This review aims to evaluate the effectiveness of de-escalation techniquesto manage the aggressive actions of the psychiatric patient. The 14 de-escalation techniques investigated in the study by Price O. et al, are applied on a continuum that goes from support to control and are divided into: 6 techniques called “Support” (passive intervention, reassurance, distraction, problem identification, resolution, reformulation) with the aim of allowing the patient to use his own resources to self-regulate aggression; 4 “Non-physical control” techniques (environmental manipulation, reprimand, deterrents, education) with more authoritative interventions that explicitly affirmed the control of personnel in containing harmful behavior; 4 “Physical control” techniques (psychotropic drugs, isolation, containment, forced intramuscular psychotropics) with the aim of eliminating further aggression through the application of restrictive practices. Decisions to adopt non-physical control techniques were influenced by: perceived function of aggression,trial-and-error , local rituals and routines concerning the management of the patient’s aggression, risk and knowledge. Learn about our cpi training nursing course at our cpi training nursing course page.

Staff find that if more effective non-physical control techniques are put in place, they could lead to a higher escalation resulting in the use of restrictive practices. Furthermore it was found that the de-escalationit is ineffective if implemented with patients with personality disorders. Environmental and organizational factors appear to be influential in the good practice of non-physical control. The data obtained from this study were generated from the synthesis of the participants’ opinions and experiences. This may not provide comprehensive evidence on the findings, but the research nevertheless represents a starting point for future studies. Furthermore, to limit the heterogeneity of the sample and to make it as representative as possible, only personnel who had experience in de-escalation techniques were included and managers were excluded instead.department. This may have omitted potentially relevant data.

A further limitation concerns the conceptualization of de-escalation techniques. In particular, study participants saw “non-physical control” techniques as coercive and an important part of the de-escalation process . It is therefore possible that the participants ,have inaccurately conceived of de-escalation techniques as a coercive rather than psychosocial therapeutic intervention. It is likely that more training to participants on these techniques would have given more comprehensive results and important insights into the clinical realities in which they are used. For example, how and why certain techniques are selected by staff, the relationship between the two levels of intervention, support and non-physical control, and the success or use of restrictive practices. Furthermore, understanding when and why supportive techniques cease to be used would have yielded important evidence for reducing violence and the use of these practices. However, the current training regarding de-escalation techniquesappears unsuitable to allow the staff to regulate and manage anxiety with consequent correct implementation of the intervention.

The study by Mary Lavelle et al. [18], identifies the events preceding the de-escalationin psychiatric wards, by evaluating the characteristics of the patient and the environment that influence the use of the techniques, it has brought to light that more than half of the patients (53%) have put in place aggressive attitudes towards the staff and in 60% of the cases the de-escalation has been successful, even if it is more complicated with subjects with a previous history of aggression, demonstrating that a lack of confidence in the effectiveness of these techniques when the risk of violence is greater. The study confirms the data in the literature that nurses often experience violence as “normal” and this “normalization” makes it difficult to identify the seriousness of the problem [20]. In Mary Lavelle’s study, in fact, events that would be classified as dide-escalations are not considered significant incidents by nurses.

Furthermore, this study is a retrospective analysis of a sample of consenting patients, and this may not provide an accurate picture of the clinical reality. Another criticality identified by the author refers to the time interval analyzed. What happens in a work shift is analyzed, losing possible relationships between events that occur distant in time. It therefore becomes essential to increase training to improve the confidence in staff to use it and to detect the prodromal symptoms of aggressive action, as the effectiveness of de-escalation is optimal if it is implemented at the beginning of the cycle of aggression. 

The last selected study, conducted by Berring L. et al. [15], describes how patients and healthcare professionals define violent situations and the meaning attached to them. Through the ethnographic and multiple study, participants were encouraged to contact the researcher after experiencing a de-escalation situation. After reporting such a situation, the first author would conduct interviews to investigate the case. The analysis indicated that both staff and patients aspired to achieve peaceful relationships when interacting in violent situations. Furthermore, the study also revealed that all parties used the same basic patterns in defining situations.

In this regard, the de-escalation solutions were defined: (a) on the basis of existing mental beliefs, (b) beliefs were changed, because what led to the situation was reflected and learning was achieved. Memories of lived situations created anticipatory expectations in the patient and these had an impact in defining the current situation. Therefore, knowledge of the patient and his past can guarantee the possibility of acting in the most adequate and timely manner in moments of agitation. It turns out, therefore, how important the reflective moment is, as it leads the patient to create positive thoughts about the situation and promote the resolution of problems. In Berring’s study, the view of social interaction is small-scale, but it provides useful information on how past experiences affect present ones in clinical practice. Therefore,