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This Risk Assessment Tool Helps You Deal With Difficult Behavior Better Than Ever

June 25, 2015
Younger hand holding an older person hand

What do you do when someone in your care comes at you, getting in your face, threatening you physically, and putting their own safety in danger too? How do you react?

If you’ve had Nonviolent Crisis Intervention® training, or if you teach the program to your colleagues, you know which intervention to use and when.

It’s called the Decision-Making Matrix, and I witnessed its power recently in an internal training here at CPI. We all went through the enhanced training program to experience the additional content, and an interesting story—and significant discovery—came up in our group.

It began with our Instructor, Nina, asking us to think of a time that someone in our care exhibited high risk behavior.

My coworker Jeff told us the following story. Later on he wrote it up for me to share with you.

In Jeff’s words:

“In early 2012 I was working as the admissions coordinator for a nursing home. As I was one of the only males working in the facility, I was often asked to assist the nurses and aides when they were working with agitated male patients.

“One of our male patients began showing very aggressive tendencies toward quite a few of the female staff when they would escort him outside so he could have a cigarette. This patient had a history of attempting to smoke inside the building and once burned a hole in his mattress because he fell asleep after lighting a cigarette late at night.

“One morning, the nurse supervisor took him outside for his cigarette. After he lit his cigarette, she attempted to gain possession of his lighter. The patient became aggressive and struck her and refused to give up his lighter. His family was called and eventually they were able to retrieve his lighter from him.

“After this incident, none of the nurses or aides would escort him outside.

“I was asked by the nurse manager if I would take him outside a few times a day to have his cigarettes, as he seemed to respond well to me. I agreed and started to take him outside two or three times a day.

“One afternoon, after he lit his cigarette and I retrieved the lighter, he attempted to grab the lighter back out of my hand. I was able to get my hand away from him and I put the lighter in my pocket.

“After seeing that I was not going to give it to him, he became angry and stood up from his wheelchair and started to scream at me and ball up his fist.

“I knew there was a chance he was going to attempt to strike me. As I had had Nonviolent Crisis Intervention® training in the past, I attempted to verbally de-escalate his behavior.

“Was I afraid I was going to be struck? Yes. But I was also thinking of how to use my training to stop this from happening. I knew that if I gave him the lighter back, the staff and the other patients could be in for more issues later.

“I also thought that if I attempted to back away from him, he could fall and injure himself even more, as he should not have been standing up out of his wheelchair.

“My best thought was to let him know that I knew he was planning to hit me and that I would accept his strike, but that he probably wouldn’t like the repercussions for his actions. I warned him that he could hurt himself further, that his family would be called and they would be asked to find him an alternative facility, and that he would be losing the last person willing to escort him out for his cigarettes.

“In my mind I was thinking, ‘He’s 86 years old—if he hits me it may hurt, but will he break his hand? If I move back and he falls, what damage would this do to him? If I block this strike, how many more strikes will I have to block?’

“My final decision was to stand my ground, provide him with all of his options, and let him make the final move.

“While he was still extremely angry with me and continued to curse at me for not giving him the lighter, he sat back down and had his cigarette.”

Pretty good response, right?

Pretty dang good! The situation defused without either man getting hurt.

This was largely because of how Jeff responded.

He was scared—of injuries, of repercussions—but he stayed calm.

And that calmness and rationality helped the patient calm down. First the man let it all out, exerting his aggressive energy, and then he calmed down without hurting himself or Jeff.

And Jeff responded without getting defensive or putting his hands on the man—approaches which, had he used them, might have set the man off more.

So there was a really positive outcome.

But it was still distressing for Jeff to relay three years later.

And here’s the thing.

For three years, Jeff thought of this as a high-risk situation.


The Decision-Making Matrix

It certainly felt high-risk in the moment, and any time after that when Jeff replayed the incident in his mind.

But Jeff’s feelings changed when Nina introduced the Decision-Making Matrix.

It’ll be available to you soon, and here’s what it is:

The Decision-Making Matrix helps staff categorize risk behaviors by considering their likelihood and their potential outcomes.

For example, the likelihood that the patient was going to strike Jeff was moderate. But because the man was frail, it was unlikely that the outcome of a strike would be severe.

Compare this to a situation where a healthy, strong 25-year-old is barreling toward staff, actively throwing punches, taking names, and bent on bodily harm. The likelihood that someone in this situation would get injured is high, and the outcome would probably be severe.

Higher risk and lower risk

The Decision-Making Matrix teaches us that a likely behavior or event with a high-severity outcome is higher risk. An example is the scenario with the strong, healthy, actively aggressing person.

And a likely behavior or event with a low-severity outcome is lower risk. An example is Jeff’s experience with the frail elderly man in the wheelchair.

(Also low risk is an unlikely behavior or event with a high-severity outcome. A good example of this is a plane crash. While plane crashes are usually severe, fortunately they’re also rare.)

After learning this and discussing it in our training, Jeff said he felt that the situation with the man in the wheelchair was actually lower risk.

The Decision-Making Matrix gave him a new perspective on the event.

He told me:

“This tool could have really come in handy during that incident. The patient had a history of becoming agitated, but only became physical with one person. Plus, if I’d had this tool during this event, I could have really used it to help me better run through my thought process—and faster.”

Why staff need this

The Decision-Making Matrix gives staff an extra, immediate tool for weighing the risk of the behavior and the risk of the intervention.

It reminds staff to use the least restrictive intervention possible in any situation.

Because least restrictive equals least distressing. Which leads to least aggression and least physical and emotional harm.

The tool also helps staff with their Rational Detachment by helping them assess threats objectively.

This can be especially helpful for staff who frequently feel fear and anxiety due to the nature of their jobs. Do they work with individuals who frequently escalate? Are they used to using physical intervention as a primary go-to? Maybe they declare in training that hands-off will never work.

The Decision-Making Matrix will help them assess the degree of a behavior, a threat, a risk. And like Jeff, with the Decision-Making Matrix, they may discover that some situations are less risky than they think. And the intervention they choose as a result may prove to be more effective—and less risky in itself.

Using the Decision-Making Matrix in a situation can also help later on—in critical incident reviews, debriefing sessions, and investigations. Right in the moment, it helps staff critically analyze situations and make appropriate decisions. And later on it can be used in post-crisis discussions of “What went well? What could have been done better?”

What it can help you do

If you use Nonviolent Crisis Intervention® training, you’re committed to Care, Welfare, Safety, and SecuritySM. You know the importance of preventing crisis situations. You know how to prevent crisis situations. And you have strategies to handle situations more safely if they do occur.

You also aim to exceed standards, strengthen trust, improve well-being, and reduce the use of restraint.

The Decision-Making Matrix gives you an extra tool to do all of this, and to stand even taller as a model for other organizations that strive to honor their missions, their staff, and the people they serve.

Stock images: Thinkstock – StasWalenga & elwynn1130

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