title: Predictors of effective de-escalation in acute inpatient psychiatric settings.
abstract: OBJECTIVE
  To explore the factors that influence the use of de-escalation and its success in halting conflict in acute psychiatric inpatient setting.
  
  
  BACKGROUND
  De-escalation is the use of verbal and nonverbal communication to reduce or eliminate aggression and violence during the escalation phase of a patient's behaviour. Although de-escalation is a first-line intervention in aggression management in acute psychiatric settings, little is known about the use or effectiveness of this technique.
  
  
  METHODS
  A retrospective case note analysis.
  
  
  METHODS
  For each patient (n = 522), their involvement in conflict (e.g. aggression) or containment (e.g. coerced medication) during the first two weeks of their admission was recorded. The frequency and order of the conflict and containment events were identified during each shift. The sequences of events occurring in shifts involving de-escalation were analysed. Sequences where de-escalation ended the pattern of conflict or containment were categorised as 'successful', and all others were categorised as 'unsuccessful'.
  
  
  RESULTS
  Over half of patients (53%) experienced de-escalation during the first two weeks of admission, with the majority of these (37%) experiencing multiple episodes. De-escalation was successful in approximately 60% of cases. Successful de-escalations were preceded by fewer, and less aggressive, conflict events, compared with unsuccessful de-escalations, which were most frequently followed by administration of pro re nata medication. Patients with a history of violence were more likely to experience de-escalation, and it was more likely to be unsuccessful.
  
  
  CONCLUSIONS
  De-escalation is frequently effective in halting a sequence of conflict in acute inpatient settings, but patients with a history of violence may be specifically challenging.
  
  
  CONCLUSIONS
  These findings provide support for de-escalation in practice but suggest that nurses may lack confidence in using the technique when the risk of violence is greater. Providing evidence-based staff training may improve staff confidence in the use of this potentially powerful technique.
authors.affiliation: The Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Lavelle
authors.affiliation: Department of Health Sciences, University of York, York, UK.
authors.forename: Duncan
authors.initials: D
authors.lastname: Stewart
authors.affiliation: Faculty of Health, Social Care and Education, Kingston and St George's, London, UK.
authors.forename: Karen
authors.initials: K
authors.lastname: James
authors.affiliation: Institute of Education, University College London, London, UK.
authors.forename: Michelle
authors.initials: M
authors.lastname: Richardson
authors.affiliation: School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
authors.forename: Laoise
authors.initials: L
authors.lastname: Renwick
authors.affiliation: Verita Ltd, London, UK.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Brennan
authors.affiliation: The Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
authors.forename: Len
authors.initials: L
authors.lastname: Bowers
mesh_terms: D000328:Adult; D000374:Aggression / Q000523:psychology*; D032763:Behavior Control; D003142:Communication; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D011567:Psychiatric Department, Hospital; D012189:Retrospective Studies; D014754:Violence / Q000517:prevention & control* / Q000523:psychology*
keywords: aggression; communication; inpatient; psychiatric nursing