Issues in Mental Health Nursing

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A Quality Improvement Project Using Verbal

De-Escalation to Reduce Seclusion and Patient
Aggression in an Inpatient Psychiatric Unit

Judy Haefner , Ifeoma Dunn & Marilyn McFarland

To cite this article: Judy Haefner , Ifeoma Dunn & Marilyn McFarland (2020): A Quality
Improvement Project Using Verbal De-Escalation to Reduce Seclusion and Patient
Aggression in an Inpatient Psychiatric Unit, Issues in Mental Health Nursing, DOI:
10.1080/01612840.2020.1789784

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Published online: 04 Aug 2020.

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ISSUES IN MENTAL HEALTH NURSING
https://doi.org/10.1080/01612840.2020.1789784

A Quality Improvement Project Using Verbal De-Escalation to Reduce Seclusion

and Patient Aggression in an Inpatient Psychiatric Unit
Judy Haefner, RN, DNP PMHCNS-BC, PMHNP-BCa , Ifeoma Dunn, BSN, DNP, RN, PMHNP-BCb, and
Marilyn McFarland, PhD, RN, FNP-BC, CTN-Aa
a
School of Nursing, University of Michigan Flint, Flint, Michigan, USA; bTuerk House, Baltimore, Maryland, USA

ABSTRACT
The use of seclusion is controversial and has been deemed an encroachment on human rights
and dignity which can cause psychological trauma and physical injury to patients in the psychi-
atric setting. This quality improvement project used a quasi-experimental design to implement the
TeamSTEPPS educational program, an evidenced-based program to inform nurses about verbal
de-escalation to reduce patient aggressive behavior that can lead to patient seclusion. The tar-
geted patient population included all patients admitted 2 months prior to initiation of Team
STEPPS (n ¼ 388) and 2 months following completion of the education modules (n ¼ 342). After
the implementation of the educational program there was a statistically significant difference in
the rate of charting aggressive behavior (p ¼ 0.024). The pre rate was 17.3%, and the post rate
was 11.4%. While there was not a statistically significant difference in the rate of seclusion events,
(p ¼ 0.349) there was a clinically significant reduction. The pre rate was 5.9%, and the post rate
was 4.4%. The results of this study support the importance of educating psychiatric nurses on ver-
bal-de-escalation to reduce patients placed in seclusion and decrease patients’ aggressive behavior
in the psychiatric settings.

Introduction Despite guidelines for promoting alternative interventions,

In a hospital setting, aggressive patient behavior can be
actual physical violence or verbal threats. Agitated behavior
can be an acute emergency which requires immediate inter-
vention to control behaviors and decrease the risk of injury
to the patient, staff, or other patients (Allen. et al., 2005).
Nurses tend to be the primary staff members tasked with
intervening with agitated patients. As a result, both patients
and staff could experience physical and psychological harm
(Carlson & Hall, 2014). Psychiatric nurses have three times
the odds of physical assault from patients than non-
psychiatric nurses (Edward et al., 2015). An international
review of violence toward nurses found that 55% of nurses
in psychiatric settings experienced physical assault and that
psychiatric settings had a higher rate of violence than any
other health care setting (Spector et al. 2014).
One of the interventions often used with agitated patients
is seclusion (Knox & Holloman, 2012). Seclusion is viewed
as a type of restraint which involves confining a patient to a
locked room or an area restricting or forbidding free move-
ments (Knox & Holloman, 2012). Seclusion, as an interven-
tion to manage acutely disruptive and violent behaviors
among patients in the psychiatric context, is a highly con-
tentious issue. It is perceived by some as an infringement of
basic human rights and dignity, while others believe it is an
unavoidable intervention to maintain safety and control.
data from the U. S. and Europe show that 10 to 30 percent
of adolescents, adults, and older adult patients in psychiatric
units still receive seclusion as the primary intervention for
agitated behavior (Agency of Healthcare Research and
Quality [AHRQ], 2015).
As early as 2003, the Substance Abuse and Mental Health
Services Administration (SAMHSA 2003) encouraged chang-
ing the culture from viewing seclusion and restraint as posi-
tive and therapeutic to one that recognizes seclusion and
restraints as violent acts that traumatize patients and others
witnessing these acts. There is no evidence seclusion is an
effective treatment for agitated behavior, and patients who
are being overpowered feel rage, terror, and stripped of their
humanity (Carlson & Hall, 2014). This intervention pro-
motes feelings of helplessness because it is an intervention
done to the person, not with the person (SAMHSA, 2009).
Seclusion does not support the fundamental rights of
patients and does not establish psychological safety for the
patient (SAMHSA, 2011).
For over 30 years the Center for Medicaid and Medicare
Services (CMS), and the Joint Commission have advocated
that seclusion of a person should only be applied in situa-
tions where the behavior affects their physical safety, safety
of the staff, and or safety of other patients through the use
of restrictive measures and should only be used as a last
resort. The CMS and Joint Commission use seclusion rates

