--- title: "Most pilots measure on the day: evaluating de-escalation training" description: "35 of 50 published de-escalation training studies measured on the day and never again. What to observe, when to check again and which data to count." canonical: https://peopletechrevolution.com/insights/evaluate-de-escalation-training-pilot --- [Insights](https://peopletechrevolution.com/insights) # Most pilots measure on the day: how to evaluate de-escalation practice so the result holds 35 of 50 published VR and simulation de-escalation studies, 2015 to 2026, measured on the day and never again (Europe PMC). By [Kim Loza](https://linkedin.com/in/kimberlyloza), Head of Product at People Tech Revolution Published 25 September 2026 · Last updated 28 September 2026 · Version 2.0 [Connect with Kim on LinkedIn ↗](https://linkedin.com/in/kimberlyloza) Cite this research 35 of 50 studies measured on the day and not again VR and simulation studies, 2015 to 2026 41 of 50 stopped at reaction or learning measures VR and simulation studies, 2015 to 2026 4 of 6 where self-report and observation disagreed Studies with self-report and observation, 2017 to 2026 20% of trained staff answered the later check Young et al., 2022 The published norm ## What do published de-escalation studies measure? Mostly how staff felt and what they learned on the day: 41 of 50 VR and simulation studies from 2015 to 2026 stopped at reaction or learning. A visitor gestures beside a service counter. A man waits at the triage counter. A resident raises a concern at a counter. A coach and learner arrange markers. ### Reaction, learning, behaviour, results [Kirkpatrick Partners](https://www.kirkpatrickpartners.com/the-kirkpatrick-model/) define Level 1 as reaction and Level 2 as learning, including confidence. Level 3 asks whether staff perform the critical behaviours at work; Level 4, whether the organisation’s targeted outcomes occur. A participant talks it through with a facilitator. ### Where the studies stopped Behaviour at work appeared in 1 study, by self-report. 8 of 50 reported restraint, injury or assault data, all from uncontrolled before and after projects or a feasibility trial on 3 wards. Colleagues sort blank cards at a bench. ### Reviews find the same gap In a [2024 simulation review](https://doi.org/10.1016/j.ijnurstu.2024.104842), 4 of 25 studies collected primary outcome data. A [2026 review of VR de-escalation training](https://pmc.ncbi.nlm.nih.gov/articles/PMC12917911/) found none of its 15 studies evaluated organisational impact. Where the 50 studies stopped, all against the VR subset Reaction or learning, all 50 82% Reaction or learning, VR 14 93% Comparison group, all 50 26% Comparison group, VR 14 21% On the day, never again, all 50 70% On the day, never again, VR 14 93% See the data (percent of studies) Measure Percent of studies Reaction or learning, all 50 82% Reaction or learning, VR 14 93% Comparison group, all 50 26% Comparison group, VR 14 21% On the day, never again, all 50 70% On the day, never again, VR 14 93% Percent of studies, 2015 to 2026. Source: [Europe PMC and PubMed records coded by PTR](https://europepmc.org/). ### Virtual reality studies stop earlier than the field Of the 14 VR studies, 13 stopped at reaction or learning and 13 never measured again. So what for you: A pilot with a comparison group and a later check already sits above the published norm. Longest follow-up in the 50 studies On the day, never again 35 of 50 At 2 weeks 2 of 50 At 3 to 6 months 7 of 50 Over 6 months 1 of 50 Not reported 5 of 50 See the data (studies of 50) Measure Studies of 50 On the day, never again 35 of 50 At 2 weeks 2 of 50 At 3 to 6 months 7 of 50 Over 6 months 1 of 50 Not reported 5 of 50 Studies, 2015 to 2026. Source: [Europe PMC and PubMed records coded by PTR](https://europepmc.org/). ### Almost no study checked again Learners were measured again at 3 months or later in 5 studies; the others that looked later counted service data. So what for you: Book the later check into the roster before the pilot starts. Self-report and observation ## Is a confidence survey enough? Not on its own: in 4 of 6 studies that measured self-report and observation, what staff reported and what an observer scored moved apart. A facilitator turns over a feedback card. ### Skill rose