VIOLENCE DE-ESCALATION

In a previous post De-escalating Agitation outlined how to identify agitation in patients.

Here are some practical steps you can take to de-escalate the risk to yourself and other patients.

1. Respect personal space

Keep at least two arms lengths of distance when approaching an agitated patient.

Give the patient the space they need and keep yourself safely out of harm’s way.

2. Do not be provocative

Show the patient that you do not want to harm them, that you want to listen and that you want everyone to be safe.

Do not conceal your hands as that implies a concealed weapon.

Avoid directly facing an agitated patient and stand at an angle to the patient.

Obviously have a calm demeanour and facial expression. 

Excessive direct eye contact can be perceived as hostile.

It is very important that the patient is not directly challenged or insulted.

Doing anything that can be perceived as humiliating may threaten the person’s integrity and self.

3. Establish verbal contact

The first person that makes contact should be the only person that interacts with the patient.

The involvement of too many people may confuse the patient and lead to increased escalation of violence.

While the first person is managing the patient, another staff member should alert other staff and remove bystanders.

Always be polite by introducing yourself with your name and title.

Explain that you are there to keep them safe and to ensure no harm comes to him or others.

Tell the patient where they are and what to expect.

Ask the patient how they want to be addressed.

4. Be concise

Use short sentences and simple vocabulary.

Complex vocabulary can increase confusion.

Give the patient time to process what has been said and to respond.

Keep repeating the message until it is heard.

Repetition is important in de-escalating violence.

5. Identify wants and feelings

Wether or not a request can be granted, all patients should be asked what it is they want.

You may say “ I really need to know what you expected when you came here” 

As well as “Even if I can’t provide it, I would like to know so we can work on it.”

Observe the patient’s body language, something they may have said in passing or past encounters to identify the patient’s needs and wants to manage the situation.

6. Listen closely to what the patient is saying.

Repeat back to the patient what they have said to confirm to the patient that you have been listening to them.

Assume that what the patient is saying is true.

The situation can be de-escalated if you convey some understanding about why the patient feels that way and is a way of showing that you care.

7. Agree or agree to disagree

Try to find something that you can agree upon.

Acknowledge that you have never experienced what the patient is experiencing but you believe that they are having that experience.

If there is no way to honestly agree, agree to disagree.

8. Set clear limits

In a matter of fact manner, tell the patient what is acceptable behaviour.

Do it in a reasonable and respectful manner.

Coach the patient in how to stay in control.

You may want to say “ I really want you sit down as when you pace, I can’t pay full attention to what you are saying.”

9. Offer choices and optimism

To stop spiralling aggression, be assertive and propose alternatives to violence.

Offer things that they may consider acts of kindness such as blankets or magazines.

The choice must be realistic.

Do not deceive a patient by promising something that cannot be provided.

Broach the subject of medication to calm the patient.

Be optimistic and let the patient know that matters are going to improve and they will be safe.

10. Debrief the patient and staff

Explain to the patient why intervention was necessary and allow them to respond about their perspective.

As well staff should be given a chance to debrief about what happened, what went well and what changes should be made the next time this type of event occurs.

To learn more about violence de-escalation:

  1. https://autonomic.com.au/autonomic/2017/4/13/de-escalating-agitation
  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).