5 Rules to Use with Escalating/Violent People

Communication effectiveness depends upon delivery, body language, and words.

When people become upset, it affects their thinking and ability to problem solve.

Talking replaces action.

Know yourself and how you usually respond in a tense situation.

Respond, donít react.

DO

Nonverbal

Verbal

Environmental

DO

Be observant of potential problems.

Pay attention to your stance and use of personal space.

Use active listening.

Present an empathetic attitude

Maintain personís dignity/self-esteem

Use a communication framework.

Keep tone of voice low and calm.

Allow the person to speak freely at first in order to grasp the difficulty.

Focus on the specific problem and use problem-solving techniques.

Offer choices, no matter how small.

Take the person to a quiet place away from others.

Allow room to pace (to burn off energy).

Offer something to drink: water, juice, or a soft drink.

Allow for enough personal space so that you or the other person has time to break.

DONíT

Nonverbal

Verbal

Environmental

DON'T

Donít touch the person.

Donít stand or sit incorrectly.

Donít use poor listening techniques.

Donít have a negative attitude.

Donít argue, challenge, or react with anger.

Donít condescend.

Donít agree or disagree with distortions of reality.

Donít get involved in a power struggle.

Donít make promises that you canít keep or have no control over.

Donít interrupt, talk too much, or hurry the communication process.

Donít "corner" the person.

Donít isolate where help is not available to you.

Donít keep the person in a crowded area.

ASSESSMENT

Escalating Person

Violent Person

Appearance

Clenched jaw

Narrowed eyes

Frowning

Anxious

Clenched hands

Looks angry and upset

Face becoming reddened

Beginning to perspire

Tremulous

Clenched jaw

Piercing stare

Reddened face

Narrowed, glaring, or darting eyes

Agitated

Fearful or angry expression

Veins standing out

perspiring heavily

Speech

Loud voice

Swearing

Muttering

Sarcastic

Examples: clipped, pressured speech, argumentative speech

Inappropriate affect

Shouting

Repetitive speech

Swearing

Rambling

Movements

Exaggerated movements

Nervous energy

Gesturing

Pacing

Wringing hands

Intrusive

Pacing

Pounding

Making fists

Tense muscles

Exaggerated movements

Behaviors

Overly sensitive

Demanding

Acting strangely

Irritable

Crying

Obnoxious

Hostile

Hostile

Throwing

Threatening

Hitting

Belligerent

Pushing

Confused

Kicking

Suspicious

Jabbing

Pounding

MANAGEMENT

Escalating Person

Violent Person

Supportive & Helpful Communication

Taking Control & Safety Precautions

Look

Assess the situation

Make rapid assessment

Call 911

Institute plan

Identify person in charge

Take safety precautions (space, exits, harmful objects)

Use correct stance and distance

Speak briefly, clearly, firmly, and simply

Listen

Use correct stance/distance
Use active listening

Interact

Introduce self

Acknowledge difficulties

Use empathetic responses

Allow time for response and feedback

Clarify, reflect, focus

Apologize Offer help

Act

Problem solve

Set short-term goals

Consult with others

Provide privacy, if appropriate

J. Rizzo, J. Kettley, 1993

UMMC

De-Escalation Interventions

Nonverbal

1. Maintain a 3-6 foot safety zone.

2. Position self with potential escape route in mind.

3. Keep facial expression and body language as interested, nonjudgmental, and nondefensive as possible.

Verbal

1. Keep voice calm, quiet, low.

2. Speak slowly, clearly, briefly

3. Use respectful tone.

Interventions

1. Acknowledge and respond to early signs of anxiety, frustration

2. Be directive as needed, e.g., "You need to return to your room so we can talk."

3. Encourage person to talk without interrupting, defending, or suggesting (talking replaces acting out).

4. Use active listening and communication techniques to identify concerns: Reflecting, Clarifying, Summarizing, Informing, Focusing.

5. Apologize, if appropriate, for inconvenience or difficulties experienced.

6. Offer short-term solutions, resolutions, or problem-solve with person.

H. Kelley, RN, 1996, UMMC

Staff Safety Reminders

Never turn away from the patient

Never directly confront a patient who is angry, escalated, and threatening to do you bodily harm. Do not even make verbal remarks, as this will only escalate the patient further. The key to managing this type of crisis is to DECREASE ALL STIMULUS AND MOVE QUICKLY FOR SUPPORT.

