Follow a stepwise approach to ensure everyone’s safety.
- Many complications can occur related to the use of restraints in the healthcare setting.
- Proper use of de-escalation techniques can help manage acutely agitated patients and avoid the use of restraints.
- Several de-escalation models and strategies exist to aid successful de-escalation attempts.
Agitation refers to extreme arousal associated with increased verbal and motor activity. Unmanaged agitation can lead to aggressive or violent behavior. Your main concern is the safety of the patient, visitors, caregivers, and other patients.
In addition to the significant time and resources required to manage a patient experiencing agitation, these stressful situations can contribute to burnout among healthcare workers, especially in psychiatric units and emergency departments with high rates of workplace violence. These situations also negatively impact the safety culture and can violate the fundamental therapeutic relationship between caregivers and patients. Using appropriate de-escalation models and techniques, healthcare workers can increase the chances of successful de-escalation attempts and minimize the use of more restrictive methods. (See What causes acute agitation?)
Management of aggressive patient situations
Workplace violence: Don’t risk it, de-escalate it
What causes acute agitation?
Determining the cause of acute agitation (organic or inorganic) can help us treat and support patients appropriately. Organic causes involve newly diagnosed medical illnesses, traumatic injuries, or exacerbations of chronic diseases. These causes include the following:
- central nervous system infections
- delirium
- dementia
- encephalopathy
- respiratory failure
- seizures (specifically the postictal state)
- sepsis/acute infections
- traumatic brain injuries
Inorganic causes include the following:
- acute poisonings
- substance use/intoxication
- substance use withdrawal
Hypoglycemia, which can result in agitation, can be categorized as organic or inorganic depending on the cause. For example, if the hypoglycemia results from a medication or substance, it’s considered inorganic. Exacerbations of mental illness, also a common cause of agitation, are considered neither organic nor inorganic.
Diagnosis
Diagnostic tests that can help determine the cause of acute agitation include the following:
- radiologic imaging
- serum ammonia level testing
- urine toxicity screens and urinalyses
Thorough patient assessments and medical history reviews (including psychosocial comorbidities and current medications) also aid in identifying causes, which may lead to determining the medical treatment needed to resolve the acute agitation and prevent reoccurrence.
Why attempt de-escalation?
Traditional forms of agitation management (chemical and physical restraints) can lead to significant harm to patients, including psychological trauma and serious adverse events. These concerns have led many organizations to develop policies that include reduced use of chemical and physical restraints.
Most organizations reserve the use of chemical restraints (sedative medications with a rapid onset and strong sedative effect) for patients exhibiting dangerous and violent agitation who are at risk of harming themselves or others. However, these medications can lead to respiratory depression and hypotension.
Physical restraints, which depend on state laws and regulations, include hand mitts, freedom sleeves, wrist or limb restraints, enclosure beds, and side rails. Different restraints are appropriate for various behaviors and levels of agitation or aggression.
Although some situations require physical restraints, all (even less restrictive types) have risks, including physical trauma, significant respiratory depression, and asphyxiation leading to cardiac arrest. These complications can occur as a result of improper restraint techniques, exacerbation of chronic medical conditions, and ligature risks. A struggling patient who resists being placed in restraints also can contribute to these risks. Potential injuries include shoulder fractures or dislocations and skin breakdown or lacerations.
Restraints can prove humiliating to the patient, impact the trust between the patient and healthcare professionals, and result in staff trauma. Some staff may feel a sense of moral injury, which can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs.
Providers should limit physical and chemical restraints to situations in which de-escalation and environmental modification prove unsuccessful. Effective de-escalation helps the patient return to a calm or manageable state that’s free of harm, which reduces the need for physical and chemical restraints. Many models and programs, such as the Management of Aggressive Patient Situations and the Crisis Prevention Institute, offer resources aimed at educating healthcare workers and improving their de-escalation skills through proper training and the use of evidence-based techniques.
Stepwise approach to managing acute agitation
Managing a patient experiencing acute agitation typically involves a stepwise approach—de-escalation and environmental modification, physical restraints, pharmacotherapy, and re-assessment.
