De-Escalation Techniques and Tools for Psychiatric Patients

Introduction

Nurses working in psychiatric services are exposed to a much greater degrees of verbal, emotional, and physical violence when compared to other nurses. Niu et al. (2019) report that, on average, nurses in psychiatric wards experience 0.55 incidents of patient-incited violence per bed per month, which is 20 times higher than in other nursing professions. The issue is magnified by the fact that patients cannot always control their violent impulses, and that nurses do not know how to appropriately diffuse the situation (van Leeuwen & Harte, 2017). Because of the high rates of violence, potential for injury and trauma, and other related factors, turnover rates among healthcare workers in mental care facilities is significantly higher (Zhao et al., 2018).

These issues lead to a broad range of consequences for mental healthcare. In the US, to attract and retain nurses, healthcare providers are forced to pay psychiatric nurses about 1/3 more than the average RN earns per year, with paychecks exceeding 100,000 dollars per nurse versus 70,000 dollars per country average (Delaney, Drew, & Rushton, 2019). While the financial compensation is certainly warranted, it imposes additional costs on the system, which are, in turn, making psychiatric assistance less available to the poor and vulnerable populations.

High turnover rates also produce understaffing issues, forcing hospitals to impose overtime on their existing staff, potentially exacerbating burnout, apathy, and care fatigue in nurses (Hulme et al. 2019). All of these factors create a full circle, where nurses leave because of various stressors, which become more pronounced due to a lack of staff.

De-escalation techniques remain some of the very few tools in a nurse’s repertoire that he or she could use in order to prevent a violent incident from occurring (Kuivalainen et al., 2017). However, the information regarding the available techniques and their comparative effectiveness is scattered and incomplete (Kuivalainen et al., 2017).

As such, it is difficult to make estimations and recommendations for situations in which particular methods would be effective. Together, all of these factors form a complex issue that reduces the effectiveness of mental care and increasing the chances of negative outcomes for patients and nurses alike. Overreliance on physical and pharmacological restraining methods as the most intuitive and readily available tools in a nurse’s arsenal has been causing short-term injuries in patients in 55% of all restraining cases (Juromski et al., 2018). In addition to this issue, the use of standard protocols is associated with long-term deterioration of trust between nurses and patients, making repeat incidents occur in the future (Vermeulen et al., 2019).

Therefore, several concerns are brought up in regards to violence towards nurses in wards. The first concern is the security of patients and nurses alike, with the overarching goal being to bring down the number of incidents and reduce the impact for all parties in those that do occur.

The second concern is to reel in the economic impacts of such behavior on the mental healthcare system. The third concern is to identify the appropriateness and effectiveness of available de-escalation tools and techniques available to nurses. The gaps of knowledge do exist, as in the majority of available sources, there is a lack of a holistic approach to all of these issues, instead seeking to provide an answer to a single piece rather than foresee the greater implications of their findings (Kuivalainen et al., 2017).

Problem Statement

As it stands, there are several methodologies of de-escalation being implemented in contemporary psychiatry. The most traditional method involves physical de-escalation and tranquilization of the patient, which relies on immobilizing the aggressive person using physical force and specialized tools (Kuivalainen et al., 2017). Pharmacological tranquilization is another method of calming down the patient by either injecting tranquilizer agents into their bloodstream or spraying it in the air in aerosol form (Kuivalainen et al., 2017).

Both of these methods are invasive and threaten injury not only for the nurses attempting it but for the patient as well. In addition, these methods are considered controversial in the scope of not only the nursing community but also the society in general, coming very close to violating patient dignity and rights.

Alternative methods of de-escalation include unorthodox ways, such as verbal de-escalation, dance-based de-escalation, repeating motion techniques, hypnosis, etc. (Brewer, Beech, & Simbani, 2017). The effectiveness and acceptance of these means is unclear, especially when compared to traditional methods (Brewer, Beech, & Simbani, 2017). In addition, the state of knowledge among nurses in regards to de-escalation techniques remain unknown (Thompson, Thompson, Gaskin, & Plummer, 2019). Therefore, the comparative viability of utilizing these techniques for nurses should be established. The proposed solution is to compare the effectiveness of DMT versus invasive ones (pharmacological, physical restraining) in reducing patient aggressiveness levels during various stages of conflict (verbal assaulting, general aggressive behavior, attempts at violence, etc.).

