Gastrointestinal endoscopy training in the United States: Program structure and competence assessment.

The general principles of gastrointestinal endoscopy training in the United States were formulated and summarized more than a decade ago and the principles have been consistent until now. To summarize, trainees should be prepared to (i) appropriately recommend endoscopic procedures as indicated by the findings of the consultative evaluation, with an explicit understanding of accepted specific indications, contraindications, and diagnostic/therapeutic alternatives, (ii) perform procedures safely, completely, and expeditiously, including possessing a thorough understanding of the principles of conscious sedation/analgesia techniques, the use of anesthesia-assisted sedation where appropriate, and pre-procedure clinical assessment and patient monitoring, (iii) correctly interpret endoscopic findings and integrate them into medical or endoscopic therapy, (iv) identify risk factors for each procedure, understand how to minimize each, and recognize and appropriately manage complications when they occur, (v) acknowledge the limitations of endoscopic procedures and personal skills and know when to request help, and (vi) understand the principles of quality measurement and improvement. This article provides an overview of the endoscopy training system and structure, evaluation scheme, and competence and credentialing process in the United States.

General nurse competencies in disaster: A delphi study.

AIM: The aim of this study is to understand the significance of a disaster-related competence framework for Portuguese general nurses and identify from ICN - Core Competencies in Disaster Nursing version 2.0 core competencies description, those that are considered crucial for a competent preparedness and response in disaster scenarios. BACKGROUND: Research suggests that the occurrence of disasters will be more recurrent, requiring that nurses, pillars of any health system, have knowledge, skills and preparedness to face these events. DESIGN: An exploratory, cross-sectional qualitative study was carried out. Delphi method was used for data collection. METHODS: The study group consisted of technical-scientific council's presidents or coordinators/directors of nursing courses, nurses integrated in the Portuguese Council of Nurses and National Nursing Specialty Colleges and nurses with experience in the field of disasters. RESULTS: Findings revealed that there is consensus on sixteen competencies, considered relevant for developing general nurse knowledge and competence, both at a national or international level, in the field of disasters. CONCLUSIONS: The development of these competencies which establishes practice standards, building nurses skills and knowledge and ultimately, influencing nursing level-entry curricula's, conferring professional autonomy and self-regulation, in the field of disaster are fundamental. Furthermore, this study may serve as a reference for future alignment of competency frameworks between European Union countries or others.

Instructional guidelines and group discussion effects on new nurses' competency regarding nursing care of preterm infants.

Background: Premature birth was once one of the leading causes of infant mortality. Premature infants require improved medical and nursing skills from a highly competent nursing team. Purpose: This investigation aimed to assess the effects of instructional guidelines and group discussion on new nurses' competency in preterm infants caring at the Neonatal Intensive Care Unit (NICU). Methods: A single-anonymized, two-group pre-test and post-test study design was accompanied in 2022. The study was accompanied for 50 newly graduated nurses concerned with competence in nursing management of preterm infants at the Neonatal Intensive Care Unit (NICU) in two hospitals: Al-Namas General Hospital, KSA, and the Pediatric Hospital of Assiut University, Egypt. Two groups were randomly selected from among the nurses to be trained on preterm infant nursing care competence either through an instructional guideline or group discussion. Nursing attitudes and practices were measured before and after training using questionnaires and checklists. Results: There was no significant difference between the instructional guideline group and the group discussion in the mean total score of attitudes (11.72 and 14.65, P = 0.455) and practices (14.36 and 14.80, P = 0.494) towards caring for preterm infants before intervention. While mean nurses' attitude and practice scores increased significantly in both groups after the intervention, in the discussion group, nurses' practice scores increased significantly (p = 0.001). Still, there were no significant changes in the instructional guideline group (P = 0.202). Conclusion: Both methods were effective on the newly graduated nurses' attitude; however, the instructional guidelines did not affect their practice regard nursing care of preterm infants. However, group discussion training techniques can effectively improve the nurses' attitude and practice toward nursing care of preterm infants. Relevance to clinical practice: The group discussion training method should be the approved and proven method for hospitals to train new nurses to increase clinical practices, especially during nursing care for premature infants, because this method has proven its worth in increasing the skill of nurses. It enables a group to talk about a specific subject and exchange personal stories. This approach involves a group leader facilitating communication and interaction between participants.

EHR-Driven Delivery of EPA Assessments Significantly Improves Participation.

