Introduction

In the emergency department (ED), it was found that healthcare workers, particularly nurses, experience high rates of verbal abuse and physical aggression, and that violence in the ED are often under-reported. The abuse is often related to substance dependence. Substance abuse enhances the chances of verbal and physical aggression in a person due to either intense withdrawals and wanting what they want to get better, or from the actual high of the drug which may cause unpredictable actions from a person. Substance dependence is a pandemic problem and a difficult challenge to solve. It is a complex disease that needs interdisciplinary collaboration in order to help these vulnerable patients.

It is noteworthy to mention that substance abuse is not always preceding abuse in the ED, sometimes people are angry or anxious whilst they are waiting. Some people are unsure of the outcomes of their loved ones, some have been waiting for a while and get angry when they don’t understand the priority of triage, some are full of emotions and are having difficulties in controlling them, and for some this is a different and unfamiliar environment.

Due to the size of rural and remote towns in Australia, the hospital emergency department (ED) may not be extensive. Sometimes it is tranquil and sometimes not, thus security is not always present (in bigger city hospitals security is constantly present). One of the key aspects to prevent injury and harm for oneself and others is to have good de-escalating skills. In this blog, I will cover some of the key steps one can take to reduce the chance of having a patient harming themselves or others.

The three de-escalation steps

There are three de-escalation steps a healthcare professional may use in de-escalating a situation with a patient. The main goal is to prevent and control any violent or disruptive behaviour that could be coming from the patient or their family members, and also to protect that particular patient or family member from injuring themselves, others and the hospital staff. These are:

• Verbal de-escalation

• Chemical restraint

• Physical restraint

Before you ask any questions, it is important to check health literacy, local languages and if the person has any cognitive syndromes. It is crucial to notice if the patient or member of the family is intoxicated, in withdrawals, undergoing psychosis or delirium, underaged, sedated or handicapped. It is also essential to not be alone when de-escalating a situation, especially if the chemical or physical restraints may be used.

Verbal de-escalation

Verbal de-escalation is the most common method used and is preferably the only method that should be used. Most of the time, the patient or the members of the family do calm down as explaining the situation or hearing their worries is enough. When you sit down for a long time whilst being anxious in a new bright, noisy and unfamiliar environment, most people would become agitated with a racing mind. We don’t do racing mind; we want calm minds and predictable movement from people. Verbal de-escalation is about hearing the patient about their worries, and why they may be agitated, hence the S.P.A.C.E. acronym is useful in remembering some of the steps in de-escalating a situation.

(SSS)pace

• Stand back and give some breathing room. Make sure you are not blocking the only exit. Be aware of the equipment that may be thrown at you and do take notice of what they have (hand-bag, crutches et cetera) as that may also be used as a weapon.

• Sit at eye level whenever you can. Standing and looking down may project a dominant or authoritative image. What is ideal is to be on the same level where it shows you think of them as equal and want to work something out.

• Security presence. Decide if the duress button should be activated. Security guards are trained and equipped to handle aggressive and violent situations (we shall talk later when the police should be called instead of the security guards but this changes depending on protocols of the hospital).

(P)als

Asking their name is a good start as using their first name creates a good connection and rapport. A good rapport creates trust and trust minimise unpredictability. Be aware of body position, tone and volume of your voice and choice of words or language. An open posture is always welcome as it shows you are not hiding anything.

(A)ffirm and Empathy

Sharing and talking about emotions is a normal human trait, which helps people who are overloaded on emotions. Hence saying something such as “Jeff I can see you are upset, can you help me understand why?” or “I can see you are frustrated and want to go home” or “Jeff we want you to go home, but we want to make sure you are safe” might help ease that person back into a more rational state of mind. They might explode such as “damn right I am upset!” but after that outburst, they might explain why they are upset, which calms them down as they can see they are being heard. Being heard of your problems and emotions is important in coping with those emotions.

(C)heck understanding

Sometimes the reason why people are upset is simply that they do not understand what is going on and that nobody has explained to them what is happening. Imagine waiting for your flights, and you wait and wait… I would start becoming upset, stressed and anxious if nobody is telling me what is going on. This emotion is enhanced in the ED as it is a foreign environment with lights and noise. Questions such as “I would like to understand what you believe is going on” or “why do you think we are worried about you?” may be asked.

(E)ase into negotiation

This may sound odd but negotiate with a patient or a member of the family how you would negotiate with a child. Remember when you were little, and your parents gave you choices? Choices enable the person to feel they are in control as they have the ability to choose what they like. Compare this to authority statements such as “do as you are told or else…” Hence focus on what you can do for them and utilise a small reward system. For example, when giving choices, you can say:

• “Would you like the left or right arm?”