De-escalation involves placing the patient in a calm, nonthreatening environment. Actively listen to and acknowledge the patient, and attempt to establish a collaborative relationship. Adjust the environment as much as possible to comfort the patient, and use nursing interventions (assisted deep breathing, music therapy) as indicated to help instill calm. (See De-escalation defined.)
De-escalation defined
De-escalation, a combination of strategies intended to reduce a patient’s agitation and aggression, includes communication, self-regulation, assessment, actions, and safety maintenance. These strategies can help reduce the risk of harm to patients and caregivers and also limit the use of restraints or seclusion.
Communicate calmly; maintain a nonthreatening tone of voice and relaxed body language. Regulating your own emotions and responses can help avoid further escalation. In addition, continuously assess the situation to determine appropriate next actions. Your primary goal is to maintain the safety of yourself, the patient, and all others in the environment. You want to achieve the following outcomes:
- Prevent violent behavior.
- Avoid the use of restraints.
- Reduce patient anger and frustration.
- Maintain the safety of patients and staff.
- Improve staff-patient connections.
- Enable patients to manage their own emotions and regain personal control.
- Help patients to develop feelings of hope, security, and self-acceptance.
Move to the second step, physical restraint, only if de-escalation and environmental modification prove unsuccessful. Begin with the least-restrictive restraints; use more restrictive types according to patient behavior and implement frequent monitoring.
Use pharmacotherapy (only after unsuccessful de-escalation and environmental modification) independently or in conjunction with physical restraints. This step is best managed by a provider experienced in managing patients with acute agitation. If the patient agrees to medication, physical restraints may not be necessary.
The final step in managing acute agitation involves frequent reassessment of intervention effectiveness and reexamination of the patient. Monitor vital signs as soon as feasible, and remain alert for signs of decompensation or development of a life-threatening illness. (See Aggression interventions.)
Aggression interventions
All healthcare providers should know how to identify agitation and escalating behavior and possess the skills to de-escalate a potentially hostile situation. Many effective interventions can help, including the following:
- Use supportive and nonconfrontational language to verbally de-escalate someone from an agitated state. For example, you might, say, “That must be scary.” Supportive words like these let the person know that you understand what’s happening, which can lead to a positive response.
- Use clear and calm communication techniques; avoid using healthcare terms or abbreviations.
- Show empathy and don’t judge; whatever the patient is experiencing may be the most important occurrence in their life at that moment.
- Respond to the patient’s expressed issue to create a sense of trust with the patient.
- Try to figure out if there’s something you can do to solve their problem or help the patient feel more secure or calm.
- Attempt to identify triggering behaviors or stimuli that cause the patient’s unease to escalate or that make them feel anxious. Then, mitigate these behaviors/stimuli as much as possible.
- Respect the patient’s personal space; if you must enter their space to provide care, explain what you’re doing to reduce fear and confusion.
- Be mindful of nonverbal gestures such as facial expressions, and use a neutral, calm tone of voice.
- Set clear limits for the patient to follow, but remember that allowing flexibility and options can help avoid unnecessary altercations.
- Allow silence for reflection and time for decisions when appropriate.
De-escalation also involves environmental modification. For example, when an agitated patient becomes medically stable, place them in a calming environment. Avoid placing them in a room with excessive stimuli (bright lights, loud noises) or any equipment that could pose a safety risk. The room should allow for rest and offer a comfortable temperature.
An environment that makes the patient feel “locked in” may increase their anxiety and seem as though they’re being punished. Avoid placing them in seclusion unless it’s deemed necessary for their safety or that of others.
Provide comfort measures (blankets, nutrition) when it’s safe to do so. Opportunities for hygiene and self-care can give the patient a sense of control and comfort. If appropriate, offer diversional activities, such as therapeutic coloring books or TV watching.
De-escalation models
The Joint Commission recognizes three cyclical de-escalation models: Dix and Page, Safewards, and Turnbull, et al. These methods can prove effective when used individually, but having knowledge of all of them can help staff tailor their de-escalation attempts with components of each. Creating unique and individualized plans for de-escalation will help increase chances for success.
