Responding to Abusive Patient Behavior

Knowing just how to respond and de-escalate challenging behaviors from spinning out of control is an essential skillset for anyone working in healthcare today. In this three-part article, we’ll share 10 ways to defuse incidents, three pitfalls to avoid when training staff, and guidance on how to reduce the risks of restraints.

10 Ways to Defuse Incidents

Healthcare facilities can be places of great hope, healing, and joy — and they can also be places of great anxiety, grief, and anger.

In heightened emotional states, patients, their family members, and even your coworkers can lose control of their behavior and become verbally abusive or physically aggressive. A comprehensive training program is the most effective means of preparing staff to address disruptive behaviors.

There are, however, some basic steps that all staff members can take to improve their interventions in potential crisis situations. The 10 strategies below are not intended to replace training, but rather to provide an overview of some of the techniques and strategies that you can master in Nonviolent Crisis Intervention^® training, which emphasizes the prevention of workplace violence.

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 that a person's behavior is moving toward a crisis. The following tips can help you and your team in early interventions and increase your likelihood of de-escalating an incident before it can become dangerous.

1. Respect Personal Space

Personal space is the area around us that we consider an extension of ourselves. How much space each of us requires to feel comfortable varies considerably. What’s almost universally true, however, is that our anxiety rises when our personal space is invaded without our consent. This heightened anxiety makes it more likely that 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 starting to escalate. In this way, you’ll be less likely to increase their anxiety. You’ll also reduce danger to yourself by maintaining a margin of safety that allows you time to move away before you can be struck or grabbed.

If you must touch an anxious person to provide medical care, explain what you’re about to do before you begin. If the person objects, decide:

• If the procedure can wait until the person calms down
• If someone else might be better suited to provide the care (for example, someone who has established a stronger rapport with the person)
• If the procedure must be done by you at this very moment (This should be a last resort, used only if there’s a medical necessity. Be mindful that the patient may respond negatively.)

2. Be Aware of Your Own Body Position

In addition to maintaining adequate space between yourself and an anxious person, avoid eye-to-eye, toe-to-toe positions, as they can be interpreted as challenging. When someone feels challenged by your body position, it can evoke a fight-or-flight response, and, of course, neither a fight nor a flight reaction is likely to be helpful.

Stand at an angle to the person and off to the side because this is much less likely to escalate an agitated person's behavior. In CPI training, we call this the Supportive Stance^℠, and it helps you ease the person’s anxiety.

3. Be Empathic to Others' Feelings

Try not to judge or discount the feelings of others. Whether or not you think their feelings are justified, those feelings are real to the other person. Pay attention to them, and don't be afraid of silence. Your supportive presence is often more important than what you might say.

4. Keep Nonverbal Cues Nonthreatening

As a person begins to lose control of rational thought, they become more tuned into your body language and less tuned into your words. Your nonverbal communication — including your gestures, facial expressions, movements, and tone of voice — becomes paramount to conveying calmness and respect. Remember, your attitudes and behaviors affect those of others, and like breeds like.

5. Ignore Challenging Questions

When a person challenges your authority or an organizational policy, redirect their attention to the issue at hand. For example, say a visitor is smoking in a waiting area. You remind her that there’s no smoking allowed in your facility and ask her to put out her cigarette. She responds by saying:

“Who are YOU to tell me what to do?”

Answering this type of question will only lead to a power struggle, and it also sidesteps the issue at hand: the woman's smoking. It's better to ignore the challenge and restate your request in a calm, respectful tone so you can keep the focus on resolving the problem.

6. Set & Enforce Reasonable Limits

If patients or family members become disruptive, establish limits and directives clearly, concisely, and kindly. When setting limits, offer simple, clear choices and consequences. Be sure the consequences are reasonable and enforceable.

For example, you might tell a family member who insists on entering an emergency treatment room:

“Please come back to the waiting area with me, and I'll be sure the doctor speaks with you about your husband as soon as possible. If you try to enter the treatment room again, I'll have to call security, and then it’ll be even longer before you can talk to the doctor.”

