De-escalation Techniques To Reduce Aggression In Mental Health Settings

NURSING3004 Mental Health Nursing

Aggressive Behavior in Mental Health Patients

One of the most serious issues associated with mentally ill or psychiatric patients is display of aggressive behavior. Fear of aggression is the most common stigma. This leads to discrimination towards the patients and creates a hindrance in the process of providing holistic patient-centered care (Kowalenko et al., 2012). Mental patients are more likely to become vulnerable to aggressive behavior that increases risk of injuries for the clinical practitioners. A clinician faces challenges while caring for such patients (Angland, Dowling & Casey, 2014). Providing care to an aggressive patient emotionally exhausts a physician and they face difficulty while interacting with these assaultive patients.

Several physical intervention strategies have been employed by physicians and nurses since ages while working with aggressive clients. De-escalation acts as an important factor that can reduce seclusion or traditional physical interventions. Recent studies lay emphasis on such techniques that have proved their potential in easing an escalated or heightened situation in a violent patient. De-escalation involves monitoring and controlling non-verbal behavior, eye contact, voice tone and body posture by the staff to avoid violent situations (Bosse & Provoost, 2014, June). These techniques focus on the identification of several triggers and cues that can make a patient upset, listening to complains and reflecting upon a proper care plan that will cater to the demands of an aggressive patient (Roberton et al., 2012). The report will focus on a literature review of some of the recently conducted studies that have established the efficacy of de-escalating techniques in reducing aggression.

Search methodology

Several studies illustrate the use of de-escalating techniques in establishing rapport with patients and emphasizing their cooperation. The studies also elaborate on negotiating different realistic options to avoid threats, showing empathy and minimizing patient concerns. To identify the research articles that were relevant for this literature review, several databases like MEDLINE, the Cochrane Library and CINAHL were searched.  Analogous search terms such as “mental disorders”, “psychotic patients and aggression”, “mental illness and violence”, “psychomotor agitation”, “violence”, “aggression”, “crisis intervention” were used (Bergamaschi et al., 2016).

Inclusion and exclusion criteria

Literature studies that dates not prior to 2012 were included. Peer reviewed journals published in English language were selected. The review focused on interventions based on reducing aggression in mental settings only. Exclusion criteria included non-English journals, published before 2012. Those intervention strategies that were carried out in ineligible population or inappropriate geographical settings were excluded. Excluded studies also encompassed articles that were irretrievable for full text. No intervention methods that were applied to reduce workplace violence were considered.

Review

Physical Intervention Strategies

A study conducted by Berring, Pedersen & Buus, (2016), monitored 5 psychiatric units like the intensive care unit, medium security unit and forensic medium units. All the units had occupancy by both male and female patients. A total of 41 people were involved in the study which comprised of 20 mental healthcare workers and 21 patients. The interviews were conducted for 14 hours and after experience of a de-escalating incident, the patients were made to interact with the researchers. The questions were based on suggestions from the staff members. Attention was paid to an agitated female patient (40-45 years). The staff became an active listener to her anger experiences and needs. The staff also went along with certain suggestions made by the agitated patients and allowed them to go for walks and take part in activities that they usually missed being a part of. Certain staff members helped the patients to reframe their agitated state of mind and suggested the patients to take showers. This led to avoidance of mechanical constraints. Thorough analysis of the 21 cases, the interview results and observation notes were manually explored to understand the efficacy of de-escalating techniques on violent and aggressive patients. Results suggested that patients and staff tried to achieve social relationship and non-confrontational situations when a violent incident arose. Past traumatic experiences influence aggressive behavior among patients (Papadopoulos et al., 2012).  

Mechanical restraints were considered by most patients to be the solution. De-escalating techniques include strategies like safety-zone protection, showing empathy and linking to the thought and actions of patients, sharing responsibilities and reflecting on the consequences. This study thus provided evidence on the effectiveness of social interaction to change violent situations. Another study carried out a systematic review on the future interventions, based on available evidence, elucidated the effect of de-escalation techniques. The major themes identified were personal control, verbal and non verbal skills, engagement with patient and ensuring safe conditions. The study proved for a de-escalation technique to be effective, it should be honest, self-aware, supportive and non-judgmental about the patient. When the mental health workers appear concerned for the patient and adopt a non-threatening approach towards them, a patient trusts the clinicians. This helps in validating their experiences and reducing the need for violent behavior. Several studies included in the systematic review suggested maintaining personal control and calm composure as effective de-escalators. Calmness reduces fear and insecurity in a patient and enables staff to focus on controlling their anxiety and making proper therapeutic decisions. The findings were consistent with other studies that emphasized on the need to show empathy towards patients, listening and understanding their states of mental distress. Forcing or patronizing a patient may increase chances of a violent behavior. Studies have proved that using morality at times of decision making and escorting the patients to private areas show success for intensive de-escalation (Price & Baker, 2012).

