How We De-Escalate Aggressive Individuals in Our Healthcare Setting

Any hospital employee can tell you that trouble calls get paged over the intercom. When the page happens, those that are required to respond come in a hurry. Those that are not responders get out of the way to avoid getting trampled in the process.

Many times, the situation is still going on when the responders arrive. It can be a stand-off, with an excited person holding the staff at bay.

Here are the steps and insights I’ve learned from years of responding to stand-offs.

Assess the situation

Determine quickly if more backup is needed and call for some, if appropriate. Also immediately observe from a sufficient distance to determine if the person is holding anything that could be used as a weapon. Anything metal, plastic, or wood in their hands, within their reach, or tucked inside their clothing can be problematic. You must deal with this issue prior to any negotiation. Move chairs, flowerpots, ashtrays, or anything else slowly out of the way. Make it look like a normal activity, not like you’re poising for a fight. If you can reasonably rule out that the person has immediate access to or is threatening the use of a weapon, then begins the de-escalation process. 

Determine the lead negotiator, and recognize staff as potential triggers

Any of the responders can be the point person that the excited individual will focus on and speak with. It becomes very quickly apparent who the people are that the excited person will speak to. The problem with this is that the excited person may negatively focus on a staff member in authority or someone they have a grudge against. In the case of a person with a mental illness, they may focus on an individual that reminds them of someone.

If the excited person focuses on someone negatively, that person needs to back away and let someone else take the lead. Otherwise, the de-escalation will never occur and a fight is almost guaranteed. Each staff member needs to recognize this in themselves, if it’s occurring, and resist the urge to help or finish the job, and pull themselves away. Likewise, if you see that someone else is blowing the excited person up, or that the excited person gets angry every time the focused-on individual speaks, stand in front of that staff member.

Break the tension by establishing trust

As far as the de-escalation process goes, there has to be a break in the tension. Go up and introduce yourself. Call the excited person by name, if you know it. Use “Sir” or “Ma’am” if you don’t know their name. In my work, I call the person “Mr.” and use his last name as a sign of respect and to show that he’s being taken seriously. I use a greeting such as “Hello” or “Good morning” to establish rapport. We get a lot of repeat customers, so rapport building is crucial. You can very easily end up dealing with the same person on more than one occasion. 

Respect the person’s space

Distance is important. Too close and one is perceived as threatening. Too far away and this allows the individual to put on a show and almost indicates fear, which the excited person will breed upon. Try to shut off exit or escape routes, but do NOT corner the person. 

Get to the root of the problem

Find out what’s bothering the person. Simply asking them what’s bothering them does quite well. I have been taught to use empathy to counter their responses. For example, I say, “I can see why you feel that way.”

To resolve a problem, you need to find its root.

Try to solve the problem

If the problem is one I can handle, I promise the person that if they go back to their room, a quiet room, or seclusion, I will work on whatever it is as soon as they go.

If other solutions are possible, I suggest these to the excited person. I will offer to speak with a nurse, a counselor, or a doctor to relay the excited person’s concerns.

There are limits to what I can promise, and I would never promise something that I couldn’t or wouldn’t do. I use many Pleases and Thank-yous in negotiations. When someone threatens fighting, I use my gray beard and advancing age and tell them, “I’m too old to fight you.” This catches them off guard and further reassures them. Since I’m a security captain, I find that wearing a uniform can be beneficial in negotiations. It can also be a negative.

Since I am not part of the treatment teams, I can act independently and offer a different viewpoint to the excited person. I try and offer a positive opinion of the event. For example, I might say, “Now we know what the problem is and that the doctors and nurses can deal with this issue.”

If hands-off fails

It’s always safest to use the least restrictive interventions possible, and to avoid hands-on. But there are some negotiations that are just going to end up failing to bring about a peaceful solution. The best thing then is to maneuver to position yourself in the best place to start hands-on escorting holds or to provide for the best route for retreating if safety is in jeopardy.

One should NEVER attempt to subdue an excited person by themselves. Good training will allow for two staff to act together. If two staff do not start at exactly the same time, one of them will probably get hit. Our staff trains extensively to learn to work together and perform seclusions and escorts seamlessly.

I should state that I work in a psychiatric hospital and that we have special tools and permissions to handle aggressive patients effectively. We use gurneys to transport combative patients. We use handcuffs and leather and nylon restraints. Large cushioned pads are available to help guide combative individuals. Another tool that’s used to calm an individual is a PRN for patients who have them set up. We can offer medications on a scheduled, as-needed, or an emergency basis.

Learn every possible solution

My advice to everyone who encounters tough situations is to become aware of every possible solution to deal with aggressive and angry people. Though we have not integrated CPI training into our own training at my facility, I find that CPI has some incredible articles that lay out many tactics to try with angry or aggressive individuals. Have that bag of tricks ready to use.

I caution you that what works once may not work every time, and won’t work with every patient. Sometimes a stern tone is needed. Sometimes calming, soothing tones are needed for others. Some excited persons need to be told what to do. Others need to figure it out for themselves.

Angry people tend to be frightened

Reassuring an angry person in calm, repetitive statements may just buy your way out of a fight. There is too much risk of liability to fight people that you don’t have to. Staff or patient injuries can be severe and long-term, and expensive treatment and recovery can result. 

TIP: Reassuring an angry person in calm words may just buy yr way out of a fight.

Choose your battles – and let people vent

My facility has a belief that property damage is not worth risking staff or patient injuries. Sometimes an out-of-control individual needs to tire themselves out wrecking things before intervention can safely occur.

Debrief

Next, follow-up needs to occur. After the person has calmed, they need to be approached and spoken with to deal with the issue and revisit the incident.

Start with letting the person know what was done to solve the problem they were having. Let the person know that everyone will be moving forward. Offer them the chance to come to staff when they’re having a problem. Point out any sanctions and when they will end. Provide encouragement. 

What you say matters, and HOW you say it matters

Many people will respond well to positive statements, even when the statement might say almost the same thing as a negative statement. For example, try “This is great! Now we all understand what happened and we can talk things out in the future,” versus “Now that you finally understand, you need to come to staff rather than wrecking everything.” 

Document incidents, and learn from them

Finally, check with your staff and the excited person to see if they were injured. Provide care for any injuries. Write any needed reports or charting to document that an event occurred. Ending a situation well can prevent future problems or make any future ones less intense.

Good luck and be safe!

James Spoerl is a 31-year veteran of the State of Wisconsin. He has spent 16 years in the Department of Corrections and 15 years with the Department of Health Services. He is a captain with the Mendota Mental Health Security Department. When he was young, he found disruptions thrilling and challenging. Now that he’s directly responsible for staff and patient safety, he uses every tactic he’s learned over the years to settle situations calmly and peaceably.