• “Would you like to call someone from your family and get them here?”

• A more extensive and aggressive step can be “we have two options here, either you take the medication to help you relax, or we will need to get help from security to help you get the medication.”

The small reward system can be like bargaining, for example:

• Let us work together, and if you do this blood test, we will give you some space to walk around, how does that sound?

• Or you can replace it with tea, coffee and biscuits.

Remember it is useful to not being ambiguous as specificity and clear guidelines are key.

Chemical restraint

Chemical restraint is not always a bad option as it sometimes goes hand in hand with verbal de-escalation; however, if verbal de-escalation does not work, then chemical restraint is the next step (in a way, you have to escalate your methods to de-escalate). This may be pain relievers, anti-anxiety medications or, where it is deemed appropriate, medications in counteracting withdrawal symptoms.

• Oral administration: least invasive, easy to take, but the patient needs to agree and be compliant.

• Intramuscularly: this is a good option if the patient agrees. Questions such as “can we give you an injection to help you feel calm?” may be asked.

• Intravenously: works very fast, but if the patient is aggressive, there is a high risk of needle stick injury. The patient may also pull out the IV line and may use the needle as a weapon.

Giving medications intravenously and intramuscularly may cause the possibility of over sedation where the airway may collapse, possible overdosed symptoms, decrease in Glasgow Coma Scale (GCS) and a prolonged QT.

Physical restraint

Physical restraint, unfortunately, sometimes occur and is important for the immediate safety of the patient, people in the surrounding area and the staff. Physical restraints lie outside of the healthcare professional’s scope and are best left for the security guards and/or the police as they are trained professionals in their fields. Some of these strategies may be used:

• The security guards or police may use the 5 point takedown as they are trained. That is the arms, legs and the forehead that is held down. Medicine must be given immediately. Be aware of the chest not being crushed so that the patient can breathe.

• Soft wrist restraints or police handcuffs may be used.

• If the patient has a knife or gun, then it is the police’s job only. Follow your hospital protocols.

• In some hospitals, there may include seclusion or isolation rooms where the walls and doors are padded with no glass windows.

A previous experience

On my of my previous placement, I witnessed a delicate situation in the ED where a patient was coming for more medications as they were going into withdrawals. This patient was a known methamphetamine user, and unfortunately, the town itself is known for its high amphetamine usage. At the time, it was only myself and the very well trained nurse with no security in sight as this was a small hospital.

The patient was persuaded that she would have access to medications to cope with her current symptoms. Upon hearing that she will be denied access to the medication as the doctor had to see her, which would be in a while, she started to become more and more agitated and demonstrate an aggressive body language. Fear of the unknown and outcomes of this patient's action definitely put all of us at a flight or fight mode and at least made me unnerving as I lacked experience. At this point, we were not sure if she had a knife or if she would become violent and hurt the staff physically.

However, this situation was amazingly de-escalated by the communication skills from the nurse. By using the right words, soothing voice and communicating efficiently, the patient managed to calm down and control herself a bit better. I decided not to make any brisk movement, changed my tone and voice volume to calm and rational, and I made sure there was space so that the patient never felt trapped or overwhelmed. The distance also protects me if anything were to happen.

For the next time

After doing my Emergency Medicine module, I can use the S.P.A.C.E. acronym and de-escalate a patient or a member of the family, as best as I can, to a more calm and rational behaviour, and recognise when a situation is out of my scope of practice.

Published 30th November 2020. Last reviewed 1st December 2021.

Reference

Center on Addiction Authors. Addiction as a disease. Center on Addiction website. https://www.centeronaddiction.org/what-addiction/addiction-disease. Updated April 14, 2017. Accessed May 2, 2020.

Dr. Zafar Smith, Emergency Physician (FACEM), 2020. Mental Health Emergencies. Lecture given at James Cook University. Friday, 22 October 2020.

Fry L. The impaired student: Substance abuse in medical students. Med Stud J Aust. 2015. https://www.amsj.org/archives/4462. Accessed October 2, 2020.

Partridge B, Affleck J. Verbal abuse and physical assault in the emergency department: Rates of violence, perceptions of safety, and attitudes towards security. Australas Emerg Nurs J. 2017;20(3):139-145. doi: 10.1016/j.aenj.2017.05.001

Stene J, Larson E, Levy M, Dohlman M. Workplace violence in the emergency department: giving staff the tools and support to report. Perm J. 2015;19(2):e113‐e117. doi:10.7812/TPP/14-187