INTRODUCTION: Digital education tools are a cornerstone in the evolution to CBME through EPAs. Successful implementation requires understanding the variable impacts of EHR-driven delivery of EPAs, flexible digital device access to EPAs, and user-behavior trends. METHODS: Through a HIPAA compliant, flexible-device accessible, surgical education platform, general surgery training programs at 21 institutions collected EPA from July 2023 to April 2024. At 5 EHR-integrated institutions (EHR+), EPA were created for clinical activities based on the OR schedule, automatically pushed to attendings and residents with built in completion reminders. At 16 institutions without EHR integration (EHR-), EPA were initiated manually. To improve user experience, care phases were bundled (cEPA). We compared the EHR+ and EHR- groups, computing descriptive statistics on the cEPAs completed and user behavior metrics. RESULTS: We collected 4187 cEPAs in total, with 82% at EHR+ institutions and 18% at EHR- institutions. Platform triggering dramatically drove cEPA completion for both faculty and residents, 88% and 81%, respectively. Only 3% were initiated by the faculty or resident. Faculty at EHR+ institutions strongly preferred the automated OR-triggered workflow to start their EPAs (Chi-squared test, p ≈ 0). Faculty completed all 3 care phases nearly 80% of the time. Time reminders specifically drive EPA completion for residents and faculty on weekdays and build habits on weekends. 71% of cEPAs completed were by computer, and 29% by phone. More comments were provided when computers were used. Residents reviewed feedback with a median lag of 1 hour and 29 min after results were available. CONCLUSIONS: EHR-driven delivery of EPA leads to a 4.6-fold increase in EPAs completed. EPA initiation is the most critical phase in the workflow and EHR-data driven alerts drive this action. These alerts are also effective drivers of habit formation. Flexible device access is important to increase EPAs completed and improve the usefulness through comments for residents.

What are the training needs of emergency department resuscitation nurses? A scoping review.

BACKGROUND: The emergency resuscitation nurse is a challenging and specialised role at the forefront of critical care practice in the emergency department. Despite their extensive specialist knowledge and skill requirements, in Australia there is no state-wide or nationally agreed approach to how to best provide training that meets a set of fixed objectives and requisite skills for resuscitation nurses. Due to an ageing nursing population and increasing workforce attrition, an efficacious accelerated pathway to acquire specialist resuscitation nursing knowledge, is necessary. AIM: The aim of this review is to identify, consolidate and summarise the available evidence on the training needs for the requisite clinical and non-technical skills of emergency resuscitation nurses ELIGIBILITY CRITERIA: Papers about nurses currently working in the emergency department; including Nurse Unit Managers (NUMs), Clinical Nurse Educators (CNEs), Clinical Nurse Consultants (CNCs), Clinical Nurse Specialists (CNSs), Registered Nurses (RNs) and Enrolled Nurses (ENs) were included. The review included primary and non-primary research, including papers addressing how emergency nurses are trained. There was no date limitation set to ensure all results could be reviewed. Papers that were not published in English, included nurses who were not working in the ED, or included doctors, allied health, and other staff where population cohorts could not be distinguished, were excluded. Abstract only, editorials, conference posters or oral presentations, were also excluded. SOURCES OF EVIDENCE: Searches were conducted in MEDLINE, CINAHL and EMCARE. The authors conducted extensive hand-searching of the included study reference lists as well as the grey literature to ensure that all relevant literature was captured. METHODS: A scoping literature review was conducted. RESULTS: Data extraction was conducted on the final 33 articles (23 peer reviewed studies and 10 competency and practice standards documents). Specific training requirements to achieve competence in the requisite clinical and non-technical skills in resuscitation nursing do not exist. A decline in competency without regular reinforcement was reported. Multi-modal approaches, incorporating diverse teaching methods, show potential in enhancing knowledge retention and skill acquisition. CONCLUSION: Resuscitation nursing lacks a standardised training approach in Australia, leading to a gap in ensuring consistent skill acquisition and knowledge among nurses. Research is required to identify what resuscitation nursing skills and training are necessary to ensure practice effectively meets the needs of patients.

Perspectives of clinical nurse educators on competency-based nursing teaching in blended learning environments during nursing internship: A descriptive qualitative study.

