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Supporting the reduction of restrictive practices in acute mental health units through an assessment of the evaluability, effectiveness, and process of implementing the Safe Steps for De-escalation
Thesis   Open access

Supporting the reduction of restrictive practices in acute mental health units through an assessment of the evaluability, effectiveness, and process of implementing the Safe Steps for De-escalation

Esario IV Pueblo Daguman
Southern Cross University
Doctor of Philosophy (PhD), Southern Cross University
2026
DOI:
https://doi.org/10.25918/thesis.602
Appears in  Recent Faculty of Health Publications
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Abstract

Coercion Intervention evaluation Mental health service De-escalation
Background: Minimising restrictive practices by maximising nurses’ relational capabilities is a key objective of reforms within acute mental health units worldwide. However, there is little high-quality evidence for implementation and evaluation of de-escalation and non-pharmacological programmes supporting these objectives. Aims: This thesis aimed to generate empirical support for Safe Steps for De-escalation. The programme targets nurses’ relational capabilities to cultivate less restrictive approaches to emotional distress, troubling behaviours, and interpersonal conflict through a structured de-escalation approach, training on its fundamental values, and restrictive practice reviews. The first study tested if and how the intervention and evaluation methods work. The second assessed effects on restrictive practices, physical injuries, service experience, staff actions related to violence prevention, and nurses’ professional quality of life, and explored implementation from nurses and individuals receiving care. Methods: The first study had a single-centre retrospective design; the second had a multi-centre, prospective, mixed-methods concurrent control design. A pragmatic complex intervention evaluation and implementation framework informed both. Data from administrative records, nurses’ records, fidelity checks, surveys, interviews, and focus groups were gathered in adult inpatient units across New South Wales, Australia, from October 2017 to April 2025. Statistical models, machine learning techniques, and reflexive thematic analysis were applied. Results: In the first study, a reduction in the seclusion rate was found compared to the within-group baseline, and evaluation methods were feasible. Findings informed change mechanisms, research questions, and hypotheses for the second study. In the second study, a significantly lower total restrictive practice rate was found in implementation sites compared to three control sites, with lower intramuscular psychotropic use contributing. Change mechanisms included restructuring the social environment, while a proxy fidelity measure was considered. Service experience and staff action scores remained unchanged, with stories from people receiving care suggesting broader influences on a humane and meaningful service experience. Two dimensions of nurses’ professional quality of life declined; however, sample sizes were smaller than planned. Nurses’ accounts suggested these findings were not due to the Safe Steps and implementation was context-dependent. Reframing behaviours through a hierarchy of needs highlighted functional, contextual, and interventional factors driving restrictive practices. Conclusion: There is now evidence for the effectiveness of Safe Steps in reducing restrictive practices in mental health units. The studies illustrate overlapping and recursive stages of knowledge creation and implicate a reversal of approaches to assessing evaluability, effectiveness, and implementation, elevating relationships between intervention, implementation context, and agents of change.

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