When approaching an angry patient which safety considerations should be taken?

There is a high tendency for health professionals to easily overlook negative patient body language, but it can also just as easily be a warning of a looming act of violence. Before the start of the pandemic, acts of healthcare violence were on an upward trend; and even now, the industry is still scrambling on how to adjust.

One solution is to train and educate staff on how to recognize the early signs of conflict, triggers, and patient anxiety.

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What are the common triggers of patient aggression?

Some triggers of anxiety are frustration, anger, or fear. Here are some of the typical root causes:

• Waiting. Long lines, although less common in a physician's office, are typical in the Emergency Department.

• Fatigue. Someone who is not feeling well is probably not sleeping very well. Fatigue becomes a big driver of anxiety when coupled with the patient’s feeling of losing control.

• Fear of injury or pain. Patients can sometimes fear treatment more than their injury. Fear of an unknown procedure can act as a trigger.

• Drugs. Prescriptions missed medications or illegal drugs can play a big role in a patient’s behavior.

Just like other behavioral patterns, the stages of conflict can typically be recognized. Stages of conflict also referred to as a spectrum of violence first begins with anxiety. For example, a patient is upset about an appointment starting late. Even while they sit and wait, this could quickly turn into some sort of verbal aggression that could turn physical. With close observation, the behaviors can be identified by looking for signs of patient anxiety at initial contact.

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What are the signs of patient anxiety?

• Head Down
• Flushing of the skin
• Rubbing of the hands
• Shallow breathing
• Sweaty hands and brow
• A nervous laugh
• Veins appear
• Dry mouth and swallowing
• Bouncing finger tapping
• Touching of the nose
• Playing with the hair

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Preventing Challenging Behaviors

How you approach challenging behavior may vary based on your experience and past training. Generally, here are some agreed-upon steps to follow.

• Pause – stand back, take a moment before approaching and assess the situation.
• Speak slowly and clearly in a calm voice.
• Explain your care actions.
• Try not to rush the person, act calmly.
• Show respect and treat people with dignity at all times.

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When challenging behavior happens, communication is the key

Avoid harsh aggressive or abrupt statements. Don’t say things such as “You must….”, “Don’t…..”, “Stop…….”. Use alternatives and “I’ language like “I would like you to…” It would help me if……”, “ I feel scared when…….”. See our checklist of phrases to avoid when dealing with aggressive patients.

When challenging behavior happens:

• Back off where possible
• Keep calm
• Call for help

Leave the person to calm down, if possible. Remove others from the environment. Be aware of your own body language and tone of voice used.

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Management of Aggressive Behaviors Training

Sometimes all the best dialogue won’t be enough to ward off an unexpected attack. Healthcare workers can benefit from the management of aggressive behaviors training. MOAB (Management of Aggressive Behavior) focuses on principles, techniques, and skills for recognizing, reducing, and managing violent and aggressive behavior. The program also provides humane and compassionate methods of dealing with aggressive people.

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Need More Resources?

Learn more here about MOAB training offered by LHA Trust Funds here.

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About The Author

Glenn Eiserloh, CHSP -Senior Risk Consultant, LHA Trust Funds

Glenn Eiserloh has more than seventeen (17) years of loss prevention and risk management experience. Mr. Eiserloh has a Bachelor’s of Science degree from the University of New Orleans in Finance with a concentration in insurance. He provides consultation services relative to workplace loss prevention, safety training, general liability risk reduction, worksite safety inspections, and trend analysis.

The purpose of this Quick Safety is to present some de-escalation models1 and interventions for managing aggressive and agitated patients in the ED and inpatient settings. There are many different de-escalation techniques; this Quick Safety is intended to guide health care professionals to resources for more information and training.

