Your patient is agitated because they haven’t been seen by a doctor yet. They are demanding – loudly – that you do something about it. What should you not do?
“Your first inclination is probably to tell the person to ‘calm down,’” said Candace Maffei, RN, nursing professional development specialist in Psychiatry at Bridgeport Hospital’s Staff Education department. “That’s probably the worst thing you can do because it minimizes what that person is going through and their feelings.”
On Feb. 1, Maffei and other Yale New Haven Health Workplace Violence Committee members discussed how to handle these and similar situations during a “De-Escalation is Key” webinar. The third webinar in a committee-sponsored series, it expanded on the Crisis Prevention Institute (CPI) Prevention First training all YNHHS employees take.
Panelists discussed how staff can spot behaviors that may indicate an escalating situation and use techniques to de-escalate it.
Instead of telling an agitated patient to calm down, the employee should first take a deep breath and ground themselves, so they’re better able to help the other person, Maffei said. The second step is to set limits by explaining what about the person’s behavior is inappropriate and why. In setting limits, provide reasonable choices and consequences (but not an ultimatum) by offering the positive choice first. You might tell an agitated patient, “I understand why you’re upset and I’m here to help you. Please lower your voice so we can continue this conversation and find the best plan to get you discharged today. If you continue to yell at me, I will have to leave until you calm down and it will most likely delay your discharge. It’s your choice.”
Next, give the person time to think about the choices. Staff should be prepared to enforce the consequences, ensuring that the limit they set is reasonable, enforceable and within their authority to set.
Maffei and other panelists cautioned staff to avoid getting into “power struggles.”
“The purpose of setting limits is not to show who’s the boss, but rather to give the individual respect, guidance and the ability to make their own decision about what to do next,” Maffei said.
Before they reach the yelling stage, people might display body language that can indicate anxiety, said panelist Robyn Hewitt, RN, nursing professional development specialist, Yale New Haven Hospital Emergency Department. She discussed the different types of communication: verbal, non-verbal, such as body language, and paraverbal, which includes volume and tone. Learning to spot non-verbal communication such as worried facial expressions and pacing can help staff intervene early.
“The key to de-escalation is recognizing when a situation is developing and acting on it quickly, so it doesn’t rise to a risk situation,” Hewitt said.
Staff can also use different forms of communication to de-escalate a crisis:
Above all, the panelists said, put yourself in the person’s shoes. Everyone, employees included, has precipitating factors that influence their behavior in a crisis situation, said Ron Kersey, manager of the Emergency Management Training Center at Lawrence + Memorial Hospital.
“Although it’s comfortable for us to come here and work every day, it’s not comfortable for everyone else,” he said. “Whether they’re here for a test or a tragic event, this is a very difficult arena to have that feeling of loss of control.”
For more information on workplace violence and links to webinars, visit the THRIVE section of the employee intranet.