AIM: To investigate the perspectives of clinical nurse educators regarding the challenges and essential elements of teaching competence in blended learning environments during nursing internships to inform the development of a competency-based teaching model. BACKGROUND: Competency-based teaching and blended learning play important roles in enhancing the learning experience of nursing internship trainees. Internship trainees refer to nursing students undergoing supervised practical training in clinical settings. However, clinical nurse educators frequently encounter challenges in acquiring the necessary competence for successful implementation of blended learning strategies. DESIGN: A descriptive qualitative study. METHODS: This study used semi-structured interviews with 11 certified nurse educators (CNEs) from diverse clinical disciplines in a tertiary hospital in China. Purposive sampling ensured diversity across key characteristics. Ethical approval was obtained and interviews were digitally recorded, transcribed and analyzed thematically. Theoretical saturation guided data collection, with precise measures taken to ensure confidentiality and anonymity. Thematic analysis, employing a constant comparison technique, systematically identified various themes related to blended teaching competence. This approach provided valuable insights into CNEs' perspectives and practices. The analysis involved theoretical sampling, line-by-line coding and comparative evaluation with supporting text materials. RESULTS: The in-depth analysis of teaching competence among clinical nurse educators in blended learning settings during nurse internships revealed five key themes: professionalism, teaching literacy, subject expertise, information literacy and interpersonal communication. CONCLUSION: These themes recognized clinical nurse educators' perspectives towards establishing a competency-based nursing teaching model for a blended learning environment for nurse internships. Moreover, these perspectives are also crucial in enhancing teaching literacy through effective instructional methods, engagement strategies and the promotion of critical thinking skills. Identifying these themes contributes to efforts to improve teaching effectiveness and enhance learning outcomes for internship trainees in a blended learning context.

Validation of entrustable professional activities for use in neonatal care residency programs.

OBJECTIVE: Define and develop a set of entrustable professional activities (EPAs) to link clinical training and assessment of the hospital components of neonatal care in neonatology medical residency programs. METHODS: An exploratory study was conducted in two phases using a modified Delphi approach. In the first phase, a committee of five neonatology residency program coordinators drafted an initial set of EPAs based on the national matrix of competencies and on EPAs defined by international organizations. In the second phase, a group of neonatal care physicians and medical residents rated the indispensability and clarity of the EPAs and provided comments and suggestions. RESULTS: Seven EPAs were drafted by the coordinators´ committee (n = 5) and used in the content validation process with a group (n = 37) of neonatal care physicians and medical residents. In the first Delphi round, all EPAs reached a content validity index (CVI) above 0.8. The coordinators´ committee analyzed comments and suggestions and revised the EPAs. A second Delphi round with the revised EPAs was conducted to validate and all items maintained a CVI above 0.8 for indispensability and clarity. CONCLUSION: Seven entrustable professional activities were developed to assess residents in the hospital components of neonatal care medicine. These EPAs might contribute to implementing competency-based neonatology medical residency programs grounded in core professional activities.

Comparing the impact of PASS-BAR handoff education for new nurses between simulation-based and case-based approaches: A quasi-experimental design.

AIM: To develop a patient, assessment, situation, safety concerns, background, action, recommendation (PASS-BAR) handoff training program and compare the educational effects of the program between simulation-based (experimental group) and case-based (control group) groups using repeated measures among new nurses. BACKGROUND: New nurses are not well prepared to provide clear handoff reports because nursing schools and healthcare institutions rarely offer structured programs or training for handoff communication practices. DESIGN: This study used a pretest-posttest quasi-experimental design with repeated measures with two non-randomized groups. METHODS: This study targeted new nurses with less than 12 months of experience and was conducted at a university hospital's clinical nursing education center in Seoul, South Korea, between September 2022 and April 2023. Seventeen participants were allocated to the experimental group and 17 participants to the control group. Both groups were given lectures and exercises for both scenarios. Participants were asked to complete a questionnaire on nursing handoff competency, handover performance competency and perceived self-efficacy of handoff at pre- and posttest and two weeks after training. Satisfaction with learning was measured after the intervention. RESULTS: We developed a simulation-based learning handoff program that includes a simulated handoff performance and debriefing and a case-based learning handoff program that includes discussion, handoff performance and feedback. This study found no immediate difference in the educational effect of PASS-BAR handoff training between simulation-based learning and case-based learning; however, over time, simulation-based learning was more effective than case-based learning in improving nursing handoff competency and handover performance competency. CONCLUSIONS: Based on the results of this study, a simulation-based handoff training program using PASS-BAR can enhance handoff competencies and help new nurses strengthen their communication skills to understand patients and convey important information. TWEETABLE ABSTRACT: Developing a simulation-based handoff training program using PASS-BAR helps nurses strengthen their communication skills with colleagues.

Overcoming Barriers to Research Competency: a nationwide mixed-method study on residency training in the field of Korean medicine.

