Skill List > De-escalation (Mental Health)
Clinical Alert
Early recognition and the use of sound interpersonal skills to defuse a volatile situation is the safest and most effective approach in managing the potential for aggression and violence (Elder et al. 2014). Admission to any unit in the hospital can be very stressful for individuals and their families. Nurses must be aware of the causes of stress to the patient and be able to de-escalate their distress skillfully. A thorough patient assessment should include both a physical and a mental health assessment. Cultural concerns must also be addressed.
Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:

Based on Mosby Nursing Skills
Adapted by: Naomi Sharples BSc MBA PGCE ProfDoc RMNH RMN; Neil Murphy BSc(Hons) MSc RMN
Updated by: Catherine Johnson RGN RMN
Last updated: July 2017


Learning Objective
After reading the skill overview, following up some of the references/web sites and completing the self-test quiz, you should be ready to be assessed in practice in the skill of de-escalation with patients with mental health issues.

Introduction

The successful management of violence and aggression requires a proactive, multifaceted and well-thought-out approach, addressing both individual and organisational matters that promote a caring atmosphere (Duxbury & Jones 2017).
During hospitalisation, patients and families have the potential to display agitated or aggressive behaviours. Mental health patients are especially vulnerable to anxiety and distress. Therefore, nurses and healthcare staff must immediately implement de-escalation strategies to prevent a potential crisis. The nurse and other staff should work with the patient, utilising well-developed verbal and non-verbal interpersonal skills to de-escalate the situation at the beginning of the crisis, empowering patients to use their own coping strategies. The nurse must validate the patient’s emotions and communicate with the patient and family in a calm, respectful, and professional manner throughout.

Where patients are in contact with their family, and with the consent of the patient, it is good practice to involve the family in all areas of evaluation and treatment.

Ask the patient and family what has been helpful in the past when the patient was upset and agitated.

Educate the patient and family regarding the reason for admission to hospital and what to expect during their stay.

If possible, let the family remain with the patient to provide comfort and support.

Make sure the family is part of the treatment from admission to discharge.

 

Cultural considerations

  • The nurse should always be aware that differences in patients’ values and beliefs may affect their responses to the nurse and the nurse should respond accordingly.
  • The nurse should always be aware that differences in language may interfere with the nurse’s or patient’s understanding and the nurse should seek ways to increase understanding immediately.
  • The nurse should maintain awareness of their own verbal and nonverbal interactions with the patient.
  • The nurse should be aware of the patient’s nonverbal cues, including eye contact and facial expressions.
  • The nurse must always talk with the patient in a calm, professional manner while displaying compassion, empathy, and reassurance.

De-escalation with young people

  • Adolescents must believe that adults acknowledge their concerns.
  • Adults should avoid lecturing adolescents.
  • Establishing a relationship that is caring and collaborative is vital.
  • Involving the family in the adolescent’s treatment is imperative.

De-escalation with older people

  • Older adults must be shown compassion and respect.
  • Use age-appropriate language throughout the de-escalation event.
  • Acknowledge and respect the older patient’s life experience and knowledge.
  • Encourage the patient to be as independent as possible.
  • Encourage family members to be participants in the care process.

Preparation and safety

 

Box 1   SOME PREDICTIVE FACTORS OF VIOLENT OUTCOMES*
Adapted from Varcarolis, E (2016) Essentials of Psychiatric Mental Health Nursing, 3rd edn. A Communication Approach to Evidence-Based Care. Elsevier, St Louis

  1. Signs & Symptoms that sometimes, but not always, precede violence:

    1. Angry irritable behaviour
    2. Hyperactivity…most important predictor of imminent violence (e.g. pacing, restlessness, slamming doors)
    3. Increasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self (patient may have shortness of breath, sweating and rapid pulse rate)
    4. Verbal abuse, profanity, argumentativeness
    5. Loud voice, change of pitch, or very soft voice forcing others to strain to hear
    6. Intense eye contact or avoidance of eye contact

  2. Recent acts of violence, including violence against property
  3. Stoney silence
  4. Suspiciousness or paranoid thinking
  5. Alcohol or drug intoxication
  6. Possession of a weapon or object that may be used as a weapon (e.g. fork, knife, rock)
  7. Milieu characteristics conducive to violence:
    1. Loud
    2. Overcrowded
    3. Staff inexperience
    4. Provocative or controlling staff
    5. Poor limit setting
    6. Staff inconsistency (e.g. arbitrary revocation of privileges)

* Violent outcomes include screaming, cursing, yelling, spitting, throwing objects, hitting and punching self or others



  • Consider your competence and whether you are safe to provide this care. If in doubt, you should immediately summon an experienced colleague to help.
  • Avoid confrontation and stand-offs
  • Assess the patient’s risk of suicidal behaviour. Where risk is identified this assessment should be performed formally at least every shift and more often if the level of suicide risk increases.
  • Assess the patient’s mood at each shift, particularly with regard to agitation, anxiety, or feelings of suspicion.
  • Assess the patient’s nonverbal and verbal cues for signs of agitation, aggression, or changes in mood.
  • Assess if the patient has pain or physical concerns each shift.
  • Assess the patient’s ability to participate in therapy.
  • Assess the patient’s understanding of the reason for admission and the treatment they are receiving.
  • Assess the patient’s compliance to the prescribed medication and any potential side-effects they may be experiencing.
  • Assess the patient’s reaction to de-escalation attempts. Ask yourself, ‘Is the de-escalation technique helping, or is the patient becoming more agitated?’
  • Teach the patient to take a ‘time out’ as needed.

