10 Ways to Defuse Incidents

Healthcare facilities can be places of great anxiety, grief and anger. Patients, their family members and even co-workers can lose control of their emotions and become verbally or physically aggressive. This second part of our series on managing abusive individuals discusses how staff members can take action to prevent or mitigate dangerous behavior.

by Judith Schubert
 

A comprehensive training program, like the one discussed in part I of this series, is the most effective means of preparing staff to address disruptive behavior or assaults. There are, however, some basic steps that all staff members can take to improve their interventions in potential crisis situations. The points below are not intended to replace training, but rather to provide an overview of some of the techniques and strategies that should be explored in training programs, which emphasize prevention of workplace violence.

For purposes of this article, crisis moments refer to those points in time when individuals lose physical and rational control of their behavior. Almost always, there are warning signs a person's behavior is moving toward a crisis. The following tips can aid in early interventions and increase the likelihood of staff de-escalating an incident before it becomes dangerous.

1. Respect All Individuals' Personal Space
   Personal space is the area around us that we consider an extension of ourselves. How much space each of us requires to feel comfortable varies considerably. What is almost universally true, however, is that anxiety rises when personal space is invaded. This heightened anxiety makes it more likely a person will act out in a more serious way.
   
   To avoid such a response, maintain at least an arm's-length distance from a person whose behavior is escalating. In this way, you will be less likely to increase the person's anxiety. You will also reduce danger to yourself by maintaining a margin of safety that allows you time to react if the person becomes physically aggressive.
   
   If you must touch an anxious person to provide medical care, explain what you are about to do before you begin. If the person objects, decide if: 1) the procedure can wait until the person is less anxious; 2) someone else might be better suited to provide the care, e.g. someone who has established stronger rapport with the person; or 3) the procedure must be done by you at this very moment. This third alternative should be a last resort, chosen only due to medical necessity. If this is your decision, be prepared for the possibility of the patient reacting negatively — and perhaps physically.
    
2. Be Aware of Your Own Body Position
   In addition to maintaining adequate space between you and an anxious person, avoid eye-to-eye, toe-to-toe positions, as they might be interpreted as challenging. Positions perceived as challenging can evoke a "fight or flight" response from the other person, and neither of those reactions is likely to be helpful. Standing at an angle to the person and off to the side is much less likely to escalate an agitated person's behavior.
    
3. Be Empathic to Others' Feelings
   Try not to judge or discount the feelings of others. Whether or not you think their feelings are justified, those feelings are real to the other person. Pay attention to them, and don't be afraid of silence. Your supportive presence is often more important than what could be conveyed with any words you might say.
    
4. Keep Nonverbal Cues Nonthreatening
   As a person begins to lose control of rational thought, the person becomes more tuned into your body language and less tuned into your words. Nonverbal communication — including gestures, facial expressions, movements and tone of voice — becomes paramount in conveying a calm, respectful attitude.
    
5. Ignore Challenging Questions
   When a person challenges your authority or an organizational policy, redirect the individual's attention to the issue at hand. For example, suppose a female visitor is smoking in a waiting area. You remind her that there is no smoking allowed in your facility and ask her to put out her cigarette. She responds by saying, "Who are you to tell me what to do?" Answering this type of question only leads to a nonproductive power struggle, and it also sidesteps the issue at hand — the woman's smoking. It's better to ignore the challenge and restate your request.
    
6. Set and Enforce Reasonable Limits
   If patients or family members become belligerent, defensive or disruptive, establish limits and directives clearly and concisely. When setting limits, offer simple, clear choices and consequences to the acting-out individual. Be sure the consequences are reasonable and enforceable.
   
   For example, you might tell a family member who is insistent about entering an emergency treatment room, "Please come back to the waiting area with me, and I'll be sure the doctor speaks with you about your husband as soon as possible. If you try to enter the treatment room again, I'll have to call security, and then it will be even longer before you can talk to the doctor."
    
7. Permit Verbal Venting When Possible
   If someone is shouting, it is often the safest and best alternative to let the person shout, removing others from the area when feasible. Allow the person to release as much energy as possible by venting verbally. Verbal venting is always safer than physical venting. As a person is venting, there will be peaks and valleys in the outburst, as the person's energy expenditure rises and falls. If you cannot allow the person to continue venting, state the directives and reasonable limits during the "valleys" in the venting process.
    
8. Identify Real Reason for the Behavior
   Even in the midst of an angry tirade, there is useful information to be gained about what a person is thinking and feeling. The real reason for a person's outburst is often not what it seems to be. Anxious patients and family members can be highly critical of hospital staff for reasons that are much more related to the fear and helplessness they are experiencing than to the ways staff members are performing their duties.
   
   Try to listen for the real message — the feelings behind the facts. Restate the message you think you have received in order to determine if you correctly understood the person's intent.
    
