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Early intervention can prevent behavior escalation

By: Debra Berard Krahling, DNP, MSN, MSHSA, BSBA, RN

Collaborative plan development between patients and staff can facilitate de-escalation.

ACCORDING to the Occupational Safety and Health Administration, patient violence against healthcare workers is the most frequent type of occupational violence in high-risk areas of healthcare, such as emergency departments and psychiatric units. Employees in healthcare settings are four times more likely to be victims of violence than employees in private industry. Common consequences of workplace violence against nursing staff are negative psychological and emotional effects and the associated impact on work function. When employees fear assault, quality care delivery may be inhibited, and staff emotional health may be impaired.

Early intervention—including identifying patient-specific triggers and behaviors and developing a plan of action when a patient responds to a trigger—is critical to preventing and decreasing unwanted behaviors and keeping both patients and employees safe.

Here is how a behavior prevention plan works at Saint Elizabeths Hospital, a large state-run psychiatric hospital in Washington, DC. The process for the plan, which can be used in any setting where patients with serious mental illness receive care, incorporates principles and strategies from several sources. (See Behavior prevention strategies.) The most important strategy is collaboration between the patient and the healthcare team.

Developing the plan

At admission, or as early as possible after admission, each patient meets with the interprofessional staff to discuss preventing behavior escalation events. The discussion focuses on identifying the following (sample questions are in parentheses):
• anxiety-producing triggers (What makes you feel anxious or angry?)
• resulting behaviors (How would those around you know that you’re feeling anxious or angry?)
• interventions that have successfully decreased unwanted behaviors in the past (What has worked in the past to soothe and decrease your feelings of anxiety or anger?)

Interventions also may come from observations by the care team and what has been recorded in the patient’s electronic health record (EHR).

The information obtained is used to develop a plan of care that helps nurses know what to do, when to do it, and why it needs to be done before an event occurs, which increases the chance for desired outcomes, including preventing behavior escalation, improving trigger thresholds, and avoiding patient retraumatization. (See Behavior plan components.) The plan, along with the patient’s answers to the questions, is included in the EHR and shared with staff caring for the patient so they’re prepared to respond quickly to behavior escalation.

Keys to success

Knowing each patient’s self-identified plan of care allows the nursing staff to identify triggers that promote aggression. The earlier a trigger is identified, the sooner attention can be brought to a specific patient’s behaviors. Plan success requires:

  • easy accessibility. If an organization uses an EHR, computers must be strategically located for quick access and the plan within the record should be easy to find.
  • staff education about how to use a behavior plan and ensuring they’re familiar with the contents of each patient’s plan. If a plan must be referred to after aggressive behavior begins, the window of opportunity for early intervention likely has already closed.

Case study

Ms. Allison Harding* shows how having a plan can successfully prevent escalation of unwanted behavior. Ms. Harding is a 57-year-old patient who has been diagnosed with schizophrenia and post-traumatic stress disorder. She currently resides on the hospital’s psychiatric unit, and loud noises trigger her to act aggressively.

Before working with Ms. Harding to develop a behavior prevention care plan, two interventions were attempted when she began pacing (a trigger signal) in response to a loud noise. On one occasion, the staff allowed her to continue pacing, but she quickly escalated to yelling and throwing chairs at staff. On a second occasion, a staff member asked Ms. Harding, “What’s the matter? May I help you?” This also resulted in behavior escalation.

After Ms. Harding met with the care team to understand her triggers, they asked her what worked in the past to help calm her. She reported that a weighted-blanket wrap, listening to music, and being alone in her room had helped to de-escalate her behavior.

Recently, during a fire drill, the fire alarm sounded for 10 minutes. When the staff saw Ms. Harding pacing, they offered her a weighted-blanket wrap and the opportunity to go to her room. Early implementation of this pre-identified plan helped to calm Ms. Harding and prevent behavior escalation.

*Name is fictitious.


Debra Berard Krahling is a clinical administrator at Saint Elizabeths Hospital in Washington, DC.


Selected references

Agency for Healthcare Research and Quality. 2015 annual progress report to Congress: National strategy for quality improvement in health care. 2016. ahrq.gov/workingforquality/reports/2015-annual-report.html

Bloom SL. The sanctuary model: Through the lens of moral safety. In: Gold SN, ed. APA Handbook of Trauma Psychology: Trauma Practice. Vol. 2. Washington, DC: American Psychological Association; 2017.

Champagne T. Sensory Modulation in Dementia Care: Assessment and Activities for Sensory-Enriched Care. Philadelphia, PA: Jessica Kingsley Publishers; 2018.

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