Keeping the Unit Safe: The Anatomy of Escalation

Abstract

BACKGROUND: Escalation has been depicted as a linear trajectory of behavioral eruption beginning with agitation and proceeding until the patient is out of control. This notion has influenced current descriptions of de-escalation strategies. OBJECTIVES: The study objective was to understand the context and conditions that influence how nursing staffs manage patients who are escalating out of control. DESIGN: Methods consistent with grounded theory were used to collect and analyze the data. Patient—staff interactions were observed for more than 400 hours on inpatient units. Sixteen staff members and 12 patients were interviewed. FINDINGS: Data analysis revealed a nonlinear process of escalation and de-escalation. Two conditions that influenced strategies used by staff members were the type and the trajectory of escalation. This report focuses on patterns of patient escalation. CONCLUSION: The data revealed a complex escalation and de-escalation process that necessitates ongoing assessments of patient status and the milieu and individualizing staff responses. J Am Psychiatr Nurses Assoc, 2007; 13(1), 42-52.