Objectives: This study aimed to analyze the educational needs of interns and residents in Korean medicine as the first step in developing an education program to improve their research competencies. Methods: A mixed-method design, incorporating both quantitative and qualitative data collection methods, was used to investigate the educational needs for research competencies among interns and residents working in Korean medicine hospitals nationwide. Data were collected through online surveys and online focus group discussions (FGDs), and processed using descriptive statistical analysis and thematic analysis. The study results were derived by integrating survey data and FGD outcomes. Results: In total, 209 interns and residents participated in the survey, and 11 individuals participated in two rounds of FGDs. The majority of participants felt a lack of systematic education in research and academic writing in postgraduate medical education and highlighted the need for nationally accessible education due to significant disparities in the educational environment across hospitals and specialties. The primary barrier to learning research and academic writing identified by learners was the lack of knowledge, leading to time constraints. Improving learners' research competencies, relationship building, autonomy, and motivation through a support system was deemed crucial. The study also identified diverse learner types and preferred educational topics, indicating a demand for learner-centered education and coaching. Conclusion: This study provides foundational data for designing and developing a program on education on research competencies for interns and residents in Korean medicine and suggests the need for initiatives to strengthen these competencies.

Assessing numeracy and medication calculations within undergraduate nursing education: A qualitative study.

AIM: To explore how undergraduate nursing students are assessed on nursing numeracy and medication calculations from the perspective of Australian nurse education leaders. DESIGN: A qualitative study. METHODS: Semi-structured interviews were conducted with 17 nurse education leaders between November 2022 and January 2023. Braun and Clarke's six phases of thematic analysis were used to analyse the data. RESULTS: Five key themes were identified: (i) high expectations to keep the public safe, (ii) diverse assessment formats, (iii) different ways of managing assessment integrity, (iv) assessment conditions incongruent to the clinical setting and (v) supporting struggling students. CONCLUSION: Nurse education leaders set high standards requiring students to achieve 100% in numeracy and medication calculation assessments, thus maintaining the reputation of nursing and patient safety. However, students struggled to meet this expectation. Diverse assessment formats were implemented, with some examination conditions contrary to clinical practice. Currently, there is no benchmark or independent point of registration examination in Australia, hence the problem is each university had a different standard to judge students' competence. Gaining insight into how these assessments are conducted provides an opportunity to work towards an evidence-based model or benchmark for the assessment of numeracy. IMPLICATIONS FOR THE PROFESSION: Dosage errors in clinical practice threaten patient safety and the reputation of the nursing profession. The accuracy rate of calculations by undergraduate and registered nurses is deficient worldwide. This research highlights a major educational issue, that being the wide variation in how numeracy assessments are conducted with no clear pedagogical rationale for a standardised method. Such assessments would establish a national standard, contributing to quality assurance, the development of the nursing profession and improve patient safety.

Escape to Patient Safety Project: A Nursing Proposal.

ANNA's Administration SPN created this proposal as a clinical practice project to re-evaluate how training and education are provided to individuals working in the dialysis setting. This article describes an education initiative based on the escape room methodology to provide a fresh approach on dialysis curriculum.

Especialización o diversificación en el desarrollo deportivo: Una revisión integrativa / Specialization or Diversification in Sports Development: An Integrative Review / Especialização ou diversificação no desenvolvimento esportivo: uma revisão integrativa

Resumen Objetivo: Explorar y discutir literatura científica teórica y práctica para comparar la diversificación y la especialización deportivas tempranas como un enfoque deportivo y educativo. Métodos: Se realizó una revisión sistemática siguiendo las pautas PRISMA, se incluyó un total de 61 estudios. Resultados: Entrenadores, padres e hijos consideran que la mejor forma de desarrollar el talento deportivo y alcanzar la élite en el deporte es participar en una sola disciplina y hacerlo lo antes posible para lograr la especialización y las máximas habilidades técnicas, físicas y psicológicas. Los caminos de especialización deportiva pueden conducir a una situación física, social y mental que comprometa su desarrollo integral. Conclusión: Se puede plantear, en primer lugar, la diversificación deportiva en edades tempranas y luego la especialización; una vez alcanzadas las bases de la fuerza, el acondicionamiento y el entrenamiento neuromuscular, así como una maduración psicomotora específica, para que su rendimiento deportivo y su salud no se vean comprometidos en el mediano o largo plazo. Es necesario considerar que pocos niños logran obtener un lugar en los deportes de élite, por lo que, para muchos de ellos, la educación en torno al deporte será la base para el ejercicio de su ciudadanía como personas activas.