while confidence stayed level In a [2017 cluster randomised trial](https://doi.org/10.1007/s40596-016-0559-2) with 26 residents, filmed performance in simulated agitation cases rose (Cohen’s d = 1.6) while self-rated confidence did not differ between groups. A facilitator and a colleague rehearse. ### Confidence rose while observed skill did not In a [2019 randomised trial](https://doi.org/10.1016/j.acap.2018.10.005), residents’ self-assessed skill rose (p <= .03) but standardised patient ratings did not beat control. After a [2025 curriculum](https://doi.org/10.1007/s11606-024-08975-5), confidence rose from 2.79 to 4.11 out of 5; an OSCE found no skill difference. A team leader discusses escalation with a colleague. ### The counts disagreed, the rating rose Surgical residents in a [2026 simulation series](https://doi.org/10.1097/sih.0000000000000934) counted more de-escalation techniques themselves (p = 0.02); a facilitator saw no significant difference (p = 0.11). A modified observation scale rose from 23.1 to 27.8. A practitioner discusses feedback with a coach. ### Observation beside the survey [AHRQ’s TeamSTEPPS guidance](https://www.ahrq.gov/teamstepps-program/curriculum/implement/pre/measure.html) warns that training can sensitise staff so that their survey ratings dip for a while, and recommends direct observation in addition to surveys. Its test: “If training does not change behavior, it was not successful.” Feedback cards sorted on a table. Sources laid out for review. A reviewer holds out a card. A reviewer watches a practice conversation. ### Scales a pilot can borrow The [De-escalating Aggressive Behaviour Scale](https://doi.org/10.1111/j.1365-2648.2009.05087.x) rates observed skill on 7 items (alpha 0.87 and 0.88; raters agree at 0.77 to 0.93). The Confidence in Coping with Patient Aggression instrument (alpha 0.81) was used in 5 of 10 studies in a [2025 meta-analysis](https://doi.org/10.1111/inr.70107). After the session ## How long does a gain last? Part of it fades: hospitalists in a 2023 study kept 55% to 67% of their confidence gain at 3 to 12 months. Share of the immediate confidence gain still present later Hospitalists, 3 months 55% Hospitalists, 6 months 67% Hospitalists, 12 months 66% Clinicians, 3 months 94% See the data (percent of gain) Measure Percent of gain Hospitalists, 3 months 55% Hospitalists, 6 months 67% Hospitalists, 12 months 66% Clinicians, 3 months 94% Percent of gain, self-report, 2022 and 2023. Source: [Gupta et al., 2023](https://doi.org/10.55729/2000-9666.1189); [Young et al., 2022](https://doi.org/10.1111/inm.13040). ### Confidence fades in part Gupta’s hospitalists scored 43.2 before in-person training, 68.5 straight after, then 57.2, 60.2 and 59.9 at 3, 6 and 12 months. Young’s clinicians held 94% of their gain, on 24 of 122 answering. So what for you: Plan a repeat at about 3 months and expect a smaller gain than on the day. A learner repeats a quiet task. ### Skills decay faster without use A [1998 meta-analysis](https://doi.org/10.1207/s15327043hup1101_3) of 189 data points found skill loss grew from 0.01 standard deviations straight after training to 1.4 after more than a year unused, faster for cognitive tasks than physical ones. Share of trained staff at the later check Young 2022, 3 months 20% Phiri 2024, 6 months 23% Mitchell 2020, 3 to 6 months 30% See the data (percent answering) Measure Percent answering Young 2022, 3 months 20% Phiri 2024, 6 months 23% Mitchell 2020, 3 to 6 months 30% Percent of those trained, 2020 to 2024. Source: [Young et al., 2022](https://doi.org/10.1111/inm.13040); [Phiri et al., 2024](https://doi.org/10.5498/wjp.v14.i10.1521); [Mitchell et al., 2020](https://doi.org/10.1186/s41077-020-00139-9). ### Later checks reached 20% to 30% of those trained 44 of 146 staff answered at 3 to 6 months; 13 of 56 ward staff gave 6-month samples, too few to test. So what for you: Later responders may differ from the rest; size the group for the later check. A facilitator briefs participants. ### Size the pilot before it starts The median published study analysed 56 people. A [2026 VR study](https://doi.org/10.1111/jan.70563) needed 34 participants for a moderate effect (d = 0.50) and approached 62; a [2022 study](https://doi.org/10.1177/08445621221101290) with 24 learners could not