Dealing with Escalating Behavior

Anger , agitation

Allow extra physical space between you - about four times your usual distance(6ft). ________ and _______ fill the extra space between you and your client.

eye level Encourage

Always be at the same ____________. ___________ the client to be seated, but if he/she needs to stand, you stand up also.

resources White

Be aware of any ________ available for back up. Know that you have the choice to leave,( if not in a health institution) tell the client to leave ( if not an in- patient) or call the police ( Code ______) should de-escalation not be effective

respectful shamed automatically

Be very ________ even when firmly setting limits or calling for help. The agitated individual is very sensitive to feeling _______ and disrespected. We want him/her to know that it is not necessary to show us that they must be respected. We _______ treat them with dignity and respect.

HISTORY CHANGE OF BEHAVIOR INCREASED MOTRICITY Mood (withdrawn, pacing) Clothing (appropriate?)

Client Considerations

smile

DO NOT ______. This could look like mockery or anxiety

abusive

DO NOT answer ______ questions (e.g. "Why are all social workers %*#@! ?) This question should get no response what so ever.​

centered calm "second nature"​

De-escalation techniques are abnormal. We are driven to fight, flight or freeze when scared. However, in de-escalation, we can do none of these. We must appear _______ and _____ even when we are frightened. Therefore these techniques must be practiced before they are needed so that they can become ___________

touch misinterpretation

Do not ______ - even if some touching is generally culturally appropriate and usual in your setting. Cognitive dysfunction in agitated people allow for easy __________ of physical contact as hostile or threatening.

point shake

Do not ______ or _______ your finger.

choices ex. empower.​​

Do not argue or try to convince, give ___________

defensive

Do not be _________ even if the comments or insults are directed at you, they are not about you.​

verbally

Do not defend yourself (_______ ) or anyone else from insults, curses or misconceptions about their roles.

Wait until he/she takes a breath; then talk. Speak calmly at an average volume.

Do not get loud or try to yell over a screaming person. Instead you should do what?

constant eye contact

Do not maintain __________. Allow the client to break his/her gaze and look away.

interpret analytic

Do not solicit how a person is feeling or_______feelings in an _________ way.​

front sidestep doorway

Do not stand full ______ to client. Stand at an angle so you can ______ away if needed. If in the same room never have your back to the doorway. Stand at the _________ , not inside the pt's room.

parental " You have a right to feel angry."​

Don't be ________ , don't join the resistance:

defensive

Don't be _________ or judgmental.​

1. Nurse recognises that Edith is angry only because the staff will not listen to her alternative treatment options. FALSE Nurse will attempt to reduce the level of arousal , which is anger. TRUE Nurse does not emphasize Edith's feelings of being out of control and feeling fear. FALSE Edith is close to her family, the nurse suggests that she spend time discussing her concerns with her family. TRUE The nurse agrees with Edith when Edith states that the hospital staff are bullying her. FALSE The nurse recognizes that Edith is not potentially dangerous as she is only expressing anxiety & has no history of aggressive behaviour TRUE Edith on the evening shift throws a chair at a staff member who enters the room bringing the supper. According to the OMEGA grid, this is destructive and the priority action is physical protection of the individuals on the unit. TRUE​ Edith prior to throwing the chair, demonstrated increased motricity, extreme moodiness and was dressing inappropriately. These are risk factors that can be identified when evaluating possible escalating behaviour. TRUE

Edith , a 41 year old woman with a history of peripheral vascular disease , surgeries for vascular grafts & repair of graft occlusions, is admitted to the hospital with severe pain in her left foot. Tests reveal that the vessels to the foot are occluded. Additional surgery is ruled out, & medication is prescribed. Unfortunately, the medication is ineffective , & the foot begins to necrotize. The doctors discuss amputation with Edith. She refuses the surgery, & demands a series of unproven alternative therapies. She is extremely angry with all members of the hospital staff. The treatment team becomes increasingly impatient to schedule surgery because the patient is beginning to exhibit signs of systemic infection. This impatience aggravates Edith's feelings of being out of control & erodes her belief that she is a competent partner in her treatment.

behavior "I understand that you have every right to feel angry, but it is not okay for you to threaten me or my staff."

Empathize with feelings but not with the___________

Anticipate (self-protection, safe distance, assistance) Observe (physical parameters) Gauge (eye contact, verbal contact, personal space)

Evaluate the individual in order to adapt our level of vigilance (extra awareness of impending problems)

limits rules respectful

Explain _____ and ______ in an authoritative, firm, but always ________ tone. Give choices where possible in which both alternatives are safe ones.

inappropriate threats

Give the consequences of ________ behavior without ______ or anger

SELF CLIENT OTHERS Environment (doors, isolation, confort) Time (admission,medication) Equipment Task

Identify elements of my work situation in order to pinpoint risk factors. ​

remove necktie, scarf, hanging jewelry, religious or political symbols

If you have time what might you want to remove (not in front of him/her)​ before you see the client?

