Using coercive and restrictive measures towards agitated mentally ill patients worsens the condition. The primary restrictive measures are forceful restriction and involuntary medication. The use of restrictive techniques in mental health settings is a common and deeply rooted culture in many mental health centers. The practices have proven problematic because it only makes the patients more agitated. The development of the PICO question seeks to compare the effectiveness of these measures with verbal de-escalation.
- P– Aggressive inpatients in mental health units
- I– Verbal de-escalation
- C– Restrictive techniques
- O– Calm patients
The evidence-based question of PICO components is, ‘Is verbal de-escalation on aggressive patients in a mental health unit effective?’
Research-Based Article
Background
The research-based article by Price et al. (2018) provides that de-escalation tactics are suggested first-line interventions in managing aggression in mental health settings. However, the use of higher-risk restrictive techniques persists in these settings internationally. This shows that de-escalation techniques are not employed at an optimum frequency or/and that critical factors limit their use and effect. The study aims to investigate patient perspectives on enablers and barriers to the use and effectiveness of de-escalation techniques for aggression in mental health settings.
Methodology and Level of Evidence
The study used a descriptive qualitative research design using semi-structured interviews and framework analysis. Twenty-six inpatient interviews examining patient, staff, and environmental factors influencing the use and effectiveness of staff de-escalation were conducted in mid-2014. Purposive sampling was deployed while considering the diversity of the inpatient population. The sample was sorted by age, ethnicity, gender, substance misuse, mental health act status, diagnosis, and experience of restrictive practices. Inclusion criteria were English speaking, informed consent, adult acute mental health inpatient admission in the past year, and those involved in incidents of escalating behavior needing staff interventions. Seven out of 14 approached wards participated across four hospitals in three UK mental Health Trusts in North-West England. Twenty-six patients from two mixed, three female, and one PICU wards were interviewed for a duration between 3 and 50 minutes. The evidence is level III because it uses qualitative study with meta-synthesis.
Summary of Data Analysis
The study used three Service User Researchers (SURs), including AS, DB, and AG, for the data analysis. These are current secondary mental health users and trained researchers with experience in using framework methodology. The data analysis employed three stages: indexing, mapping and summarizing, and interpretation. Indexing entailed six days of physical meetings with the lead author and the SURs. The SURs read all transcripts in the author’s absence while noting themes and subthemes according to the staff, environment, and patients. They then gave feedback while avoiding interpretations but clarifying concepts when needed. Mapping, interpretation, and mapping were done remotely between the SURs and authors due to the challenges of meeting over extended periods. Mapping and interpretation entailed refining categories and explaining ideas. When the framework represented a complete account of aspects described in the data, analysis was shared with SURs, who then gave feedback.
Ethical Considerations
The ward nurses distributed the study informed consent packs of information to only eligible patients. Patients interested in the research then returned consent-to-contact forms to the ward nurses. The study personnel did not approach any patient until they submitted their consent-to-contact documents and the nurses assessed their capacity to participate. The participants consented to voluntarily participate, be recorded, and have direct quotes used in the final report. Furthermore, National Health Service (NHS) ethics preferred opinions were received on February 2014.
Quality of Rating
The rating quality is good, with reasonable results and a sufficient sample for the study design. The study used 16 females and eight males, indicating an imbalance in sampling, but the researcher says that the males were enough for the study. The research had complete control and some definite conclusions. However, the study lacked consistent recommendations for the overarching problems or barriers to the effective use of de-escalation techniques. It positively used a scientific literature review to evaluate the study findings. The limitation of strictly including subjects who had de-escalation experiences in the past year reduced the chances of effectively analyzing the enablers of de-escalation.
Results
The result of the study shows that the use of restrictive practices increases barriers to the use and effectiveness of de-escalation techniques. Mental health institutions use restrictive measures to retain power dominance and control, reduce disrespect, reduce social distance, and maintain order in the units. Patients indicated that de-escalation tactics were hard to apply because the staff practiced rule subversion, were disrespectful, had little value for the patients, and wanted to stay in control. Environmental factors influencing de-escalation include inadequate staff to perform de-escalation, a culture of using restrictive measures, an organizational culture of disrespect towards patients, rule-bound culture, and social distance and nursing practices.
The research results inform the EBP practice by answering whether or not the de-escalation measures work in a mental health setting. The findings from the inpatients show that mentally challenged patients are willing to cooperate with de-escalation techniques if used effectively. They also indicate that such measures could only work with a changing staff culture of disrespect and rule subversion. It, however, would be challenging for patients with behavioral disorders to respond to de-escalation tactics. Mental health center wards need to be increased to avail enough nurses to use de-escalation techniques.
Non-Research Article
The article “Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup” by Richmond et al. (2012) provides de-escalation techniques and ways of ensuring their effectiveness. Traditional methods of treating agitated mental health patients, such as involuntary medication and restraints, have been replaced by de-escalation methods that seek noncoercive approaches. The study shows that using traditional methods towards mental patients only worsens their aggression levels. The article outlines a 3-step approach to use in verbal de-escalation. One of the steps entails verbally engaging the patient with a voice they can hear. The second step demands establishing a one-on-one relationship with the patient. Lastly, the patient is verbally de-escalated out of the agitated situation. These approaches resolve the concept of calming the patient by adopting a more collaborative goal of helping them calm themselves down.
The study provides four primary objectives when working with an aggressive patient. One of the objectives is to ensure the safety of the patient, other patients, and the staff. The second objective is to help the agitated patients manage their emotions and distress and regain control of their behavior. Another objective is to avoid restrictive practices unless there is no other option. Finally, the de-escalating staff must avoid coercive interventions that would escalate the patient’s level of agitation. Richmond et al. (2012) note that these objectives may be difficult to pursue, especially in the emergency department, where a doctor has many patients to attend to in a limited time. However, effective use of these strategies requires adequate staff training. The personnel working in these settings must be appropriate by having the ability to effectively multitask and tolerate rapid changes in patient priorities. Furthermore, a facility should have enough trained staff to effectively use verbal de-escalation measures. The conclusion is that verbal de-escalation techniques can decrease agitation and associated violence in emergency and mental health settings.
References
Price, Owen, et al. “Patient Perspectives on Barriers and Enablers to the Use and Effectiveness of De-escalation Techniques for the Management of Violence and Aggression in Mental Health Settings.” Journal of Advanced Nursing, vol. 74, no. 3, Wiley, 2017, pp. 614–25. Web.
Richmond, Janet, et al. “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, vol. 13, no. 1, Western Journal of Emergency Medicine, 2012, pp. 17–25. Web.