The Institute of Mental Health (IMH) has successfully reduced physical assaults on staff by half through a specialized training program aimed at equipping nurses with advanced de-escalation and negotiation skills. The six-month pilot, conducted from January to July 2025, focused on preventing tense situations from escalating into violence by teaching nurses to manage psychiatric emergencies, known as “Code Grey” incidents, more effectively.

Code Grey situations refer to emergencies involving aggressive or disruptive behavior by psychiatric patients, requiring tailored responses to ensure safety. This differs from “Code Blue,” which denotes life-threatening medical crises. IMH’s initiative, led by assistant director of nursing Kalaivanan Dakshnamoorthy and senior nurse manager Win Min Htet, targeted nurses working on the front lines of psychiatric care. The aim was to foster safer work environments while improving patient care quality.

Twenty registered nurses—selected for their interpersonal skills and medical fitness—underwent a three-day intensive Code Grey training program. This course, developed over three months ending in late 2024, equipped these nurses with skills in risk assessment, verbal de-escalation, negotiation, and safe physical intervention. The curriculum was informed by current literature on psychiatric care as well as practical insights from experienced Care and Response (C&R) instructors.

The training emphasized the importance of language in managing patient behavior. For example, staff were encouraged to avoid phrases such as “What is your problem?” or “Calm down,” which might be perceived as confrontational. Instead, nurses learned to use collaborative language like “Help me understand what happened” or “Let’s take a moment to work through this together” to engage patients constructively and promote shared responsibility in managing their conditions.

Role-playing scenarios and discussions with nursing leaders helped reinforce these skills. Code Grey-trained nurses reported improved ability to recognize early signs of agitation—such as clenched fists or pacing—and to intervene before situations escalated. Observations from the pilot highlighted the value of staff maintaining emotional composure when dealing with distressed patients, enabling de-escalation without the need for physical restraint.

During the trial, the trained nurses were deployed in four wards receiving a high volume of emergency psychiatric admissions. Incidents involving physical assaults—including pushing, punching, or slapping—decreased from 108 to 58 cases. Staff feedback indicated greater feelings of safety, enhanced support, and increased confidence in handling challenging interactions. Patients also benefited from the resulting calmer ward environment.

Following the pilot’s success, IMH plans to expand the initiative across all 40 wards by the end of 2027. The goal is to have approximately five Code Grey-trained nurses per ward, ensuring coverage around the clock. Nurses represent the largest staff group at IMH, accounting for about 40% of its 3,000 employees.

The project received external recognition when IMH was awarded the Wellbeing Innovation Award at the WorkWell Leaders Award ceremony in April 2026. The accolade, presented by the charity WorkWell Leaders, honors organizations that demonstrate effective leadership in advancing workplace wellbeing.

Kalaivanan described the recognition as unexpected and noted that the project began as a commitment to safeguard both patients and staff. Win Min Htet emphasized their shared goal to prioritize the wellbeing and safety of healthcare workers and psychiatric patients alike.