CONTACT Judy Haefner jhaefner@umich.edu School of Nursing, University of Michigan Flint, 2180 William S. White Building, Flint, MI 48502.
ß 2020 Taylor & Francis Group, LLC
2 J. HAEFNER ET AL.
as one of the measures to evaluate the quality of care pro-
vided by a psychiatric hospital (AHRQ, 2015). Livingston
et al. (2010) reported most training in the prevention and
management of aggression and violence now recommends
de-escalation techniques as the main intervention for vio-
lence prevention in healthcare settings.
The purpose of this project was to introduce verbal de-
escalation through the TeamSTEPPSTM education modules
to increase knowledge and awareness of these techniques to
reduce patient aggression and seclusion with the psychiatric
nursing staff, thereby improving the quality of care and pro-
moting workplace safety. An objective was to see a change
in the nurses’ behavior away from the primary use of seclu-
sion for managing aggressive patients to verbal de-escalation
as the first intervention. A second objective was to encour-
age patients to regain emotional control and decrease their
aggressive behavior through verbal de-escalation.
Team strategies and tools to enhance performance and
patient safety/TeamSTEPPSTM
TeamSTEPPSTM is an evidenced-based educational tool for
improving techniques for de-escalation of patient aggression
that can lead to a reduction in patients being placed in seclu-
sion. TeamSTEPPSTM was developed by the Department of
Defense (DoD) and the Agency for Healthcare Research and
Quality to integrate teamwork in the delivery of health care
designed to improve patient safety in high risk environments.
The program is public domain available from Agency for
Healthcare Research and Quality (https://www.ahrq.gov/team-
stepps/index.html). TeamSTEPPSTM has an established record
with significant objective data from U.S. studies to support its
efficacy for teamwork that is necessary to engage patients in
verbal de-escalation (AHRQ, 2015).
TeamSTEPPSTM has been successfully incorporated in
many practice environments such as a Level I Trauma Center
(Peters et al., 2018), perioperative care units (Shaw, 2015),
operating rooms (Weld et al., 2016), medical-surgical inpatient
units (Parker et al., 2019), and mental health inpatient units
(Mahoney et al., 2012; Stead et al., 2009).
Recognizing the importance of teamwork and communi-
cation for the safety of patients, Stead et al. (2009) intro-
duced TeamSTEPPSTM in a mental health facility. Seclusion
rates were chosen as an indicator of clinical improvement.
Stead revealed that seclusion rates before the implementa-
tion of TeamSTEPPSTM were significantly greater than after
implementation of TeamSTEPPSTM. The clinical staff
increased team communication to better understand the
patient’s behavior and resolve patient aggression.
Communication included verbal and nonverbal communica-
tion as well as listening that connoted empathetic under-
standing. This team communication improved techniques
for verbal de-escalation such as staff knowledge, skills and
attitudes that resulted in a culture for patient safety.
TeamSTEPPSTM demonstrated a significant improvement in
two dimensions of patient safety—frequency of event report-
ing and organizational learning resulting in a 6.8% increase
in the total staff knowledge, skills and attitudes score (Stead
et al., 2009).
Use of seclusion
According to the World Health Organization (WHO, 2017)
Quality Rights training (pilot version 2017), seclusion could
be broadly defined as isolating an individual away from
others by physically restricting their ability to leave a defined
space. It may be by locking someone in a defined space (e.g.
room, cell) or containing them in a specific area by locking
access doors or by telling them they are not allowed to
move from a defined space and threatening or implying
negative consequences if they do.
Knox and Holloman (2012) reported that most staff view
seclusion as the safest and most effective intervention for
the agitated patient but are relatively unaware that these
interventions are also associated with an increased incidence
of injury for both the patients and the staff. These injuries
can be both physical and psychological. Using restraint and
seclusion is emotionally injurious to both staff and patients
(Carlson & Hall, 2014; Jovanovic & Johnsen, 2006) leading
to a sense of uneasiness, culpability and fear in the nursing
staff (Moran et al., 2009). The rate of injury to staff when
placing a patient in seclusion or restraint, is greater than
workers in other high-risk industries (SAMHSA, 2011).
Patients viewed restraint and seclusion as punishment mini-
mizing their autonomy (Keski-Valkama et al., 2010).
A study by Knox and Holloman (2012) reported 44% of
people requiring restraint were diagnosed as psychotic while
another study by Miodownik (2019) reported 53% of
patients secluded had a schizophrenia diagnosis. The
National Association of State Mental Health Program
Directors (NASMHPD recommends that for adult individu-
als with a specific psychiatric disorder (including substance
abuse disorders who are showing active aggression) inter-
vention strategies such as verbal de-escalation with support-
ive language, changing the milieu, or changing staffing, can
reduce the agitation or prevent aggressive behavior
(Huckshorn, 2016). The Six Core Strategies to prevent and
or reduce aggressive behavior by the NASMHPD included
providing a calm environment, increasing staff–patient ratio,
and staff training programs that are specific to prevention of
using restraints or seclusion. NASMHPD emphasized using
data driven risk assessment decisions at the organization
leadership level to develop training the workforce to apply
preventive tools to minimize seclusion and to debrief staff if
there is patient escalation of aggression (Huckshorn, 2016).
Effectiveness of verbal de-escalation in reducing
aggressive behavior
A best practice statement from the American Association
for Emergency Psychiatry is traditional use of restraints
and involuntary medication should be replaced with a non-
coercive approach to de-escalate the agitated state by
verbally engaging the patient that leads to a collaborative
patient-staff relationship (Richmond et al., 2012). Richmond