De-escalation as an Important Factor in Reducing Aggression

Another systematic review was carried out to investigate the potential of non-physical intervention for managing violence and aggression in mental health settings. It identified 38 studies that focused on direct skills teaching and influence of de-escalating therapies on staff behavior modification. Direct skills teaching have shown the strongest impact on management of aggressive behavior among mental patients. Wards where the staff showed more compliance to skills training, benefitted most and reported less number of violence cases. Whole team approaches effectively reduced the cases of assaults. Self awareness and interpersonal skills play a pivotal role in de-escalation (Björkdahl, Hansebo & Palmstierna, 2013). These outcomes exhibited a significant improvement in countering aggressive situations. This study provided evidence that training interventions can be used to address violent behavior among mental patients in the ward (Price et al., 2015).

In another study, a randomized controlled trial was conducted among 84 male patients who were non-actively psychotic. The patients reported a history of violence and primary psychotic disorder. The patients were made to participate in reasoning and rehabilitation program that utilized cognitive skills and its efficiency on reducing violence was measured with respect to treatment as usual (TAU). On assessing rates of violent behavior during and post-treatment, it was found that verbal aggression incident rates and violations were significantly low among patients subjected to the R&R program. This effect on verbal aggression was maintained even after 12 months, post treatment. This study proved that a reduction in anti-social behavior can be obtained if cognitive skills and rehabilitation programs are implemented as de-escalating techniques (Cullen et al., 2012). Efficacy of certain de-escalating interventions was also tested in a randomized control trial that consisted of patients and staff chosen from 31 psychiatric wards in 15 hospital settings. Safewards interventions included mutual agreement, advisory statements, sharing of personal information, expanding staff skills, inter-patient support and a display of positive messages in the ward. Improvement in physical health of the staff was advocated as another intervention that would promote in providing better healthcare facilities. The total rates of conflict and containment were measured as primary outcomes. A statistical analysis revealed that rates of conflicts got reduced by 15% and that of containment got reduced by 26.4% when the de-escalating techniques were adopted (Bowers et al., 2015).

Another study evaluated the impacts of an educational program on the attitude of nurses and staff regarding prevention and management of aggression among patients. A rapid emergency department intervention program was carried out among 471 participants belonging to public sector hospitals. Statistically significant improvements were observed in few post-test conditions (Gerdtz et al., 2013). Thus, the test failed to provide evidence for the relationship between specific changes in staff attitude and management of aggression among patients in mental health settings.

Critical appraisal

Studies on the Use of De-escalating Techniques in Establishing Rapport

A CASP tool will be used to assess and analyze the effectiveness of the interventions used in the studies, the precision of the outcomes and their applicability in target population (Munn et al., 2014).

Parameters	(Berring, Pedersen & Buus, 2016)	(Bowers et al., 2015)
Did the trial address a clearly focused issue?	Yes	Yes
Was the assignment of patients to treatment non-randomized?	Yes (study was focused in 5 psychiatric mental units)	Yes (patients from psychiatric wards were recruited)
Were all patients accounted for at conclusion?	Yes (21 cases were explored for meetings, interviews and recordings)	Yes (pre and post treatment outcomes were measured)
Were patients, health workers and study personnel blind to treatment?	No	No
Were the groups similar at start of trial?	Yes (all units experienced violent situation regularly)	Yes (acute psychiatric patients of both genders were enlisted)
Were the groups treated equally?	Yes (24 minutes of interview for each patient were conducted, supported by meetings and observations)	Yes (Ten intervention methods based on the Safewards package were implemented on all participants)
How large was the treatment effect?	Comparative analysis process was used to measure the outcomes; interview texts, theoretical explanation and combination of themes were performed	Baseline data measurements were collected for 8 weeks, implementation of the interventions were done for another 8 weeks, followed by statistical analysis
How precise was the estimate of treatment effect?	Interpretations were discussed with peers and service users; data findings were shared with supervisors.	MCMCglmm package was used to analyse the data; primary outcome- conflict rates reduced by 15% after intervention; secondary outcome- control group showed improved physical health than intervention.
Can the results be applied in this context?	Yes	Yes
Were all clinically important outcomes considered?	Yes (analysed memories and hope, safety, creativity and reflections)	No (baseline measures showed high missing data for control compared to intervention conditions)

