___________________________________________________________ Violence in the Healthcare Workplace
Techniques for De-Escalating Violence De-escalation involves defusing potentially agitated patients and reducing maladaptive behaviors using conflict resolution methods, limit-setting, and calm and empathic verbal strate- gies [71; 167]. Ultimately, this depends upon the clinician’s ability to negotiate and use conflict resolution [71; 72]. One of the goals of de-escalating potentially aggressive patients is to promote autonomy and dignity by providing options [73]. To achieve this goal, clinicians must learn to recognize the warn- ing signs of agitation. Behavioral cues may include increased pacing, increased volume and tempo of voice, flushed face, or agitated body movements [71]. Verbal de-escalation strategies can be effective. The National Association of Therapeutic Schools and Programs recommends that clinicians remain calm and convey an attitude of respect by listening to the patient [72]. The patient should be viewed as an individual requiring support or help versus someone with a condition or who is resistant or misbehaving [195]. Next, it is important to identify what is provoking the individual, and then to assist the individual to use prosocial means to express his/her feelings. Clinicians should approach the client calmly [69]. It is important not to convey any cues that may be perceived as confrontational. For example, clinicians should not maintain unrelenting or persistent eye contact. Permission should be given to express feelings of frustration and anger without interruption. It is also important to avoid using terms like “you should” when speaking [195]. Verbal strategies to de-escalate tension in cases in which clients have weapons can also be effective. When clinicians talk to clients in a calm and rational manner, both clinicians and the clients suffer less physical injury or property damage than when clinicians opt to use verbal or physical aggression [74]. Active listening skills are helpful and involve appropriate eye contact and body language, empathizing, and paraphrasing to convey understanding [69]. Clinicians should also be aware of their tone, volume, rate, and rhythm of speech, also referred to as paraverbals. If not careful, paraverbals can convey the opposite of what is communicated verbally [75]. Empathetic listening and communication can help to de-escalate violent situations [105]. Instead of trying to suppress emotions, listening and talking through the frustration can help mitigate potentially violent anger. Redirection is another effective de-escalation strategy [76]. In some cases, this may simply involve changing the topic. Alter- nately, it can be as concrete as offering a patient a glass of water or cup of coffee. This conveys to patients that the clinician is aware of and sensitive to their needs [76]. The use of de-escalation techniques as early intervention results in more therapeutic gains for patients as opposed to using more restrictive management techniques to deal with aggressive behaviors [71]. Clinicians who successfully use de-escalation techniques report improved relationships with patients and increased feelings of self-efficacy, which can lead
to greater job satisfaction [71]. It is vital that the environment supports patient self-management of anxiety [168]. Facilities can promote this by providing access to massages, relaxing sounds, aromatic oils, comforting blankets, guided imagery, and other soothing techniques. In summary, the following best practices for de-escalation have been recommended [196]: • Respect the patient/client’s personal space • Avoid provoking • Be brief and clear • Establish eye contact • Engage in active listening by listening to the patient/client’s needs • Identify and empathize with their feelings • Agree to disagree • Establish clear expectations and consequences • Offer options • Debrief with staff about their feelings, experiences, and what worked well and did not Training to Increase Self-Efficacy and Confidence Workers should be given an arsenal of tools to increase their sense of confidence and self-efficacy. Practitioners who work with patients who can become highly volatile and violent should be aware of the warning signs of potential violence and physiological overview to agitation. They should also be taught calming communication approaches, restraining techniques and when to use them, de-escalation techniques, and medical evaluation and triage [91; 131; 167; 195]. For example, tone of voice and use of eye contact can be employed to calm poten- tially violent or aggressive patients [91]. Using traditional and simulated trainings, practitioners can also learn how to prepare for violent situations and learn self-defense techniques [169]. Clinician Self-Awareness Clinicians should also be attuned to their own feelings and reactions. If they sense that a client will be violent, a safety plan should be implemented immediately. Not only should clinicians be aware of their feelings, but they must be aware of how their body language and facial expressions mirror their feelings. For example, if they feel fear and anxiety, these reac- tions should be masked so as not to communicate the fear to their patients [69]. If patients sense fear, open communication, trust, and rapport can be negatively impacted [69]. When employees are trained to assess their environment, encouraged to listen and be aware of their feelings and reac- tions toward patients and their environment, and to report potentially violent incidences, their responses will differ dramatically compared with those who have not been trained [106]. According to a 2011 study, employees who have been educated will initially express a startled reaction/response to a violent incident, but they are more likely to prepare themselves
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