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Basics: 1. There are often two or more people in an incident. 2. If one initiates an incident, the other has a choice to a. Escalate the incident further. b. Not escalate the situation. Deescalation is the art of not escalating a situation and bringing about the possibility of resolution through communication, not force. If the situation is de-escalated there are 2 main benefits: 1. Quicker resolution 2. Less harm In normal situations (i.e. when not at work) there are two well recognised choices if someone is aggressive to you: Escalation De-escalation Fight Flight High aggression. Low aggression.

Reflection: When is it ok to use a flight response in a care setting?

Why is flight sometimes not an option (although it may be what we feel like doing)?

In order to understand de-escalation, it is important to understand what makes up escalation.

Reflection: Consider an incident you have witnessed that resulted in some form of aggression (verbal or physical). This does not have to be at work, but could be from observing people in your everyday life (if you have two young children, think if them having an argument), or from television/films/ drama etc. What happens? What are the behaviours or actions of the parties involved? What is their body language like? What do they say and how do they say it? How does it end?

From this, what are the escalation skills you observed? (To be an escalation skill it must be something someone has done that keeps the argument and hostility going.)

The majority of situations, where there is a potential for violence, can be handled through communication. (Guidance to Prison Officers) Main Principles of de-escalating a situation: 1) 2) 3) 4) 5) Don't Deny It's Happening Don't Challenge Don't Insult Be Calm - Listen and Negotiate Provide A Face Saving Exit

Staff De-Escalation skills/responses. You should seek to: Appear confident Displaying calmness Create some space Speak slowly, gently and clearly Lower your voice Avoid staring Avoid arguing and confrontation Show you are actively listening Calm the situation before trying to solve the problem "English is a language in which hostilities and abuse are carried primarily by the melodies that go with the words, rather than by the words themselves." (Suzette H. Elgin, The Gentle Art of Verbal SelfDefence at Work (New Jersey: Prentice Hall, 2000). To do all the above, you should Use a calm, open posture (sitting or standing). Reduce direct eye contact (as it may be taken as a confrontation) Allow the other person/people adequate personal space Keep both hands visible Avoid sudden movements that may startle or be perceived as an attack Avoid audiences as an audience may escalate the situation

NEVER THREATEN: Once you have made a threat or given an ultimatum you have ceased all negotiations and put yourself in a potential win lose situation.

Positioning

Confrontation

Non-Confrontation

Reflection: Given that you know all the above what can stop staff (including you) from being able to use these skills in an actual situation?

You may think de-escalation is obvious but it can be affected if

It is unsafe to do so. You have an agenda which does not allow you to remain calm and nonjudgmental. (Can you think of any issues which make you less likely to be calm and non-judgemental?) There are others who are using escalation while you are de-escalating.

Did you come up with others in your reflection?

Timing is everything! Now that we have got some idea of what Ii meant by De-Escalation (and just as importantly escalation) we now need to decide when is the best time to use it and, given your reflection in the previous section, when it will not be possible to use it. To begin with, look a the following situation which charts an incident on a ward

A R O U S A L A

D C

TIME
A John, who is on a Section 3, is informed in ward round that he is to remain on the ward due to a positive drug screen following last leave period. John argues in the ward round, walks out before it is completed, and takes himself off to his room. John receives phone call from friend who says they are unable to continue feeding his cat. John becomes annoyed on the phone, and his friend puts the phone down. Goes to ward office door. At office, barges past Jim, another patient and bangs on the door. Nurse inside is on the phone and doesnt turn around on hearing the bang. John bangs again. Nurse continues with phone call. John kicks the door and shouts at the nurse. Nurse activates her alarm and other nurses come running. Nurse comes to the door and opens it saying John, calm down. I am not going to talk to you until you have calmed down. John begins to speak, but Jim says I was here first, wait your bloody turn. John pushes Jim, who falls over. Nurses grab John in confusion and there is a struggle. John is manhandled to his rooms. Nurses asks him to calm down as they cant understand what he is saying, he is so aroused. PRN medication is offered, but he refuses. Eventually he is able to talk to Sylvia, a nurse he trusts who promises to ring his community worker. Sylvia comes to Johns room where is calming. Has been able to get the STaR worker, Mathew, to make time to go and feed the cat. John admits his hallucinations have got worse since the incident and now feels tired. Accepts a small dose of medication. Sylvia tells him Jim is annoyed, but unhurt. Suggests they talk to Jim when both he and John are ready. Nurses leave his alone

Notice in this incident that de-escalation has happened AFTER the actual aggression. This is a well recognised part of conflict and is to be expected, but re-escalation can occur. (see Kaplan & Wheeler Assault Cycle 1983 in Breakaway Handbook). What could have been different in A B and C, up to the point where John lays hands on Jim? Looking at each scenario, can you give alternative responses for the WARD TEAM (not the patients)? Situation Alternative Responses A

What was done in D and E to promote de-escalation?

Seeing conflict coming. You may have noted that the ward team could have intervened before John became too aroused, although that would have required some courage! The following are identified by the Royal College of psychiatry in their booklet Management of imminent violence as possible antecedents to violence that can assist in knowing when to intervene earlier. Increased restlessness, bodily tension, pacing, arousal. Increased volume of speech, erratic movements Facial expressions tense and angry, discontented Refusal to communicate,, withdrawal. Thought processes unclear, poor concentration. Delusions or hallucinations with violent content. Verbal threats or gestures. Knowledge of signs from earlier episodes. Service users self-reporting angry or violent feelings. Carers reporting users imminent violence.

Can you think of times on your ward or in your experience when these antecedents have been there? Have there been times when a relative/ friend/ fellow patient has drawn you r attention to these antecedents? In some research it was found that other patients can be very aware when someone is becoming aroused and often draw the attention of staff as a means of protecting themselves. It is worth noting the findings of this research Risk management by patients on psychiatric wards in London: An ethnographic study (Alan Quirk, Lelliott P, Seale C) Abstract This paper is concerned with the issue of how patients manage risks arising from their interaction with other patients on the ward, such as assault and sexual harassment. Patients were observed doing this in various ways including: (a) avoiding risky situations or individuals; (b) de-escalating potentially risky situations; (c) seeking safety interventions by staff or increased surveillance; and (d) protective involvement with other patients. These findings show that patients routinely take an active role in making a safe environment for themselves, partly because they cannot rely on staff to do this for them. Mental health professionals should consider how to build upon what patients are already doing to maximise ward safety. (Health, Risk & Society, Volume 7, Issue 1 March 2005, pages 85 91) Do you agree with this? Is there more we can do WITH Patients to make wards safer?

Finally : the good news -WE DE-ESCASLATE ALL THE TIME! Having spent some time thinking about de-escalation it is worth watching out for when it is evident and who is good at it. Use the space below to record any evidence of de-escalation in your daily experience. You may also wish to note who is good at it, why they are good at it and what you can beg/steal or borrow for yourself.

Daren Bailey & Geoff Brenan 2008 Berkshire Healthcare NHS Foundation Trust

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