Mental Health Nursing: De-escalation Strategies for Aggression

This report investigates the strategies employed by nurses in adult mental health inpatient units to de-escalate aggressive behavior in patients, exploring whether these strategies represent best practices. The author, a student, observed instances of patient non-compliance and potential triggers for illness exacerbation, prompting an inquiry into effective interventions. The research involved discussions with staff members, revealing the stress associated with managing aggression and the variety of approaches used. The report reviews existing literature, including studies on de-escalation techniques, training programs, and the role of nurses' attitudes. Key findings highlight the importance of verbal and non-verbal communication, environmental planning, and the use of voluntary medication. The report also discusses the limitations of current research, the ethical dilemmas faced by staff, and the need for evidence-based practices to promote a negotiating culture that replaces coercive measures with de-escalation techniques through effective training and collaborative practices.

Running head: MENTAL HEALTH NURSING
Mental health nursing
Name of the Student
Name of the University
Author note

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What strategies do nurses in an adult mental health inpatient unit use to deescalate aggression displayed by
patients? Are these strategies best practice?
The rationale for choosing aggression as issue because I have observed patients being non-compliant when they are
aggressive and they refuse to comply with everything or it may trigger their illness, if proper interventions are not in
placed. During my exploration of issue, I had talk with different staff about the particular issue in inpatient unit. Every
answer revolved around aggression and how stressful for staff on certain occasion when it is not managed in certain
time and risk to staff from aggression. Every staff had different approach in order to manage aggressive patient and
make them comply with PRN medication in safe possible environment. During my placement I witnessed few different
strategies to manage aggressive patient, some of them escalated the situation, and some of them were able to calm
the patient, resulting in-patient taking PRN medication and sharing concern with staff. By choosing this as my project
question, I would investigate more about techniques used by mental health staff in managing aggression in inpatient
unit.
Violent and aggressive behaviors are common among the mental health patients and
nurses and medical staffs employ various approaches to manage the aggressive and violent
patients. The technique like de-escalation approach is a therapeutic intervention that is frequently
used to prevent aggression and violence in mental health services. A thematic literature review
conducted by Price & Baker, (2012) depicted that skilled staffs are required to perform these
techniques. They need to be de-escalators who maintain personal control and have effective non-
verbal and verbal skills. They employ the technique of engaging with the patient to ensure safe
de-escalation approach that confirm autonomy and is considered it a complex intervention
process. It consists of psychological techniques that are aimed at reducing the violent or
aggressive behaviour. The nurses use non-verbal and verbal communication skills to control
aggressive behaviour in patients. These de-escalators are honest, open, self-aware, confident and
non-judgmental without being arrogant to the mental health patients. The strength of the study is
that it elucidates the current and best practices in de-escalation techniques. However, the

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limitation of this research is that there is no randomized controlled trials (RCTs) performed in
this thematic literature review.
In another study conducted by Dickens, Piccirillo & Alderman, (2013) demonstrated that
prevention and management of aggressive behaviour could be done through training of nursing
and medical staffs. For this research, confirmatory factor analysis was done to study the
underlying factors to manage violent behaviour. The attitude of the nurses plays an important
role in managing aggressive behaviour in mental health settings. The data was collected in
medium and low secure adult mental health wards at St Andrew’s Healthcare in May and June
2011 through MAVAS Scale. The nurses’ perceptions depicted that restrictive environments
contribute to the aggressive behavior. To manage violence and aggression, they use medication
that is considered a valuable approach for treating violent behavior. They also use seclusion and
physical restraint under necessary conditions. The alternatives to this are use of sedation and
containment to manage physical violence. However, the sample size for the study is too small
and requires further trials for exploring the attitudes and perceptions of nurses.
A study conducted by Richmond et al., (2012) has demonstrated the verbal de-escalation
technique that uses engagement of patient to help them become active partner in the evaluation
and treatment process to de-escalate agitation. Environmental planning and voluntary medication
are also important for dealing with aggression in mental health patients. They have lessened the
coercive interventions where staff members manage behavior by calming down the patient.
According to Spencer & Johnson, (2016) de-escalation technique arrests the progress of the
agitation in mental health patients. The technique involves the use of effective attitude and
language to deal with aggression along with confrontation avoidance and posture. This study
evaluated the effectiveness of de-escalation techniques to establish a positive relationship and

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control aggression. RCs and quasi-RCTs were used for the study that showed that de-escalation
techniques could help to ameliorate aggressive behaviour immediately without any long-term
benefits.
Berring, Pedersen & Buus, (2016) studied the de-escalation process used during violent
and aggression episodes in mental health settings. The post hoc analysis used in this study
comprised of responsive interactions between patients and staff members to analyse their
perceptions and attitudes in managing aggression. The results indicated that staffs and patients
always thrive for peaceful solutions with sociological understanding to de-escalate the violent
and aggressive behaviour.
Shah et al., (2016) studied the effectiveness of de-escalation technique in preventing
aggressive behaviors through a systematic review and inclusion criteria. The findings showed
that there are knowledge gaps in nursing and by addressing that, the effectiveness of de-
escalation techniques can be effectively employed. According to guidelines provided by
Department of Health, Australia, de-escalation techniques are employed that require a safe
environment, proper training of the nurses and medical staffs, assessment of the risk and
observation and engagement.
In a study conducted by Steinert, Noorthoorn & Mulder, (2014)it showed that coercive
interventions are being employed in mental health settings in Netherland and Germany in dealing
with aggressive behaviour. Coercive treatment is common in Germany or involuntary patients
who are subjected to aggression with use of mechanical restraint to seclusion. Coercive
medication is also used as it approved in special conditions since 2013 in Germany. Gerdtz et al.,
(2013) depicted that training program are required for the nurses to prevent aggression in

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emergency departments. For this, nurses’ attitudes are important that was studied through
multisite evaluation. The semi-structured interviews showed that training helped the nurses to
change their attitude towards prevention of aggression in mental health patients and its
sustainability. Pulsford et al., (2013) depicted that although nurses’ perceptions towards
controlling regression is positive, however, these aggression management techniques are highly
complex for meeting the best practices in adult mental health settings. There are also ethical
dilemma associated with the nurses and staffs when to use these interventions. According to
Hallett & Dickens, (2015) de-escalation technique is an important tool for the prevention and
management of aggressive behaviour; however, there is no proper conceptualization and practice
guideline. Through questionnaire survey of 72 participants and data analysis through qualitative
thematic analysis, de-escalation technique provides optimal clinical practice to control
aggression. However, it also requires proper understanding and use of appropriate de-escalation
techniques based on clinical practice guidelines.
The above findings suggested that de-escalation technique is an important tool to control
aggression and violent behavior in patients in adult mental health settings. However, this
technique is based on theoretical concepts and a complex interactive process (Roberton et al.,
2012). It is actually based on learning session and collaborative approach to illustrate and
enhance its effective use in the clinical settings. Although, de-escalation technique is the best
practice, however, little empirical evidence is present for evaluating its effectiveness. Moreover,
the nurses and staffs face dilemmas while using this technique, as they cannot decide how and
when to intervene (Berring et al., 2016). In few mental health settings, seclusion and physical
restraint is also used under practical guidelines and legal system. Therefore, this research might
raise awareness among the nurses and mental health organizations regarding use of safe practice

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of de-escalation that contribute in forming a negotiating culture and sense of community
replacing coercive measures with de-escalation techniques through effective training and
collaborative practices.

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References
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http://journals.lww.com/jbisrir/Abstract/2016/12000/
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