A guide to mastering the fine art of verbal de-escalation in the face of increasing emergency department violence.
A 56-year-old male presents to the emergency department for back pain. According to the triage note, he suffers from chronic back pain, but it has worsened after lifting a heavy box 2 days ago. It is a busy Monday afternoon and the patient has been waiting for over two hours when the nurse comes up to you, stating that the patient is requesting something for pain. You are currently swamped, so after performing a short chart check you write an order for ibuprofen. Not long afterwards, you hear the metallic crash of a mayo stand hitting the ground and down the hall you see a patient towering over your nurse, screaming at the top his lungs, “You think that crap is gonna help me? I’m in real pain, dammit!”
The emergency department is, by anyone’s assessment, an inherently unsafe environment. We routinely care for the intoxicated, demented, delirious, and incarcerated. In addition to our responsibilities as an clinician, circumstances often arise necessitating that we function as de facto security. The ability to effectively manage aggressive behavior is an essential skill that allows us to defuse situations before they escalate to the point of physical violence.
Verbal de-escalation, when carried out with genuine commitment, is proven to be a powerful and effective way to help calm agitated and aggressive patients. Among properly trained providers, this process takes less than five minutes (see Richmond 2012), decreases the likelihood for physical restraints and sedation (Beck 1991), and results in shorter stays (Compton 2006).
In order to most effectively employ the principles of verbal de-escalation, we must first address our inherent biases and fundamentally reframe our approach to agitated patients. It’s common to feel annoyed or irritated by the agitated patient. In general, these patients disrupt workflow, require significant resources, and divert attention away from others who need it.
You may be tempted to ignore the patient or avoid involvement all together. However, delaying action often leads to further escalation. Instead, an early intervention takes less time overall and is more likely to result in a successful de-escalation (Price 2012). Furthermore, we need to recognize that agitation, regardless of etiology, is an acute behavioral emergency that requires our attention, just like any other emergent condition.
Verbal de-escalation has two primary goals: first and foremost, to ensure the safety of your patient and your staff and secondly, to help the patient regain control over their emotions. Consider verbal de-escalation a collaborative effort where the provider helps the patient gain control over their own behavior (Duperouzel).
There are 10 steps to verbal de-escalation. Whenever possible, you should limit the intervention to one provider, which simplifies communication and allows the provider to build rapport. Introductions should include name and title and, in order to respect personal space, the provider should keep at a distance of two arms’ lengths.
Non-verbal communication is paramount, so be aware of your stance, gestures, and facial expressions. Do not cross your arms, conceal your hands, or stare directly at the patient, since these can be perceived as acts of aggression. Allow the patient to express how they feel, and do not interrupt. When responding, use plain language, speak in a low tone, and use short, concise sentences. It may be helpful to use phrases that demonstrate your understanding, for example: “It sounds like you’re feeling…” or “Tell me if I have this right…”.
Although not necessary, it is helpful to try and agree with some aspect of the patient’s situation. You can agree either in principal or in theory or when you simply cannot agree, using an “I wish…” statement could be helpful. For example: “I wish that was possible.”
Next, in a non-threatening, matter-of-fact way, inform the patient about acceptable and unacceptable behaviors. For example, “This kind of behavior could lead to injury to you, other patients, or our staff. We can’t allow that. If it continues, we may have to involve the police.”
Remember that even displays of aggression that do not result in injury, such as yelling or throwing equipment, should be met with appropriate consequences, such as seclusion or loss of privileges. Setting reasonable and behavior-specific limits allows the provider to express their desire to help the patient without being abused.
Remember, the bottom line is that good working conditions require both the provider and the patient to treat each other with respect. Providers and staff simply cannot do their jobs if they feel threatened by a patient’s behavior.
Finally, you can offer the patients options, careful to never promise something that can’t be provided. Even small gestures such as offering the patient a blanket or food can demonstrate kindness and serve to mitigate aggressive behavior.
In an environment like the Emergency Department, where the number of patients far exceeds available time and resources, it’s tempting to reach for sedatives quickly. While this may be appropriate for the violent patient, it’s inappropriate first-line therapy for patients who are able to engage in conversation.
Prematurely using medication when a patient is able to engage in conversation may lead to worsening escalation (Richmond 2012). Therefore, sedation should only be used when there is an immediate risk of harm or when verbal de-escalation fails. When broaching the topic of sedation, be straightforward and try to make an objective statement that summarizes the situation. For example: “You are having a crisis, and I think you would benefit from some emergency medication. It is safe and will help you gain control.”
Under no circumstances should coercive interventions be used, at they tend to break down provider-patient trust and may result in further escalation. Remember that sedation is an adjunctive therapy and should never be used as a threat or punishment. Physical restraints, if necessary, should be temporary and promptly removed once sedation is adequate. If possible, it can be helpful to relocate the patient to a private area, void of equipment that could prove hazardous, where the patient can be monitored for improvement.
And just like with other stressful skilled procedures, when you conclude an interaction with an agitated patient, gather your colleagues and involved staff to conduct a short debrief. This can be as simple as recapping the case, discussing what went well, identifying opportunities for improvement, and reviewing current policies and procedures. A debrief can really help reinforce your de-escalation skills and transmit that knowledge through the rest of your department.
CASE RESOLUTION
You approach the patient, mindful to respect their personal space. You introduce yourself by name and title and ask the patient explain what’s wrong. The patient, who is still yelling, tells you how he has been waiting for over two hours to see a doctor and how the medication you gave is not going to help with his pain. The patient explains that he has been to physical therapy, tried on various medications but has not experienced any relief. You respond with an empathetic summary: “Waiting can be frustrating for anyone, especially when you are experiencing pain.”
Next, you offer your assistance and inform the patient of acceptable and unacceptable behavior. “I want to help you and I want to treat your pain, but when you yell and knock over equipment it frightens my staff. Yelling and throwing equipment is never acceptable in the Emergency Department because it disrupts patient care. We can more easily help you if you lower your voice.”
Next, you offer choices. “There are several medications that work for acute back pain. Would you like to try some oral medication that may help with your pain?”