Keeping Cool When Patients Get Hot

Curbing aggression and violence requires de-escalation skills

In a packed hospital ED, a patient is agitated. He’s clearly in distress, complaining loudly. When he’s finally seen, he protests the medical attention and gets even more belligerent. Suddenly, he takes a swing. Meanwhile, in a long-term care home a resident is upset at meal time. After unleashing verbal abuse at staff, she flings her tray.

Violent episodes are a huge problem in health care. In fact, just this past November, gunshots were fired inside a Kingston hospital. In a world where code whites are increasingly common, how do you crack the code to reduce or prevent incidents of aggressive or violent patients?

The causes and remedies are complex. For instance, some medical conditions and circumstances — from dementia, to metabolic disturbances, to the effects of certain drugs — boost the chances of acting out. Sometimes patients won’t respond to reason or can’t due to psychosis. Other times weapons, or items that can be used as weapons, are involved, posing an imminent threat.

There are different challenges in different health-care settings. This patient and workplace safety issue requires responses on many fronts. That includes systemic action around issues like staffing, security and risk assessments. Doctors and health care colleagues also play a key role in taking steps to try and de-escalate.

Look Through the Patient’s Eyes

First, consider what the environment is like for the patient. Henrietta Van Hulle, VP Client Outreach at the Public Services Health and Safety Association, reminds that healthcare professionals navigate their settings and system every day. It makes sense to them. They’re comfortable there. But that is not necessarily so for patients.

Patients can be anxious. They’re often dealing with the unknown. At the best of times, that can get the pot boiling. Now, add in whatever else is going on in the patient’s life. Or maybe they’ve had previous undesirable experiences with health care.

All of this, even without aggression and violence present, is reason enough for the health care team to pacify. In practice, that can mean providing enough information, speaking slowly and giving patients enough time to process what you’re saying, and making eye contact. “Keep a calm outer demeanour,” Ms. Van Hulle says.

Sound too simplistic? Not really, says Dr. Brittany Poynter. She’s clinical head of the ED at the Centre for Addiction and Mental Health (CAMH) in Toronto, and an assistant professor in the Department of Psychiatry at the University of Toronto’s Faculty of Medicine. When patients are in a heightened state, some basic steps to build rapport and show understanding can go a long way.

At CAMH, Dr. Poynter is part of a team working to de-escalate patients who are exhibiting a variety of psychiatric symptoms. Her advice, however, applies to a large swath of patients. Many individuals, in certain cases and at certain times, could potentially turn aggressive or violent.

Consider, she says, some common patient experiences: wait times, absence of privacy, negative attitudes of staff, lack of respect or courtesy, not feeling heard, insufficient communication. These and other realities of being a patient can set people on edge.

Dr. Poynter says it’s vital to be preventative, i.e., act at the first signs of agitation. Even before it gets to that point, some de-escalation strategies are really just good proactive care interventions.

For instance, introduce yourself, provide reassurance that you’re there to help, be clear and concise (short sentences, simple vocabulary), and identify the patient’s wants and feelings. Listen closely to what patients say, and acknowledge that you’re listening.

Repeat information as necessary to ensure clarity. Set limits for safety, like acceptable behaviours, and do it in a respectful manner. Offer choices, even something as simple as where to sit. And perform little acts of kindness, like meeting a basic request or just providing hope.

“It’s important to put yourself in the other person’s shoes and offer empathy,” says Dr. Poynter.

These strategies can work, not all the time and not for everybody but even in quite challenging cases. In an article for the Toronto Star, Dr. Poynter wrote specifically about patients who are experiencing a mental health crisis. They’re probably scared, she said, and their actions are likely driven more by fear than a desire to harm. Some people can’t tell what’s real from what’s not.

Look for something about the patient’s position to agree with – you could agree with their truth (even a bit of it), agree with the principle, or agree to disagree. Finding common ground fosters trust, she said. What if someone is brandishing a knife? Dr. Poynter explained that rather than saying “No weapons allowed, give it to us or we’ll call the police”, she might try this approach: “I’m glad you’re at the hospital. You’re in a safe place now. We’re going to hold on to the knife for you, so that we can all be safe. Let’s sit down and talk.” It won’t always work and it’s not the only answer. Still, some of these communication fundamentals are the go-to protocols.

Using Common Sense

De-escalation tips from various health-care facilities emphasize the same sort of common sense approach.

Ask patients what got them upset. Apologize if you did something that inadvertently upset them. Acknowledge feelings, not necessarily opinions, but recognize legitimate concerns or grievances. Don’t overreact, even if the patient screams and swears. Don’t talk over them or argue back. Minimize power struggles. Make sure your body language doesn’t contradict your words. Move slowly and deliberately. Give people time to express themselves. Offer concessions in the effort to calm things down.

Empower patients too, by encouraging them as they work to calm themselves. And if what you’re doing isn’t working, see if a colleague might have more success before you turn to other options.

Studying data around incidents can also lead to solutions. At St. Joseph’s Healthcare in Hamilton, the Schizophrenia and Community Integration Service noted an increased risk of responsive behaviours at breakfast. They interviewed staff, looked at patterns and found many early warning signs in the 12 hours prior, during the night shift. So the team worked to de-escalate responsive behaviour before it turned into a violent incident. They also moved team safety huddles to before breakfast for the most at-risk units, and increased staff presence at breakfast. Incidents have since gone down.

When responsive behaviours are happening, always try to get at the root causes, says Dr. David Conn, VP of Education and a staff psychiatrist at Baycrest in Toronto. He notes that a lot can be at play, like physical reasons (e.g., the condition or pain), changes in cognition, emotional reactions, the environment (is it noisy or crowded?), etc. For doctors, patient-centred care and level-headedness should prevail. “If we get upset, they’ll get more upset,” says Dr. Conn.

Dr. Peter Prendergast, CPSO Medical Advisor and a psychiatrist, says restraints, both physical and chemical should be the last resort. They’re especially dangerous for the frail elderly. Skilled non-confrontational communication, he says, is the key to lowering the temperature. Baycrest is working on an app that will give staff instant information on patients (mostly those with dementia), such as their background, family, likes and dislikes, etc. It will encourage staff during tense moments to see patients as people, not as a situation to handle. And knowing more about them, says Dr. Conn, just might help people keep their own tone or attitude respectful.

In implementing de-escalation techniques, think too of logistics, says Dr. Prendergast. He says that when a coronary event happens at a hospital, everyone knows what role to play. Yet when a patient or visitor has a violent outburst in a hospital, there’s confusion as to who does what. It can create chaos and uncertainty.

That shouldn’t happen, he says. Staff should have an understanding as to who will take the lead role in calming and relationship-building with the patient, who will clear the room of other patients, and who will ensure that chairs and other potential weapons in the room are not at hand.

A training program organized by the facility and taken by employees will foster a team approach that ensures everyone is working from the same script. Responding on the fly makes things more dangerous for everyone, including the patient, other patients and staff.

Dr. Prendergast says that it’s not necessarily the doctor who has to take the lead. In fact, if a doctor happens onto the scene and tries to take the lead, but hasn’t been trained in de-escalation, he or she could undo the work of whomever may have been having some success in calming the agitated patient.

Some doctors are better than others at de-escalation. When de-escalation programs started, nurses (being the most vulnerable to assault) were the ones who pushed for change. Dr. Prendergast suggests that all doctors should take de-escalation training, because you never know which patient will become aggressive or violent.

Doctors and other health-care professionals should never be surprised by or unprepared for such situations – and that means having strategies to defuse them.