Background

Prevalence of aggression in the mental health setting

Aggression is a known major workplace hazard in the healthcare setting. An aggressive episode refers to both physical and verbal abuse, threatening behaviors, assaults and any other behaviors directed at an individual that compromises his or her safety.1 Aggressive episodes are especially common in the psychiatric setting as compared to other clinical fields. Studies have shown that nurses are susceptible to patients' aggression at their workplace.2 Between 68% and 96% of nurses have experienced at least one form of verbal aggression.1 Each year, 25% of mental health nurses in public sector hospitals are subjected to a violent incident resulting in injury, a rate three times higher than that of other professions. Involuntary admissions, enclosed environments, co-morbidities, substance use, history of aggression and having mental disorders such as schizophrenia and bipolar disorder place an individual at a higher risk of being aggressive.3 The widespread prevalence of aggression in the mental health setting illustrates the need for de-escalation approaches to ensure the safety of healthcare professionals and minimize workplace hazards in the psychiatric setting.

Effect of aggression on nurses and patients

Both the nurse and patient are adversely affected following any aggressive episode if it is not managed effectively. Aggression toward nursing staff results in anxiety, burnout and post-traumatic stress, which adversely affect their mental wellbeing. It can also result in a decrease in quality of care, longer rates of absenteeism and deterioration in the work climate. Simultaneously, implications for the patient involved in the aggression include increased length of hospitalization, impaired nurse-patient relationship and interruption in the recovery process. Within the ward, other patients' morale gets affected, and ward routines become easily disrupted. At the organizational level, aggressive episodes result in utilization of more manpower for additional supervision, compensation for injury, official enquiries and litigation costs.1 The implications of aggressive episodes are debilitating and extend beyond the individual to the healthcare organization.

Importance of de-escalation

The high prevalence in aggression1,3,4 as well as the adverse consequences3,5 that result from aggression highlights the importance of effective management of aggressive patients. De-escalation is one such method and has been identified as the first line of management in addressing aggressive patients. It involves intervening in a potentially violent and aggressive situation through building rapport with the aggressor, limiting the setting and empathetic communication both verbally and physically in a respectful and non-confrontational manner.1

Current knowledge and gaps

Various studies have shown the effectiveness of de-escalation programs in reducing aggression among patients and preventing violent episodes in the psychiatric setting.1,5,6-8 Current programs designed to teach nurses the necessary skills to manage aggressive patients can influence the incidence and outcome of aggression. Evaluation of the Nonviolent Crisis Intervention course and the Handle with Care program developed in the USA has shown positive outcomes of nurses' skills in managing aggressive patients.7 However, it is reported that there are still many of the current aggression minimization programs that remain haphazard and unstructured. This results in confusion among nurses as to precisely what aspects constitute an effective de-escalation approach.

Furthermore, while these training programs have been designed to address aggression in the psychiatric setting, the applicability of these interventions has yet to be determined.1 In addition, emphasis is still placed on skills relating to physical restraints.9 Physical restraints refer to the use of cloth or belts to restrict a patient's movement, whereas chemical restraints refer to the use of drugs to bring about the same outcome. Many studies have shown the adverse impact of physical restraints on patients. It is reported that physical restraints do little to help calm a patient down and instead can potentially increase the aggression further.10 Yet, it is reported that physical restraints continue to be a common practice in nursing management of aggressive patients.6 This recurring phenomenon further highlights the necessity to steer away from coercive methods of managing aggressive patients and to maximize effective de-escalation approaches.

Studies that have established the effectiveness of de-escalation interventions in reducing aggressive episodes have highlighted several de-escalation strategies that have been utilized. However, there has been no systematic review in the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library and PROSPERO that has synthesized available evidence across studies in identifying the key strategies that constitute an effective de-escalation approach. As a result, the techniques and strategies required to effectively de-escalate aggression remain unclear to the nurse confronting the aggressor.