detect group differences. Service data ## Which incident data can show change? Rates with a baseline as long as the follow-up, such as restraints per emergency visit. A charge nurse briefs nurses at a ward station. ### A rate, not a raw count A [2023 emergency department pilot](https://doi.org/10.7759/cureus.39847) reported monthly restraints as a ratio of that month’s visits, over the 6 months before and after training. A supervisor checks in with a seated officer. ### A before and after result needs its context A [2025 psychiatric emergency project](https://doi.org/10.1177/10783903241308529) recorded 35% fewer restraints and 52% fewer injuries over 5 months after simulation than before, with teamwork perceptions unchanged. With no comparison, staffing, reporting and chance remain explanations. Facilitators hand over a practice session. ### Match the baseline to the follow-up The [EDITION feasibility trial](https://doi.org/10.3310/fggw6874) on 10 wards collected 8 weeks before training, 8 of embedding and 8 after. Its authors write that “there have been no high-quality trials evaluating the effectiveness” of de-escalation training. A facilitator leads a conversation at a table. ### A controlled ward design The [Safewards cluster trial](https://doi.org/10.1016/j.ijnurstu.2015.05.001) randomised 31 wards and counted incidents per shift: conflict was 15% and containment 23.2% lower than on control wards ([corrected figures](https://doi.org/10.1016/j.ijnurstu.2015.12.006)). Safewards is a set of ward interventions, broader than a course. Seclusion and physical restraint per 1,000 bed days, Australia, 2008-09 to 2022-23 Seclusion Physical restraint See the data (events per 1,000 bed days) 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19 2019-20 2020-21 2021-22 2022-23 Seclusion 15.6 13.9 12.1 10.6 9.8 8.2 7.9 8.1 7.4 6.9 7.2 8.1 7.3 7 6 Physical restraint 11.2 10.1 10.3 11.4 11.0 11.6 Events per 1,000 bed days; last 2 years rounded, 2008-09 to 2022-23. Source: [AIHW tables RP.5 and RP.8](https://www.aihw.gov.au/getmedia/c493b52f-27f3-4c0d-bd71-109f9880c4f4/Restrictive-practices-in-mental-health-care.xlsx.aspx); [AIHW](https://www.aihw.gov.au/mental-health/topic-areas/seclusion-and-restraint). ### Seclusion halved while physical restraint held steady Seclusion fell from 15.6 (2008-09) to 6 (2022-23); physical restraint stayed between 10 and 12 from 2015-16. So what for you: Report your ward’s own rate on the same denominator, before and after. NHS staff reporting physical violence from patients or the public, England, 2021 to 2025 Physical violence from patients or the public See the data (percent of staff) 2021 2022 2023 2024 2025 Physical violence from patients or the public 14.57% 14.82% 13.88% 14.38% 14.47% Percent of staff, 2021 to 2025. Source: [NHS Staff Survey briefing 2025](https://www.nhsstaffsurveys.com/static/98fbf017ea18aad1523254e02072cd02/National-Results-Briefing-2025.pdf). ### A national staff-report measure moves by about a point The share ranged from 13.88% to 14.82% over 5 years on the same question, and stood at 14.47% in 2025. So what for you: Keep the question fixed, and read a small change as noise. A community nurse sits alone in a carpark. A receptionist leans over the desk. A supervisor beside a quiet driver. PTR-built projects ## What did PTR-built projects measure? Evaluation design rather than de-escalation outcomes: 73.2% of eligible leaders completed baseline in a Mayo Clinic study with a control group; 30% returned an optional survey after Google’s training. Response or completion by evaluation design Mayo Clinic study, baseline survey 73.2% Mayo Clinic education evaluation 52.4% Google training, optional survey 30% See the data (percent) Measure Percent Mayo Clinic study, baseline survey 73.2% Mayo Clinic education evaluation 52.4% Google training, optional survey 30% Percent of those eligible, 2022 to 2024. Source: [Social Science & Medicine, 2024](https://doi.org/10.1016/j.socscimed.2024.117648); [Journal of Nursing Administration](https://doi.org/10.1097/NNA.0000000000001503); [CHI 2024 paper](https://peopletechrevolution.com/work/case-studies/google-vr-dei-training). ### Measurement built into the design kept more of the group PTR built the VR for the Mayo Clinic study, where 841 of 1,149 eligible leaders