Response Options

Having considered both the subjects behaviour and  situational impact factors, we now need to determine our response.

The following are options for a response to any kind of threat to safety:

Disengage depart and call for help, put barriers between you and the aggressor
(This is the best option for any serious threat)

Two communication strategies:

Verbally de-escalate the situation with communication skills

Every effort should be made to first determine whether the aggressive behaviour can be managed at the verbal or behavioral level, without employing other means of restraint. The agitated but cooperative person may be amenable to verbal de-escalation techniques alone. This allows for the opportunity to assess the subjects mental status and comprehension, as well as his or her perception of the current situation.

There are two communication strategies that allow us to verbally de-escalate and manage challenging situations. For subjects exhibiting warning signs we can adopt the LEAPS approach. The tone of our voice and intonation are  very important during this process.

Table 1: Key principles of LEAPS

Tips and ground rules which may be helpful in confronting situations

• Create a calm, polite, respectful environment. The American College of Emergency Physicians recommends that the ED should contain at least one secure examination room for the evaluation of psychiatric patients.
• Respect a patients personal space: Maintain a safe distance (at least two arm lengths) and provide space for easy exit, for all involved.
• Avoid touching an angry or agitated person
• Stay on the same physical level as the patient; do not look down on them; Avoid sudden movements
• Keep your posture neutral and maintain a non-confrontational body posture
• Do not stare at the patient; eye contact should convey sincerity

Establish a verbal contact in a calm and clear voice

• Use concise yet  simple language
• Example: Asking, “How can we help you?” This display of compassion on the part of the treating provider or other ED staff may serve to calm the patient.

Active Listening

Restate what the patient has said. This may help to improve a mutual understanding (Example: Tell me whether I have this right)

Avoid confrontation; offer to help solve the problem

Acknowledge their frustration

Aligning goals

• Emphasize common interests
• Focus on the big picture
• Find ways to make small concessions

Monitoring

• Be aware of progress
• Know when to disengage
• Do not insist on having the last word
• Have a staff member sit with the patient

Agree or agree to disagree: (a) Agree with clear specific truths; (b) Agree in general (e.g., “Yes, everyone should be treated with respect.”); (c) Agree with unusual situations (e.g., “There are others who might feel like you.”).

Refer to rules of common decency and set clear limits: Inform the patient that violence or abuse cannot be tolerated.

Offer alternate choices for optimism: Patients feel empowered if they have some choice in the outcome.

Debrief the patient and staff: Be sure to include opportunities for both the patient and the staff member (s) to speak

Activate hospital security to ensure the safety of the patient and of the staff (if these conservative measures fail).

In these situations, consider the following security measures:

• The security staff should not rush to the patients bedside but rather they should gather outside the door or close by, within eye contact of the patients room.
• A strong show of force may calm a potentially violent patient without the need for restraint
• Directly address the issue of violence

Inquire about

• Suicidal, or homicidal ideation or plan
• Possession of weapons: their belongings should be searched for any weapons or objects that could be used as weapons
• Current use of medications
• Acknowledge the obvious (e.g., “You look angry.”)
• If the patient becomes more agitated, it may be helpful to speak in a conciliatory manner. Offer supportive statements such as, “You obviously have a lot of will power and are good at controlling yourself.”

Assertions using different communication skills

For subjects who display a higher-level threat (warning signs), but without signs of imminent violence (danger signs), we may need to escalate our communication strategy to assertion.

There is a need to clearly indicate any offensive behaviour, to offer clear options, to provide boundaries and to confirm expectations.

Here are some good examples:

• ‘I want to help you; but I need you to stop shouting/swearing.’
• ‘This is what we can offer you’
• ‘If you remain calm we will be able to help you’
• ‘If you cant control your behaviour then the only option we have is to ask you to leave.’
• ‘You tell me what it is that you want to do.’

Offer a reasonable, proportionate and necessary physical response when no other options remain,  when there is a need to establish control or to prevent harm to anyone..

When standing outside the fighting arc it is best to adopt a stance which allows us to communicate; it also confers some protection to the upper body and serves as a starting position to a number of physical intervention skills, including blocks or restraint techniques.

Adopt a stance, which affords minimal body exposure and protection, and shows a readiness to communicate.