	(Price & Baker, 2012)	(Price et al., 2015)
Did the review address a clearly focused question?	Yes (investigated the effectiveness of de-escalation training in reducing aggression)	Yes (analysed the clinical and learning outcomes of de-escalating techniques)
Did the authors look for the right type of papers?	Yes (electronic databases were searched with  stringent inclusion criteria)	Yes (20 electronic databases were screened)
Were all relevant studies included?	Yes (11 studies  were used from 94 retrieved articles)	Yes (38 relevant studies were identified)
Did the author do enough to access the quality of included studies?	Yes	Yes
If the results have been combined, was it reasonable to do so?	Yes (most of the studies illustrated the role of empathy, cognitive skills, calm composure, self control and gentle behaviour as effective de-escalators)	Yes (all studies focused on the strong impacts of training in aggression management)
What are the overall results?	Ensuring safe conditions for the patients, maintaining a gentle voice tone, calmness, engaging with patients and good verbal communication can be used as de-escalation interventions	De-escalation training improved staff ability to manage violent and aggressive behaviour
How precise are the results?	All studies used de-escalation as first line of intervention strategies	The trainings were used all first line if intervention procedures
Can the results be applied to local population?	Yes	Yes
Were all important outcomes considered?	Yes	Yes
Are the benefits worth the harm and costs?	Yes (There are no potent harm associated)	Can’t tell (failed to link efficacy of these training on preventing injuries and assaults)

Conclusion

Understanding violent behavior in mental hospital settings are quite challenging. It is integral to the job of a caregiver. If violence is not well handled, they lead to patient and staff injuries. Moreover, violence is harmful for all staff and patients and leads to high containment levels. Lack of engagement and cooperation from the staff may worsen the situation. This literature review identifies several studies that described the efficiency of de-escalation practices or psychosocial interventions on managing imminent harm caused by rage, anger, or violence in mental healthcare settings. Thus, it can be concluded that maintaining a calm personal space, interacting with the patient and developing cognitive skills are most effective to manage such aggressive situations.

References

Angland, S., Dowling, M., & Casey, D. (2014). Nurses’ perceptions of the factors which cause violence and aggression in the emergency department: a qualitative study. International emergency nursing, 22(3), 134-139.

Bergamaschi, S., Ferro, N., Guerra, F., & Silvello, G. (2016). Keyword-based search over databases: a roadmap for a reference architecture paired with an evaluation framework. In Transactions on Computational Collective Intelligence XXI (pp. 1-20). Springer Berlin Heidelberg.

Berring, L. L., Pedersen, L., & Buus, N. (2016). Coping with violence in mental health care settings: patient and staff member perspectives on de-escalation practices. Archives of psychiatric nursing, 30(5), 499-507.

Björkdahl, A., Hansebo, G., & Palmstierna, T. (2013). The influence of staff training on the violence prevention and management climate in psychiatric inpatient units. Journal of Psychiatric and Mental Health Nursing, 20(5), 396-404.

Bosse, T., & Provoost, S. (2014, June). Towards aggression de-escalation training with virtual agents: A computational model. In International Conference on Learning and Collaboration Technologies (pp. 375-387). Springer, Cham.

Bowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial. International journal of nursing studies, 52(9), 1412-1422.

Cullen, A. E., Clarke, A. Y., Kuipers, E., Hodgins, S., Dean, K., & Fahy, T. (2012). A multisite randomized trial of a cognitive skills program for male mentally disordered offenders: Violence and antisocial behavior outcomes. Journal of consulting and clinical psychology, 80(6), 1114.

Gerdtz, M. F., Daniel, C., Dearie, V., Prematunga, R., Bamert, M., & Duxbury, J. (2013). The outcome of a rapid training program on nurses’ attitudes regarding the prevention of aggression in emergency departments: a multi-site evaluation. International journal of nursing studies, 50(11), 1434-1445.

Kowalenko, T., Cunningham, R., Sachs, C. J., Gore, R., Barata, I. A., Gates, D., … & McClain, A. (2012). Workplace violence in emergency medicine: current knowledge and future directions. The Journal of emergency medicine, 43(3), 523-531.

Munn, Z., Moola, S., Riitano, D., & Lisy, K. (2014). The development of a critical appraisal tool for use in systematic reviews addressing questions of prevalence. International journal of health policy and management, 3(3), 123.

Papadopoulos, C., Ross, J., Stewart, D., Dack, C., James, K., & Bowers, L. (2012). The antecedents of violence and aggression within psychiatric in?patient settings. Acta Psychiatrica Scandinavica, 125(6), 425-439.

Price, O., & Baker, J. (2012). Key components of de?escalation techniques: A thematic synthesis. International journal of mental health nursing, 21(4), 310-319.

Price, O., Baker, J., Bee, P., & Lovell, K. (2015). Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. The British Journal of Psychiatry, 206(6), 447-455.

Roberton, T., Daffern, M., Thomas, S., & Martin, T. (2012). De?escalation and limit?setting in forensic mental health units. Journal of forensic nursing, 8(2)