As health care professionals, we are sometimes faced with patients in crisis. An estimated 4 percent of visits to primary care physicians involve psychiatric or social crises. Proper assessment and intervention are essential to ensure the safety of the patient and others.
For purposes of this article, crisis moments refer to those points in time when individuals lose physical and rational control of their behavior. Almost always, there are warning signs a person’s behavior is moving toward a crisis.
EMOTIONAL SIGNS: Crying, Yelling, No Talking at All, Arguing, Inappropriate Laughter, Fear, Confusion
BEHAVIORAL SIGNS: Rocking/Swaying, Rapid Breaths, Shaking Extremities, Pressured Speech, Tenseness in Body, Loud or Quiet, Clenched Fists, Poor Eye Contact, Pacing, Skittish Behaviors
The following tips can aid in early interventions and increase the likelihood of staff de-escalating an incident before it becomes dangerous.
- Respect All Individuals’ Personal Space
Personal space is the area around us that we consider an extension of ourselves. Anxiety rises when personal space is invaded. Heightened anxiety makes it more likely a person will act out in a more serious way.
To avoid such a response, maintain at least an arm’s-length distance from a person whose behavior is escalating. In this way, you will also reduce danger to yourself by maintaining a margin of safety that allows you time to react.
If you must touch an anxious person to provide medical care, explain what you are about to do before you begin. If the person objects, decide if: 1) the procedure can wait; 2) someone else might be better suited to provide the care; or 3) the procedure must be done at this very moment. This third alternative should be a last resort, chosen only due to acute medical necessity.
- Be Aware of Your Own Body Position and Feelings
In addition to maintaining adequate space between you and an anxious person, avoid direct, eye-to-eye, toe-to-toe positions, as they might be interpreted as challenging. Positions perceived as challenging can evoke a “fight or flight” response from the other person, and neither of those reactions is likely to be helpful. Standing at an angle to the person and off to the side is much less likely to escalate an agitated person’s behavior. Be aware of your own feelings (e.g., fear, anger, etc.) and consider asking for assistance from other staff if you feel the need.
- 3. Be Empathic to Others’ Feelings
Try not to judge or discount the feelings of others. Pay attention to them, and don’t be afraid of silence. Your calm, supportive presence is often more important than what could be conveyed with any words you might say.
- Keep Nonverbal Cues Nonthreatening
As a person begins to lose control of rational thought, the person becomes more tuned into your body language. Nonverbal communication — including gestures, facial expressions, movements and tone of voice — becomes paramount in conveying a calm, respectful attitude.
- Ignore Challenging Questions
When a person challenges your authority or an organizational policy; try to redirect the individual’s attention to the issue at hand. In general, it’s better to ignore the challenge and restate your request.
- Set and Enforce Reasonable Limits
If patients or family members become belligerent, defensive or disruptive, and calmly establish limits and directives clearly and concisely. When setting limits, offer simple, clear choices and consequences to the acting-out individual. Be sure the consequences are reasonable and enforceable. Be clear and firm, but avoid displaying anger, fear or hostility.
- 7. Permit Verbal Venting When Possible
It is often the safest and best alternative to let the person shout, removing others from the area when feasible. As a person is venting, there will be peaks and valleys in the outburst. If you cannot allow the person to continue venting, state the directives and reasonable limits during the “valleys” in the venting process.
- 8. Identify Real Reason for the Behavior
Even in the midst of an angry tirade, there is useful information to be gained about what a person is thinking and feeling. Anxious patients and family members can be highly critical of hospital staff for reasons that are much more related to the fear and helplessness they are experiencing than to the ways staff members are performing their duties. Try to listen for the feelings behind the facts. Restate the message you think you have received in order to determine if you correctly understood the person’s intent.
- Stay Composed, Avoid Overreacting
It’s hard not to take things personally. It is essential to do your best to remain calm and professional — at least on the outside. Your composed, rational response can go a long way toward influencing the person’s behavior in a positive way.
- Use Physical Techniques Only as a Last Resort
Physical restraint should be used only when people’s behaviors are dangerous to themselves or others. Physical intervention itself always carries some risk of injury to staff or to the person being restrained. Such interventions should be used, therefore, only when it is more dangerous NOT to intervene and by competent staff members who are trained.
These are some basic steps we hope all staff members can use to improve their interventions in potential crisis situations. The points above are not intended to replace training, but rather to provide an overview of some of the techniques and strategies that can be effective.