Employees in psychiatric emergency services and in acute psychiatry wards are frequently confronted with the aggressive behavior from patients or even relatives in their day-to-day work. Aggression can develop if those affected perceive their environment differently, feel overwhelmed, helpless, or frustrated, or if they are anxious. This can result in yelling, swearing, and physical aggression towards others as well as self-harming behavior.
To defuse escalating situations and avoid measures depriving patients of their freedom as far as possible, qualified employees need special skills as well as support and advice both in and after crisis situations. A concept for systematic and practice-based de-escalation management was developed for the first time at the CIMH in 1999 and implemented from the year 2000. Starting from a crisis intervention team made up of two nurses and day training sessions, the concept has since been supplemented to include additional components. Following an evaluation in 2021, the new role of practical de-escalation trainer was created. For Director of Nursing Doris Borgwedel, the coordinated elements of de-escalation management are critical to manage day-to-day life in the clinic. "Our goal is to ensure safety on the wards and tracks to protect employees and patients. It is therefore important for our teams to be well prepared for crisis situations, that they are supported in difficult moments, and that they process stressful experiences together."
Knowledge and practice provide safety
All employees at the CIMH with direct patient contact are trained on preventing aggression and violence and handling crisis situations professionally. The compulsory training program for nurses, therapists, and employees in the medical service comprises a day seminar on de-escalation, which teaches the theoretical principles: what can trigger aggression in patients? How do you communicate in a way that de-escalates the situation? How can you prevent an escalation and what should you do after an escalation to stabilize the therapeutic relationship again? In regular exercise practice lessons, attendees learn even more and repeatedly practice what they have learned. This comprises the areas of verbal de-escalation, physical contact techniques for attendees to protect themselves and protect other people, and securing patients. The practical de-escalation trainers guide the practical units and tailor them to the needs of various professional groups. Training videos on the intranet supplement the seminars provided so employees can refresh their skills at any time, for example on the topics of communication, defensive and protection techniques, and securing techniques.
Rolf Oster-Ritter, Head of Nursing and practical de-escalation trainer at the CIMH, regularly experiences how important training sessions and assistance are: "when employees feel well pre-prepared and know that they will receive support from their colleagues immediately in crisis situations, the feeling of safety increases and their trust in their own abilities is enhanced." There are other positive effects too: injuries to patients and employees are reduced, the psychological strain on employees decreases, and there are fewer absences due to illness following escalated situations.
In day-to-day ward life, the seven-person team of practical de-escalation trainers helps employees to handle aggression and violence in all professional groups and across all departments. Among other things, they are there in crisis situations to guide and support colleagues, they conduct confidential discussions after stressful or traumatic events, and provide advice on caring for patients. "In their feedback to us, colleagues tell us that they find our work to be an asset and that they feel under significantly less strain as a result of the direct support and the discussions we offer," says Juliane Nübling, a practical de-escalation trainer at the CIMH.
The crisis intervention team provides support
Despite the preventative and de-escalating measures, psychiatric emergencies occur in day-to-day working life that are difficult to handle alone or in pairs. This is why the crisis intervention team (KIT) is available to provide support to colleagues in an emergency situation, and then takes on the task of de-escalating the situation. The goal of the KIT is to de-escalate the situation verbally if this is possible. If this is not possible, measures will be taken to deprive the patient of their freedom. After a KIT intervention, the situation is analyzed and assessed with all of those involved, including the patient.
The KIT is made up of five alternating employees, who can be called in an emergency. There is a full work schedule to staff the KIT. All employees who have completed the de-escalation day seminar and have been trained by the practical de-escalation trainers are involved in the KIT. The exceptions to this are employees over the age of 55 and those with physical limitations.
Standards in psychiatric emergencies
In psychiatric emergencies and when securing patients, employees at the CIMH follow clear standards and guidelines. The concept of a psychiatric emergency contains flow charts that define the legally compliant use of various measures up to and including securing patients or emergency medication and ensure full documentation of emergency events. The nursing standard on securing patients describes in detail how securing and releasing a patient is done so as to be as non-traumatic as possible.
The use of enforcement measures in psychiatric facilities encroaches on patients' personal rights. For employees who work in the clinical and therapeutic areas at the CIMH, this contradicts the joint vision of the institute's values. "We treat all patients respectfully and as equals, and want to include them in all treatment decisions. In an emergency situation, however, this is hardly ever possible, and of course this harms the therapeutic environment and the therapeutic relationship," says Sven Mengel, Head of Nursing and practical de-escalation trainer. This is why everyone works together in a multi-professional team to avoid dangerous situations as far as possible – watching for early warning signs, calming the patient with de-escalating measures, or reacting with mild tools. In cases in which a situation has escalated and enforcement measures have been used, there are discussions afterwards with all of those involved to return to a trusting treatment relationship.
Self-efficacy through treatment agreements
To make the inpatient stay at the CIMH as pleasant as possible, the patient is recommended to conclude a written agreement with their treatment provider. This records their personal wishes about various aspects of treatment and is recognized by both sides as being binding. This creates trust and ensures transparency. Among other things, the parties discuss which de-escalating tools the therapeutic team should try in a crisis to prevent an imminent deprivation of freedom. This can be going for a walk together, the option to withdraw, doing sport, or intensive support. Even though this cannot always be successful, it improves the feeling of self-efficacy for those affected. Patients report that it is particularly important for them to be included in treatment decisions and for their needs to be taken seriously.
The fact that de-escalation management has proven to be effective in practice is demonstrated by the assessments of all measures depriving patients of their freedom in the last five years at the CIMH: the number of times patients needed to be secured remained constant, while isolations reduced significantly. The average duration of both measures decreased considerably. The police were also deployed fewer times. On the basis of this experience in day-to-day life, the practical de-escalation trainers pass on their expertise both internally and to external parties. The on-the-job further training as a de-escalation trainer is offered nationwide for employees caring for mentally ill patients to qualify multipliers in the handling of aggression and violence.
Further training as a de-escalation trainer
The on-the-job further training is primarily aimed at employees in the nursing and education service in clinical treatment and youth welfare facilities. It teaches expertise and skill in handling particularly difficult behaviors in a manner that de-escalates the situation. The course comprises three modules: theoretical principles, focus on disorders, and practical training in non-traumatic tactile techniques. The further training was developed jointly by the CIMH and the Center for Psychiatry (ZfP) in Weinsberg. Information on the further training as a de-escalation trainer.