completed baseline. In the Google training, built with Equal Reality, a subsidiary of People Tech Revolution, 7 of 26 trainees returned an optional survey. So what for you: Neither project is a de-escalation study; they show how design changes who answers. A facilitator and participant discuss an exchange. ### What a reaction result looks like Mater’s own evaluation of its immersive pilot, with more than 60 participants: 90% reported better concentration, 77% found it more engaging than face-to-face delivery, 93% enjoyed it. All Level 1. Demand ## Why does evaluation carry more weight now? Obligations are growing: since January 2022 the Joint Commission has asked US hospitals to train staff at hire and annually. A clinician sits with a young woman outside. ### An annual repeat is already built in Under the [Joint Commission’s standards](https://digitalassets.jointcommission.org/api/public/content/0c8d9cd5ed3145b6bc9369920b69ca21?v=9dec6a64), hospitals train at hire, annually and when the program changes, and run an annual worksite analysis. US states with prevention laws rose from 11 before 2015 to 27 by June 2024 ([Health Affairs Scholar](https://doi.org/10.1093/haschl/qxag022)). An employee sits across a meeting table. ### Interest rises while federal rules wait Worldwide search interest in de-escalation training averaged 3.35 across 2022 and 19.37 across 2025 on [Google Trends](https://trends.google.com/trends/explore?date=today%205-y&q=de-escalation%20training)’ relative scale. The federal OSHA healthcare rule moved to the long-term agenda in March 2026 ([GAO](https://www.gao.gov/products/gao-16-11)). The plan ## What should a pilot plan settle before training starts? An observed behaviour, a confidence scale and a service indicator, each with a baseline and a repeat at about 3 months. A supervisor gives feedback on a warehouse floor. A supervisor checks in with a crew member. A carer approaches a man at a handrail. A manager rehearses a feedback conversation. ### Start from the result you need [Kirkpatrick Partners](https://www.kirkpatrickpartners.com/the-kirkpatrick-model/) advise starting with Level 4 and the program’s purpose, with early and later indicators, then working back to the behaviour that should change. A family support worker sits with a woman. ### What a strong design adds A [2020 Cochrane review](https://doi.org/10.1002/14651858.CD011860.pub2) asks for institutional aggression reports, validated measures, a 1-year follow-up and an active comparison, so reporting does not rise in the trained group alone. Colleagues review a screen together. ### Use data you already hold [AHRQ](https://www.ahrq.gov/teamstepps-program/curriculum/implement/pre/measure.html) notes existing organisational data make results more credible and less burdensome to collect, if they cover the trained area and the period after training. Evidence ## Which studies does this rest on? The primary studies behind each figure, with design and sample. Primary studies this analysis rests on, 2015 to 2026 Study Design Sample What was measured Result Vestal et al. (2017), [Academic Psychiatry](https://doi.org/10.1007/s40596-016-0559-2) Cluster randomised trial 26 residents Performance; confidence d = 1.6; confidence did not differ Weaver et al. (2026), [Simulation in Healthcare](https://doi.org/10.1097/sih.0000000000000934) Simulation series 16 residents Technique counts; mDABS Counts disagreed; 23.1 to 27.8 Young et al. (2022), [Int J Ment Health Nurs](https://doi.org/10.1111/inm.13040) Pre-post, follow up 122, then 24 Self-efficacy 62.9, 83.2, 81.9 Gupta et al. (2023), [J Community Hosp Intern Med Perspect](https://doi.org/10.55729/2000-9666.1189) Pre-post to 12 months 37 hospitalists Confidence 43.2 to 68.5; 59.9 later Bowllan et al. (2025), [J Am Psychiatr Nurses Assoc](https://doi.org/10.1177/10783903241308529) Before and after Psychiatric emergency unit Restraints, injuries 35% and 52% fewer Price et al. (2024), [Health Technol Assess](https://doi.org/10.3310/fggw6874) Feasibility trial 10 wards Conflict, containment 8 weeks each side Bowers et al. (2015), [Int J Nurs Stud](https://doi.org/10.1016/j.ijnurstu.2015.05.001) Cluster randomised trial 31 wards Incidents per shift 15% and 23.2% lower (corrected) Decisions ## What does this mean for a buyer? Decisions the figures inform, written as actions for the pilot plan. - Put an observed measure beside the survey. Self-report and observed skill disagreed in 4 of 6 studies; score rehearsals on a rubric such as the DABS. - Book a repeat at about 3 months. 