7. Allow Verbal Venting When Possible

It’s often the safest and best alternative to let the person shout, removing others from the area when feasible. Allow the person to release as much energy as possible by venting verbally. As they’re venting, there will be peaks and valleys in the outburst, as their energy expenditure rises and falls. If you can’t allow the person to continue venting, give them calm directives and reasonable limits during the valleys in the venting process.

8. Identify the Real Reason for the Behavior

Even in the midst of an angry behavior, there’s useful information you can gain about what a person is thinking and feeling. The real reason for a person's outburst is often not what it seems to be. Physically or verbally abusive patients and family members can be highly critical of hospital staff for reasons that are much more related to the fear and helplessness they’re experiencing than to the ways staff are performing their duties.

Try to listen for the real message — the feelings behind the facts. Restate the message you think you’ve received in order to determine if you correctly understood the person's intent.

9. Stay Composed — Avoid Overreacting

It's hard not to take things personally, especially when people make unkind personal remarks. But it’s critical 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.

10. 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 (see below) to staff and/or to the person being restrained.

Such interventions should be used, therefore, only when it’s more dangerous not to intervene. Furthermore, physical interventions should be used only by competent staff members who are trained to use the safest, least restrictive methods of intervention possible and who are well-versed in any applicable regulations or laws pertaining to restraint use in their facilities.

Not every crisis situation can be successfully prevented, but trained staff members who know these key principles are much more likely to influence behavior in a positive way, defusing potential crisis situations before they can become dangerous.

3 Pitfalls to Avoid When Training Staff

Healthcare workers, police, and security personnel greatly benefit from training that shows them how to appropriately de-escalate situations with patients, visitors, and even other employees who may become disruptive or violent. But if that training isn't delivered properly and to the right people, problems can result.

In order for your training to be successful in achieving your goals of minimizing risk and creating a safer workplace, it’s crucial that you implement it in a way that provides the highest possible chance of success. Here are the three key pitfalls to avoid in order to increase training effectiveness.

Pitfall No. 1 — Training Only Your Security Staff

One of the strategies often used in healthcare and human services organizations is training security personnel or a crisis response team to respond to potentially violent incidents. This strategy allows a relatively small group of workers to specialize and become experts in responding to threatening situations. While this is a good strategy, it’s an incomplete one.

Staff members who are not part of the crisis response team often interact with an individual before the response team is called and until they arrive. Their responses and attitudes can be critical in defusing the stress and anxiety of irrational individuals. In fact, if they respond appropriately, the crisis response team might not be needed at all.

When untrained staff members are confronted with potentially dangerous behavior, it’s more likely that they’ll respond instinctually with a fight-or-flight response. Neither fighting nor fleeing is consistent with one's duty of care. The body's fight response will usually cause a disruptive person's behavior to escalate further. And a flight response from staff — admittedly the best option in some situations — may create an even less safe situation as the disruptive individual is left alone. Training helps transform these instinctive responses into more strategic interventions.

By training ALL staff, as the Joint Commission recommends, every employee gains the skills and confidence to intervene safely. Staff who are closest to a given patient or situation are often in the best position to defuse escalating behavior and eliminate the need for a crisis response team call. Therefore, it’s best if all employees have a foundation in the same training, even if a crisis response team or security staff has more specialized training in responding to violence.

Pitfall No. 2 — Using the One-and-Done Approach

Providing training on a one-time basis is unlikely to produce lasting effects, yet it’s the approach chosen by many organizations, due to time and cost constraints. If training is to be more than just a Band-Aid for workplace violence, it must be part of a process that includes opportunities for review, practice, and drills. Just as with other emergency response procedures, such as CPR, regularly scheduled refresher training prevents staffs’ skills from eroding. Exactly how often should you train?  CPI recommends that staff attend a formal training every 6-12 months.

