Reconceptualizing de-escalation in mental health care: A qualitative study

Patient aggression is a pervasive challenge in global mental healthcare. Although de-escalation is a cornerstone of non-coercive care, a significant theory-practice gap persists. This is often attributed to a research focus on fragmented techniques rather than on de-escalation as a continuous, relational process embedded in clinical practice. This gap is particularly pronounced in China's unique socio-cultural context, characterized by high-context communication and pronounced hierarchical power dynamics, which directly shape trust-building and authority navigation during de-escalation.

This study aimed to bridge this gap by exploring the lived experiences of psychiatric nurses in China, reconceptualizing de-escalation, and generating an integrated practice framework.

A qualitative descriptive study with interpretive thematic analysis was conducted using semi-structured, in-depth interviews with thirty registered psychiatric nurses from multiple tertiary hospitals across China. Data were analyzed using reflexive thematic analysis.

The analysis yielded a novel four-phase process model: pre-emptive prevention ('building a defensive levee'), an in-the-moment operational trilogy ('Stabilise, Connect, Resolve'), and post-intervention consolidation ('achieving a therapeutic closed-loop'), all sustained by an organizational ecosystem. The model repositions effective de-escalation not as an isolated skill but as a multidimensional outcome of relational, cognitive, and systemic factors. The model's novelty lies in its integration of discrete skills into a temporal, phase-based process, emphasizing the cyclical nature of relational work and the foundational role of the organizational ecosystem. Thus, it moves beyond a 'technocratic' training focus on fragmented skills in isolation. The core operational trilogy ("Stabilise, Connect, Resolve") provides a cognitive-behavioral framework for in-the-moment clinical reasoning.

This study provides a robust, experience-based framework that addresses the theory-practice gap by capturing de-escalation as a complex, continuous process. The findings underscore the necessity of moving beyond technocratic training towards systemic, relationship-centered support, offering a critical foundation for safer and more therapeutic mental healthcare environments.