9. Stay Composed, Avoid Overreacting
   It's hard not to take things personally, especially since angry people often say very personal things. But it is essential to do your best to remain calm and professional — at least on the outside. Your composed, rational response can go a long way toward influencing the person's behavior in a positive way.
    
10. Use Physical Techniques Only as a Last Resort.
    Physical restraint should be used only when people's behaviors are dangerous to themselves or others. Physical intervention itself always carries some risk of injury to staff or to the person being restrained. Such interventions should be used, therefore, only when it is more dangerous NOT to intervene. Furthermore, physical interventions should be used only by competent staff members who are trained to use the safest, least restrictive methods of intervention possible and who are wellversed in any applicable regulations or laws pertaining to restraint use in their facilities.

Prevention Promotes Culture of Caring
Not every crisis situation can be successfully de-escalated, but trained staff members who know these key principles are much more likely to influence behavior in a positive way, defusing potential crisis situations before they become dangerous. Prevention is the best way to promote a culture of caring and a safe and respectful workplace for everyone.
 

Judith Schubert is president of the Crisis Prevention Institute (CPI).  The information above was adapted from "10 Tips for Crisis Prevention," by CPI ©2002 and is provided with permission.
 

Case Study: Hurricane Katrina's Aftermath
The tips described here are part of a comprehensive approach that can help staff minimize or defuse aggressive behavior or assaults. A Certified Instructor of Crisis Prevention Institute's Nonviolent Crisis Intervention^® training program, shared a true story from a hospital in Gulfport, Miss., in the days after hurricane Katrina ravaged the area. It provides a powerful illustration of how preventive strategies, embedded in a workplace culture, translate to practice.
 

A hospital educator was faced with a number of local residents who were understandably distraught because their family members were either missing or injured. Some of these residents were trying to gain access to the already overwhelmed hospital, seeking information about their family members who may or may not have been inside. In an effort to prevent looting and vandalism, the hospital's disaster response procedures limited access to the facility. Additionally, members of the Mississippi National Guard were called to the scene to help maintain order.
 

Using the principles learned through training, the hospital staff member continually reminded himself that this was an otherwise normal group of people who had been thrown into an unbelievably difficult situation. He empathized with their frustration and worry, and tried to remain calm, ensuring that his body position did not send cues that were challenging or threatening. He allowed individuals to release some of their frustration through venting and did not take their angry comments personally. As he listened to the verbal tirades, it was clear the underlying message was the fear of not knowing where relatives were, not knowing if they were receiving necessary medical care, and worst of all, not knowing if they were alive.
 

When some of the individuals began to make threatening comments and attempted to intimidate the staff member, he took those threats seriously and set appropriate limits. He told the people that if they could wait patiently and calmly, he would be able to fill their requests for information more quickly. On the other hand, if they could not control their anger, the next person they would be speaking to would be "that gentleman over there, dressed in green" — an armed member of the Mississippi National Guard.
 

By using a number of the approaches described above, the staff member provided a positive influence on the behavior of the group — a group that could easily have turned into an unruly mob. Instead, the angry, aggressive behavior abated, and the staff member was able to turn his attention to finding out the names and condition of those in the hospital.
 

Basic Prevention Strategies for Hospitals
The National Institute for Occupational Safety and Health recommends healthcare facilities apply these general security tactics:
 

Environmental Design:

• Develop emergency signaling, alarms and monitoring systems
• Install security devices such as metal detectors to prevent armed persons from entering the hospital
• Install other security devices such as cameras and good lighting in hallways
• Provide security escorts to the parking lots at night
• Design waiting areas to accommodate and assist visitors and patients who may have a delay in service
• Design the triage area and other public areas to minimize the risk of assault:
  • Provide staff restrooms and emergency exits
  • Install enclosed nurses stations
  • Install deep service counters or bulletresistant and shatterproof glass enclosures in reception areas
  • Arrange furniture and other objects to minimize their use as weapons

Administrative Controls:

• Design staffing patterns to prevent personnel from working alone and to minimize patient waiting time
• Restrict the movement of the public in hospitals by card-controlled access
• Develop a system for alerting security personnel when violence is threatened

Behavior Modifications:
Provide all workers with training in recognizing and managing assaults, resolving conflicts and maintaining hazard awareness.
 

This article originally appeared in the July/August 2007 edition of Campus Safety magazine and is reprinted with permission.

• Read Part 1—Responding to Abusive Patient Behavior: 3 Pitfalls to Avoid When Training Staff
   
• Read Part 3— Responding to Abusive Patient Behavior: Reducing the Risks of Restraints

Download our free eBook, Creating a Safe and Caring Hospital.

Already an Instructor or Site Member? Login to access your free resource.