Background

Psychiatry is one of the most demanded fields of medicine in the US and the world. The number of US citizens that have experienced a mild mental disorder is 19.1% a year, with additional 4.6% experiencing significant mental impairments (NAMI, 2019). Thus, roughly ever 4th American requires short-term psychiatric assistance, and roughly 1 in 25 requires long-term psychiatric surveillance. The reasons for such an increase in mental health reliance are associated with the increased job-related stress, higher population mobility, the ever-shifting demands of the market, the development of addictive technology, and the atomization of the society, among various others. Therefore, the necessity for a well-developed psychiatric healthcare system in modern society is well-pronounced.

At the same time, the US and the world healthcare systems are experiencing a chronic shortage of nurses. With the increase in population numbers as well as the growth in geriatric patients, it is estimated that 11 million additional nurses would be required by 2040-2060, roughly 11% of which would need to be psychiatric nurses (Ong et al., 2017). At the same time, the overall growth of nurse numbers is very slow, roughly 0.5% a year, which is bound to be offset by a looming retirement of nearly 20% of nurses representing the baby boomer generation (Ong et al., 2017). This is especially threatening to the psychiatric segment of healthcare, where the number of new recruits has been historically low.

Low retention rates in psychiatric medicine has always been associated with increased physical and psychological pressure on nurses working with potentially dangerous patients (Niu et al., 2019). Whereas nearly all other areas of medicine can expect their patients to be actively interested in assisting nurses in their work, psychiatric nurses have to deal with individuals who are confused, disoriented, or openly hostile to their wards, leading to increased chances of violence escalation during various procedures, without much of a warning or provocation patients (Niu et al., 2019). Recent reports indicate that roughly 50% of men and 80% of women in the profession have been exposed to patient attacks at least once in the past year (Niu et al., 2019).

While recruitment and retention of nurses are a global issue that requires a multi-vectoral approach, one of the interventions that could be done to improve the immediate situation require the assessment and implementation of effective de-escalation techniques that would prevent nurses from being endangered, assaulted, and hurt by patients either through emotional, verbal, or physical confrontation. Vermeulen et al. (2018) report that the first serious threat of violence can result in a nurse leaving the profession, especially if any physical damage was taken as a result. The study also shows that the effects of violence have a bigger effect on nurses than patients, whereas physical de-escalation has a greater negative impact on patients as a result (Vermeulen et al., 2018).

Verbal aggression is another form of violence instigated by patients against nurses. In some cases, it is reciprocated, creating a power dynamic that is unfavorable towards patients, who are relying on nurses in order to continue daily functioning. Report by Oyelade, Smith, and Jarvis (2017) state that verbal aggression usually serves as prelude to physical violence, leading to the deterioration of perception of hospitals as safe spaces and nurses – as individuals who are there to help out. Therefore, de-escalation of verbal aggression and the principles of nonaggression are considered primary in defusing such situations. Nevertheless, the repetitiveness and ease of delivery make verbal aggression an important detriment to nurse resilience (Oyelade et al., 2017).

The set of guidelines for de-escalation as provided by NICE (2015) offers the official view on the issues of violence against psychiatric nurses. The guide provides information on main de-escalation techniques and recommends physical restraint as one of the safest ways of preventing violence. In addition, the guide refers to the interceptive nature of de-escalation, stating that predicting when violence would occur and avoiding it is much easier than to deal with the consequences of an attack (NICE, 2015).

These findings align with several other studies on the issue, namely the one by Halett (2018), which investigated the instances and effectiveness of conflict management techniques. According to the research, conflict avoidance is a viable strategy, especially in patients that are not in a constant fit of aggression. Knowing the triggers that provoke patients and leaving them alone for the anger to dissipate saves time, nerves, and money for both parties (Halett, 2018).

At the same time, the study indicates that the implementation of conflict avoidance is not always an option, as procedures that involve unpleasant feelings are often unavoidable, and tend to be the primary triggers for patients (Halett, 2018). The current situation in regards to nursing shortage, the incidence of violence, and the general mood in psychiatric hospitals show that the existing guidelines are only partially effective in changing the trends.

With pharmacological and physical de-escalation techniques being considered too invasive and only focused on the short-term benefits, some researchers focused on milder and non-invasive approaches utilizing a variety of cognitive-behavioral methods, ranging from verbal de-escalation techniques to dancing and mimicking approaches (Biondo, 2017). The idea behind these methods is similar – to make the individual perceive the nurse as less of a threat or bring their minds in a state of confusion in order to prevent an impending attack.

