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Maximising relational capabilities and minimising restrictive practices in acute mental health units: the Safe Steps for De-escalation evaluation
Journal article   Open access   Peer reviewed

Maximising relational capabilities and minimising restrictive practices in acute mental health units: the Safe Steps for De-escalation evaluation

Esario IV Daguman, Jacqui Yoxall, Richard Lakeman and Marie Hutchinson
Frontiers in psychiatry, Vol.16, pp.1-16
06/11/2025
DOI: https://doi.org/10.3389/fpsyt.2025.1676743
Appears in  Recent Faculty of Health Publications
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Abstract

de-escalation psychiatric nursing mental health services coercion psychiatric hospital intervention evaluation
Objectives: De-escalation is widely endorsed as an intentional strategy to replace and reduce restrictive practices in acute mental health units. However, high-quality evidence for its effective implementation remains limited. In response, a pragmatic, complexity-informed evaluation was undertaken to generate empirical support for the impact of an intervention, Safe Steps for De-escalation, on restrictive practices. The intervention centres on a four-step framework for therapeutic responding, with implementation supported by codesigned training and restrictive practice reviews. Methods: A mixed concurrent control study was conducted in three adult inpatient units in New South Wales, Australia, from March 2023 to April 2025. A priori weighted linear, linear mixed-effects, and generalised linear mixed-effects models were fitted between and within groups, to assess the impact of the intervention on restrictive practice events, including seclusion, physical restraint, as-needed intramuscular psychotropics, event duration, and physical injury. A priori hierarchical cluster analysis and between-cluster comparison were used to examine the most active de-escalation response components and any associated concurrent supplementary strategies contributing to the overall impact. Results: Compared to three control sites, implementation sites had a lower total restrictive practice event rate (incidence rate ratio [IRR] = 0.65, 95% CI [0.60, 0.69], p <.001) over a twelve-month intervention period. At a granular level, implementation sites had lower IRRs for seclusion and as-needed intramuscular psychotropics than controls; however, within-group rates fluctuated over the year. Two clusters of de-escalation responses and additional supplementary strategies (including stimulus reduction, music, and one-on-one staff time) were noted. The differential associations between clusters and the outcomes were insignificant. Conclusion: Despite mixed results, the evaluation offers support that structured therapeutic responding helps minimise restrictive practices, without evidence suggesting a substitution of one form of coercion for another.

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