The medical setting from hospitals to clinics can be an emotionally charged one, which means nurses can be placed in volatile situations when dealing with upset or confused patients and their family members. Just about every nursing setting can experience aggression in one form or another. Trauma, pain, fear, and confusion can cause patients and their family members to become agitated and combative. Nurses also work with patients who have various degrees of mental health issues such as dementia, schizophrenia, and drug and alcohol addiction. Because of this, nurses need to have the tools necessary to defuse potentially violent situations.
There is currently not a lot of research on the efficacy of de-escalation (Joint Commission, 2019). However, until more research is done, de-escalation remains the best and most important tool available to nurses and staff when patients and families become combative. The definition of de-escalation in healthcare is “a collective term for a range of interwoven staff-delivered components comprising communication, self-regulation, assessment, actions, and safety-maintenance which aims to extinguish or reduce patient aggression/agitation irrespective of its cause and improve staff-patient relationships while eliminating or minimizing coercion or restriction (Hallett & Dickens, 2017).
Understanding and assessing the patient’s level of agitation is critical to figuring out if the patient is just mildly irritated or if the patient is becoming increasingly hostile. Fortunately, several tools can be utilized to assess the patient’s level of agitation depending on the setting or type of patient. One such tool is the STAMP system. STAMP stands for Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling and Pacing (Hilton, 2022). Staring or lack of eye contact can both be signs of impending agitation. Tone and volume can mean yelling and or sarcasm. Many patients and family members experience Anxiety when entering the hospital setting. However, anxiety can be heightened due to mental illness or substance abuse as well. Mumbling and pacing can also be associated with agitation (Blackwell, 2007). Another assessment tool is BARS or the Behavioral Activity Rating Scale. BARS is set on a scale from 1 to 7 and ranges from 1 being difficult or unable to arouse to 4, which is quiet and awake (normal activity), and 7 being the most violent and requiring restraints (Nordstrom, et al., 2012). There is also the BRACHA tool or brief rating of aggression by children and adolescents. BRACHA is a 14-item questionnaire that rapidly assesses the child’s or adolescent’s tendencies toward aggression and violence. There are other tools available, but regardless of the tool that is used, assessment and de-escalation work together simultaneously.
The Joint Commission highlights 3 de-escalation models in the Quick Safety article on de-escalation in healthcare. These models are flexible and enable the nurse to utilize a variety of skills and interventions by monitoring the patient’s response and adjusting accordingly. The Dix and Page Model utilizes assessment, communication, and tactics, which are continually revisited during an incident. The Turnbull et al. Model evaluates the aggressor’s response to the de-escalator’s interventions. This allows for flexibility since what can be calming for one individual may be agitating or not useful for another. Lastly, the Safewards Model focuses on moving the patient to a safe area, maintaining a safe distance, finding the source of anger via effective communication, and mutual agreement on a solution. These models provide useful guidelines but also allow for different interventions and skills to be utilized so that the interventions can be better tailored to the patient and the situation. However, for these models to be utilized effectively, The Joint Commission emphasizes that senior management must also be dedicated to educating staff by providing training, auditing interventions, incorporating assessment tools, involving the patient, and using debriefing techniques (The Joint Commission, 2019).
Some useful tips to practice when confronting an agitated patient are:
- Stay at least 2 arms-length away.
- Maintain a relaxed posture and look.
- Speak calmly with visible hands.
- Acknowledge what the patient is saying.
- Do not threaten.
- Set clear boundaries.
- Refrain from using medical argon.
- Be non-judgmental.
- Show empathy.
- Use the patient’s name.
- Be ok with silence – This allows the patient time to reflect and calm down.
- Do not argue.
- Define consequences of behavior.
- Be respectful.
- Do not answer inappropriate questions.
- Treat the patient with dignity.
- Use trauma-informed care
(Hilton, 2022)
Nurses should be equipped with the appropriate de-escalation tools such as the assessment tools and de-escalation models for their type of work setting and should be provided with the support needed by upper management to be able to maintain a calm and therapeutic work environment for the medical staff, the patients, and their families. Workplace safety should always be a priority for all members of the medical staff. Continuous training and staying ahead of the latest research are critical to maintaining a safe, stress-free, and healthy work environment.
References
Blackwell Publishing Ltd. (2007, June 21). STAMP System Can Help Professionals To Identify Potentially Violent Individuals. ScienceDaily. Retrieved June 2, 2024 from www.sciencedaily.com/releases/2007/06/070620085620.htm
Hallett N, Dickens GL. (2017, October). De-escalation of aggressive behaviour in healthcare settings: Concept analysis. International Journal of Nursing Studies, (OCT 75) 10-20. doi: 10.1016/j.ijnurstu.2017.07.003. https://pubmed.ncbi.nlm.nih.gov/28709012/
Hilton, Lisette (2022, February 21). Use These De_Escalation Techniques to Help Keep Staff, Patients Safe. Nurse.com. https://www.nurse.com/blog/use-these-de-escalation-techniques-to-help-keep-staff-patients-safe/
The Joint Commission. (January 2019). Quick Safety: De-escalation in healthcare, (Issue 47). https://www.jointcommission.org/-/media/tjc/documents/resources/workplace-violence/qs_deescalation_1_28_18_final.pdf?db=web&hash=DD556FD4E3E4FA13B64E9A4BF4B5458A
Nordstrom, K., Zun, L. S., Wilson, M. P., MD, V. S., Ng, A. T., Bregman, B., & Anderson, E. L. (2012). Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup. Western Journal of Emergency Medicine, 13(1), 3-10. https://doi.org/10.5811/westjem.2011.9.6863