Biondo (2017) evaluated the potential for a dance therapy to not only help de-escalate violent behavior of nurses and patients, but also act as a stress reliever for both parties. Brewer et al. (2017) provide a complex review of both types of approach, comparing their effectiveness. While pharmacological and physical methods were deemed effective at preventing immediate aggression, the effectiveness of milder forms of restrained offered only conflicting information on the subject (Brewer et al., 2017).

The state of knowledge is one of the major indicators of nurse response towards aggression as well as the levels of appropriateness of de-escalation. While psychiatric nurses as well as healthcare workers from other departments are given a course in de-escalation during their education, such knowledge tends to fade away or be replaced by realities of work. Therefore, it needs to be refreshed in order to increase nurse responsiveness, reduce care fatigue, and encourage mindfulness when dealing with patients. Thompson et al. (2019) indicate that educational intervention aimed at nurses have a largely positive response and offer great improvements in handling patients as well as increasing the overall morale of the participants involved in the study. These findings make educational interventions viable for implementation in the course of this study.

Purpose

The purpose of the study is to implement an educational intervention for psychiatric nurses, in order to improve their morale, knowledge, and handling of violent patients. In addition, the study wishes to provide a comparative analysis of situations and different methods of de-escalation in short-term and long-term perspectives. As such, it will answer the questions posed in several articles in one and provide a solid framework for future research.

The overarching purpose of the research includes improving the state of practice in psychiatric wards and giving guidance to other studies in order to improve the existing techniques and throw away ones that do not work as expected. While pharmacological and physical restraints are likely to remain in practice, the overreliance of nurses and wards on such can be put into question, especially in the light of new, less invasive methods being brought into practice. The issues of current levels of nursing knowledge of de-escalation techniques will also be brought into the light.

The broader implications of the research for the state of nursing and medicine are that, should the proposed intervention be successful, it could be replicated in other hospitals and at a larger scale, thus improving patient and nursing outcomes. Additional purposes include reducing turnover rate, violence rates towards nurses, ineffective or over-the-top responses from the psychiatric ward towards patient violence escalation, and highlighting various leadership and organizational challenges the study will encounter along the way, as well as ways of overcoming them.

The Nature of the Project

The proposed project is an educational and applicational intervention, that will use a quantitative design. Such a methodology is preferable in medical research, as it offers statistically-significant data that is difficult to misinterpret. The data of interest for this project is as follows: the state of knowledge of de-escalation techniques before and after the educational intervention, the implementation of such techniques during conflict situations, and the effectiveness of it in different scenarios. Due to the relatively small estimated number of participants within a single ward, as well as the inability to create a control group, the project will follow a quasi-experimental design. The results will be compared to the baseline of patient-nurse conflict incidents in the past years as well as the country’s overall average.

The first part of the intervention would involve examining the theoretical and practical knowledge of all nurses that expressed the desire to participate. This will be done using a custom test that will be based on those used in examination of nurses to fit for registration, in order to learn how much knowledge was retained during the years of practice. The scores would present quantitative data to be compared later with similar tests administered after the training. It would help evaluate the improvements and the immediate effectiveness of the intervention on the knowledge levels of the nurses. Finally, the third test would be held after they are given the opportunity to use their newfound and rediscovered knowledge in a practical setting.

After training was administered, nurses would be allowed to return to their duties. For the duration of the practical part of the study, they would be required to fill out special forms whenever a potential event of violence occurred, including a brief description of what happened, the type of de-escalation technique implemented, and its effectiveness in resolving the situation.

This would provide additional qualitative and quantitative data that would help evaluate the effectiveness and frequency of use of different de-escalation techniques in the setting, allowing for a comparative analysis. The results will allow creating a correlation between different de-escalation methods, success/unsuccess rates, and frequency of use. The total number of successful and unsuccessful incidents will be compared with data from previous years, in order to understand whether the intervention managed to reduce the number of violent attacks on nurses.

Finally, the third batch of tests would involve the evaluation of nurse burnout and care fatigue before and after the intervention. It will be done using the Maslach Burnout Inventory, which contains 26 items that could be used to determine the levels of burnout in individual nurses. It is theorized that with the improved effectiveness as a result of the educational intervention and greater understanding of the mechanisms behind patient aggression, the levels of burnout are bound to go down, associated with greater safety of the working environment.