and colleagues recommend four objectives when working
with an agitated patient: (a) ensure safety of patient, staff
and all others in the area, (b) help the patient regain control
of behavior, emotions and distress, (c) avoid restraints when
at all possible, and (d) avoid coercive interventions that will
probably escalate the agitation. Richmond and colleagues
(2012) emphasized that patients spiraling into agitation can
be calmed with a verbal de-escalation intervention that can
empower the patient to stay in control while building trust
with caregivers. These techniques may encourage patients in
the future to seek help earlier, or avoid subsequent episodes
of agitation altogether
Gaynes et al. (2017) provided a review of evidence on
preventing and de-escalating aggressive behavior among
adult psychiatric patients. They concluded two preventive
interventions were most beneficial: (a) a risk assessment for
all individuals on the inpatient psychiatric unit will result in
overall less aggressive behavior and less use of seclusion and
restraint and (b) a multimodal intervention based on the Six
Core Strategies of NASMHPD (Huckshorn, 2016) will
decrease use of restraints and seclusions.
Effectiveness of verbal de-escalation in
reducing seclusion
Verbal de-escalation for engagement with a patient encourages
the patient to become an active partner in the evaluation and
treatment process. It is a non-coercive intervention which pro-
motes care, love and a healing environment. Hallet and
Dickens (2017) stated that verbal de-escalation should actively
include patient participation in self evaluation and treatment of
aggressive behavior. They concluded that de-escalating techni-
ques are beneficial for reducing coercive interventions for
aggressive behavior such as seclusion. The de-escalating techni-
ques should help the patients manage their emotions and dis-
tress that are often the triggers for agitation. According to
Richmond and colleagues (2012) the skill of verbal de-
escalation is a critical requirement for healthcare providers
who handle potentially aggressive patients. During verbal de-
escalation the staff should face the patient and project empathy
and a positive attitude, understanding that the actions of the
patients are not intentional but rather caused by symptomatol-
ogy of the mental health condition he/she is experiencing.
Kuivalainen et al. (2017) reported de-escalation techniques
are more effective to calm agitated patients than using seclu-
sion. In a 4-year cross-sectional study, 549 patients were div-
ided into seclusion, restraints, or de-escalation groups to
evaluate which intervention most often reduced the aggres-
siveness of the patients. Interventions based on de-escalation
most often used by the staff were one-to-one discussion, ver-
bal redirection, and escorting the patient to a meaningful
activity or to an area with less stimulating activity.
Gaynes et al. (2017) in a review of evidence of 17 studies
concluded staff trained in appropriate risk assessment and
interventions based on the Six Core Strategies developed by
NASMHPD (Huckshorn, 2016) decreased aggressive behav-
ior and lowered use of restraints and seclusion. A study by
Ryan and colleagues (2007) showed that when de-escalation,
ISSUES IN MENTAL HEALTH NURSING 3
restraints, seclusion were introduced in a K-12 special day
school, de-escalation reduced aggression by 40% while
restraints and seclusion reduced aggression by 20%.
Effects of seclusion on psychiatry patients
The overuse of seclusion in mental healthcare is a threat to
the quality of care, as well as to patients’ human rights.
Seclusion increases the risk of accidents, which, in some
cases, have resulted in the death of the patient (Gabriel
et al., 2017). Negative psychological effects such as frustra-
tion, fear, loss of dignity, anger, aggression, and decline in
social interaction have also been identified. Seclusion is con-
sidered a violation of the autonomy and freedom of the
individual and their right to take risks (Gabriel et al., 2017).
A review of literature on the effects of seclusion and
restraint in adult psychiatry looked at 35 articles out of a
possible 438 studies (Chieze et al., 2019).
They identified post-traumatic stress disorder occurring
25%47% following a patient seclusion or restraint inter-
vention. Patients reported feeling that they were being pun-
ished by isolation and a perception of helplessness.
Theoretical framework
Jean Watson’s theory of human care formed the framework
for this quality improvement project. Watson’s theory
endorses caring and empathy and encourages a more
emotional and open approach for the care of patients in
healthcare practices. The theory was used to guide a mind-
body-soul engagement with one another. The theory views a
human being as a part of his/her environment which should
be comfortable and peaceful (Watson, 2012). The philosoph-
ical foundation for the science of caring includes the prin-
ciple which reflects the therapeutic use of self to
development a helping-trust relationship between the nurse
and patient, that includes congruence, empathy, and warmth
(Watson, 2012). Persons are encouraged to engage authen-
tically and spiritually with their patients and their patient’s
families, in order to allow a more positive experience of the
healthcare environment for all parties (Clark, 2016). In this
project, this theory was foundational for promoting a verbal
de-escalation intervention, which encouraged a more
authentic engagement with the patients to reduce patients’
aggressive behavior thereby reducing the use of seclusion as
the primary intervention for aggression.
Change theory
Lewin’s Change Theory has been widely applied to enhance
the understanding of human behavior concerning change
and patterns or resistance to change (Suc, Prokosch, &
Ganslandt, 2009). Resistance to change was a barrier for suc-
cessful implementation of TeamSTEPPSTM to facilitate a bet-
ter patient outcome. This model involves three distinct
phases: the unfreezing, moving, and freezing phases (Suc et
al., 2009).
4 J. HAEFNER ET AL.

