Nurse-driven algorithms to de-escalate crisis situations in psychiatry and its effect on safety/reduced restraint use

Purpose:
To share evidence-based operational algorithms developed by our team in the care and treatment of psychiatry inpatients which promote an environment of safety and minimize the use of restraints while improving staff satisfaction.

Significance:
Although yearly training augments clinician knowledge, critical identification of appropriate strategies to maintain safety are often lacking. Emergent situations, potentially dangerous scenerios/imminent danger are safely managed by role specific interventions and establishment of a crisis leader.

Strategy and Implementation:
Using an algorthimic approach a nursing crisis team leader is empowered to create a safe environment for patients families and staff through identification of behaviors necessitating appropriate interventions to de-escalate behaviors. Using the algorithm, the crisis team leader offers therapeutic listening, creates strategic environments to facilitate de-escalation and communicates support in a healing environment. These strategies include use of calm soothing tones, relaxed body structure, observation of personal space and ultimately communicate the desire to help. Appropriate use of strategies supports the patient to identify specific stressors, thereby fostering an ability to problem solve with the clinician. Patients are instructed on distress tolerance techniques such as deep breathing, appropriate distraction activities,spending time alone in a quiet place, and appropriate medication management. Seclusion and restraint is identified as a last resort measure for imminent danger.

Evaluation:
Use of the algorithmic approach has been shown to reduce the use of restraints, decrease the number of assaults, increase staff satisfaction and a create a positive perception of a safe healing environment by staff and patients.

Implications for Practice:
Algorithms will be presented to provide useful information not only in psychiatry, but in other inpatient environments. Nurses possess unique skills and talents to de-escalate behaviors. Further testing of the algorithm in other patient care environments shows promise in future research studies.