Date of Degree


Document Type

Doctoral Project

Degree Name

Doctor of Nursing Practice (DNP)




Holly A. DiLeo


Background: Physical restraint and psychiatric emergency medication use, especially psychotropic medications, is problematic, negatively impacting patient safety on psychiatric units (Ambwani et al., 2021; Iuppa et al., 2013; Rahman, 2021). The Bröset Violence Checklist (Woods & Almvik, 2002), a short-term violence-predicting tool, has been used in the inpatient setting to predict violent outbursts and determine when high-level violence interventions are needed.

Purpose: The purpose of this project was to recognize signs and symptoms of aggression and agitation early and intervene to reduce the use of physical restraints and emergency restraint medications on an inpatient psychiatric unit, thereby improving patient safety.

Objectives: The objectives of this project were to assess 90% of patients within 24 hours of admission and daily using the Bröset Violence Checklist, then employ de-escalation techniques in 100% of patients scoring a 3–6 on the tool. These objectives were anticipated to reduce physical restraints and emergency restraint medications by 50%.

Interventions: After education sessions for the providers and staff on the Bröset Violence Checklist, copies of the tool were placed in the providers’ offices, nurse’s station, psychiatric department, and on patient charts. A handout reviewing de-escalation techniques was also available at the nurse’s station. Patients were assessed within 24 hours of admission and daily during the project, and de-escalation was used on patients scoring a 3–6 on the checklist.

Results: (N = 46)

  • The use of personal physical restraints, defined as the application of physical force without a device (De Berardis et al., 2020), decreased by 86%, and intramuscular emergency psychiatric medications decreased by 83% after the intervention was implemented.
  • Mechanical restraints, defined as restraining a person by applying a restraint device (De Berardis et al., 2020), increased by 23%, potentially due to the number of moderate and high-risk patients admitted to the unit.
  • 100% of moderate and high-risk patients screened received de-escalation interventions.

Implications for Practice: Doctorally prepared Advanced Practice Registered Nurses can provide the oversight necessary to successfully implement evidence-based interventions to improve the screening and management of agitation and aggression, thereby decreasing the need for restraints and emergency psychiatric medications on psychiatric units.