Perspectives and Experiences of Nurses Implementing the Safe Steps for De-Escalation in Acute Mental Health Units

Efforts to reduce restrictive practices in acute mental health units require more than operational reform; they also need to give voice to clinicians who implement these changes.

This paper forms part of a broader evaluation of the Safe Steps for De-escalation, which was aimed at investigating the impact of the Safe Steps implementation on the perceived professional quality of life of the nurse participants. This paper also presents a qualitative assessment of the process, aimed at identifying the factors that influence the successful implementation of the Safe Steps from the perspective of the nurse participants.

Safe Steps is a structured approach for de-escalation, intended to reduce restrictive practices and promote the development and maintenance of therapeutic relationships, as well as individuals' self-management. It was implemented in three adult inpatient units in New South Wales, Australia, from March 2024 to April 2025. This paper was nested within a mixed concurrent control study and was informed by a pragmatic and complex intervention research framework. Nurse focus group discussions were analysed using reflexive thematic analysis. Paired measures of compassion satisfaction, burnout, and compassion fatigue before and after one-year implementation were compared.

Scores after implementation indicated a decline in compassion satisfaction and an increase in burnout, compared to the baseline. Two superordinate themes were identified from seven focus groups, with twenty-six nurse participants: (i) de-escalation is a relational, adaptive, and collective nursing practice, and (ii) ecological pressures shape the practice of de-escalation. These superordinate themes were developed from seven subordinate themes.

A cautious interpretation of the quantitative measures is warranted, given the challenges of obtaining follow-up responses in busy, under-resourced inpatient units. The thematic findings suggest that successful implementation depends on the organisational and relational contexts in which interventions are deployed.

Future evaluations of the Safe Steps need to consider extending beyond nurses' relational capabilities to encompass the relational responsiveness of multidisciplinary teams.