All too often, healthcare professionals are exposed to violence from patients, patients’ families and visitors. In fact, in China some doctors have died from these attacks. Nurses are not exempt from such threats of violence, and the consequences of this vary from fear and frustration to leaving that healthcare sector altogether.

Justin Stephens, a senior lecturer at the University of Greenwich in England believes that de-escalation and breakaway skills are essential and should be taught to all nursing and midwifery students. The university has therefore developed an annual session to teach them the skills necessary to protect themselves and prevent disillusionment with an industry designed to help others.

De-escalation techniques to prevent a crisis

Prevention is always better than cure and measures taken to minimise the risk of a violent outburst from a patient can go far in protecting nurses and the patient themselves. Almost always, there are warning signs that a person's behavior is moving towards a crisis and these signs are usually easily detected by the body’s innate fight-or-flight system. Stephens divides these signals into early warning signs and danger signs.

Box 1. Signs indicating risk (Credit: Nursing Times)
Box 1. Signs indicating risk (Credit: Nursing Times)


One of the first conflict avoidance skills nurses are taught is to maintain at least an arm’s length distance from the patient. This respects the patient’s personal space and diminishes any anxiety they may feel. Heightened anxiety can cause people to act out in a manner they normally wouldn’t. This also puts the nurse at a safe distance enabling time to react should the patient’s behaviour escalate. As is the usual practice, if the patient must be touched, they are informed beforehand.

In some instances however, touch helps calm an agitated patient. Prabha Nayyak, a cardio thoracic ward theatre nurse says, “I once had a patient who tried to jump off the operating table and the only way to relax him was to gain his confidence slowly. I did that by patting his back, holding his hand and using a coaxing voice to comfort him.”

Nonverbal communication skills also crucial

High anxiety situations force an individual’s senses to become sharply attuned to non-verbal communication, sometimes leading to misinterpretation of an otherwise careless gesture. Posture can reveal intention and an eye-to-eye and toe-to-toe stance may be misconstrued as challenging and evoke a negative response from the patient.

Standing off to the side and at an angle or sitting down instead, invites the person to open up and share their concerns. Nurses though, are generally known for their gentle demeanor and achieve this by maintaining neutral facial expressions, a calm tone of voice and refraining from movements that are sharp or sudden.

Often, the safest alternative to a physical altercation with a patient is to allow them to vent verbally, as this expends energy till the person is calm enough to discuss their grievances. Empathy, the language of medicine is key in such situations where reacting to abusive statements and judgement of the patient’s emotions can be dangerous.

To create a safe space in which patients can share their thoughts, nurses often use the technique of reflective questioning - putting the individual’s statements into their questions so they know they have been heard and using open-ended sentences to provide opportunities for the patient to verbalise their feelings.

But breakaway skills are also crucial

Many hospitals around the world have now created escape routes and provided training of their usage for all medical staff should a situation escalate. Staff are taught not to let the aggressor get between themselves and the door and to escape without turning their back on the person. Opportunities to call for help are also becoming increasingly integrated into workplaces in the form of panic buttons, silent alarms or coded messages.

Amee Thaker, a trainee psychotherapist explains: “We are not allowed to meet some clients alone - there needs to be other medical practitioners within close proximity.” Isolating the individual, from family and friends who might incite them, in a calming room allows the nurse to establish trust with the patient.

Breaking free techniques are entirely physical and usually only taught to those students who will be placed in environments where the skill set is a necessity, for example, when working with mental health patients. Additionally, the nature of the techniques (breaking free from wrist grabs, deflecting blows or kicks, hair pulls and strangle holds) means that they are difficult to apply in real-time situations unless the person has a lot of experience.

Restraint is the last and final resort and there are, on occasion, legal restrictions in place which nurses are well familiarised with and must consider before implementing options such as tranquilisers. MIMS

Read more:
The art of empathy to become a better healthcare professional
The nurse’s role in obtaining informed consent from the patient
Utilising nonverbal communication in the nurse-patient relationship
Patient satisfaction vs. job responsibility: A nurse's call of duty

Sources:
https://www.crisisprevention.com/Blog/June-2011/Responding-to-Abusive-Patient-Behavior-Part-2
http://www.phsa.ca/Documents/Occupational-Health-Safety/ReportPreventingViolentandAggressiveBehaviourinHea.pdf
https://www.omicsgroup.org/journals/work-place-violence-in-nursing-2167-1168-1000335.pdf
https://www.nursingtimes.net/roles/nurse-educators/benefits-of-teaching-students-de-escalation-and-breakaway-skills/7014415.article