Over the last six months, the TMLT Risk Management Department has received a number of urgent requests from physicians looking for information on how to de-escalate angry patients or how to diffuse a tense situation in the office.
To begin, it’s important to understand that no single response or technique will work in every situation. When responding to escalating behavior, consider the individual patient, the circumstances, and the overall context of the situation. If at any time the patient threatens harm or you feel unsafe, contact the police or call 911 immediately.
De-escalation is one technique that can be used when confronted with violent or aggressive behavior. De-escalation means “transferring your sense of calm and genuine interest in what the patient wants to tell you by using respectful, clear, limit setting [boundaries].” (1)
The following tips — published by the Crisis Prevention Institute and the Western Journal of Emergency Medicine — may provide a useful starting point for the de-escalation process. (2-3)
1. Move to a private area.
If it seems safe to do so, it may be helpful to move the patient away from public spaces and into a private area to talk.
2. Be empathetic and non-judgmental.
“Focus on understanding the person’s feelings. Whether or not you think those feelings are justified, they’re real to the other person.”
Possible response: “I’m sure other patients have felt this way too.”
3. Respect personal space.
“If possible, stand 1.5 to three feet away from the person . . . Allowing personal space tends to decrease a person’s anxiety and can help prevent acting-out behavior. Do not block exits.”
4. Keep your tone and body language neutral.
“The more a person loses control, the less they hear your words — and the more they react to your nonverbal communication. Relax your body and keep your hands in front of you, palms facing outward.”
5. Avoid over-reacting.
“Remain calm, rational, and professional. While you cannot control the person’s behavior, how you respond to their behavior can affect whether the situation escalates or defuses. Empathize with feelings, not behavior.”
Possible response: “I understand you are ___________, but it’s not okay to yell at staff.”
6. Focus on the thoughts behind the feelings.
“Some people have trouble identifying how they feel about what’s happening to them.”
Possible response: “Help me understand what you need.”
Possible response: “What has helped you in the past?”
Possible response: “Tell me if I have this right.”
Not: “Tell me how you feel.”
7. Ignore challenging questions.
“Answering challenging questions often results in a power struggle. If a person challenges your authority, redirect their attention to the issue at hand. Ignore the challenge, not the person.”
Patient: “Why is that other doctor such a ________________?”
You: “Please tell me again when your symptoms started?”
8. Set boundaries.
“If the person’s behavior is belligerent, defensive, or disruptive, give them clear, simple, and enforceable limits. Offer concise and respectful choices and consequences.”
Possible response: “It's important for you to be calm in order for us to be able to talk. How can that be accomplished?”
9. Choose boundaries wisely.
“Carefully consider which rules are negotiable and which rules are not. If you can offer a person options and flexibility, you may be able to avoid unnecessary altercations.”
Possible response: “I understand it’s confusing when rules change, but federal law says we have to check your ID.”
10. Allow silence.
By letting silence occur, you are giving the person a chance to reflect on what’s happening and how to proceed.
11. Allow time for decisions.
“When a person is upset, they may not be able to think clearly. Give them a few moments to think through what you’ve said.”
Sample response: “I’ve just shared a lot of information with you. I’ll come back in about 10 minutes after you’ve had time to think about it.”
More on de-escalation
Dealing with the aggressive patient
De-escalating anger: a new model for practice
The Joint Commission Quick Safety 47: De-escalation in health care
Crisis Prevention Institute’s Top 10 De-escalation Tips
Videos
Verbal de-escalation of the agitated patient (from the University of Colorado School of Medicine)
- Chapter 1: Identification and assessment of agitation
- Chapter 2: Basic elements of verbal de-escalation
- Chapter 3: More practice with verbal de-escalation
- Chapter 4: Advanced skills in de-escalation
- Chapter 5: Personal safety and escape skills
Understanding agitation: De-escalation (psychiatric care example)
Sources
1. Pope K. Crisis intervention in dealing with violent patients: De-escalation techniques. Available at paetc.org/wp-content/uploads/2014/10/De-escalation-PACE.pdf. Accessed March 30, 2023.
2. Crisis Prevention Institute. Top 10 De-escalation tips. Available at https://institute.crisisprevention.com/De-Escalation-Tips.html/?ref=branded. Accessed March 30, 2023.
3. Richmond JS, et al. Verbal de-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012 Feb; 13(1): 17–25. Available at https://pubmed.ncbi.nlm.nih.gov/22461917/. Accessed March 30, 2023.
Laura Hale Brockway can be reached at laura-brockway@tmlt.org.
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