/Forms

Patient Resources

Resources

Tool Kits

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

Registered Nurses Association of Ontario (RNAO). Crisis intervention for adults using a trauma-informed approach: initial four weeks of management, third edition. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017 Dec. 104 p. [61 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2017 Dec

Guideline Developer(s)

Registered Nurses' Association of Ontario - Professional Association

Source(s) of Funding

This work is funded by the Ontario Ministry of Health and Long-Term Care. All work produced by Registered Nurses' Association of Ontario (RNAO) is editorially independent from its funding source.

Guideline Committee

Registered Nurses' Association of Ontario (RNAO) Expert Panel

Composition of Group That Authored the Guideline

Expert Panel Members

Nancy Poole, PhD, MA, Dip.C.S., BA
Panel Co-Chair
Director
British Columbia Centre of Excellence for Women's Health
Victoria, BC

Rosanra Yoon, NP, MN, PhD (cand.)
Panel Co-Chair
Nurse Practitioner
The Jean Tweed Centre
Toronto, ON

Oluremi Roseline Adewale, RN, MScN
Mental Health Nurse Consultant
Toronto Public Health
Toronto, ON

Jennifer Chambers, BSc (Hon)
Executive Director, Empowerment Council
Centre for Addiction and Mental Health
Toronto, ON

Aaron Clark, RN, BScN, CPMHN(C)
Registered Nurse, Parkwood Institute
St. Joseph's Health Care
Chair, Mental Health Nursing Interest Group
London, ON

Rosanna DiNunzio, RN, MSc, CPMHN(C)
Patient Care Manager
Sunnybrook Health Sciences Centre
Toronto, ON

Tanya Dion, RN, MA, CCHP
Health Care Manager
Quinte Detention Centre
Napanee, ON

Susan Engels, RN, MN, Phd (cand.)
Vice President, Quality and Professional Practice
Chief Nursing Executive
The Royal Health Care Group
Ottawa, ON

Elizabeth Harrison
BScN Year 4 Student
Ryerson University
Toronto, ON

Ron Hoffman, BA, MA, PhD
Assistant Professor
School of Criminology and Criminal Justice
interRAI Fellow
Nipissing University
North Bay, ON

Michelle Jubin, RN, MN
Mental Health Nurse Consultant
Toronto Public Health
Toronto, ON

Betty-Lou Kristy
Peer Support Substance Use System Lead
Consumer Survivor (CSI) Lead
Mississauga Halton LHIN Enhancing and Sustaining
Peer Initiative
TEACH: Teach Empower Advocate Community Health
Support and Housing Halton
Oakville, ON

Elaine Mordoch, RN, PhD
Associate Professor
College of Nursing, Faculty of Health Sciences
University of Manitoba
Winnipeg, Manitoba

Kim Nash, RN, MN
Clinical Nurse Educator
Waypoint Centre for Mental Health Care
Penetanguishene, ON

Kathryn Ryan, RN, MSc(N), CPMHN(C)
Advanced Practice Clinical Leader (Nursing)
Complex Care and Recovery Program
Centre for Addiction and Mental Health
Toronto, ON

Mike Serr, BA
Deputy Chief Constable, Abbotsford Police Department
Abbotsford, BC

Vicky Stergiopoulos, MD, MHSc
Physician-in-Chief, Centre for Addiction and Mental Health
Professor, Faculty of Medicine, University of Toronto
Vice Chair, Clinical and Innovation, Department of Psychiatry, University of Toronto
Toronto, ON

Financial Disclosures/Conflicts of Interest

Declarations of interest that might be construed as constituting an actual, potential, or apparent conflict were made by all members of the Registered Nurses' Association of Ontario (RNAO) expert panel, and members were asked to update their disclosures throughout the guideline development process. Information was requested about financial, intellectual, personal, and other interests and documented for future reference. No limiting conflicts were identified. Details regarding disclosures are available (see the "Availability of Companion Documents" field).

Guideline Endorser(s)

Canadian Centre on Substance Use and Addiction - Professional Association

Guideline Status

This is the current release of the guideline.

This guideline updates previous versions:

Registered Nurses Association of Ontario (RNAO). Crisis intervention. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Aug. 55 p. [46 references]

Registered Nurses Association of Ontario (RNAO). Crisis intervention supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2006 Mar. 6 p. [22 references]

This guideline meets NGC's 2013 (revised) inclusion criteria.

Guideline Availability

Availability of Companion Documents

The following are available:

  • Registered Nurses Association of Ontario: Nursing Best Practice Guidelines Program: Crisis intervention for adults using a trauma-informed approach: initial four weeks of management. Systematic review search strategy. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017 Sep. 4 p. Available from the Registered Nurses Association of Ontario (RNAO) Web site External Web Site Policy.
  • Registered Nurses Association of Ontario: Nursing Best Practice Guidelines Program: Crisis intervention for adults using a trauma-informed approach: initial four weeks of management. Bibliography and quality appraisal scores. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017. 12 p. Available from the RNAO Web site External Web Site Policy.
  • Declarations of competing interests. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017. 2 p. Available from the RNAO Web site External Web Site Policy.
  • Toolkit: implementation of best practice guidelines. Second edition. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2012 Sep. 154 p. Available from the RNAO Web site External Web Site Policy.

Various tools, including critical incident debriefing steps; a crisis template plan; resources for persons experiencing crisis, organizations providing peer support, telecommunication and technology, and training; long-term interventions to mitigate crisis, and critical incident stress management program components, are available in the appendices of the original guideline document.

Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on December 17, 2003. The information was verified by the guideline developer on January 16, 2004. This summary was updated by ECRI on June 23, 2006. This summary was updated by ECRI Institute on April 16, 2018. The information was verified by the guideline developer on May 8, 2018.

This NEATS assessment was completed by ECRI Institute on April 12, 2018. The information was verified by the guideline developer on May 8, 2018.

Copyright Statement

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses' Association of Ontario (2017). Crisis intervention for adults using a trauma-informed approach: initial four weeks of management, third edition. Toronto (ON): Registered Nurses Association of Ontario.

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