35 of 50 studies never measured again, and hospitalists held 55% to 67% of their gain. - Size the group for the later check. Later checks reached 20% to 30% of those trained; a 2026 study needed 34 participants. - Report service data as a rate against a matched baseline. Use events per 1,000 bed days or per visit; 35% fewer restraints with no comparison cannot be told apart from other changes. Board paper lines, ready to paste into a business case 41 of 50 published VR and simulation de-escalation training studies from 2015 to 2026 stopped at reaction or learning measures, and 35 of 50 measured on the day and never again (PTR coding of Europe PMC and PubMed records, 2026). In 4 of 6 studies that measured self-report and observation, they disagreed, and AHRQ TeamSTEPPS guidance recommends direct observation in addition to staff surveys. Our pilot will score an observed behaviour on a validated scale, repeat it at 3 months, and report incidents per 1,000 bed days against a matched baseline, as the EDITION trial did with 8 weeks each side. ## Limits and method What these figures cannot show, and how they were counted. - The 50-study table is PTR’s coding of abstracts by 1 reviewer, without risk-of-bias scoring, not a systematic review; the Mitchell 2024 and Tang 2026 reviews are the cross-check. - Kirkpatrick levels follow the model page as live in 2026, whose wording changed after January 2024. - Instrument figures come from later studies; the original 1987 CCPA reliability figures were not read. - Retention figures are self-report from self-selected responders; Gupta 2023 does not say whether simulation was used; Arthur 1998 covers skills in general. - AIHW rates cover public acute specialised mental health hospital services, exclude Queensland from physical restraint before 2017-18 and round 2021-22 and 2022-23. NHS figures use the 2025 weighting. National series set denominators, not ward targets. - Before and after service results (Duncan 2023, Bowllan 2025) are uncontrolled. - PTR-built projects are not de-escalation studies; their response rates illustrate evaluation design. Mater figures are Mater’s own evaluation. - Every source was read on 26 September 2026. ## Where PTR fits PTR builds de-escalation practice in a headset, on screen and with AI characters, and plans the measures with the pilot. See [de-escalation training](https://peopletechrevolution.com/training/de-escalation), [VR de-escalation training](https://peopletechrevolution.com/training/vr-de-escalation-training), [how a pilot runs](https://peopletechrevolution.com/training/how-a-pilot-runs), [the business case and evaluation](https://peopletechrevolution.com/training/business-case-and-evaluation) and [what earlier projects measured](https://peopletechrevolution.com/work/research-evidence). - [What VR de-escalation research measured](https://peopletechrevolution.com/insights/vr-de-escalation-training-evidence) - [Designing a scenario and its debrief](https://peopletechrevolution.com/insights/design-de-escalation-scenario-debrief) - [What a training record should show](https://peopletechrevolution.com/learn/standards/workplace-violence-training-records) - [Training for safety and wellbeing leads](https://peopletechrevolution.com/training/for-safety-and-wellbeing-leads) ## Cite this research Free to quote and cite with a link to this page. Name the version you read, so readers can see what has changed since. APA 7 Loza, K. (2026, September 27). Most pilots measure on the day: how to evaluate de-escalation practice so the result holds (Version 2.0). People Tech Revolution. https://peopletechrevolution.com/insights/evaluate-de-escalation-training-pilot Copy citation Data: 50 primary VR and simulation de-escalation training studies from Europe PMC and PubMed (2015 to 2026), coded by PTR; the cited trials and reviews; AIHW restrictive practices tables (2022); NHS Staff Survey briefing 2025; Kirkpatrick Partners and AHRQ guidance. Read 26 September 2026. The Mayo Clinic and Google response rates illustrate evaluation design, not de-escalation