DE-ESCALATING AGITATION

As Autonomic has written previously, workplace violence is a fact of life for nurses.

One quarter of all workplace violence takes place in a health care setting.

There are proven steps to treat agitated patients without restraints and involuntary medication.

Agitation is an acute behavioural emergency.

And it requires immediate intervention using a 40 year old method.1.

But it requires genuine commitment for a successful outcome.

A three step approach is used.

  1. The patient is verbally engaged.
  2. A collaborative relationship is established
  3. The patient is verbally de-escalated out of the agitated state.

There are four objectives in working with agitated patients.

(i) Ensure the safety of the patient, staff and others in the area.

(ii) Help the patient manage his emotions and distress and maintain or regain control of his behaviour.

(iii) Avoid the use of restraint when at all possible.

(iv) Avoid coerce interventions that escalate agitation.

These objectives may be difficult to implement in some settings.

A busy ward or emergency department are such challenging environments.

But the alternative is medication which can lead to more agitation and violence.

There are “10 domains of de-escalation” identified by an American Association for Emergency Psychiatry best practice workgroup.2.

Agitation is a behavioural set of medical signs and symptoms that are connected to different basic emotions.

The behaviours include foot tapping, hand wringing, hair pulling and fiddling with clothes and other objects.

Repetitive thoughts are vocalized such as ‘wanting to get out of here’.

Irritability and an increased responsiveness to stimuli may also be present.

The workgroup said that

Agitation exists on a continuum, eg, from anxiety to high anxiety, to agitation, to aggression.The agitated patient may be unable to engage in any conversation, and may be on the edge of new or repeated violence, requiring vastly different management than a person who may be willing and able to engage.”

There are four reasons why a nurse should use non-coercive de-escalation to calm an agitated patient.

Firstly, if staff members physically intervene to subdue a patient , it reinforces to the patient the violence is necessary in the interaction.

Second, patients who are restrained are more likely to be admitted into a psychiatric facility and have a longer inpatient stay.

Third, low restraint rates is a key quality indicator.

And finally, patients and staff are less likely to be hurt when physical violence is prevented

A future post from Autonomic will look at practical steps to de-escalate agitated patients.

To learn more about de-escalating agitation:

  1. Lazare, Aaron, Sherman Eisenthal, and Linda Wasserman. “The customer approach to patienthood: Attending to patient requests in a walk-in clinic.” Archives of General Psychiatry 32.5 (1975): 553-558.
  2. Richmond, Janet S., et al. “Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.” Western Journal of Emergency Medicine 13.1 (2012).