Responding to Escalating Behaviors on a Child Inpatient Unit: Five Elements Often Missing in De-escalation Dialogs

This discussion paper elaborates the elements of patient engagement and teamwork that support the effective use of de-escalation during tense situations marked by increasing threat, lability, or hostility. Staff training often involves de-escalation techniques which equip staff with important basic skills. Yet what often fails to be explained during training are subtle elements operating on inpatient child/adolescent milieus that are critical to the effectiveness of this intervention.

Synthesis of practice experience and the literature on select elements such as milieu leadership, teamwork, and relationship leverage which supports de-escalation efforts on child inpatient psychiatric units.

Five elements of inpatient practice were identified: teamwork, charge nurse leadership, staff holding a common understanding of behavior and a sense of the underlying dynamics of aggression, and use of relationship leverage. How these elements support de-escalation is briefly discussed. Included in the elaboration of these elements are the strategies unit managers might draw upon to cultivate these critical team and engagement elements.

Unit leadership should find opportunities to cultivate knowledge and skills related to teamwork, a shared understanding of a youth's behavior, the dynamics underlying aggression, and building engagement. These dimensions of practice are nuanced and often involve implicit aspects of teamwork and unit culture. Yet they are critical to keeping units safe and supporting de-escalation. These elements and how they support de-escalation should be articulated and cultivated with novice staff and new team hires.