Procedure

  1. Always talk to the patient in a kind and non-judgemental manner. Be aware of non-verbal communication, tone of voice, facial expression, and body language.
    Rationale Patients are very sensitive to non-verbal communication and easily perceive rejection or disapproval.
     Maintain normal eye contact, avoiding someone's gaze can seem dismissive and staring can be perceived as threatening (Sookoo 2013).
  2. Be aware of personal space to protect both the patient and yourself.
    Rationale When talking with patients, you need to be aware of your physical presence in relation to the patient’s physical space. If you are too close to the patient, they may feel threatened (Cihlar 2014).
  3. Ask the patient what techniques for de-escalation have worked in the past.
    Rationale Reminding the patient of past successes is always important; it gives the patient and nurse a place to begin the de-escalation process and helps the patient feel more in control. NICE guidelines (2015) promote service user involvement in decision making and ascertain if they have made advanced decisions or statements regarding the use of restrictive interventions when required.
  4. Intervene at the patient’s lowest level of agitation.
    Rationale As the patient becomes more agitated, they are less able to de-escalate their behaviour. Verbal intervention can be successful during the escalation stage when the patient is beginning to become agitated but much less so during the crisis stage when the patient is out of control. ​Prevention is the key to managing aggressive or violent behaviour (Townsend 2015).  
  5. Maintain empathy so that the patient knows their concern is being heard.
    Rationale Patients are more responsive to interventions if they believe that their concern is being heard and addressed in a timely manner. By communicating to a patient that they are understood and that their feeling are respected is key to de-escalation, empathy is the basic value that drives all helping behaviour (Egan 2013).
  6. Encourage the patient to move to a quiet place.
    Rationale As the patient’s behaviour escalates, focusing becomes more difficult. Environmental noise can increase the patient’s agitation (Sookoo 2013).
  7. Provide positive feedback.
    Rationale
    Acknowledging how well the patient uses strategies to de-escalate is important and encouraging. Self-awareness and the nurse’s ability to connect interpersonally with the agitated patient is suggested to have a pivotal role in de-escalation (Price et al. 2015).
  8. Ensure that other staff are available for support, but not a ‘show of force’; this will maintain safety for the patient and staff.
    Rationale
    Having sufficient staff to maintain safety for both the patient and staff is always important. A ‘show of force’ may increase the patient’s agitation or fear of being hurt or both, which could cause the patient to escalate into a fight-or-flight response (Cihlar 2014).
  9. Document all strategies and outcomes of interventions in the patient’s record.
    Rationale – Accurate and thorough documentation is essential and allows for consistent care and communication. It is important to see whether medications are effective in improving the psychiatric symptoms and that any side effects are closely monitored. Documenting affect, mood, thought patterns, behaviours, and sleep are very important when caring for patients with psychiatric illness. Likewise, the careful documentation of each element of the nursing care plan (its implementation and re-evaluation) will assist and ensure the most appropriate interventions are used to progress towards a complete recovery.

Ongoing care, monitoring and support

  • Reassess the patient’s level of anxiety or agitation after staff intervention.
  • Reassess the patient’s ability to use coping strategies.
  • Reassess the patient’s ability to participate in therapy.
  • Reassess the patient’s suicide level where suicide is a risk.
  • Intervene and support patient in the outcome of these assessments if appropriate

Documentation and reporting

Document the issues and intervention in the patient’s nursing notes and include:

  • The patient’s antecedent behaviours, behaviours during event and post de-escalation.
  • Staff interventions and patient response to interventions. ‘The nurse should document all strategies in order to communicate with the team what works for this patient and what does not work in the de-escalation process.  This information can be used to facilitate the patient’s coping skills and allow the staff to be consistent and effective in their approach (Varcolis 2016).
  • Plan of care.
  • Medications and patient response. Any side-effects to medication.
  • Patient and family education.
  • Safety concerns, such as threat to self or others.
  • Risk of absconding.
  • Follow hospital policy in regard to completing an incident form. These tend to be applicable in incidents where there is physical injury to any individual or near physical injury, distressing outbursts of aggression, or damage to property.

Special considerations

A clear management approach to dealing with violent situations and individuals includes staff well versed in unit protocols and well trained in de-escalation techniques (Varcolis 2016).

Inexperienced staff, provocation by staff, poor milieu management, understaffing, close physical encounters, inconsistent limit setting and a norm of violence may all negatively affect the inpatient environment (Knutzen et al. 2011). 

 

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