Two major themes were generated: the recognition of agitation and the management of agitation. A number of subthemes were generated within each major theme (Figure 1).
Recognition of Agitation
Two themes were identified from the nurses’ accounts of the recognition of agitation: the role of the patient and the role of the nurse. The nurses also described these roles as having a ‘symbiotic’ relationship.
The role of the patient
Self-awareness and self-report of agitation
Nurses described the patients’ own identification of their level of agitation as playing a key role in the recognition of agitation. One nurse described that is was common for patients to approach nurses to let them know they were becoming agitated, pre-empting the nurse’s assessment.
A lot of the time the patients will come up and say, I need some medication, I’m agitated. (Group C)
Another nurse commented that it was in the patients’ best interests that they self-reported increased feelings of agitation to assist with early intervention.
If someone identifies that they are getting aroused or getting agitated, it is probably the best thing for them to approach the nurses. (Group A)
Nurses also described the completion of the ‘Coping and Safety Plan’ on admission by the patient as a valuable form to assist nurses in gathering information about symptoms, triggers, and management strategies.
The role of the nurse
Within this theme, four sub-themes were identified: clinical knowledge of the signs and symptoms of agitation; knowledge of the patient’s ‘baseline behaviour’ and signs of agitation; the use of tools for assessing agitation, and communication among staff members.
Clinical knowledge of the signs and symptoms of agitation
Nurses described various signs and symptoms related to agitation. In every focus group pacing, restlessness and raised voices were identified. Banging on the nurses’ station or slamming doors was mentioned in two groups, while another group said agitated patients could be uncooperative and engage in anti-social behaviour. Symptoms such as pallor, clenched fists, exaggerated hand gestures, sweating, and tightly pursed mouths were also described as signs of agitation in patients. The nurses described their observation of patients’ behaviour and physical activity and their ability to act quickly to diffuse agitation when signs and symptoms arose.
It’s about being able to observe closely and then pick up on the early warning signs earlier. (Group D)
Knowledge of the patient’s ‘baseline behaviour’ and signs of agitation
Nurses acknowledged that patients are diverse and as such display different signs and symptoms of agitation and reasons for becoming agitated. Knowing and understanding each patient was described as aiding the recognition of the onset of agitation.
Those kind of things are obvious ones but there are much more subtle ones, if you know someone’s baseline and the way they behave when they are not agitated you start to see signs of them changing in their behavior. (Group D)
Nurses reported that they used the patient history and the ‘Coping and Safety Plan’ to gain an understanding of the baseline behaviour of the patient and establish an “early warning sign” of agitation and how to manage agitation. Even so, one nurse acknowledged that agitation can occur without such warning signs.
So, identifying early warning signs of people's agitation is very important and what we focus on in the training. (Group D)
The use of tools for assessing agitation
Nurses described the different assessment tools used in the mental health unit to assess risk and measure the degree of agitation in patients. The ‘Brief Risk Assessment Tool’ was used on the wards to identify whether patients were at high or low risk of agitation based on their history. Nurses also acknowledged the use of a ‘Targeted Risk Assessment’ tool, which is a new initiative within the psychiatric intensive care unit (i.e., the locked ward) specifically aimed at the daily assessment of patients who are involuntarily admitted.
Special psychiatric intensive care unit patients are assessed on a daily basis. Patients are assessed on a daily basis. Then um, you sort of mark them off, in regards how mentally in terms of how they are like maybe aroused or whether they are generally settled on the ward, whether they are actually escalating. (Group A)
Nurses mentioned however, that they only use these assessment tools as guidelines since they must be prepared for unexpected changes in the behaviour of their patients.
So, although we use different types of risk assessment tools we don't particularly rely on them wholeheartedly. You know we've come to use as a guideline. Well of course we know this but at any point anything can happen, or it may not so you just have that in your thinking. (Group D)
Communication among staff members
The nurses stated that effective communication among staff members around observed signs and symptoms of agitation in patients was crucial in the assessment of patients and the need for timely intervention and management.
I think communication is key. (Group D)
We’re quite good at coming together as a team. (Group A)
Communication could occur at any time during the shift and during handover. Debriefing sessions involving staff following an incident were also helpful in equipping nurses with better skills for recognising and managing agitation in the future. The outcomes of the ‘Targeted Risk Assessment’ were also said to be discussed within the team to initiate measures where necessary to minimise the risk of an escalation in agitated behaviour.
The management of agitation was organised into two themes: the type of interventions used and, the processes that support successful management.
Types of interventions
Nurses described the use of non-pharmacological and pharmacological interventions to manage agitation and how the two can be used in conjunction to manage agitation.
The use of various de-escalation strategies was discussed in all focus groups as the first choice strategy to manage agitation.
We go on de-escalation being the first line of call when we are trying to solve agitation on the ward. (Group C)
In particular, nurses described ‘talking with patients’ as the first and least restrictive option to de-escalate the agitation and determine the cause.
Well, non-pharmacological would be to talk to the patient to try and de-escalate, we do that all the time. (Group B)
One nurse considered the staff were skilful in the use of verbal de-escalation since other more invasive measures such as seclusion were infrequently used.
We are really quite talented in our de-escalation skills. Otherwise we would have a lot more seclusion than we actually do. (Group C)
Nurses also described their use of other methods such as diversion and distraction to de-escalate agitation.
We have things like weighted blankets, sometimes they’re useful. Like you mentioned distraction techniques, like maybe just suggesting they go and watch TV for a little bit or read a book …. Just maybe things they’d like to do like drawing or coloring in or write in journals, is often quite popular. (Group A)
The use of restraint and/or seclusion was mentioned by three focus groups to manage agitation. One nurse described restraint as the last line of intervention in the secure ward, while other nurses described the need to use restraints under certain circumstances, including, when de-escalation strategies and the use of medication has not been effective or when patients refuse medication.
