De-escalation strategies for dealing with the agitated patient

Parts of this presentation were presented at the DevelopingEM- conference 2014 in Salvadore de Bahia during the De-escalation Workshop.

For starting this presentation I want to begin with a case presentation of a prehospital mission. The fotos of this mission will be the backround of my slides, so you can imagine the circumstances.

There was a call to the border- bridge between Germany and Poland in a litte border town. The header for this mission was „man on bridge with weappon“. When we arrived there were police, firefighters and paramedics on site or were comming across. As it was the border-bridge, the same amount of people came from poland, too. And there were spectators on both sides of the bridge. First of all we noticed, that the weappon was a fishing rod, so we were happy not to be confronted with pure violence. Then we tryied to communicate with the patient. It turned out, that he was a polish citicen, but he was on german territory. As one of our paramedics was polish, she was choose to be the communicator with the man. For her safety she was lifted in the turntable ladder up to the patients level. There she was able to figure out the patients concerns. It seemed like he was depressed and afraid to be murdered by his family. He went for fishing on top of the bridge, because he thought there would be the best place for it. At the beginning, he was quite agitated and wanted to stay up there. It took at least one hour to establish report to the patient and to find an agreement how to get him to the ground in a safe way. Finally he went voluntary into the polish turntable ladder for admission in the german psychatry. Our paramedic had no special training in de-escalation. But she was the only one who was able to communicate properly with the patient. She stayed calm, found out the reasons for the agitation and was able to bring the level of arousal down to a safer place.

We were lucky that this patient was not aktivly aggressive against us. But about half of the health care workers had experienced at least one incident of physical or psychological violence in the previous 12 months: In figures 67 % in Australia and 46 % in Brazil.
Violence possibly accounts for approximately 30% of the overall costs of ill-health and accidents in health-care providors. So it’s quite important to have a strategy to deal with aggressions in health care settings.

Especcially Emergency departments and prehospital care settings, (apart of psychatric wards) are at greater risk for confrontation with agitated or aggressive patients. The reasons are manifold. Acute Pain, Fear and Helplessness are the circumstances many patients have to deal with. Some are Intoxicated or have Cognitive disorders, what lowers their personal control. There can be feelings of Rejection. And often they have limited access to informations about the proceedings and workflows of the environement. Or the bustle, noise and waiting time provokes aggressive behavior.

Aggressive behavior has traditionally been classified into two distinct subtypes. These were refered as instrumental and hostile aggression.
On one hand, there is the controlled-planned-proactive-offensive-constructive type for whom agression is conceived as a tool for solving problems. This type uses aggression for obtaining profit or advantages like power, money, control and domination. It is purposeful and goal-oriented. Thus, it’s requiring neither provocation nor anger. It’s the type „bank-robber“, who is less frequently our patient.
On the other hand, the hostile-impulsive-uncontrolled-unplanned-reactive type will more often show up in the emergency department. This kind of aggression has been conceived as being thoughtless or thought confusion emotionally charged. It can be driven by anger and characterized by loss of behavioural control. Psychologically, it is associated with disruptive behavior and deficits in interpretation. Physiologically, it is characterized by a marked sympathetic over-arousal.

Research has demonstrated that assaults on staff are often a result of interactions. An escalated person should not be seen out of it’s context. There you have the social system in which everyone interacts and the mental system of a person. Health-care providers have their roles in the health-care -systems. The expectations of a patient could be disappointed through the setting of the emergency department. That could be driven by anger and is characterized by loss of behavioural control, which can lead to violence. That can also occur as a reaction to some perceived provocation. As healthcare-providers we have to have the situation of the patient in mind and we have to act with empathy to the patient. Empathy and theory of mind for the patients are part of the key components to recognize a conflict and prevent an escalation.

As you can see there are different phases of escalation to distingush. After a triggering impulse, there is an escalation phase, which can lead to a crisis in the metal state of the patient. Autonomy safing De-escalation strategies interveen during the escalation. When it has come to a crisis with the risk or the occuring of an assault, de-escalation strategies turn to authorative interventions with physical or chemical interventions.

De-escalation techniques will be an important, but not sole factor in achieving non- violent situations. Clinical managers should aim to provide safe and structured environments with adequate staffing levels and skill mix. There should be a focus on activity and positive interaction between staff and patients. In addition to the use of de-escalation techniques, health-care providers must aim to maintain self-awareness throughout all interactions and focus on developing effective therapeutic relationships, to reduce the frequency of escalating incidents. Maintaining personal control and using of verbal and non-verbal skills are also key components in de-escalation.