Research Questions

Based on the background studies and evaluations of the existing problem, the research questions to be addressed in the scope of this research are as follows:

1. Evaluate the existing state of knowledge of de-escalation techniques in nurses working in a psychiatric ward.
2. Evaluate the existing levels of burnout as a result of patient violence as well as other conjoining factors.
3. Evaluate the improvements (or lack thereof) on both the knowledge and burnout rates as a result of the intervention.
4. Test out the effectiveness of DMT on patients as well as their applicability to various situations.

The PICO framework for the research is as follows:

• P= Patient violence against psychiatric nurses;
• I= Education in de-escalation techniques;
• C= Baselines for patient violence incidents from previous years;
• O= Decreases in patient violence incidents, burnout rates, increases in knowledge levels and nurse satisfaction.

The complete PICO question, thus, is as follows: In psychiatric nurses (P), does education in DMT (I), when compared to baselines for patient violence incidents from previous years (C), result in decreases in violence, burnout rates, and increases in nurse satisfaction and knowledge levels (O)?

Summary

Nurse psychiatrists are in very high demand due to increasing rates of mild and significant psychiatric disorders in the US and the world in general. At the same time, it is one of the most dangerous and exhausting professions due to the constant physical and emotional stress as well as the potential for violence. One of the ways of mitigating these issues is to engage in de-escalation techniques that seek to prevent a violent incident early on or reduce the damage dealt to the nurse by the patient.

There are different types of violence, including verbal, psychological, and physical. While physical violence is typically handled using physical restraints or medicaments, verbal and emotional violence has a broader variety of potential responses. Some of the de-escalation techniques that recently attracted attention dance-movement therapy.

The proposed research seeks to improve the quality of life in nurses, reduce the number of violent incidents with patients, and increase their knowledge of de-escalation techniques. This is proposed to be done via an educational intervention of quasi-experimental design. Quantitative data will be gathered by using tests, self-report cards, and the Maslach 26-item burnout inventory. The research has a broad range of implications for the nursing profession and psychiatric medicine in general, as positive results would suggest its viability to be implemented in larger settings. Reduction of violent incidents in patients would not only benefit nurses, but patients as well, by protecting them from the ability to cause damage, improving nurse behavior, reducing burnout, and facilitating better patient outcomes in both the short-term and long-term perspectives.

Literature Review

Lodwick (2018) defines dance/movement therapy (DMT) as a collection of techniques that focus on the psychotherapeutic effects of movement in order to promote calmness in a patient and achieving short-term and long-term physical, social, and psychological integration of the individual. He highlights the connection between mind and body, and states that, due to them being integrated in a single system, a positive effect on one could improve the other (Lodwick, 2018).

The studies of effectiveness reviewed in the article reflect on the major mechanisms that enable DMT to achieve success, those being kinesthetic empathy, mirror neurons, attunement, and therapeutic movement relationships (Lodwick, 2018). These mechanisms enable the formation of a trusting relationship between the patient and the nurse, enabling better mental and body control (Lodwick, 2018).

The effectiveness of DMT is connected to its effect on the patients and nurses alike. The research by Biondo (2017) evaluated the results of DMT in comparison to restraint and seclusion, which, though common and widespread, remained a controversial method of de-escalating violence. The study featured a 5-hour training session for 73 psychiatric medicine students, during which they were enabled to build up their observational skills, empathy, and self-efficacy, which are important skills for nurses to have in order to work with psychiatric patients (Biondo, 2017). Positive increases in all three parameters were reported as a result of the intervention (Biondo, 2017).

DMT shows its effectiveness not only when working with adults, but also with children. Lundy and McGuffin (2015) states that body-based therapy helps reduce the risks of violence escalation between children, nurses, and parents, allowing for holding maneuvers to be accepted without provoking violence. The results of the intervention were clear: DMT helped improve adult awareness, sensitivity, perspective-shifting ability, and confidence for all parties involved (Lundy & McGuffin, 2015).

The psychosomatic connection between trauma, movement, and the potential for violence against nurses is further explored by Vicario (2017), who asserts that the human body is designed to move, therefore the use of movement can be beneficial to many forms of therapy. In relation to DMT and the reduction of violence in nurses, Vicario (2017, p. 6) points out that “from a depth psychological perspective, the use of movement is explored as a therapeutic way of accessing and releasing repressed or unconscious emotions and memories associated with trauma.”

