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

INTRODUCTION: 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. AIM: 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. METHODS: 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. RESULTS: 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. DISCUSSION: 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. RECOMMENDATIONS: Future evaluations of the Safe Steps need to consider extending beyond nurses' relational capabilities to encompass the relational responsiveness of multidisciplinary teams.