outcomes. ### Version history Version Date What changed Version 2.0 27 September 2026 Rebuilt on published study data: 50 coded de-escalation studies, self-report against observation, retention, AIHW and NHS series; 7 charts, evidence table, decisions and limits. Version 1.0 25 September 2026 First published. ## Sources Each study, dataset and framework at its publisher. ### [Kirkpatrick Partners (2026). The Kirkpatrick Model. Kirkpatrick Partners](https://www.kirkpatrickpartners.com/the-kirkpatrick-model/) Model page, read 26 September 2026 The levels and where evaluation design starts. ### [Agency for Healthcare Research and Quality (2025). TeamSTEPPS: Measurement. AHRQ](https://www.ahrq.gov/teamstepps-program/curriculum/implement/pre/measure.html) Implementation guide Observation beside surveys; data from the trained area and period. ### [Agency for Healthcare Research and Quality (2024). TeamSTEPPS Measurement Tools. AHRQ](https://www.ahrq.gov/teamstepps-program/resources/tools/index.html) Tools page Observation worksheet and questionnaires. ### [Geoffrion et al. (2020). “Education and training for preventing and minimizing workplace aggression directed toward healthcare workers”. Cochrane Database of Systematic Reviews](https://doi.org/10.1002/14651858.CD011860.pub2) Systematic review What a strong evaluation includes. ### [Mitchell et al. (2024). Simulation-based education for teaching aggression management skills to healthcare providers in acute healthcare settings. International Journal of Nursing Studies](https://doi.org/10.1016/j.ijnurstu.2024.104842) Systematic review Outcomes the simulation studies used. ### [Price et al. (2024). Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial. Health Technology Assessment](https://doi.org/10.3310/fggw6874) Feasibility trial Matched 8-week windows. ### [Bowers et al. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial. International Journal of Nursing Studies](https://doi.org/10.1016/j.ijnurstu.2015.05.001) Cluster randomised trial; corrigendum 2016 Incidents per shift against control wards. ### [Nau et al. (2009). The De-Escalating Aggressive Behaviour Scale: development and psychometric testing. Journal of Advanced Nursing](https://doi.org/10.1111/j.1365-2648.2009.05087.x) Scale development An observation rubric with reliability figures. ### [Vestal et al. (2017). Simulation-Based Training for Residents in the Management of Acute Agitation: A Cluster Randomized Controlled Trial. Academic Psychiatry](https://doi.org/10.1007/s40596-016-0559-2) Cluster randomised trial Performance against confidence. ### [Gupta et al. (2023). Prevalence of Workplace Violence and Effects of De-escalation Training Among Hospitalists: A Pilot Study. Journal of Community Hospital Internal Medicine Perspectives](https://doi.org/10.55729/2000-9666.1189) Pilot study Confidence to 12 months. ### [Arthur, Bennett, Stanush and McNelly (1998). Factors that influence skill decay and retention: a quantitative review and analysis. Human Performance](https://doi.org/10.1207/s15327043hup1101_3) Meta-analysis Skill loss with time unused. ### [Australian Institute of Health and Welfare (2022). Restrictive practices in mental health care, data tables. AIHW](https://www.aihw.gov.au/getmedia/c493b52f-27f3-4c0d-bd71-109f9880c4f4/Restrictive-practices-in-mental-health-care.xlsx.aspx) Tables RP.5 and RP.8 National rates per 1,000 bed days. ### [NHS Staff Survey (2026). National Results Briefing 2025. NHS England](https://www.nhsstaffsurveys.com/static/98fbf017ea18aad1523254e02072cd02/National-Results-Briefing-2025.pdf) National briefing Staff reporting physical violence. ### [Tang et al. (2026). “The utilization of virtual reality in the training of de-escalation of aggression for both providers and users of public and healthcare services from the new millennium to the COVID-19 era: a systematic review”. Frontiers in Medicine (open access copy, PubMed Central)](https://pmc.ncbi.nlm.nih.gov/articles/PMC12917911/) Systematic review Organisational impact in VR studies. ### [The Joint Commission (2021). R3 Report Issue 30: Workplace Violence Prevention Standards. The Joint Commission](https://digitalassets.jointcommission.org/api/public/content/0c8d9cd5ed3145b6bc9369920b69ca21?v=9dec6a64) Accreditation report Training at hire and annually.