This is further explored in relation to violence, which is often described as an unconscious self-defense mechanism often triggered by said memories (Vicario, 2017). Additional claims made in the scope of this paper include the fact that physical and drug treatment of patient aggression do little to solve the root cause of violence (memories and triggers), instead supplanting them by portraying the nurse as an aggressor of a different kind, to ensure compliance (Vicario, 2017).

One of the primary characteristics in a significant portion of patients, who had to deal with physical as well as psychological trauma and abuse is the somatic response to certain patterns of movement they perceive as a threat (Pranzo, 2018). In this context, violence is incited by miscommunication between the intent and purpose of approach by nurses, unintentionally. Pranzo (2018) finds that dance and motion therapy address the somatic response issues by getting the patient aware of the true intentions behind treatment and facilitates familiarization with specific individuals, resulting in the reduction of violent incidents. Therefore, DMT is recommended as a means of treatment in trauma survivors in short-term and long-term psychiatric wards.

Lapum et al. (2018) support the value of DMT in patients that have been experiencing violence for a prolonged period of time. Patients that have been placed in a psychiatric ward as a result of domestic and sexual abuse often perceive the behavioral patterns of people who assaulted them in everyone else, and often lash out in self-defense (Lapum et al. 2018). The research finds that dance and motion therapy not only assist in normalizing the responses towards particular movement patterns as expressed by nurses, but also leads to a better state of being by reducing somatic symptoms of psychiatric disorders, achieving focus of body and mind, and facilitating a consensus in both (Lapum et al. 2018).

The specifics of movement therapy are elaborated by Chodorow (2018), who identifies the primary methods of DMT and the place of the nurse in it. According to his findings, the therapist is not allowed to follow a singular pattern, instead they must respond to movements, assess body language, and practice analysis of non-verbal behaviors to better fit the situation and facilitate emotional peace, that contributes to the de-escalation of violence (Chodorow, 2018).

As per nature of the intervention, movement is both the facilitator of information transfer and the means of changing behavior. According to Chodorow (2018), the primary methods include mirroring and movement metaphors. The purpose of mirroring in the context of de-escalation is to demonstrate empathy and understanding towards what the patient is going through. Movement metaphors, on the other hand, are nonverbal communication patterns used to present challenges, applaud achievements, and presenting rewards for good behavior (Chodorow, 2018).

DMT as a means of violence de-escalation in a psychiatric ward can target numerous aspects of the patient’s psyche. However, there are several specific issues that are coincidental to the incitement of a fight-or-flight response in patients. The dance therapy intervention by Dietrich-Hartwell (2017) sought to address the three main aspects related to violence in psychiatric wards. Namely, these aspects include safety, patient hyperarousal and hypersensitivity to potential threats, as well as a lack of enteroception, which is present in the majority of trauma survivors (Dietrich-Hartwell, 2017). The study found that the first-stage clinical model proposed has a high chance of succeeding based on the results of similar interventions performed in aggressive post-traumatic psychiatry patients.

The effectiveness of DMT as a means of relating the nurses and patients one to another and reducing the amount of violence by increasing trust between individuals varies from one culture to another. Capello (2017) indicates that dancing as a form of self-expression resonates better in cultures where dancing is more socially acceptable as a means of spending leisure time. Notably, it was discovered that Latino, African, and Indian patients are more responsive to dance, finding it culturally appropriate (Capello, 2017).

At the same time, Asian cultures are deeply rooted in concepts of personal space, respect, and social image, making dancing as a means of therapy a less acceptable notion. Western countries hold the middle ground here, with some nations within the cultural paradigm of the continent being more open to DMT, while others – less so. Nevertheless, the analysis of DMT interventions across the continents reveals a moderate effectiveness of such in creating empathy between nurses and patients, which was observed as an effective means of reducing incidents of violence (Capello, 2017).

Theoretical Framework

The theoretical framework used to conduct this research is Lewin’s Change Theory. The framework suggests three distinctive stages through which the participants would have to go through in order to solidify changes to their behavior in practice. These steps include Unfreezing, Changing, and Freezing. The first step does with the dismantlement of existing preconceptions of practice. In the scope of the proposed intervention, this will be achieved by explaining the necessity and rationale for change towards nurses.

