Evidence
Alert

Strong patient-staff relationships are key to reducing conflict in high-security psychiatric hospitals

Aggression and conflict are common in high-security psychiatric hospitals. High-risk interventions – including restraint, seclusion and tranquilisers – are sometimes used to manage violence. De-escalation is an alternative approach which may help staff respond to aggression without using these restrictive interventions. It trains staff to recognise and understand the early signs of agitation and irritation. It guides them to respond in a calm way to negotiate a solution with patients, distract and relax them.

But there is no model of best practice in de-escalation and there has been little research into its use. A new study marks the first time that researchers have asked patients, carers, and staff about their experiences of de-escalation in high security psychiatric hospitals.

Researchers found that the fears and anxieties of both patients and staff are a key barrier to successful use of de-escalation. They found that stronger therapeutic relationships between patients and staff could make a difference.

The findings are being used to develop a de-escalation training package for mental health professionals.

What’s the issue?

Physical conflict is common in mental health settings. This is especially true of high security psychiatric hospitals that confine and treat people who are considered to pose 'a grave and immediate danger to the public'. People receiving care in these settings are detained involuntarily under the Mental Health Act.

Most staff (up to 82%) and almost half the patients (up to 46%) in these settings have been involved in violent or aggressive incidents. Trauma is a key driver of illness and aggressive behaviour in high-secure patients. Almost all patients (95-100%) have experienced trauma, often from many different types of abuse.

Staff often manage aggressive behaviour with high-risk interventions that include restraint, seclusion, and the use of tranquilisers. Where physical restraint is used, it can cause injury or even death.

Staff are also trained in de-escalation, using verbal and non-verbal techniques. This is not just as an immediate response to anger or frustration among patients. It involves the development of an environment within the hospital which promotes de-escalation.

However, current training is not evidence-based and there has been no prior investigation into its use in high-secure hospitals.

What’s new?

Researchers gathered the perspectives of staff, patients, and carers. They ran three focus groups about de-escalation with 25 members of staff in a high-secure, male-only hospital in England. Nurses, healthcare facilitators, managers, occupational therapists, psychologists, psychiatrists, social workers and specialists in the prevention and management of violence and aggression took part. They also interviewed eight patients and four carers.

Fear among both patients and staff was an overarching theme and had a negative impact on effective de-escalation. Examples of specific barriers included:

  • the strict rules and lack of patient privacy inevitable in high-secure settings
  • a lack of resources and staff time
  • staff attitudes which are focussed on the confinement of patients rather than on their treatment
  • insufficient understanding of psychiatric symptoms and causes
  • staff trauma as a consequence of working in high-secure environments.

Participants said that de-escalation could be supported by stronger staff-patient relationships based on trust, fairness, and consistency. Staff needed to demonstrate empathy, respect, genuine concern and appreciation of the patient’s point of view. Specific measure that would help included:

  • a personalised approach that relates to patients’ diagnoses and addresses past trauma
  • greater opportunity for collaboration and discussion amongst staff, including debriefs
  • greater awareness and sensitivity to early indicators of aggression.

Why is this important?

This study identifies that the high rates of violence in high-security psychiatric hospitals creates fear in patients and staff. The findings signpost ways for mental health staff to use de-escalation techniques to address and manage these fears.

Most of these findings are relevant to other settings and could help improve de-escalation training across the mental health sector.

What’s next?

The team have combined their findings with research from different mental health settings to develop a de-escalation training package. They have trialled the training package in a range of wards, from the least secure through to high-secure forensic wards housing offenders with severe mental illness.

The study has been paused during the pandemic and will continue when feasible. Before this, the researchers say that the training had been well-received and evaluated.

If the training package proves feasible as a way of improving de-escalation practice, the researchers will extend the study into a full-scale randomised controlled trial.

You may be interested to read

The full paper: Goodman H, and others. Barriers and facilitators to the effective de-escalation of conflict behaviours in forensic high-secure settings: a qualitative study. Int J Ment Health Syst. 2020;14:59

Research exploring patients’ perspectives on de-escalation: Price O, and others. 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. J Adv Nurs. 2018;74:614-625

Review of outcomes from de-escalation training: Price O, and others. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. Br J Psychiatry. 2015;206:447-455

Research exploring staff perspectives on de-escalation: Price O, and others. The support-control continuum: An investigation of staff perspectives on factors influencing the success or failure of de-escalation techniques for the management of violence and aggression in mental health settings. Int J Nurs Stud. 2018;77:197-206

Funding

This research was funded by the NIHR Health Technology Assessment Programme.

Commentaries

Study author

Our results highlight how poorly resourced mental health services are. They show the negative consequences of that, both on staff and on patients.

Fear amongst patients and staff – often underpinned by past trauma – is a driver to the over-use of restrictive practices and serves as a barrier to effective de-escalation. Without a therapeutic staff-patient relationship, de-escalation attempts are unlikely to succeed.

Research about de-escalation is biased in favour of psychiatric intensive care and crisis settings. Many of our findings are relevant and transferable to all inpatient mental health settings, where incidents of violence and aggression coupled with restrictive practices are commonplace.

Helena Goodman, Research Assistant, University of Surrey

Patient experience

When you see a patient who looks distressed, you should try and calm them down before it gets worse … even if it feels hard to communicate with them at the time because they are speaking in a certain way, just approach them slowly, don’t rush, don’t be too strong, be soft and settled and try and understand how he is feeling.

Patient interviewed as part of the study

Clinician

Understanding the differences and similarities between patient and staff views is useful. The views of patients and carers in high-secure settings do not appear to be well-represented within training or in practice.

These findings should be shared with patients and carers because they are not typically involved in the development or communication of de-escalation processes. Upon admission, patients could be advised on how staff might assist with de-escalation, and also told about elements of restrictive practice. As part of an individualised process, their views could be further sought, and processes amended as necessary.

These findings could inform further work on de-escalation training and help standardise it nationally.

Leah Riley, Speciality Trainee in Forensic and General Adult Psychiatry, Midlands Partnership NHS Foundation Trust

Conflicts of Interest

None declared.