How this review addresses gaps

The present knowledge gaps found in the literature have prompted the need for more rigorous research into the field of de-escalation in the psychiatric setting. Given the close association between aggression and patients with mental illness, it is important for nurses in psychiatric settings to be equipped with adequate, relevant and applicable knowledge in the effective de-escalation of aggression in patients with mental illness. This review addresses knowledge gaps and contributes to the growing literature on the understanding of the key components required to provide effective de-escalation. It also further emphasizes the importance of de-escalation in the management of aggressive patients and the collective efforts across mental health agencies to steer away from coercive practices such as usage of restraints. Findings from this review can provide evidence-based knowledge on the key strategies for effective de-escalation that will be useful for nurses to apply in the psychiatric setting.

Inclusion criteria

Types of participants

The current review will consider studies that include adults aged 18-65 years with at least one form of mental illness in in-patient psychiatric settings. In-patient psychiatric settings include acute and long-stay settings, residential care facilities, nursing homes, half-way houses and day centers providing services for people with mental illnesses. Studies of populations in the non-psychiatric setting, for example, paramedics attending to people with mental health conditions in the community, will be excluded.

Types of intervention(s)

For this systematic review, the term de-escalation refers to structured interventions or approaches directed at reducing the intensity of anger and aggressive events. This review will consider studies that evaluate the utilization of de-escalation techniques and strategies (methods of engagement with patients during de-escalation) in the psychiatric setting and used or delivered by nurses. These can involve general strategies (applied to all patients in psychiatric setting usually by policy) such as speaking in a calm tone or specific strategies (applied to specific patients who are at increased risk of becoming aggressive) such as setting limits with patients. Different de-escalation strategies will be compared to each other.

From these studies, where de-escalation is utilized, it is expected that components of de-escalation, for example, the elements or factors that are involved in de-escalation such as staff skills, environmental factors or the timing to intervene, will be revealed.

Outcomes

The outcomes of interest include incidence of aggressive behavior and severity of aggressive behaviors. Incidence of aggressive behavior can be measured by rates or frequency of acts of violence, challenging staff, hostility or assault incidents. Severity of aggressive behavior can be evident through the change in the use of seclusion and restraint.

Types of studies

The review will primarily consider randomized controlled trials (RCTs). In the absence of RCTs, other quantitative research designs such as quasi-RCTs, cohort studies, case-control studies, longitudinal studies, descriptive studies and correlational design studies will be considered for inclusion.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published from 1999 to present will be considered for inclusion in this review, as in 1999 the Health Care Financing Administration first published an interim rule that patients have the right to be free from seclusion and restraint. It is expected that the development of de-escalation approaches came to light in the literature following 1999.

The databases to be searched include:

PsycINFO

CINAHL

PubMed

Cochrane Central Register of Controlled Trials.

The search for unpublished studies will include

ProQuest Dissertations and Theses Database

Google Scholar.

Initial keywords to be used will be: de-escalation, aggression minimization, strategies, components, techniques, violent, aggression, disturbed, psychiatric patients, psychiatric setting, mental illness and mental health.

Keywords and related search terms relating to the PICO elements (that aid the identification of the Population, the Intervention being investigated and its Comparator and ends with a specific Outcome(s) of interest to the review) that will be used are shown in Appendix I.

Assessment of methodological quality

Studies selected will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the JBI System for the Unified Management, Assessment and Review of Information (JBI-SUMARI) (Appendix II). The study type will be determined by the primary reviewer. Both reviewers will then independently consider if the retrieved study fulfils the criteria stated in JBI-SUMARI based on the type of study. Where reviewers differ in their opinion on whether the retrieved study fulfils the criteria stated in JBI-SUMARI, these disagreements between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix III). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Disagreements in the extracted information that may arise between the reviewers will be resolved through discussion.

Data synthesis

Where possible, quantitative research study results will be pooled using JBI-MAStARI. All results will be doubly entered. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard chi-square and also explored using subgroup analysis based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form.

Acknowledgements

The reviewers acknowledge Institute of Mental Health, Singapore, for its support in this review.

Appendix I: Search strategy

Keywords and related terms used to search literature in the databases

Appendix II: Appraisal instruments

Appendix III: Data extraction instruments

References