Academic and statistic evidence will be presented as a means of convincing them that the current backbone of patient-handling, which includes physical restraints and tranquilization, is not the only method of treating the situation. In fact, many findings indicate that these methods cause long-term issues by making the patient perceive the hospital personnel as a threat (Vicario, 2017).

The second stage, which is Change, introduces new concepts after the convictions of nurses in the infallibility and inescapability of their previous methods have been shaken. They would be introduced to the idea of DMT, its strong sides and long-term effectiveness, as well as the knowledge required to make effective use of it. During this stage, nurses will practice DMT under supervision, learning to utilize it effectively within their practice setting. Any potential resistance left from the first stage should be overcome during this period, achieving universal compliance.

The freezing stage is when DMT becomes the new standard of practice. For the purposes of this intervention, DMT will be used as a novel primary method of pre-emptively reducing patient-incited violence through building empathy, rapport, and understanding of each other on the body-mind level. Physical and medical means of handling violent outbursts would be removed from primary response and be used only when the situation cannot be handled in other ways. In so doing, the new promoted practice will be solidified in the psychiatric ward undergoing intervention.

Implementation and Evaluation

The implementation of proposed changes would be conducted in nurses constituting the personnel of a psychiatric ward. They will be asked to attend a series of seminars regarding DMT as a potential avenue of reducing patient violence towards nurses. The first class will be an introductory one, during which the motivation and rationale for the intervention will be presented to the audience, to convince them for the necessity of change. Theoretical knowledge will be taught in several sessions afterward, for the duration of one-two months. The third month will be utilized to introduce a practical component to the training, being led by DMT practitioners and, potentially, patients, under the supervision of an advisor. By the end of these three months, nurses will be capable of implementing changes needed in the psychiatric ward.

The evaluation of knowledge in nurses will be conducted by tests, both practical and theoretical, held after the course has been completed. In addition, tests will be used before the intervention to assess the current levels of knowledge about the practice. In addition, the knowledge-practice test will be held 6 months after the course, in order to determine knowledge retention. The tests utilized in nurses would be the same as those approved by the Dance/Movement Therapy certification board, and focus on these competencies:

• The ability to integrate DMT into professional practice;
• The ability to make goal-oriented interventions during treatment within the theoretical frame of DMT;
• The ability to communicate the issues regarding one’s own practice, clinical work, and DMT body of knowledge.
• The capacity for responsible and professional self-evaluation.

Survey Questions

The research will follow a quantitative quasi-experimental design, with tests being used before and after the educational intervention, followed by a survey of the respondents’ experiences with the knowledge during their practice in a psychiatric ward. The survey will consist of the following items:

• How often did you encounter patient violence in the last 3-6 months?
• Were the incidents of violence more or less frequent than in the past year?
• What methods did you utilize to de-escalate violent situations?
• Did you utilize dance therapy as a method of de-escalation?
• On the scale of 0 to 10, how would you grade the effectiveness of dance therapy as a de-escalation method in your practice?
• On the scale of 0 to 10, how would you grade the effectiveness of physical restraining as a de-escalation method in your practice?
• On the scale of 0 to 10, how would you grade the effectiveness of medical sedation as a de-escalation method in your practice?

This survey should offer a modicum of knowledge through which the effectiveness of dance therapy in their practice could be analyzed. Additional questions regarding other methods were added to provide a comparison of nurse perceptions of effectiveness for both methods. The results of knowledge tests as well as surveys could be analyzed using statistical software in order to generate the overall mean and median results for nurse knowledge and perceptions of effectiveness of dance therapy before and after the intervention. The latter could be evaluated using the Student’s T-test as a statistical method, due to the expected small size of the population participating in the research (Ali & Bashkar, 2016).

References

Ali, Z., & Bhaskar, S. B. (2016). Basic statistical tools in research and data analysis. Indian Journal Of Anaesthesia, 60(9), 662-669.

Biondo, J. (2017). De-escalation with dance/movement therapy: A program evaluation. American Journal of Dance Therapy, 39(2), 209-225.

Brewer, A. I., Beech, R., & Simbani, S. (2017). Using de-escalation strategies to prevent aggressive behaviour. Mental Health Practice, 21(2), 22-28.

Capello, P. P. (2017). Crossing continents: Global pathways of dance/movement therapy. American Journal of Dance Therapy, 39(1), 47-60.