Unfreezing stage Results

In the ‘unfreezing stage,’ the problem is identified, and strat-
Evaluation plan
egies are developed to reduce the forces that are acting to
keep the status quo (Suc et al., 2009). The identified prob- The project used Chi-square test for independence (with
lem on this psychiatric unit was that injuries to patients had Yates Continuity Correction) to assess each individual vari-
occurred during seclusion. The barrier which prevented able with P value of less than .05 representing statistical sig-
change (to accept the new intervention of verbal de-escal- nificance. While not statistically significant, TeamSTEPPSTM
ation) was the nurses’ firm belief on this unit that seclusion education demonstrated a clinical significance, the use of
was safer and easier for managing aggressive seclusion by psychiatric nurses decreased by eight events
patient behavior. comparing October/November 2018 (group 1, n ¼ 23) to
January/February 2019 (group 2, n ¼ 15) There was not a
statistically significant difference in the rate of seclusion
Moving stage
events (p ¼ 0.349). The pre rate was 5.9%, and the post rate
The ‘moving stage’ involves actual change in practice by the
was 4.4%.
equalizing the opposing forces to allow the driving forces to
A patient chart review evaluated the number of docu-
implement the change (Suc et al., 2009). The change process
mentations made by nursing staff of patients’ aggressive
involved the implementation of the educational program
behavior over the 2 months prior to the education modules
aimed at increasing the nurses’ knowledge of verbal de-
October/November 2018 (n ¼ 67) was compared to the
escalation and provided them with the skills for using verbal
number of documentations following the education January/
de-escalation to manage aggressive patients.
February 2019 (n ¼ 39). There was a statistically significant
difference in the rate of charting aggressive behavior
Refreezing stage (p ¼ 0.024). The pre rate was 17.3%, and the post rate
During the ‘refreezing stage,’ the stability of the change and was 11.4%.
inclusive effectiveness within the practice are ensured (Suc The provider population were nurses (n ¼ 31) from both
et al., 2009). day and night shifts. Among the 31 nurses, nine (29%) were
This step involved changes in values, attitudes, and male and 22 (71%) were female. Most of the nurses were
behaviors by internalizing the intervention. The nurses were aged 35 years or older (n ¼ 23, 74%), had less than 5 years
greatly influenced by the results of the project that demon- of any nursing experience (n ¼ 16, 51.6%), and 22 nurses
strated a significant decrease in patients being placed in (72.4%) had a bachelor’s degree (Table 1).
seclusion had occurred during the 2-months following the Based on the Chi-Square Homogeneity Test of
TeamSTEPPS education. Characteristics between Pretest and Posttest provider groups,
group variations of general characteristics between the pre-
test and posttest group were found not to be significantly
Methods different The majority of nurses who used seclusion to man-
Setting age aggressive behavior were female (n ¼ 12, 80%) age 25–35
(n ¼ 9, 60%) BSN educated (n ¼ 10, 67%) with five or fewer
The research setting was a 37-bed psychiatry unit in a hos- years of experience (n ¼ 11, 73%) (Table 2).
pital in a mid-sized city in North Central U.S. The multi- The targeted patient population included all patients
disciplinary team included register nurses, a psychiatric admitted 2 months prior to initiation of Team STEPPS
pharmacy technician, psychiatric nurse practitioners, social
workers, an occupational therapist, and activity therapists. Table 1. Demographic characteristics of provider population.
The unit leadership was supportive of the project aimed at Characteristics n (%)
reducing the patient seclusion rate. Age
This quality improvement project provided nurses with 24–34 8 (26)
education on de-escalation using the TeamSTEPPSTM to 35–44 12 (39)
45–54 6 (19)
decrease seclusion. The education was performed in two 55–64 4 (13)
steps. The first step was three self-learning TeamSTEPPSTM 65> 1 (3)
computer modules, each about one hour to complete, fol- Gender
Female 22 (71)
lowed by in-class demonstrations of de-escalation techniques Male 9 (29)
based on the TeamSTEPPSTM methods. Posters summarizing Years of Experience
0–5 16 (52)
the education were placed at the nurses’ station, the staff 6–10 8 (26)
lounge, and the report room. Each nurse received a lami- 11–15 3 (10)
nated card with the de-escalation process to attach to her/ 16–20 2 (6)
21> 2 (6)
his identification badge. Level of Education
The quality improvement project was Institutional Associate degree 3 (10)
Review Board (IRB) reviewed from The University of Bachelors 23 (74)
Masters 3 (10)
Michigan-Flint and determined not subject to IRB oversight. Doctorate 2 (6)
There was no IRB review in the project unit facility.
 ISSUES IN MENTAL HEALTH NURSING 5