( NO DESTRUCTIVE Behavoir)

Incidents without confrontation

protect yourself concealed weapon

Keep hands out of your pockets, up and available to __________. It also demonstrates non-verbal ally, that you do not have a _____________

client exhibits anxiety , is crying, is withdrawn, fluctuating ​ YOUR RESPONSE: listen , reassure, empathize

OMEGA 1. EMOTIONAL TENSION

client states yes but...... ​ YOUR RESPONSE: evaluate arguments, foster mutual agreement

OMEGA 2. CONDITIONAL COLLABORATION

pt states no, no, no, plays deaf, ignores the request.​ YOUR RESPONSE: Clear instructions with reminder and consequences.

OMEGA 3 NEGATIVISTIC

pt throws or breaks objects​ YOUR RESPONSE: Priority : physical protection of individuals . Reduce the supply. ​

OMEGA 4 DESTRUCTIVE

OMEGA 4 DESTRUCTIVE: OMEGA 8 HOSTAGE TAKING. THREAT WITH A WEAPON PRIMARY RESPONSE: physical protection of individuals. Reduce the Supply (chairs, objects)

OMEGA 4-8​

Lets say you get taken hostage: Gain time, you must remain calm, speak if you can , negotiate if possible, establish a link. If threatened with a weapon, remain silent.

OMEGA 8 HOSTAGE TAKING. THREAT WITH A WEAPON

Appear calm, centered and self-assured Relax facial muscles and look confident. Modulated, low monotonous tone of voice Dont be defensive Do not defend yourself or anyone else( verbally) Be aware of any resources available for back up. Be very respectful

PART 1: THE WORKER IN CONTROL OF HIM / HER SELF​

Never turn your back for any reason​ Always be at the same eye level Allow extra physical space between you 6ft Do not stand full front to client Do not maintain constant eye contact Do not point or shake your finger Do not touch Keep hands up and available to protect yourself

PART 2: THE PHYSICAL STANCE

Do not argue or try to convince, give choices Don't be defensive or judgmental.​ Don't be parental, don't join the resistance Focus on calmly lowering level of arousal down Do not get loud or yell over a screaming person. Respond selectively; answer all informational questions no matter how rudely asked Explain limits & rules in an authoritative, firm, but always respectful tone. Give choices where possible in which both alternatives are safe ones Empathize with feelings but not the behavior Do not solicit how a person is feeling or interpret feelings in an analytic way.​ ​Do not argue or try to convince. Tap into the client's cognitive mode Suggest alternative behaviors where appropriate Give the consequences of inappropriate behavior without threats or anger Represent external controls as institutional rather than personal.​ Trust your instincts There is nothing magic about talking someone down.

Part 3: ​ THE DE-ESCALATION DISCUSSION​

Omega

Potential dangerous grid used to asses someone

Incidents without confrontation :​ OMEGA 1. EMOTIONAL TENSION : OMEGA 2. CONDITIONAL COLLABORATION: OMEGA 3 NEGAVISTIC :

Potential dangerous grid: Omega stages 1, 2, 3

calmly anger

Remember that there is no content except trying to _______ bring the level of arousal down to baseline, reduce the _________.​

institutional

Represent external controls as _________ rather than personal.​

alternative "Would you like to take a break and have a cup of coffee or some water?​

Suggest _______ behaviors where appropriate

calm interest

There is nothing magic about talking someone down. You are transferring your sense of______ and genuine ________ in what the client wants to tell you, and of respectful, clear limit setting in the hope that the client actually wishes to respond positively to your respectful attention.

STOP

Trust your instincts. If you assess or feel that de-escalation is not working, you should ________! You will know within 2 or 3 minutes if it's beginning to work.

DE-ESCALATION

VERBAL ____________ TECHNIQUE FOR DEFUSING OR TALKING DOWN AN EXPLOSIVE SITUATION

ER Psychiatry When a nurse is alone

What situations/area have a higher risk of incidence?

1. There is emotional tension, conditional collaboration, negativistic responses OMEGA 1-3 2. Reasoning with an enraged person is not possible. The first and only objective in de-escalation is to reduce the level of arousal so that discussion becomes possible. Reduce the anger.

When a potentially violent situation threatens to erupt on the spot and no weapon is present, verbal de-escalation is appropriate. There are two important concepts to keep in mind:

cognitive mode "Help me to understand what your are saying to me" People are not attacking you while they are teaching you what they want you to know.

Wherever possible, tap into the client's __________: DO NOT ask "Tell me how you feel". Instead say, ....

escalate

Your anxiety can make the client feel anxious and unsafe and that can _________ aggression.​

Reflect ethical improve

________ on your own experiences. Adhere to the standards of practice,. Apply ________ principals in your nursing practice. Identify in what way you can ______ your nursing performance.

OMEGA

did I follow the ________ and was it ethical?

Would you like to continue our meeting calmly or would you prefer to stop now and come back tomorrow when things can be more relaxed? Would you prefer going to your room where we can talk calmly & in private? Once in the room, would you like to calm down and/or accept an oral medication ?

examples of choices to give an upset person

high tight

our normal tendency is to have a _____ pitched, _______ voice when scared

MOTRICITY

the faculty or power of movement by the body or a body part

SELF (confidence, experience, strengths/limitations) OTHERS (Experience, social role, Employment status) CLIENT

trifecta of elements

argue

​Do not _________ or try to convince.