Abstract Purpose: To explore and discuss theoretical and practical scientific literature to compare sports diversification and early sports specialization as a sport and educational approach. Methods: A systematic review was conducted following PRISMA guidelines, and 61 studies were included. Results: Coaches, parents, and children consider that the best way to develop sports talent and enter the elite in sports is to practice a single discipline as early as possible to achieve specialization and maximum technical skills and physical and psychological conditions. Sports specialization paths may lead to a physical, social, and mental state that compromises their integral development. Conclusion: Sports diversification should be considered first at an early age and, afterward, the specialization once the bases of strength, conditioning, neuromuscular training, and a specific psychomotor maturation have been achieved, so that sports performance and health are not compromised in the medium or long term. It is necessary to consider that few children enter elite sports, so for many of them, sports education will be the basis for exercising their citizenship as active people.

Resumo Objetivos: Explorar e discutir literatura científica teórica e prática para comparar a diversificação e especialização esportiva precoce como uma abordagem esportiva e educacional. Métodos: uma revisão sistemática foi realizada seguindo as diretrizes do PRISMA, um total de 61 estudos foram incluídos Resultados: Treinadores, pais e crianças acreditam que a melhor maneira de desenvolver talentos esportivos e ingressar na elite do esporte é participar de uma única disciplina e fazer o mais cedo possível para alcançar a especialização e o máximo de habilidades técnicas, físicas e psicológicas. Os caminhos da especialização esportiva podem levar a uma situação física, social e mental que comprometa seu desenvolvimento integral. Conclusão: Primeiro, a diversificação esportiva pode ser considerada em uma idade precoce e depois a especialização, uma vez que os princípios básicos de força, condicionamento e treinamento neuromuscular tenham sido alcançados, bem como a maturação psicomotora específica para que seu desempenho esportivo e saúde não sejam comprometidos a médio ou longo prazo. É necessário considerar que poucas crianças conseguem obter um lugar nos esportes de elite, de modo que, para muitas delas, a educação em torno do esporte será a base para o exercício de sua cidadania como pessoas ativas.

Perceived efficacy of case analysis as an assessment method for clinical competencies in nursing education: a mixed methods study.

BACKGROUND: Case analysis is a dynamic and interactive teaching and learning strategy that improves critical thinking and problem-solving skills. However, there is limited evidence about its efficacy as an assessment strategy in nursing education. OBJECTIVES: This study aimed to explore nursing students' perceived efficacy of case analysis as an assessment method for clinical competencies in nursing education. METHODS: This study used a mixed methods design. Students filled out a 13-item study-advised questionnaire, and qualitative data from the four focus groups was collected. The setting of the study was the College of Nursing at Sultan Qaboos University, Oman. Descriptive and independent t-test analysis was used for the quantitative data, and the framework analysis method was used for the qualitative data. RESULTS: The descriptive analysis of 67 participants showed that the mean value of the perceived efficacy of case analysis as an assessment method was 3.20 (SD = 0.53), demonstrating an 80% agreement rate. Further analysis indicated that 78.5% of the students concurred with the acceptability of case analysis as an assessment method (mean = 3.14, SD = 0.58), and 80.3% assented its association with clinical competencies as reflected by knowledge and cognitive skills (m = 3.21, SD = 0.60). No significant difference in the perceived efficacy between students with lower and higher GPAs (t [61] = 0.05, p > 0.05) was identified Three qualitative findings were discerned: case analysis is a preferred assessment method for students when compared to MCQs, case analysis assesses students' knowledge, and case analysis assesses students' cognitive skills. CONCLUSIONS: This study adds a potential for the case analysis to be acceptable and relevant to the clinical competencies when used as an assessment method. Future research is needed to validate the effectiveness of case analysis exams in other nursing clinical courses and examine their effects on academic and clinical performance.

Developing an entrustable professional activity for providing health education and consultation in occupational therapy and examining its validity.