Pitfall No. 3 — The Administrative Disconnect

Training does not stand alone as a solution to the problem of workplace violence. Best practices call for integrating training into a culture of care that includes an organizational commitment to a values-based philosophy. Your mission, values, and goals must be clearly stated to all and reinforced through policies and procedures that reflect your organizational philosophy. Staff development is then seen as a tool to help staff members put your philosophy into daily practice.

Administrators who take the time to participate in training take a huge step toward ensuring the effectiveness of that training. By their very participation, the following outcomes are realized:

• Employees take the training more seriously when they see administrators are also taking the time to participate
• Administrators learn more about the day-to-day realities their staff members face
• Administrators themselves gain de-escalation skills they can use when confronted with disruptive behavior
• Any disconnect between policy and training content will be apparent and can be adjusted, as necessary
• Administrators gain a greater understanding of the need for an ongoing training process in order to sustain the learning and momentum generated by the initial training sessions

Reducing the Risks of Restraints

Although physical intervention is considered by most in healthcare security to be a last resort solution, sometimes hospital employees are left with no alternative but to use this approach on someone who becomes a danger to themselves or others. This last part of our article on handling abusive patient behavior discusses how hospital personnel can appropriately use restraints.

To protect the health and safety of both staff and patients, various accrediting and regulatory agencies have established standards relating to the use of restraints in healthcare, mental and behavioral health settings — as you likely know, and as you’ll see outlined below. It’s also important to be familiar with your state’s regulations related to restraints, as these vary from state to state. Some states ban certain types of interventions altogether. Others have time limits governing use of restraint.

One key element that virtually all regulatory, statutory, and accrediting bodies have in common is the emphasis on staff training in de-escalation techniques that can prevent the need for physical interventions. Equally important is staff training in the appropriate use of restraints as a last resort.

Know Which Interventions to Use and When

Several key points should be included in all staff training on the topic of physical techniques:

• When to restrain
• When not to restrain
• How to use safer restraint techniques
• How to minimize risks associated with the use of restraints

Awareness of restraint-related positional asphyxia and how to avoid positioning that could restrict breathing is of critical importance, as it can cause death.

Through both policy and training, staff members should know there are limited circumstances in which physical interventions are an appropriate response to acting-out behavior. The following criteria should always be met:

1. The person is an immediate physical danger to self or others
2. Other ways to manage the person's dangerous behavior have failed
3. Staff members are trained in the proper use of restraints

Physical restraints should never be used as a form of punishment or coercion, for the convenience of staff, or as a means to inflict pain. Instead, they should be seen as a temporary, emergency measure to use only until the person has regained control of their own behavior and is no longer a physical danger to self or others.

Need strategies for deciding whether or not to use the last-resort practice of physical intervention? The Decision-Making Matrix helps staff choose their options wisely.

Key Steps to Reduce Risk

Because all physical intervention carries some risk of physical and/or psychological injury — to staff and to the person being restrained — such interventions should be used only when it’s more dangerous not to intervene. Furthermore, there are several key steps your facility and staff can take to reduce the risks of restraint:

Train staff members in safer ways of restraining, and provide opportunities to practice those skills on a regular basis

Physical interventions should be used only by competent staff members who are trained to use the safest, least restrictive methods of intervention possible and who are well-versed in any applicable regulations, laws, or policies pertaining to restraint use in their facilities.

Furthermore, physical restraint should be recognized as an emergency response procedure — not so different from CPR or first aid. As with any emergency response procedure, staff members need to rehearse these skills on a regular basis.

Choose safer restraint techniques

Some restraints are more dangerous than others. A Pulitzer Prize-winning series of articles published in the Hartford Courant detailed 142 restraint-related deaths throughout the United States. Many of these deaths were the result of positional asphyxia, which occurs when a person being restrained is placed in a position in which they cannot breathe properly and are unable to take in enough oxygen.

Especially dangerous positions include facedown floor restraints or any position in which a person is bent over and held in a way that makes breathing difficult.

