1 Quicker resolution 2. when not at work) there are two well recognised choices if someone is aggressive to you: Escalation De-escalation – Fight – – Flight – High aggression. 2. Not escalate the situation. De–escalation is the art of not escalating a situation and bringing about the possibility of resolution through communication.e. 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)? 2 . There are often two or more people in an “incident”. Less harm In “normal” situations (i. the other has a choice – to… a. Low aggression. not force. If the situation is de-escalated there are 2 main benefits: 1. Escalate the incident further. If one initiates an incident.Basics: 1. b. but could be from observing people in your everyday life (if you have two young children. Reflection: Consider an incident you have witnessed that resulted in some form of aggression (verbal or physical). 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.) 3 . it is important to understand what makes up escalation. 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.In order to understand de-escalation. think if them having an argument). or from television/films/ drama etc. This does not have to be at work. You should seek to: Appear confident Displaying calmness Create some space Speak slowly. 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. you should Use a calm. 2000). To do all the above. where there is a potential for violence.” (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 ." (Suzette H. 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. 4 . can be handled through communication. open posture (sitting or standing). The Gentle Art of Verbal SelfDefence at Work (New Jersey: Prentice Hall.Listen and Negotiate Provide A Face Saving Exit Staff De-Escalation skills/responses. Elgin. rather than by the words themselves.“The majority of situations. 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? 5 . You may think de-escalation is obvious – but it can be affected if… It is unsafe to do so. (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? 6 . You have an agenda which does not allow you to remain calm and nonjudgmental. PRN medication is offered. barges past Jim. Sylvia comes to Johns room where is calming. Nurses asks him to calm down as they can’t understand what he is saying. Nurse continues with phone call.” John pushes Jim. a nurse he trusts who promises to ring his community worker. John becomes annoyed on the phone. Accepts a small dose of medication. At office. when it will not be possible to use it. John receives phone call from friend who says they are unable to continue feeding his cat. calm down. Suggests they talk to Jim when both he and John are ready. he is so aroused. Sylvia tells him Jim is annoyed. Nurse activates her alarm and other nurses come running. I am not going to talk to you until you have calmed down”. To begin with. another patient and bangs on the door. Nurses leave his alone B C D E 7 . John bangs again. who is on a Section 3. look a the following situation which charts an incident on a ward A R O U S A L A D C B E TIME A John. Goes to ward office door. but he refuses. Nurses grab John in confusion and there is a struggle. Mathew. but Jim says “I was here first.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. John kicks the door and shouts at the nurse. and his friend puts the phone down. Nurse comes to the door and opens it saying “John. to make time to go and feed the cat. given your reflection in the previous section. is informed in ward round that he is to remain on the ward due to a positive drug screen following last leave period. Eventually he is able to talk to Sylvia. Has been able to get the STaR worker. Nurse inside is on the phone and doesn’t turn around on hearing the bang. John begins to speak. wait your bloody turn. John is manhandled to his rooms. walks out before it is completed. but unhurt. who falls over. John admits his hallucinations have got worse since the incident and now feels tired. John argues in the ward round. and takes himself off to his room. (see Kaplan & Wheeler Assault Cycle 1983 in Breakaway Handbook). 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 B C What was done in D and E to promote de-escalation? 8 . but re-escalation can occur. This is a well recognised part of conflict and is to be expected. What could have been different in A B and C.Notice in this incident that de-escalation has happened AFTER the actual aggression. erratic movements Facial expressions tense and angry. Verbal threats or gestures. and (d) protective involvement with other patients. Carers reporting users imminent violence. poor concentration. Patients were observed doing this in various ways including: (a) avoiding risky situations or individuals. 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. withdrawal. pages 85 – 91) Do you agree with this? Is there more we can do WITH Patients to make wards safer? 9 . partly because they cannot rely on staff to do this for them. It is worth noting the findings of this research Risk management by patients on psychiatric wards in London: An ethnographic study (Alan Quirk. Issue 1 March 2005.. 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. Delusions or hallucinations with violent content. arousal. Mental health professionals should consider how to build upon what patients are already doing to maximise ward safety. pacing. (c) seeking safety interventions by staff or increased surveillance. (b) de-escalating potentially risky situations. Increased volume of speech. such as assault and sexual harassment. You may have noted that the ward team could have intervened before John became too aroused. Increased restlessness. Service users self-reporting angry or violent feelings. Risk & Society. 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. Knowledge of signs from earlier episodes. Lelliott P. These findings show that patients routinely take an active role in making a safe environment for themselves. Volume 7. discontented Refusal to communicate. (Health. Thought processes unclear. bodily tension.Seeing conflict coming. 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. Use the space below to record any evidence of de-escalation in your daily experience.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. Daren Bailey & Geoff Brenan 2008 Berkshire Healthcare NHS Foundation Trust 10 .