(n ¼ 388) and 2 months following completion of the educa- the de-escalation education 185 (54.1%) were male and 157
tion modules (n ¼ 342). Among the 388 patients in the pre (45.9%) were female. The majority had a schizophrenia diag-
intervention group, 203 (52.3%) were male and 185 (47.7%) nosis (n ¼ 107, 31.3%), were 26–35 years old age group
were female. The majority had a schizophrenia diagnosis (n ¼ 101, 29.5%), and 203 (59.4%) of the patients were
(n ¼ 118, 30.4%), aged between 26–35 years (n ¼ 149, admitted voluntarily while 139 (40.6%) were admitted invol-
38.4%), 211 were admitted voluntarily (54.4%) and 177 untarily. Patients considered compliant to treatment were
(45.6%) were admitted involuntarily. Patients considered 218 (63.3%) while 124 (36.3%) of the patients were consid-
compliant with treatment were 267 (68.8%) and 121 (31.2%) ered non-compliant (Table 4).
of the patients were considered non-compliant (Table 3). Also, based on the Chi-Square Homogeneity Test of
Among the 342 patients admitted in the 2 months following Characteristics between Pretest and Posttest patient groups,
the decrease was not dependent on age, gender, diagnosis,
Table 2. Homogeneity test of characteristics between pretest and posttest admission status, and medication compliance. The majority
provider groups. of patients placed in seclusion were (n ¼ 26, 68%), 14 (36%)
( N ¼ 62) were 18–25 years-old, 30 (64%) were 26-years old or older
Pretest (n ¼ 23) Posttest (n ¼ 39) with a schizophrenia diagnosis (n ¼ 17, 44%) admitted invol-
Characteristics Categories n (%) n (%) v2 p untarily (n ¼ 22, 56%) and were compliant with their medi-
Gender Female 19 (82.6) 12 (80.0) 0.19 .664 cations (n ¼ 24,62%) (Table 4). The general characteristics
Male 2 (8.7) 2 (13.3) between the pretest and posttest patient groups and the pro-
Age 26–35 11 (47.8) 9 (60.0) 1.04 .594 vider groups were not significantly different.
36–45 6 (26.1) 4 (27.7)
46> 4 (17.4) 1 ( 6.7)
Years of experience 0–5 14 (60.9) 11 (73.3) 0.37 .831
6–10 6 (26.1) 3 (20.0) Discussion
46 1 (4.3) 1 (6.7)
Level of education Associate’s 6 (26.1) 4 (27.7) 0.07 .966 Agitated behavior often requires immediate intervention to
Bachelor’s 14 (60.9) 10 (66.7) control symptoms and decrease the risk of patient self-harm
Master’s 1 (4.3) 0 (0.0)
Total 335 195 and injury to others (Allen. et al., 2005). Seclusion is widely
used as an intervention to manage acutely disruptive behav-
iors among patients in psychiatric settings (Knox &
Table 3. Demographic characteristics of patient population. Holloman, 2012). However, it is a highly contentious issue
Pretest (n ¼ 388) Posttest (n ¼ 342) which to some is an infringement of basic human rights and
Characteristics Categories n (%) n (%) dignity and to others it is an unavoidable measure to main-
Gender Female 185 (47.7) 157 (45.9) tain patient safety and control (Carlson & Hall, 2014; Knox
Male 203 (52.3) 185 (54.1) & Holloman, 2012).
Diagnosis Schizophrenia 118 (30.4) 107 (31.3) Best practices of aggressive behaviors advocates for the
Schizoaffective D/O 55 (14.2) 61 (17.8)
Depression 41 (10.6) 31 (9.1) use of less coercive interventions such as verbal de-
Bipolar 97 (25.0) 87 (25.4) escalation unless the patient is actively violent (Jayaram
Psychotic D/O 75 (19.3) 56 (16.4) et al., 2016). Staff training targeting de-escalation of aggres-
Age 18–25 85 (21.9) 93 (27.2)
26–35 149 (38.4) 101 (29.5) sive behavior through verbal de-escalation should be seen as
36–45 76 (19.1) 82 (24.0) the primary intervention for violence prevention in health-
46> 78 (20.1) 66 (19.3) care settings. Verbal de-escalation intervention can empower
the patient to stay in control while building trust with