Staff members must be especially careful not to use their own bodies in a way that restricts someone's ability to breathe, such as sitting or lying across a person's back or stomach. When a person is lying face down, even pressure to their arms and legs can interfere with their ability to move their chest or abdomen in order to breathe effectively.

Be aware of risk factors that increase the danger of restraints

Some people are more at risk for restraint-related positional asphyxia than others. Risk factors include obesity, extreme physical exertion or struggling prior to or during a restraint, heart disease, breathing problems such as asthma or emphysema, and use of alcohol or drugs.

Monitor the person being restrained

Staff must be trained to watch for signs of distress from the individual being restrained. This can best be accomplished by assigning a staff member who is not directly involved in performing the restraint to monitor for signs of trouble, such as breathing difficulties. It's important to note, however, that there are documented cases of individuals who have gone from a state of no apparent distress to death in a matter of moments. Monitoring the person's status is not a substitute for avoiding high-risk positions that interfere with breathing.

Debrief

When restraints are deemed necessary, a debriefing process should follow so that staff can review the circumstances that occurred before and during the restraint.

• What triggered the event?
• Could it have been prevented?
• Were any warning signs missed?
• What could have been handled differently?

The purpose of the debriefing is not to point fingers or place blame but to creatively consider alternatives that might prevent the next restraint.

Use Physical Techniques Sparingly on Abusive Individuals

Following these guidelines will reduce the risk of injury for everyone involved in a situation requiring the use of restraints. But the very best way to eliminate injuries due to restraint — both for staff and for the person being restrained — is to eliminate the need to restrain in the first place. Remember, the safest restraint is the one that doesn't have to happen.

U.S. Regulatory and Accrediting Organizations: Key Elements of Restraint-Related Standards

Centers for Medicare & Medicaid Services (CMS)

• Requires training for hospital employees who work with potentially violent patients
• Training must include:
  • Identifying events or factors that may trigger a need for emergency intervention
  • Using nonphysical intervention skills
  • Choosing least restrictive intervention based on patient's condition or status
  • Safe application of all types of restraints used at a hospital
  • How to recognize and respond to signs of distress
• Requires staff to demonstrate competency in application of restraints and in caring for patients in restraint
• Requires training to be ongoing
• Training must be part of initial orientation and on a periodic basis thereafter

See exactly how CPI can help you meet CMS standards [PDF]

The Joint Commission Standards on Restraint and Seclusion

• Differentiates restraint used for an aggressive patient for behavioral reasons and restraint used for medical purposes to prevent substantial harm to patient
• Staff using restraint to manage assaultive or abusive behavior must be trained in the following areas:
  • Identifying underlying causes of threatening behavior
  • Understanding possible links between medical conditions and aggression
  • Understanding how staff behaviors can affect patient behaviors and vice versa
  • Use of de-escalation, mediation, and other nonphysical techniques
  • Recognizing signs of physical distress in persons being restrained or secluded

See exactly how CPI can help you meet Joint Commission standards [PDF]

The Joint Commission also recommends CPI's Top 10 De-Escalation Tips, a free eBook that we've included with this article. Click here to download it!

Occupational Safety and Health Administration (OSHA)

OSHA recommends that employees receive at least annual training in workplace violence prevention. It also encourages hospitals to make a concentrated effort to reduce identified risks factors. These include long waits, low staffing levels during times of increased activity, and "lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff."

See exactly how CPI can help you meet OSHA’s Guidelines for Preventing Workplace Violence.

Safely de-escalating physically and verbally abusive patients is possible.

We've created our industry-leading offerings to empower every member of your staff with the skills to reduce and avert violence. If you’d like to learn more about our training programs, click here.

In closing, we know how hard it can be to navigate your way successfully and safely through  challenging patient behavior. It takes experience, skill, patience, and know-how. We hope you’ve found the ten ways to defuse incidents, as well as the pitfalls to avoid when training staff, and our keys to risk reduction helpful in your journey of creating a culture of Care, Welfare, Safety, and Security^℠ throughout your organization.