When patients come to Encompass Health, they are usually recovering from a traumatic injury or learning to navigate a life-changing diagnosis. It’s not uncommon for depression, mood swings and confusion to present as a symptom of a condition or an adverse side effect of a new medication. If patients show hostility to their clinical caregivers, tensions can rise quickly. That’s why it’s so important to diffuse the situation quickly to keep everyone safe from harm.
What is De-escalation?
De-escalation is an approach to conflict resolution that uses communication rather than physical force. In the healthcare setting, the goal is always for patients and their family members to have a positive, supportive relationship with the clinical team. If there is a conflict or misunderstanding, it’s critical to ensure that neither patients nor employees fall victim to harassment or assault.
Usually, all it takes to resolve a tense situation—for example, if a patient is refusing to bathe or not complying with medication regimens—is to make the patient feel understood. This can lead to better outcomes for the patient and less stress for the care team.
Identifying the Cause of Patient Outbursts
A patient’s unruly behavior (i.e. anger, resistance, combativeness) may be caused by stress, fear, fatigue, pain, or even the remnants of a past trauma. These causes don’t excuse bad behavior, but they can help you objectively understand why the event is happening.
If you encounter a patient in a combative state, always ask the person what’s bothering them, rather than assuming you know the trigger. If you don’t get a direct answer, pause to ask yourself a few level-setting questions:
- Maybe the person feels powerless. How can I restore some of their autonomy? What options can I provide to give them a voice in their care plan?
- Maybe the person is confused. How can I prompt them to vocalize their questions? What literature can I provide? If verbal directives aren’t working, can we try an active demonstration?
- Maybe the person doesn’t recognize me or trust me. How can I help this person understand that I want the best for them? Can I involve someone else who may be better received?
Thoughtful Ways to Guide the Conversation
Yesenia Cabral-Fletcher, chief nursing officer at Encompass Health Rehabilitation Hospital Vision Park in Texas, says that body language and tone can be critical when trying to calm down a patient in distress.
“If you are safe and comfortable doing so, sit down and speak at their level. Let your voice and body language project compassion,” Cabral-Fletcher said. “This will decrease the perception of authority. Really listen to the patient and resist responding right away. It’s so important for the individual to get their thoughts out without disruption.”
Here are some additional tips to consider:
- If you’re explaining a treatment decision and your words aren’t getting through, re-phrase the statement. Avoid using medical jargon and abbreviations that may cause more confusion.
- If the person needs to vent, confirm that you’re listening. You might say, “Will you share with me how you’re feeling?” or “Thank you for telling me what happened.”
- Instead of simply declining a request, remind the patient that you’re adhering to established rules.
You might say, “I wish I could do that for you, but our policy is very clear.” It may be helpful to remind them that rules are in place for their safety and protection. - Show empathy by using phrases such as, “I can imagine you’re very frustrated,” or “I really hate to see you so upset. How can I make you more comfortable?”
- Assume a non-defensive posture, keeping your hands relaxed and in front of the body. Maintaining eye contact can also illustrate genuine compassion.
- If you aren’t making progress, ask for help. “Engage the family. They know the patient better than we do and may have just the right tools to calm the patient down,” Cabral-Fletcher said.
- If a patient raises their voice, maintain a safe but appropriate distance of at least three feet. Crowding the person could make you more vulnerable to physical harm.
Setting Healthy Boundaries
While all clinicians want to provide compassionate care, it’s also important to establish boundaries regarding how a patient can speak and interact with you. Patients and their family members should be informed of the consequences—such as calling building security or police—should the hostile behavior continue or escalate. This information should be communicated in a nonthreatening way, reminding the person that they will be shown mutual respect while under your care.
For legal purposes, always document patient complaints (especially when they escalate) including your attempts to resolve them and the results of each intervention. After the incident is settled, debrief the patient and staff to discuss what happened, understand the patient’s perspective and identify how both parties can help prevent the conflict in the future.
More Resources from the Experts
A 2019 Quick Safety Guide from The Joint Commission (TJC) details de-escalation models and interventions for managing agitated patients in the inpatient setting. TJC recommends using systems such as risk assessment tools for early detection of potential patient violence, publicized behavior standards, a formal de-escalation model, regular patient support meetings and more.
The Centers for Disease Control and Prevention also offers a free Online Workplace Violence Prevention Course for Nurses, designed to help nurses better understand the scope of workplace violence, including prevention strategies and post-event response tips.
Every healthcare provider should have a formal, written workplace violence prevention program, including resources to support staff who have been affected. Speak with your clinical leaders to review your organization’s policies and best practices.
The content of this site is for informational purposes only and should not be taken as professional medical advice. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding any medical conditions or treatments.