Table 4. Homogeneity test of characteristics between pretest and posttest patient groups.
( N ¼ 44)
Pretest (n ¼ 67) Posttest (n ¼ 39)
Characteristics Categories n (%) n (%) v2 p
Gender Female 21 (31.3) 13 (33.3) 1.02 .313
Male 46 (97.7) 26 (67.7)
Diagnosis Schizophrenia 29 (43.3) 17 (43.6) 2.26 .687
Schizoaffective D/O 19 (28.4) 9 (23.1)
Depression 2 (3.0) 0 (0.0)
Bipolar 5 (7.5) 5 (12.8)
Psychotic D/O 12 (17.9) 8 (20.5)
Age 18–25 37 (55.3) 14 (35.9) 5.92 .116
26–35 11 (16.4) 11 (28.2)
36–45 15 (22.4) 8 (20.5)
46> 4 (6.0) 6 (15.4)
Admission status Voluntary 24 (36.8) 17 (43.6) 0.63 .428
Involuntary 43 (64.2) 22 (56.4)
Medication compliance Compliant 48 (71.6) 24 (61.5) 1.16 .283
Non-compliant 19 (28.4) 15 (38.5)
Total 335 195
6 J. HAEFNER ET AL.
caregivers (Richmond et al., 2012). Also, this approach may
increase patients’ confidence to seek help earlier and avoid
episodes of agitation.
Using theoretical foundations such as the Jean Watson
Caring Theory, with an open approach to care that encour-
ages cooperation and collaboration between patient and pro-
vider, will improve the quality of care using techniques such
as the TeamSTEPPSTM evidenced–based tool. Alternative
approaches to seclusion and restraint should be considered
to improve the safety and standards of care for patients and
healthcare workers in healthcare settings. The patient
becomes a collaborative partner with staff members in man-
aging behavior in less coercive interventions such as verbal
de-escalation.
Due to the dynamic nature of the nursing work environ-
ment, some study limitations were inevitable. A limitation of
this study is the sample size. The power analysis suggested that
a sample size of 35 nurses would be adequate for the study.
However, the study sample size was 31 nurses. Time-constraints
for formal follow-up after each episode of a patient being placed
in seclusion was a limitation of the study. The period between
the pretest and posttest was relatively short, and as such, a fol-
low-up evaluation of data to determine the sustainability of the
intervention over time is needed.
Conclusions
This study sought to educate staff using an evidence-based
educational program to reduce the use of seclusion and
reduce patient aggressive behavior, through verbal de-
escalation on a psychiatric unit setting. It is generally
acknowledged that the behavior patterns of patients with
chronic psychiatric illnesses are challenging to modify, but
this study demonstrated that nursing staff-education on ver-
bal de-escalation significantly decreased patient’s aggressive
behavior and the nursing staff’s use of seclusion over a period
of 2 months. The findings of this study correspond with other
studies on the impact of staff education on staff verbal de-
escalation in the use of seclusion intervention to manage
patient aggressive behavior in psychiatric units (Mahoney
et al., 2012; Parker et al., 2019; Peters et al., 2018; Shaw, 2015;
Stead et al., 2009; Weld et al., 2016). The fact that there was
a decrease in the use of seclusion and a significant decrease
in documented patient aggression from pretest to posttest
suggests that a TeamSTEPPSTM educational intervention on
verbal de-escalation directed at nurses is an effective behavior
change strategy to increase staff knowledge on verbal de-
escalation in the management of aggression in psychiatric set-
tings. This preliminary data shows a decline of patients placed
in seclusions and it is expected overtime with the nursing
staff using verbal de-escalation as the main intervention for
the management of aggressive behavior will require signifi-
cantly less seclusion of patients.
Disclosure statement
No conflicts of interest; IRB approval through University of Michigan;
HUM 001567230; project was determined not regulated.
ORCID
Judy Haefner http://orcid.org/0000-0001-5932-1720