BACKGROUND: Entrustable Professional Activities (EPA)-based assessment is easily and intuitively used in evaluating the learning outcomes of competency-based medical education (CBME). This study aimed to develop an EPA for occupational therapy focused on providing health education and consultation (TP-EPA3) and examine its validity. METHODS: Nineteen occupational therapists who had completed online training on the EQual rubric evaluation participated in this study. An expert committee identified six core EPAs for pediatric occupational therapy. TP-EPA3 was developed following the EPA template and refined through consensus meetings. The EQual rubric, a 14-item, five-point criterion-based anchor system, encompassing discrete units of work (DU), entrustable, essential, and important tasks of the profession (EEIT), and curricular role (CR), was used to evaluate the quality of TP-EPA3. Overall scores below 4.07, or scores for DU, EEIT, and CR domains below 4.17. 4.00, and 4.00, respectively, indicate the need for modifications. RESULTS: The TP-EPA3 demonstrated good validity, surpassing the required cut-off score with an average overall EQual score of 4.21 (SD = 0.41). Specific domain scores for DU, EEIT, and CR were 3.90 (SD = 0.69), 4.46 (SD = 0.44), and 4.42 (SD = 0.45), respectively. Subsequent revisions clarified observation contexts, enhancing specificity and focus. Further validation of the revised TP-EPA3 and a thorough examination of its reliability and validity are needed. CONCLUSION: The successful validation of TP-EPA3 suggests its potential as a valid assessment tool in occupational therapy education, offering a structured approach for developing competency in providing health education and consultation. This process model for EPA development and validation can guide occupational therapists in creating tailored EPAs for diverse specialties and settings.

Enhancing nursing students' clinical competency using a multi-patient simulation learning model: A randomized controlled study.

BACKGROUND: For nurses, clinical competency is paramount in ensuring that patients receive safe, high-quality care. Multi-patient simulation (MPS) in nursing education is gaining attention, and evidence shows its suitability for real-life situations. MPS can be an effective solution for nurses' continuing clinical education. OBJECTIVES: This project compares the effectiveness of MPS (involving both a standardized patient and a high fidelity simulator) and a single high-fidelity simulation (single HFS; only involving a high fidelity simulator) for enhancing the clinical competency of nursing students. DESIGN: A stratified, permuted, block randomized controlled study design was used. SETTINGS AND PARTICIPANTS: Sixty undergraduate nursing students in years 3, 4, and 5 were selected to participate. Subgroups with each comprising three undergraduate nursing students from different years were formed. METHODS: The participants were randomized to receive either an MPS (intervention group) or single HFS (control group) for 1 day; they later received the same intervention after a 30-day washout period. One objectively measured questionnaire and two self-reported questionnaires were used to measure clinical competency: the Creighton Competency Evaluation Instrument (CCEI), Clinical Competence Questionnaire (CCQ), and Simulation Effectiveness Tool - Modified Questionnaire (SET-M). RESULTS: The results revealed significant between-group differences. Specifically, the intervention group showed greater improvement than the control group in both the CCQ (linear contrast [d] = 71.4; 95 % confidence interval [CI] = 53.407, 89.393; P < 0.001) and CCEI total scores (d = 7.17; 95 % CI = 5.837, 8.503; P < 0.001). The SET-M results indicated that 85 % of the participants (n = 51) strongly agreed that they felt more confident about performing a patient handover to the healthcare team after the simulation. CONCLUSIONS: The study findings indicated that both the MPS and single HFS effectively enhanced students' clinical competency. However, MPSs have superior educational outcomes relative to traditional single HFSs.

Incident of violence escalation of patients with psychiatric emergencies boarding in the emergency department in the central region of Thailand and its association: a prospective observational study.

BACKGROUND: This study investigates the incidence of violence escalation among psychiatric emergency patients admitted to general emergency departments in hospitals in central Thailand. In addition, patient and service delivery system factors associated with the survival time of violence escalation in 16 emergency departments in the central region of Thailand are determined. This is a prospective observational study, and the study sample includes 507 psychiatric emergency patients who are ≥ 18 years old. The patients are selected through stratified random and purposive sampling. METHODS: Patient data-including demographic data, emergency services used, and clinical characteristics-are analyzed using descriptive statistics. The Kaplan-Meier method estimates the violence escalation curve, and the log-rank test compares the violence escalation-free time between the levels of the violent behavior group. In addition, univariable and multivariable Cox proportional hazard analyses are performed to investigate the factors affecting violence escalation. RESULTS: The incidence of violence escalation in psychiatric emergency patients in the emergency department is 7.3%, whereas the incidence rate of violence escalation is 3 per 100 psychiatric emergency patient visit hours. Factors affecting violence escalation include the violent behavior score at triage (aHR = 2.004; 95% CI: 1.051-3.823) and the nurse competency score (aHR = 0.147; 95% CI: 0.032-0.680). CONCLUSIONS: Assessing the violent behavior of psychiatric emergency patients at triage may assist emergency providers in monitoring patient behavior and providing early intervention to prevent the escalation of violent behavior. Furthermore, training emergency nurses in psychiatric emergency care is necessary.