3 DE-ESCALATION FRAMEWORKS
De-escalation training is modeled on validated de-escalation frameworks, which develop a structure for how and when to assess aggression, use mitigating techniques to limit the possibility of aggressive action, and intervene during a violent episode. The Joint Commission (2019) endorses the Turnbull, et al. (1990), Dix and Page (2008), and Bowers Safewards (2014) models. However, some elements of those models are outdated.
3.1 Turnbull et al.
Turnbull and Patterson (1990) do not discuss a theoretical model of de-escalation, but rather an actual training program characterized by a collection of learning objectives and verbal and non-verbal tips. The Turnbull et al. (1990) model emphasizes flexibility, with the result that there is no “order” to their de-escalation framework. While some elements of the Turnbull training program have been validated and incorporated into more recent de-escalation frameworks, the recommendations on restraint and seclusion tactics are largely outdated.
3.1.1 Learning Objectives
Turnbull’s de-escalation training teaches 10 learning objectives: legal aspects (such as the “right to restrain”), theories of aggression, triggers of aggression, de-escalation skills, disengagement breakaways (strangle holds, disarming, bear hugs, etc.), basic control and restraint (wrist locks, bear hugs, etc.), advanced control and restraint (the three-arm team, removal, relocation, etc.), integration of de-escalation and control and restraint, guidelines for practice, and reporting incidents. These learning objectives are hands-on, with clear applications in clinical practice. Teaching restraint techniques in de-escalation training is beneficial in that it limits the incorrect use of potentially fatal techniques. It is important to note, however, that restraint mechanisms are now only recommended to prevent immediate injury to the patient or staff. It is therefore important to emphasize de-escalation strategies that prevent the requirement for restraint in the first place.
3.1.2 Verbal and Non-verbal Responses to Aggression
Turnbull’s tips for de-escalation have largely been incorporated into more recent de-escalation frameworks, such as the Dix and Page model. The “responses to aggression” section includes seven skills: enlist colleagues for help, ask questions about the patient’s feelings, give clear instructions, maintain friendly eye contact and body posture, be personable and separate yourself from “the system,” show concern, and demonstrate empathy to match the patient’s mood.
Turnbull et al. (1990) delivered their two-week de-escalation training program to nearly 150 nurses over a two-year period. The nurses who completed the course reported increased confidence in performing de-escalation techniques and avoiding the use of restraint and seclusion. However, there is no evidence regarding the efficacy of the Turnbull model for quantifiable outcomes, such as reduced violent events, reduced instances of restraint and seclusion, and reduced injuries to patients and staff.
3.2 Dix and Page
The Dix and Page (2008) model was originally developed for mental health units, though it since has been referenced as a validated de-escalation metric generally. It is comprised of three basic components: assessment, communication, and tactics (ACT).
Dix and Page emphasize that it is imperative that members of a treatment team share the same definition of an aggressive action, so that the assessment of a given incident is consistent. They recommend the seven-point Assaultive Rating Scale, developed by Lanza and Campbell (1991), which ranks potential consequences of an aggressive action, ranging from “threat of assault without physical contact” to “death.” With this scale in mind, Dix and Page describe how “situational analysis”—i.e., assessing the likelihood of violence using recent interactions as data points—is better suited to predicting aggression than psychopathology. Dix and Page use Frude’s (1989) progression of five factors—situation, appraisal, anger, inhibitions, and aggression—as the model by which to understand, and therefore assess, a patient’s aggression.
- Situation – the events that the patient focuses on immediately prior to his/her aggressive behavior
- Appraisal – the patient’s understanding of the situation
- Anger – the emotional response to the appraisal
- Inhibitions – the patient’s attitude and general ability (or lack thereof) to manage aggression
- Aggression – the behavioral result
The suggested communication techniques are only tools, intended for flexible use by the de-escalating practitioner. Communication, Dix and Page argue, must appear sincere and therefore cannot be taken verbatim from a fact sheet. Their communication strategies include both non-verbal and verbal principles, such as maintaining non-aggressive posture, avoiding touching the patient (even in a reassuring or gentle way), self-disclosing, avoiding using jargon, and bringing attention to the impact of the patient’s behavior.
3.2.3 De-escalation Tactics
Dix and Page describe abstract models that offer a reimagining of the patient-staff relationship rather than specific de-escalation techniques. These include the “attitude and behavior cycle,” the “win-lose equation,” “debunking”, “aligning goals,” and “transactional analysis.” Dix and Page’s strategies are intentionally made vague so as to discourage practitioners from using a script, which is inflexible and presents as insincere. Generally, they suggest that the de-escalator shed assumptions about how processes “must be done,” negotiate situations such that a perceived “win-win” is met, invalidate the need for aggression by fully empathizing with the patient’s grievances, and frame staff goals to align with the patient’s goals.
Just as every component of Dix and Page’s de-escalation model is fluid, the three components together are interdependent. This means that assessment, communication, and negotiation tactics should consistently be revisited throughout the de-escalation process.