References
Agency of Healthcare Research and Quality (AHRQ). (2015).
Comparative effectiveness of strategies to de-escalate aggressive
behavior in psychiatric patients in acute care settings. https://effecti-
vehealthcare.ahrq.gov/topics/aggression/research-protocol
Allen, M. H., Currier, G. W., Hughes, D. H., Reyes-Harde, M., &
Docherty, J. P. (2005). The expert consensus guideline series:
Treatment of behavioral emergencies. Journal of Psychiatric Practice,
11(suppl 1), 110–112.
Carlson, K., & Hall, J. M. (2014). Preventing restraint and seclusion: A
multilevel grounded theory analysis. Sage Open, 4(4), 1–12. https://
doi.org/10.1177/2158244014556641
Chieze, M., Hurst, S., Kaiser, S., & Sentissi, O. (2019). Effects of seclu-
sion and restraint in adult psychiatry: A systematic review. Frontiers
in Psychiatry, 10, 491–419. https://doi.org/10.3389/fpsyt.2019.00491
Clark, C. S. (2016). Watson’s human caring theory: Pertinent transper-
sonal and humanities concepts for educators. Humanities, 5(2), 21.
https://doi.org/10.3390/h5020021
Edward, K., Stephenson, J., Ousey, K., Lui, S., Warelow, P., &
Giandinoto, J. (2015). A systematic review and meta-analysis of fac-
tors that relate to aggression perpetrated against nurses by patients/
relatives or staff. Journal of Clinical Nursing, 25, 289–299. https://
doi.org/10.1111/jocn.13019
Gabriel, E. J., Lopez, E. F., Nunez-Gonzalez, E., Gandoy-Crego, M,
Calvo-Frances, F., & Capezuti, E. (2017). The use of physical
restraints in long-term care in Spain: A multi-center cross-sectional
study. BioMed Central, (17) 29.
Gaynes, B. N., Brown, C. L., Lux, L. J., Brownley, K. A., Van Dorn, R.
A., Edlund, M. J., & Viswanathan, M. (2017). Preventing and de-
escalating aggressive behavior among adult psychiatric patients: A
systematic review of the evidence. Psychiatric Services, 68(8),
819–831. https://doi.org/10.1176/appi.ps.201600314
Hallett N. & Dickens G.L. (2017) De-escalation: A survey of clinical
staff in a secure mental health inpatient service. International
Journal of Mental Health Nursing, 24, 324–333. https://doi.org/10.
1111/inm.12136
Huckshorn, K. A., LeBel, J., & Caldwell B (Eds). (2016). Six core strat-
egies: Preventing violence, conflict and the use of seclusion and
restraint in inpatient behavioral health settings. An evidence-based
practice curriculum training manual. National Association of State
Mental Health Program Directors, 2018. https://www.nasmhpd.org/
content/six-core-strategies-reduce-seclusion-and-restraint-use
Jayaram, G., Samuels, J., & Konrad, S. S. (2016). Prediction and pre-
vention of aggression and seclusion by early screening and compre-
hensive seclusion documentation. Innovations in Clinical
Neuroscience, 9(7–8), 30–38.
Jovanovic, G., & Johnson, M. (2006). Restraint and seclusion: Can they
be obsolete practices? Center for Mental Health Services Research
University of Massachusetts Medical School Issue Brief, 3(2).
Keski-Valkama, A., Sailas, E., Eronen, M., Koivisto, A. M., L€ onnqvist,
J., & Kaltiala-Heino, R. (2010). The reasons for using restraint and
seclusion in psychiatric in-patient care: A nationwide 15-year study.
Nordic Journal of Psychiatry, 64(2), 136–144. https://doi.org/10.3109/
08039480903274449
Knox, D. K., & Holloman, G. H. (2012). Use and avoidance of seclu-
sion and restraint: Consensus statement of the American
Association for Emergency Psychiatry Project BETA Seclusion and
Restraint Workgroup. The Western Journal of Emergency Medicine,
13(1), 35–40. https://doi.org/10.5811/westjem.2011.9.6867
Kuivalainen, S., Vehvilainen-Julkunen, K., Louheranta, O., Putkonen,
Repo-Tiihonen, E., & Jari Tiihonen, J. (2017). De-escalation techni-
ques used and reasons for seclusion and restraint, in a forensic psy-
chiatric hospital. International Journal of Mental Health Nursing, 26,
513–524. https://doi.org/10.1111/inm.12389