Chodorow, J. (2018). Dance/movement therapists in action: A working guide to research options. Charles C Thomas Publisher.

Dănilă, O., & Herb, S. (2017). Back to the Basics–emotionally focused psychotherapy approach in times of unpredictability and isolation. Journal of Experiential Psychotherapy, 20(4), 14-24.

Delaney, K. R., Drew, B. L., & Rushton, A. (2019). Report on the APNA national psychiatric mental health advanced practice registered nurse survey. Journal of the American Psychiatric Nurses Association, 25(2), 146-155.

Dieterich-Hartwell, R. (2017). Dance/movement therapy in the treatment of post traumatic stress: A reference model. The Arts in Psychotherapy, 54, 38-46.

Hulme, K., Little, P., Burrows, A., Julia, A., & Moss‐Morris, R. (2019). Subacute fatigue in primary care–two sides of the story. British Journal of Health Psychology, 24(2), 419-442.

Juromski, K., Pressel, D., Fingado, E., Tomaszewski, J., & March, P. (2018). Characteristics of violent restrained patients in a children’s hospital. Pediatrics, 141(1), 400.

Kuivalainen, S., Vehviläinen‐Julkunen, K., Louheranta, O., Putkonen, A., Repo‐Tiihonen, E., & Tiihonen, J. (2017). De‐escalation techniques used, and reasons for seclusion and restraint, in a forensic psychiatric hospital. International Journal of Mental Health Nursing, 26(5), 513-524.

Lapum, J. L., Martin, J., Kennedy, K., Turcotte, C., & Gregory, H. (2019). Sole expression: A trauma-informed dance intervention. Journal of Aggression, Maltreatment & Trauma, 28(5), 566-580.

van Leeuwen, M. E., & Harte, J. M. (2017). Violence against mental health care professionals: prevalence, nature and consequences. The Journal of Forensic Psychiatry & Psychology, 28(5), 581-598.

Lodwick, K. E. (2018). Promoting kinesthetic empathy with dance/movement therapy: an evidence-informed protocol to support de-escalation (Doctoral dissertation, Drexel University).

Lundy, H., & McGuffin, P. (2005). Using dance/movement therapy to augment the effectiveness of therapeutic holding with children. Journal of Child and Adolescent Psychiatric Nursing, 18(3), 135-145.

NAMI. (2019). Mental health by the numbers. National Alliance of Mental Health. Web.

NICE. (2015). Violence and aggression: Short-term management in mental health, health and community settings. National Collaborating Centre for Mental Health. Web.

Niu, S. F., Kuo, S. F., Tsai, H. T., Kao, C. C., Traynor, V., & Chou, K. R. (2019). Prevalence of workplace violent episodes experienced by nurses in acute psychiatric settings. PloS One, 14(1), e0211183.

Pranzo, E. (2018). Imagery of Elements: A trauma/informed dance movement therapy method to stabilize adults in a short-term psychiatric hospital (Doctoral dissertation, Drexel University).

Oyelade, O., Smith, A. A. H., & Jarvis, M. A. (2017). Dismissing de-escalation techniques as an intervention to manage verbal aggression within mental health care settings: Attitudes of psychiatric hospital-based Nigerian mental health nurses. Africa Journal of Nursing and Midwifery, 19(2), 1-18.

Ong, H. L., Seow, E., Chua, B. Y., Xie, H., Wang, J., Lau, Y. W.,… & Subramaniam, M. (2017). Why is psychiatric nursing not the preferred option for nursing students: A cross-sectional study examining pre-nursing and nursing school factors. Nurse education today, 52, 95-102.

Vermeulen, J. M., Doedens, P., Boyette, L. L. N., Spek, B., Latour, C. H., & de Haan, L. (2019). “But I did not touch nobody!” – Patients’ and nurses’ perspectives and recommendations after aggression on psychiatric wards – A qualitative study. Journal of Advanced Nursing, 75(11), 2845-2854.

Zhao, S. H., Shi, Y., Sun, Z. N., Xie, F. Z., Wang, J. H., Zhang, S. E.,… & Fan, L. H. (2018). Impact of workplace violence against nurses’ thriving at work, job satisfaction and turnover intention: A cross‐sectional study. Journal of Clinical Nursing, 27(13-14), 2620-2632.

Vicario, M. (2017). Dancing with trauma: A psychosomatic exploration of dance movement therapy and trauma release. Pacifica Graduate Institute.