It should be noted that there is little research about the efficacy of de-escalation, and there is no guidance of what constitutes the gold standard for practice.1 A Cochrane review acknowledges that this leaves nurses to contend with conflicting advice and theories regarding de-escalation.3 However, some de-escalation studies have concluded that the positive consequences of de-escalation include:1

• Preventing violent behavior
• Avoiding the use of restraint
• Reducing patient anger and frustration
• Maintaining the safety of staff and patients
• Improving staff-patient connections
• Enabling patients to manage their own emotions and to regain personal control
• Helping patients to develop feelings of hope, security and self-acceptance

What is de-escalation and what is its purpose?

The literature has several definitions of de-escalation1,3 and uses other terms for de-escalation, including conflict resolution, conflict management, crisis resolution, talk down, and defusing.1 For the purposes of this Quick Safety, we describe de-escalation as a combination of strategies, techniques, and methods intended to reduce a patient’s agitation and aggression. These can include communication, self-regulation, assessment, actions, and safety maintenance in order to reduce the risk of harm to patients and caregivers as well as the use of restraints or seclusion. (See the sidebar for an example of using de-escalation.)

Injuries to patients and staff can occur during the use of restraints. Data from the Cochrane Library reveals that in the United States, 40 percent of restraint-related deaths were caused by unintended asphyxiation during restraint.3 The use of restraint and seclusion creates a negative response to the situation that can be humiliating to the patient, and physically and emotionally traumatizing to staff involved.3 Also, it impacts the trust between the patient and health care professionals. Restraint and seclusion should be a last resort, used after other interventions have been unsuccessful, and done to protect the patient, staff and other patients in the area from physical injury.

Recognizing the aggressive patient

In the mental health setting, dealing with aggressive patients can be an everyday occurrence.3 Acute inpatient psychiatric settings may have patients who exhibit risk-prone behaviors, such as verbal aggression, attempts to elope, self-harming behaviors, refusing to eat or drink, and displaying aggression to objects or people.4 The ED has its own set of challenges. Patients come to the ED with hallucinations, hearing voices, or they may be under the influence of unknown substances. Upon entry, a triage nurse must assess the patient.

A number of assessment tools are available to help health care professionals recognize the aggressive patient, including:

• STAMP (Staring, Tone and volume of voice, Anxiety, Mumbling, and Pacing) is a validated tool for use in the ED.5
• Overt Aggression Scale (OAS) is a reliable tool for use in the inpatient setting for children and adults.6
• Broset Violence Checklist (BVC) has been validated for use in the adult inpatient psychiatric unit.5
• Brief Rating of Aggression by Children and Adolescents (BRACHA) has been found to be a valid tool for use in the ED to determine the best placement on an inpatient psychiatric unit.6

De-escalation models

The following cyclical de-escalation models from the literature advocate considerable flexibility in the use of different skills and interventions:

• The Dix and Page model consists of three interdependent components: assessment, communication and tactics (ACT). Each should be continuously revisited by the de-escalator during the incident.1
• Similar to Dix and Page, the Turnbull, et al. model additionally describes how the de-escalator evaluates the aggressor’s response to their use of de-escalation skills by constantly monitoring and evaluating feedback from the aggressor. The authors stress that flexibility in individual cases is more important than basing de-escalation on a few well practiced skills, or using those skills in a pre-determined order, since what may be de-escalatory for one person may be inflammatory for another.1
• A linear model is the Safewards Model, which begins with delimiting the situation by moving the patient or other patients to a safe area and maintaining a safe distance; clarifying the reasons for the anger using effective communication; and resolving the problem by finding a mutually agreeable solution. The model stems from a randomized control trial conducted in the United Kingdom to look at actions that threaten safety and how staff can act to avoid or minimize harm. The trial concluded that simplistic interventions that improve staff relationships with patients increase safety and reduce harm to both patients and staff.4

Interventions for defusing aggression

The following interventions can be used to defuse an aggressive situation in both the ED and inpatient psychiatric setting:3,5

• Utilize verbal communication techniques that are clear and calm. Staff attitudes must be non-confrontational in use of verbiage. Avoid using abbreviations or health care terms.
• Use non-threatening body language when approaching the patient.
• Approach the patient with respect, being supportive of their issues and problems.
• Use risk assessment tools for early detection and intervention.
• Staff attitudes, knowledge and skill in using de-escalation techniques must be practiced and discussed in an educational format.
• Respond to the patient’s expressed problems or conditions. This will help create a sense of trust with the health care professional.
• Set clear limits for patients to follow.
• Implement environmental controls, such as minimizing lighting, noise and loud conversations.

