Barriers and facilitators to the effective de-escalation of conflict behaviours in forensic high-secure settings: a qualitative study

Abstract

Background: Violent and aggressive incidents are common within mental health settings and are often managed using high-risk physical interventions such as restraint and seclusion. De-escalation is a first-line technique to manage conflict behaviours and prevent violence and aggression. There is limited research into the use of de-escalation in high-secure settings. This study investigated staff, patient and carer perspectives on the barriers and facilitators to using de-escalation for conflict behaviours. Methods: Semi-structured individual interviews (n = 12) and focus groups (n = 3) were conducted with eight patients, four carers and 25 staff members in a high-secure hospital in England. Interviews and focus groups were informed by the theoretical domains framework and were digitally recorded, transcribed verbatim and analysed using framework analysis and the COMB behaviour change model. Results: Four themes and 15 sub-themes (barriers and facilitators) were identified. Themes related to capabilities (building relationships: knowing the patient and knowing yourself), opportunities (filling the void: challenges within the high-security environment; dynamic relationships) and motivation (keeping everyone safe). Strong staff-patient therapeutic relationships underpinned by trust, fairness, consistency and an awareness of the trauma-aggression link were considered key to successful de-escalation. Specific psychological and interpersonal skills including empathy, respect, reassurance, sincerity, genuine concern and validation of the patient perspective are needed to achieve this. Barriers related to the physical environment; organisational resources, practices and systems; staff traumatisation; hierarchical and punitive attitudes towards patient care, and an insufficient understanding of psychiatric diagnoses, especially personality disorder. It was apparent across themes that fear, which was experienced by both staff and patients, was a driver for many behaviours. Conclusions: This work has identified organizational and behaviour change targets for interventions seeking to reduce violence and restrictive practices through the use of de-escalation in high-secure hospitals. The potential for, and occurrence of, violence in such settings is high and leads to fear in patients and staff. The factors which promote fear in each group should be addressed in de-escalation training.

Sensitive, Challenging, and Difficult Topics: Experiences and Practical Considerations for Qualitative Researchers

“…Consistency can also be key in boundary maintenance and should be considered whilst striving to communicate interest, compassion and authenticity. Conveying calmness rather than nervousness may ameliorate participant anxiety from which hostility, aggression or perceptions of having the 'upper hand' may arise (Goodman et al, 2020). Awareness of suitable deescalation strategies, breakaway skills (Stephens, 2017) and tailored distress protocols (Draucker et al, 2009) to call upon if required, may increase feelings of competence and confidence.…”

Perceptions of patient aggression in psychiatric hospitals: a qualitative study using focus groups with nurses, patients, and informal caregivers

“…We also systematically searched and identified nine qualitative studies that described both patient, staff and/or caregiver perspectives in a same study on aggression in psychiatric hospitals. Only one of them included family members ( n = 4 persons in individual interviews) and this study used group format interviews (only for staff) [ 17 ]. In a study by Wright et al [ 18 ], patients in security units felt that staff had negative attitudes towards them, which potentially caused aggressive situations.…”

“…On the contrary, staff thought that they were doing their best to bring patients and nurses closer together. In a study by Goodman et al [ 17 ], staff expressed that patients can be labelled as ‘mad, bad or sad’. Especially aggression from the perspectives of patients diagnosed with personally disorder could be responded to in negative, unempathic ways.…”

“…On the contrary, patients and family members criticised power and control over patients, which was seen by setting unnecessary limits on patient behaviour. Aggression management practices were not well-accepted by patients, as staff may have used heavy-handed approaches to escalating aggression, causing fear and traumatisation [ 17 ]. On the other hand, harsh handling of aggressive patients was reported by both staff and patients in a study by Pelto-Piri & Kjellin [ 14 ].…”

Is Deescalation Training Effective in Reducing Violent Incidents in Forensic Psychiatric Settings? – A Systematic Review of the Literature

“…high-secure forensic setting needs strong therapeutic relationships and knowledge about the relationship between trauma and aggression(Goodman et al 2020). However, regarding the ndings of our review, i.e.…”