Deciding on a strategy for de-escalation is an instinctive and intuitive process, which is requiring flexibility and creativity and is based on the individual needs and characteristics of each patient displaying aggression.
Early Intervention, depending of dangerousness of the patients are recommended. There should be only one communicator, which the one with the best chance to de-escalate. Listening to the patient, use of empathy, and interpretation of non-verbal cues were considered useful in terms of accurate assessment of the individual’s emotional state and the formulation of appropriate interventions.

Effective de-escalators are open, honest, supportive, self-aware, coherent, non-judgemental and confident, without appearing arrogant. They express genuine concern for the patient, appear non-threatening and have a permissive, non-authoritarian manner. These qualities help to gain the patient’s trust. This is making appeals for self- control more likely to be accepted. The ability to empathize is also vital, because it makes the patient feel understood and reduces the need for aggressive behaviour.

The importance of appearing calm when faced with aggression is emphasized throughout studies. The sense of calm conveyed by the staff helps the patient to manage their feelings of anger and aggression. Calmless communicates to the patient that, despite their anger, they are trusted not to be violent. Calmness conveys also, that the member of staff is in control of the situation, whereas fear can increase anxiety and make the patient feel unsafe or even that they have gained the ‘upper hand’.
Feelings of anger or offence should be suppressed and it is crucial that personal feelings toward the patient are avoided.

Some common signs show obviosly, that a person has become escalated: The sympathetic over-arousal lead to Raised, High-pitched Voice and Rapid Speech. There can be Excessive Sweating and Excessive Hand Gestures or Balled Fists. Erratic Movements and Aggressive Posture or Shaking signal the escalation of the patient.

Staff must be aware of their body language in terms of posture, eye contact, proximity and touch. Body language should express concern for the patient. A degree of eye contact is necessary to maintain rapport and the patient’s attention, Loss of eye contact may be interpreted as an expression of fear or lack of interest. Fixed eye contact is not recommended as it may be seen as a threat or challenge. There are some ambiguity regarding the use of touch. It could be calming for some patients, yet threatening for others. Personal space should not be invaded. Minimize your body movements and keep a relaxed and alert posture. Stand up straight with feet about shoulder width apart and weight evenly balanced. Positioning of yourself for safety is essential and never turn your back for any reasons.

Using a calm, gentle and soft tone of voice is central to the technique. Tactful language and the sensitive use of humour are also evident, although care is required that this is not perceived by the patient as belittling. Reasoning with an enraged person is not possible. The first and only objective in de-escalation is to reduce the level of patient arousal so that discussion becomes possible. Do not get loud or try to yell over a screaming person. Wait until he or she takes a breath, then talk. Speak calmly at an average volume. Respond selectively and be honest. Lying to a patient to calm them down may lead to future escalation if they become aware of the dishonesty. Do not be defensive even if comments or insults are directed at you. But be very respectful even when setting limits or calling for help. The agitated individual is very sensitive to feeling shamed and disrespected. Trust your instincts.

Attempts should be made to find out the reason for the patient’s agitation. The patient should be asked what the problem is, what can be done to resolve it, and what normally helps the patient to feel calmer. Guidance should be given to the patient without appearing commanding. Staff should avoid threats of sanctions or entering into power struggles. The focus should be on establishing rapport, answering questions, and finding agreements without making unreasonable concessions or appearing uncompromising. The patient should be encouraged to communicate openly with staff about their emotions and discuss feelings of anger and frustration. Recognizing the right to expression of anger (provided the patient can do so without harming themselves or others) is viewed as a key factor in successful de-escalation of patients displaying aggression.

The focus should be on promoting the autonomy of the patient, through minimizing restriction as far as possible. The patient should be made to feel valued and respected. Aggression is often a response to lost dignity and feeling respected enables the patient to reclaim their sense of dignity.
Find aggreements and list consequences of inappropriate behavior. Alternatives to aggression should be highlighted to the patient. Depending on the degree of risk to the patient or others, giving the patient the choice of a ‘cooling off’ period might be an option. Several studies emphasize the importance of offering ‘face-saving’ alternatives, which involve negotiation of a mutually agreed alternative to aggression. The aim is to empower the patient to feel they are choosing to de-escalate, rather than being forced by staff.

To sum up: The process of de-escalation is about establishing rapport to gain the patient’s trust. Therefore Remaining calm, Valuing the patient and Reducing fear is of great importance. Enquiring about patient’s queries and anxiety and Providing guidance to the patient are autonomy saving interventions to work out possible agreements.
That will bring the level of arousal down to a safer place.
But over all Take no risk

references

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Di Martino, V. (2002). Workplace violence in the health sector – Country case studies Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand, plus an additional Australian study: Synthesis Report. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector, forthcoming working paper.

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Centre for Clinical Practice
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NAU J. Et al. (2009) The De-Escalating Aggressive Behaviour Scale: development and psychometric testing. Journal of Advanced Nursing 65(9), 1956–1964.

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