Dix and Page model
The Dix and Page cyclic model requires the de-escalator to continuously revisit three interdependent components: assessment, communication, and tactics. The intentionally vague process encourages flexibility and discourages the use of a script.
Assessment. Repeatedly assess the individual for safety and signs of escalating behavior. Promptly recognizing these signs aids the prediction of behavior and helps determine necessary interventions and responses.
Communication. Use calm speech and body language to help establish a positive relationship with the patient experiencing agitation. Repeatedly communicate clear and consistent behavioral expectations.
Tactics. Use tools such as negotiation, therapeutic listening, and emotional regulation to encourage the patient to return to a calm state. In a nonconfrontational manner, seek clarification to better understand the patient’s needs and determine further necessary measures.
Turnbull, et al. model
The Turnbull, et al. model, similar to the Dix and Page model, describes how the de-escalator should continuously monitor and evaluate the patient’s response to de-escalation methods so they can re-evaluate the plan and determine appropriate next steps and potential alterations. This model stresses the importance of flexibility in de-escalation rather than proposing specific techniques in a particular order.
Each de-escalation attempt is unique and requires a personalized approach; what might help de-escalate in one situation may inflame it in another. This model emphasizes the need for therapeutic communication, but it specifies that de-escalators must possess a wide range of de-escalation tools and skills—such as therapeutic verbal and non-verbal communication techniques and environmental modification—to create individualized plans and responses.
Safewards model
Safewards, a linear de-escalation model, takes a stepwise approach to de-escalation and offers several suggestions to improve the chances of success. Start by moving the patient to a protected area and maintain a safe distance. Next, through effective communication, aim to clarify the reasons for anger. Lastly, seek to resolve the issue by finding a mutually agreeable solution.
Patient and staff win
Effective de-escalation can help improve outcomes for patients who become agitated. It also can lead to an improved perception of healthcare, which might encourage a patient to seek help when needed and discourage the avoidance or underutilization of healthcare resources in the future. Ultimately, de-escalation can improve relationships between healthcare professionals and their patients. Consistent use of effective de-escalation strategies also can contribute to an improved working environment for all staff by decreasing burnout, increasing job satisfaction, reducing feelings of moral injury, and improving the safety culture.
Samantha Byrd is a clinical educator in the adult emergency department at University Hospitals Cleveland Medical Center in Cleveland, Ohio, and a clinical instructor at Kent State University in Kent, Ohio.
American Nurse Journal. 2025; 20(5). Doi: 10.51256/ANJ052514
References
Crisis Prevention Institute. Top 10 de-escalation tips. institute.crisisprevention.com/Refresh-De-Escalation-Tips.html
Day SW, Sharp J, Jackson GL, et al. Management of aggressive patient situations. Am Nurse J. 2022;17(4):34-7. myamericannurse.com/management-of-aggressive-patient-situations/
The Joint Commission. Quick safety issue 47: De-escalation in health care. January 28, 2019. jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-47-deescalation-in-health-care
Spencer S, Johnson P, Smith IC. De-escalation techniques for managing non-psychosis induced aggression in adults. Cochrane Database Syst Rev. 2018;7(7):CD012034. doi:10.1002/14651858.cd012034.pub2
Springer BL, Silver D. The agitated patient in the emergency department. Emerg Med Rep. 2021;42(6):61-72.
Wong AH, Ray JM, Iennaco JD. Workplace violence in health care and agitation management: Safety for patients and health care professionals are two sides of the same coin. Jt Comm J Qual Patient Saf. 2019;45(2):71-3. doi:10.1016/j.jcjq.2018.11.001
Wong AH, Sabounchi NS, Roncallo HR, Ray JM, Heckmann R. A qualitative system dynamics model for effects of workplace violence and clinician burnout on agitation management in the emergency department. BMC Health Serv Res. 2020;22(1):75. doi:10.1186/s12913-022-07472-x
Key words: de-escalation, agitation, aggression, restraints, patient safety