On inpatient behavioral health units, there are three approaches that can be used to decrease aggression throughout the unit, using a multidimensional aggression assessment process:7

• Patient-centered care approach: Each patient should undergo a medical exam to rule out any underlying disease or condition; a nursing history and social history should be obtained; an aggression assessment should be conducted using a valid or reliable tool; and a psychiatric evaluation should be completed, including observation for cues or signals of approaching anxiety or aggression.
• Staffing-centered approach: Therapists and staff have training, skills, knowledge and competencies in appropriate areas, including de-escalation. Staff and therapist approach patients with respect, and are non-controlling, unprovocative, non-confrontational, and non-coercive. Staff have very good interpersonal skills.
• Environmental-centered approach: Diversionary activities should be available at all times. The physical layout should allow patients to move about freely, without feeling cramped, and provide for personal space. Apply consistent unit rules to every patient. Avoid loud conversations and additional noise whenever possible. Maintain a small census and shorter length of stay whenever possible.

The 10 interventions to reduce conflict and minimize harm of the Safewards Model are:

1. Mutually agreed upon and publicized standards of behavior by and for patients and staff. Patients and staff meet as a group to discuss these expectations for behaviors while on the unit.
2. Short advisory statements (called soft words) to be used during flashpoints, hung in the nursing office and changed every few days.
3. A de-escalation model used by best de-escalator on the staff (as elected by the ward concerned) to increase the skills of others on the ward.
4. A requirement to say something good about each patient at nursing shift handover.
5. Scanning for potential bad news a patient might receive from friends, relatives or staff, and intervening promptly to talk it through.
6. Structured, shared innocuous personal information between staff and patients (such as, music preferences, favorite films, and sports) via a ‘know each other’ folder kept in the day room.
7. A regular patient meeting to bolster, formalize and intensify interpatient support.
8. A crate of distraction and sensory tools to use with agitated patients (for example, stress toys, mp3 players with soothing music, light displays, textured blankets).
9. Reassuring explanations to all patients following potentially frightening incidents.
10. A display of positive messages about the ward from discharged patients.

In addition, the Crisis Prevention Institute (CPI) published a list of Top 10 De-Escalation Tips that can be used in health care, human services, business, or any field where workers might deal with angry, hostile, or noncompliant behavior. The tips are designed to help workers respond to difficult behavior in the safest, most effective way possible.

Safety actions to consider:

There are a number of actions that health care organizations can take to make sure that staff is prepared to intervene and de-escalate a potentially dangerous or harmful situation should a patient become aggressive or agitated. The following strategies are derived from the Safewards Model:4

• Commitment by senior management to change. Leadership must endorse resources needed to educate staff, and allow time to audit the interventions and environmental changes needed to create the most therapeutic unit possible.
• Use audits to inform practice. The Patient Staff Conflict Checklist (PCC)4 is an example of a reliable and valid tool. At the end of each shift, the charge nurse records the number of times conflicts (actions that threaten safety) and containments (restraint, seclusion or observation) occurred — not the number of patients involved.
• Implement workforce training on new techniques and interventions.
• Incorporate the use of assessment tools.
• Involve patients.
• Use debriefing techniques.

Should violence occur despite efforts to de-escalate the situation, organizations should be prepared to address workplace violence issues, as described in Sentinel Event Alert 59, “Physical and verbal violence against health care workers.”9 The alert provides suggested actions, including:

What actions should you take if confronted by an angry patient?

Which of the following is the best response for nurses to manage anger of a client?

Which interventions would the nurse choose to help a patient manage anger in a healthy way?

Which method for dealing with an aggressive patient who is out of control is the most restrictive?