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Violent And Aggressive Behaviors Are Common

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Violent And Aggressive Behaviors Are Common

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What Strategies Do Nurses In An Adult Mental Health Inpatient Unit Use To Deescalate Aggression Displayed By Patients? 


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 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 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 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 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.
Berring, L. L., Hummelvoll, J. K., Pedersen, L., & Buus, N. (2016). A co-operative inquiry into generating, describing, and transforming knowledge about de-escalation practices in mental health settings. Issues in mental health nursing, 37(7), 451-463.
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.
Dickens, G., Piccirillo, M., & Alderman, N. (2013). Causes and management of aggression and violence in a forensic mental health service: perspectives of nurses and patients. International journal of mental health nursing, 22(6), 532-544.
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.
Hallett, N., & Dickens, G. L. (2015). De?escalation: A survey of clinical staff in a secure mental health inpatient service. International journal of mental health nursing, 24(4), 324-333.
Price, O., & Baker, J. (2012). Key components of de?escalation techniques: A thematic synthesis. International journal of mental health nursing, 21(4), 310-319.
Pulsford, D., Crumpton, A., Baker, A., Wilkins, T., Wright, K., & Duxbury, J. (2013). Aggression in a high secure hospital: staff and patient attitudes. Journal of Psychiatric and Mental Health Nursing, 20(4), 296-304.
Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman Jr, G. H., Zeller, S. L., Wilson, M. P., … & Ng, A. T. (2012). Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, 13(1), 17.
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), 94-101.
Shah, L., Annamalai, J., Aye, S. N., Xie, H., so Pavadai, S., Ng, W., … & Manickam, M. (2016). Key components and strategies utilized by nurses for de-escalation of aggression in psychiatric in-patients: a systematic review protocol. JBI database of systematic reviews and implementation reports, 14(12), 109-118.
Spencer, S., & Johnson, P. (2016). De?escalation techniques for managing aggression. The Cochrane Library.
Steinert, T., Noorthoorn, E. O., & Mulder, C. L. (2014). The use of coercive interventions in mental health care in Germany and the Netherlands. A comparison of the developments in two neighboring countries. Frontiers in public health, 2.

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