Livingston, J. D., Verdun-Jones, S., Brink, J., Lussier, P., & Nicholls, T.
(2010). A narrative review of the effectiveness of aggression manage-
ment training programs for psychiatric hospital staff. Journal of
Forensic Nursing, 6(1), 15–28.
Mahoney, J. S., Ellis, T. E., Garland, G., Palyo, N., & Greene, P. K.
(2012). Supporting a psychiatric hospital culture of safety. Journal of
the American Psychiatric Nurses Association, 18(5), 299–306. https://
doi.org/10.1177/1078390312460577
Miodownik, C., Friger, M. D., Gansburg, Y., Reis, N., & Lerner, V.
(2019). Clinical and demographic characteristics of secluded and
mechanically restrained mentally ill patients: A retrospective study.
Israel Journal of Health Policy Research, 8(9). https://doi.org/10.
1186/s13584-018-0274-4
Moran, A., Cocoman, A., Scott, P. A., Matthews, A., Staniuliene, V., &
Valimaki, M. (2009). Restraint and seclusion: A distressing treat-
ment option? Journal of Psychiatric and Mental Health Nursing, 16,
599–605. https://doi.org/10.1111/j.1365-2850.2009.01419.x
Parker, A. L., Forsythe, L. L., & Kohlmorgen, I. K. (2019).
TeamSTEPPSTM: An evidence-based approach to reduce clinical
errors threatening safety in outpatient settings: An integrative
review. Journal of Healthcare Risk Management, 38(4), 19–31.
https://doi.org/10.1002/jhrm.21352
Peters, V. K., Harvey, E. M., Wright, A., Bath, J., Freeman, D., &
Collier, B. (2018). Impact of a TeamSTEPPSTM trauma nurse acad-
emy at a level 1 trauma center. Journal of Emergency Nursing, 44(1),
19–25. https://doi.org/10.1016/j.jen.2017.05.007
Richmond, J., Berlin, J., Fishkind, A., Holloman, G., Zeller, S., Wilson,
M., Rifai, M. A., & Ng, A. (2012). Verbal de-escalation of the agi-
tated patient: Consensus statement of the American Association for
Emergency Psychiatry Project BETA De-escalation Workgroup.
Western Journal of Emergency Medicine, 13(1), 17–25. https://doi.
org/10.5811/westjem.2011.9.6864
Ryan, J. B., Peterson, R., Tetreault, G., & Vander Hagen, E. (2007).
Reducing seclusion timeout and restraint procedures with at-risk
youth. The Journal of At-Risk Issues, 13(1), 7–12.
Shaw, B. (2015). Evaluation of the impact of TeamSTEPPSTM training
on perceptions of teamwork and resilience in the intensive care and
ISSUES IN MENTAL HEALTH NURSING 7
perioperative units in a tertiary care hospital. All Regis University
Theses. 682. https://epublications.regis.edu/theses/682
Spector, P. E., Zhou, Z. E., & Che, X. X. (2014). Nurse exposure to
physical and nonphysical violence, bullying, and sexual harassment:
A quantitative review. International Journal of Nursing Studies,
51(2014), 72–84. https://doi.org/10.1016/j.ijnurstu.2013.01.010
Stead, K., Kumar, S., Schultz, T. J., Tiver, S., Pirone, C. J., Adams, R. J.,
& Wareham, C. A. (2009). Teams communicating through STEPPS.
The Medical Journal of Australia, 190(Suppl 1), S128–S132. https://
doi.org/10.5694/j.1326-5377.2009.tb02619.x
Substance Abuse and Mental Health Services Administration (SAMHSA).
(2003, May). A national call to action: Eliminating the use of seclusion
and restraint: Summary report. U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration.
http://www.samhsa.gov/seclusion/SRMay5report1.htm
Substance Abuse and Mental Health Services Administration
(SAMHSA). (2009). Alternatives to seclusion and restraint. https://
www.samhsa.gov/trauma-violence/seclusion
Substance Abuse and Mental Health Services Administration
(SAMHSA). (2011). Promoting alternatives to the use of seclusion
and restraint issue brief #4: Making the business case. https://www.
samhsa.gov/sites/default/files/topics/trauma_and_violence/seclusion-
restraints-4.pdf
Suc, J., Prokosch, H.-U. & Ganslandt, T. (2009). Applicability of Lewins
change management model in a hospital setting. https://www.seman-
ticscholar.org/paper/Applicability-of-Lewin-s-change-management-
model-in-Suc-Prokosch/912ed329d26a64f006eed66ee41457afff45b3da
Watson, J. (2012). Human caring science: A theory of nursing (2nd ed.).
Jones & Bartlett Learning.
Weld, L. R., Stringer, M. T., Ebertowski, J. S., Baumgartner, T. S.,
Kasprenski, M. C., Kelley, J. C., Cho, D. S., Tieva, E. A., & Novak,
T. E. (2016). TeamSTEPPSTM improves operating room efficiency
and patient safety. American Journal of Medical Quality, 31(5),
408–414. https://doi.org/10.1177/1062860615583671
World Health Organization (WHO). (2017). Strategies to end the use
of seclusion, restraint and other coercive practices. Training to act,
unite and empower for mental health (PILOT VERSION). https://
extranet.who.int/iris/restricted/handle/10665/329605