Always be sure to have enough people when implementing physical management. Utilize Security staff.

When in a physical management situation remember to remain calm.

Maintain a safe personal space from the patient.

Never attempt to deescalate an angry patient without other staff support and presence.

To intervene with a verbally or physically acting out patient alone is to set yourself up for unsafe situations where a patient may make allegations per your behavior.

Only the "in charge" person should speak to the patient. All other staff should be silent, awaiting instructions or assisting in a non-verbal manner. It is important to DECREASE unnecessary stimuli. Several people talking to the patient adds CHAOS and CONFUSION to the situation.

Utilize the "Work-Connections Employee-Centered Illness or Injury Report Form" for any employee injuries.

B. Watson, RN, 2000, UMHS

DO	Nonverbal	Verbal	Environmental
DO	Be observant of potential problems. Pay attention to your stance and use of personal space. Use active listening. Present an empathetic attitude Maintain personís dignity/self-esteem	Use a communication framework. Keep tone of voice low and calm. Allow the person to speak freely at first in order to grasp the difficulty. Focus on the specific problem and use problem-solving techniques. Offer choices, no matter how small.	Take the person to a quiet place away from others. Allow room to pace (to burn off energy). Offer something to drink: water, juice, or a soft drink. Allow for enough personal space so that you or the other person has time to break.
DONíT	Nonverbal	Verbal	Environmental
DON'T	Donít touch the person. Donít stand or sit incorrectly. Donít use poor listening techniques. Donít have a negative attitude.	Donít argue, challenge, or react with anger. Donít condescend. Donít agree or disagree with distortions of reality. Donít get involved in a power struggle. Donít make promises that you canít keep or have no control over. Donít interrupt, talk too much, or hurry the communication process.	Donít "corner" the person. Donít isolate where help is not available to you. Donít keep the person in a crowded area.

ASSESSMENT	Escalating Person	Violent Person
Appearance	Clenched jaw Narrowed eyes Frowning Anxious Clenched hands Looks angry and upset Face becoming reddened Beginning to perspire Tremulous	Clenched jaw Piercing stare Reddened face Narrowed, glaring, or darting eyes Agitated Fearful or angry expression Veins standing out perspiring heavily
Speech	Loud voice Swearing Muttering Sarcastic Examples: clipped, pressured speech, argumentative speech	Inappropriate affect Shouting Repetitive speech Swearing Rambling
Movements	Exaggerated movements Nervous energy Gesturing Pacing Wringing hands Intrusive	Pacing Pounding Making fists Tense muscles Exaggerated movements
Behaviors	Overly sensitive Demanding Acting strangely Irritable Crying Obnoxious Hostile	Hostile Throwing Threatening Hitting Belligerent Pushing Confused Kicking Suspicious Jabbing Pounding

MANAGEMENT	Escalating Person	Violent Person
	Supportive & Helpful Communication	Taking Control & Safety Precautions
Look	Assess the situation	Make rapid assessment Call 911 Institute plan Identify person in charge Take safety precautions (space, exits, harmful objects) Use correct stance and distance Speak briefly, clearly, firmly, and simply
Listen	Use correct stance/distance Use active listening
Interact	Introduce self Acknowledge difficulties Use empathetic responses Allow time for response and feedback Clarify, reflect, focus Apologize Offer help
Act	Problem solve Set short-term goals Consult with others Provide privacy, if appropriate

Nonverbal	1. Maintain a 3-6 foot safety zone.
	2. Position self with potential escape route in mind.
	3. Keep facial expression and body language as interested, nonjudgmental, and nondefensive as possible.

Verbal	1. Keep voice calm, quiet, low.
	2. Speak slowly, clearly, briefly
	3. Use respectful tone.

Interventions	1. Acknowledge and respond to early signs of anxiety, frustration
	2. Be directive as needed, e.g., "You need to return to your room so we can talk."
	3. Encourage person to talk without interrupting, defending, or suggesting (talking replaces acting out).
	4. Use active listening and communication techniques to identify concerns: Reflecting, Clarifying, Summarizing, Informing, Focusing.
	5. Apologize, if appropriate, for inconvenience or difficulties experienced.
	6. Offer short-term solutions, resolutions, or problem-solve with person.