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5 Communication – de‐escalation

Table 5.1 Signs of aggression.

Early signs of aggression	Danger signs of aggression
Prolonged eye contact	Continual staring; this will be at the intended target
Darkening of facial colour	Facial colour pales
Invasion of person space	Stance changes from square to side‐on
Speaking loudly or yelling	Disengages from the conversation, may not be speaking
Intrusive or threatening gestures	Fist clenching and unclenching

Figure 5.1 Invasion of personal space.

Figure 5.2 Calm, confident, and non‐threatening approach.

Figure 5.3 Showing concern and support.

Background

In healthcare, patients, relatives, and significant others often experience heightened emotions, due to pain, anxiety, grief, physical impairments, and confusion. These heightened emotions can present in different ways and can potentially produce aggressive behaviour. Healthcare professionals are required to care for their patients, and this includes supporting them during these times of heightened emotion (Nursing & Midwifery Council 2018). To provide support during these instances, healthcare workers need to be trained in de‐escalation skills and techniques (NICE 2015). NICE (2015) recognises that this training should include:

 Recognition of the early signs of anger (Table 5.1).

 Providing an understanding into the causes of aggression.

 Use of verbal and non‐verbal techniques to distract and relax the patient.

 Responding to anger appropriately and in accordance with professional and legal frameworks.

It is important to remember that there are some instances where certain behaviours could be mistaken for signs of aggression. These could be:

 People who are shouting – this could be due to a loud environment or even a hearing impairment which could be chronic or from a new injury.

 People invading personal space – this could be due to the above reasons and they could also be seeking reassurance (Figure 5.1).

 Hypoglycaemia, which can cause people to display signs of aggression. Checking records and taking a full history can help avoid such errors.

Influencing Factors

 People who are under stress.

 People experiencing substance misuse.

 People experiencing restrictions to their limitations.

 Those with mental health issues, new or long term.

 Confusion, either new or of longer standing, e.g. delirium, dementia, hypoxia.

 Your own emotions, time pressures and other factors that may affect your behaviour (Sookoo 2018).

Professional Approach

 Ensure that you are appropriately trained in de‐escalation skills and feel both confident and competent to engage in communication.

 If the situation escalates it could be that you are unintentionally aggravating the situation. In this instance you should delegate the conversation to prevent further escalation; not doing so is unprofessional and puts you and the patient at risk.

 Be aware of your scope of practice and rights: all nursing staff and all those considered emergency workers – i.e. those working in the emergency department and urgent care centres, as well as paramedics – are protected under the Assault on Emergency Workers [Offenses] Act 2018 c.23.

Equipment

 Equipment is not specifically required but be mindful that a uniform could escalate, or calm, the situation.

 Ensure that you have enough time to engage.

 Ensure that you have a way to call for help, i.e. a panic alarm, personal alarm.

Procedure

 Inform colleagues prior to approach.

 Be calm, confident and non‐threatening to support early rapport (Figure 5.2).

 Listen to the patient and assess verbal and non‐verbal cues that could inform your decision regarding which de‐escalation strategy to use.

 Use active listening to identify the patient's concerns.

 Following initial assessment, suggest a quieter area if it is safe to do.

 Use your fundamental communication skills, and ensure that you speak slowly and calmly using VAPER (volume, articulation, pitch, emphasis and rate; Nelson‐Jones 2014) to ensure that you communicate in a calm and caring manner.

 Maintain an open, non‐threatening posture and encourage the patient to sit if currently standing, then ensure you follow SOLER (see Table 4.3; Egan 2014).

 Adjust your body language to ensure that you are expressing concern and support for the patient (Figure 5.3).

 Maintain appropriate social physical distancing; closeness could aggravate the aggression.

 Engage in shared ownership of the problem and work towards attaining a solution together.

 Once a solution has been found, reiterate your actions and the dates and times you will provide the patient with this information.

 If a solution is not found, continue to monitor cues whilst attempting to gain a resolution.

 If the patient then moves from early warning signs to danger signs of risk (Table 5.1), remove yourself from the situation and involve colleagues as appropriate.¹

Red Flag

  Sudden change in consciousness level should be escalated immediately.

  If you perceive changes in behaviour to be threatening, remove yourself immediately.

References

1 Egan, G. (2014). The Skilled Helper: A Problem Management and Opportunity Development Approach to Helping, 10e. California: Brooks‐Cole.

2 Emergency Workers (Offenses) Act 2018 c.23. https://www.legislation.gov.uk/ukpga/2018/23/contents/enacted/data.htm (accessed 17 May 2021).

3 National Institute for Health and Care Excellence (2015). (NG10) Violence and Aggression: Short‐Term Management in Mental Health, Health and Community Settings. London: National Institute for Health and Care Excellence.

4 Nelson‐Jones, R. (2014). Nelson‐Jones' Theory and Practice of Counselling and Psychotherapy, 6e. London: Sage Publications.

5 Nursing & Midwifery Council (2018). Professional Standards and Practice of Behaviour for Nurse, Midwives and Nursing Associates. London: Nursing & Midwifery Council.

6 Sookoo, S. (2018). Identifying and managing risk of aggression and violence. In: The Art and Science of Mental Health Nursing: Principles and Practice, 4te (eds. I. Norman and I. Ryrie), 222–238. London: Open University Press.

Note

1 1 It may be that you feel it is outside of your skillset to reach a resolution. In this instance you may want to hand over care to a more experienced colleague. You may also find yourself in a situation where you feel risk is imminent. In this instance, extract yourself and call for help. This may involve using a silent panic button.