We sometimes use restraint in patients who have been refusing medication. Then they might be refusing oral medication written by the doctor they need to have medication for treatment if they're under the act and that treatment can then be forced on them. Under the act and if they still refuse then we sometimes have to restrain somebody in a prone position to give them an injection. (Group D)
While non-pharmacological interventions were described as the first approach, the respondents also reported there were occasions when medication was a necessity. For example, when de-escalation interventions have not been successful and the agitation was observed to be escalating, or when the agitation was related to substance withdrawal.
They just escalate from 0-100, no matter how many times you try to talk to them. But then they start, you know, throwing chairs, doing whatever they do. (Group C)
Nurses also described their use of the patients agitation and arousal chart to determine the level of agitation that necessitated a medication and the type of medication that could be administered.
Processes that support successful management
Nurses described a range of processes considered important to or underpinning how particular interventions were implemented and their success. Adaptability and flexibility on the part of nurses; adopting an individualised approach with patients; training and experience; rapport with patients, and patient involvement in care were discussed.
Adaptability and flexibility
When dealing with agitation, nurses described the need to adapt to the situation to ensure they remain calm and maintained an ‘adult’ perspective. Communicating in this manner was said to be key to effective de-escalation.
Trying not to personalise somebody else's behavior to remain calm to stay in an adult mode, not become annoyed by the patient so that you’re not escalating the situation. (Group D)
Two focus groups described the importance of being sufficiently flexible to consider alternative management strategies.
So I guess it’s about identifying what could actually diffuse the patient agitation in the situation…..in that particular point in time….if that fails….then it could be about you know, trying to look at maybe things that have worked in the past if you know that particular patient. (Group A)
One example described assisting a patient to fulfil their nicotine needs by providing a cigarette. This eased the episode of agitation and helped build rapport with the patient.
With the immediate addiction needs like nicotine- one to one is not going to necessarily help with that. So, we really try hard to get some tobacco basically for them. (Group D)
Nurses also described the need to be flexible and seek assistance from other staff to manage the patient’s agitation. For example, recognizing that another staff member might be more successful in de-escalating the patient’s agitation.
I will go and ask someone, you know, I have tried to talk to this patient, do you mind talking to that patient. So you find some times that they do listen better to someone else. (Group C)
Adopting an individualised approach
In relation to being adaptable, the nurses described the need to acknowledge the uniqueness and individual needs of patients and to tailor a management strategy that was best suited to them. There was an understanding that a ‘one size’ management response would not work for all patients.
I find that I approach patients differently depending on their diagnosis, how long I know them, whether I have got any rapport and you know there's so many different forms of agitation as well. So, it just depends on so many factors, what works with one person may not work with a different person with a different type of agitation. So it's about knowing your patient as well as you can I guess to make those judgements. (Group D)
The nurses were mindful that approaches that worked for one person may not also work for another.
Training and experience
Nurses described how training and experience influenced how they approached the management of an episode of agitation. They considered that being ‘experienced’ was a considerable advantage and a critical factor in the provision of care to manage agitated patients.
Staff that have been around for a long time, know what to use and when to use it. (Group C)
In relation to training, the nurses in all focus groups described mandatory completion of the Professional Assault Response Training (PART) program to deal with agitated or aggressive patients (which they are required to complete every three years). The training focused on the development of empathy and de-escalation techniques plus the use of physical restraint interventions. One focus group also mentioned undergoing Transactional Analysis training and receiving education and training sessions by the resident clinical psychologist. These education and training sessions helped with managing patients generally and in regard to agitation and assisted with their own personal development.
Our clinical psychologist comes in and actually does different education sessions with us. And that’s invaluable. On deescalating as well and understanding why you are doing what you are doing. (Group C)
Some nurses were critical however, of the training they had received and described how additional training and supervision to manage agitated patients was required.
Regular clinical supervision, a formalized standard of clinical supervision, where on a particular day, you’ve got the chance to have one on one, but also like a group session on education, constantly educating staff on identifying triggers, how to manage situations…….best practice guidelines from around the world, and what works, what doesn’t and a standard formalized version of that would help. (Group A)
Building rapport with patients was acknowledged to be a key factor in de-escalating the behaviour of patients experiencing agitation. This could be achieved through honest and effective verbal communication with the patient, undertaking behaviours that eased the patient’s distress (such as the provision of a cigarette to deal with a patient’s nicotine addiction), and demonstrating a willingness to be adaptable. Nurses acknowledged that agitation could be more easily de-escalated if the patient trusted the nurse and associated ‘positive thoughts’ with the nurse.
You can de-escalate to a certain extent, sit down and actually step through what is making them frustrated, rather than just going off getting medications straight away and build that rapport, build that trust because that in a nut shell is just so important. If you can, that is, instead of using medication every time. That should be the back-up, you know the rapport is actually meant to be the first, if you can do that. (Group C)
When they become agitated if you have built some rapport … it’s a useful tool to have later down the track they become agitated by other things they might remember the rapport. (Group D)
Nurses described the involvement of patients in the management of their agitation as important. The Unit’s ‘Coping and Safety Plan’ completed by the patient on admission was described as helpful for facilitating involvement, as well as a post-episode interview between the nurse and the patient to discuss the incident and the management of it.
I asked if she could have anything that would help her calm down in regards to, in terms of medications and she didn’t want anything. After persuading her to eat, she agreed to a calmative medication in the form of a benzodiazepine…..maybe after thirty or so minutes, she had sort of like, calmed down. (Group A)