Feature Article De-escalation: A survey of clinical staff in a secure mental health inpatient service Nutmeg Hallett and Geoffrey L. Dickens St Andrew’s, Northampton, UK ABSTRACT: De-escalation is an important tool for preventing aggression in inpatient settings but definitions vary and there is no clear practice guideline. We aimed to identify how clinical staff define and conceptualize de-escalation, which de-escalation interventions they would use in aggressive scenarios, and their beliefs about the efficacy of de-escalation interventions. A questionnaire survey (n = 72) was conducted using open and closed questions; additionally, clinical vignettes describing conflict events were presented for participants to describe their likely clinical response. Qualitative data were subject to thematic analysis. The major themes that de-escalation encompassed were communication, tactics, de-escalator qualities, assessment and risk, getting help, and containment measures. Different types of aggression were met with different interventions. Half of participants erroneously identified p.r.n. medication as a de-escalation intervention, and 15% wrongly stated that seclusion, restraint, and emergency i.m. medication could be de-escalation interventions. Those inter- ventions seen as most effective were the most commonly used. Clinical staff’s views about de-escalation, and their de-escalation practice, may differ from optimal practice. Use of containment measures and p.r.n. medication where de-escalation is more appropriate could have a negative impact; work is needed to promote understanding and use of appropriate de-escalation interventions based on a clear guideline. KEY WORDS: aggression, forensic nursing, inpatients, mental health, prevention and control. INTRODUCTION In the UK, clinical staff have a legal duty to respond to patient violence and aggression only in proportion to the threat posed (Paterson et al. 2004). National clinical guidelines state that coercive interventions including seclusion, restraint, and rapid tranquilization should only be considered once de-escalation strategies have failed (National Institute for Clinical Excellence 2005). De-escalation comprises ‘a complex range of skills designed to abort the assault cycle during the escalation phase, and these include both verbal and non-verbal communication skills’ (National Institute for Clinical Excellence 2005; p. 8). De-escalation involves the use of ‘verbal and physical expressions of empathy, alliance and non-confrontational limit setting that is based on respect’ (Cowin et al. 2003; p. 65). However, there is currently no widely accepted gold standard definition of de-escalation or clear guidance on the de-escalation techniques that clinical staff should use (Roberton et al. 2012). Various authorities have identified and described elements of de-escalation, many providing a list of the basic ‘rules’ (e.g. National Institute for Clinical Excellence 2005; Richter 2006; Stevenson 1991). The NICE guidelines identify the need for identification of triggers, and for staff to be aware of their own verbal and non-verbal behaviour, Correspondence: Geoffrey L. Dickens, Abertay University, Kydd Building, Bell Street, Dundee DD1 1HG, UK. Email: g.dickens@ abertay.ac.uk Nutmeg Hallett, RMN, BNurs (Hons). Geoffrey L. Dickens, RMN, BSc (Hons), PGDipN, MA, PhD. Author contribution: N. H. made a substantial contribution to con- ception and design, acquisition of data, analysis of data, and drafting of the article, and revised the article for important intellectual content. G. L. D. made a substantial contribution to conception and design, acquisition of data, analysis of data, and drafting of the article, and revised the article for important intellectual content. Both authors had final approval of the version to be published. Accepted February 2015. International Journal of Mental Health Nursing (2015) ••, ••–•• doi: 10.1111/inm.12136 © 2015 Australian College of Mental Health Nurses Inc.