SINGAPORE – Something as simple as a different turn of phrase has the power to prevent a tense situation from turning violent.
By specially training nurses in techniques ranging from de-escalation to negotiation to deal with incidents before they get out of hand, the Institute of Mental Health (IMH) was able to cut the number of physical assaults by half during a six-month trial.
The institute now plans to scale up this effort, called the Code Grey team initiative, to all 40 of its wards by December 2027 to elevate psychiatric care standards and create safer workplaces for staff.
In the healthcare setting, “Code Blue” refers to a life-threatening medical emergency. “Code Grey”, on the other hand, is a psychiatric emergency that requires a response appropriate to the “grey situation” of dealing safely with somebody who is aggressive or disruptive, but unarmed.
The IMH initiative was helmed by two IMH front-line staff – assistant director of nursing Kalaivanan Dakshnamoorthy, 47, and senior nurse manager Win Min Htet, 36.
IMH staff care for patients with acute psychiatric conditions every day, which is meaningful work, though demanding, they said.
When patients become acutely unwell, they may not be fully aware of their own conditions and can feel distressed. This can escalate rapidly to aggression.
“There are various treatment modalities that nurses have to use, one of which is using themselves as a therapeutic tool to calm the patient down, using their verbal de-escalation skills. As long as the end result of the crisis doesn’t result in the patient being restrained, that is successful de-escalation,” Kalaivanan said.
All IMH clinical staff go through a standard three-day Care and Response (C&R) training programme, and have the skills and knowledge to manage disturbed patients. Code Grey takes this further by giving staff additional intensive training.
IMH ran the six-month pilot from January to July 2025, where 20 registered nurses – those with a diploma or a bachelor’s degree in nursing – were specially selected for Code Grey training, based on their personality, interpersonal skills and medical fitness.
Three-day intensive training programme
The three-day Code Grey training programme taught the nurses skills related to risk assessment, de-escalation, negotiation and physical intervention.
For instance, Kalaivanan said that commonly used phrases such as “What is your problem?” or “Calm down” might end up triggering patients instead of resolving the issue at hand, as these might be perceived as blaming, dismissive or pressurising to the patients.
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