Using de-escalation skills with patients, families and colleagues

National Violence Reduction Network for Nurses chair Ana Waddington, who is rough sleeper outreach nurse for University College Hospital NHS Foundation Trust, says she has used de-escalation skills in all the places she has worked, with patients, families and, when needed, colleagues.

‘These skills are needed more than ever,’ says Ms Waddington, who was the 2020 RCN Nurse of the Year. ‘Tensions are high. Things are tough for everyone, there are long waits in healthcare, plus the cost of living crisis – I feel that everyone is very tense and gets angry quite quickly. It doesn’t look like it’s going to get any easier any time soon.’

Here she offers some tips for nurses on how to help prevent a situation escalating and deal with tension when it arises.

1 Prepare before meeting people who are agitated or angry

When called in to help diffuse a situation, Ms Waddington tries to first take some time to read the patients’ notes and history.

While time is tight in all healthcare settings, this can make a big difference when trying to build a relationship with the person who is upset, she says.

‘Try and gather information so that you know a bit about what is going on and find out people’s names,’ she says. ‘Going in with the wrong name or pronoun really doesn’t help.’

Picture credit: iStock

2 Introduce yourself to patients and relatives

Having worked for many years in child emergency departments, Ms Waddington says establishing good communication with a frustrated patient or relative starts with stating your first name, then asking if they are happy to be addressed by their first name.

‘Don’t call them Mr or Mrs, or Mum and Dad, unless that is what they want. I always say ‘I’m Ana, I would like to call you by your first name if that is okay?’

Listen to people and validate their concerns

Picture credit: iStock

3 Move into a private but safe space

Don’t try to discuss a situation with an angry relative or service user in a corridor or busy, overlooked spot.

Guidance from the National Institute for Health and Care Excellence (NICE) recommends moving agitated people away from others to quiet areas of the ward, bedrooms, comfort rooms or gardens, while avoiding staff becoming isolated.

‘I always tell a colleague where I am going and leave the door open, but try to find somewhere calm and peaceful,’ says Ms Waddington.

‘I also leave the bleep with someone else and switch my phone to silent. When people are in fight or flight mode, their emotional responses are very quick, and these sounds can be really distracting.’

4 Think about your physical position

Sitting down is the first thing Ms Waddington does in a tense situation, and this can help bring down the tension.

‘Often people won’t sit down initially, they will be angry and remain standing – but they quite quickly don’t like looming over me and, in most cases, will also sit. This really calms a situation rapidly.

‘Also, by sitting, you are showing that you will give people time and attention, which is often what they most need at that point.’

5 Respond with empathy

Go into a situation without judgement and respond with compassion.

NICE calls for empathy and respect to de-escalate aggression and agitation, and UK research in mental health settings has emphasised this.

A study in the Journal of Mental Health Systems in 2020 found that ‘specific psychological and interpersonal skills including empathy, respect, reassurance, sincerity, genuine concern and validation of the patient perspective’ are needed for de-escalation.

Moves to prevent violence against NHS staff

• » All healthcare staff should receive de-escalation training to help them with patients who display violence or aggression, National Institute for Health and Care Excellence guidance says

• » Violence against NHS staff remains an ongoing problem, however. The 2022 NHS Staff Survey found almost 15% of NHS staff had experienced at least one incident of physical violence by patients, service users, relatives or others in the previous 12 months

• » In the same survey, almost 1% of NHS staff reported violence from their managers, and 2% from other colleagues

• » Almost 28% said they had experienced bullying, harassment or abuse from service users, patients or their relatives

Picture credit: iStock

6 Listen to people and be honest

People often get angry and frustrated due to fear. This can be because they don’t know what is happening, so taking the time to listen properly is essential, says Ms Waddington.

‘If people get angry this is mainly due to fear, and this can be due to poor communication or miscommunication.

‘Listen to them, validate their concerns and be honest – if you don’t know the answer, tell them that. If you say you are going to find something out, actually do that and come straight back. This helps build trust.’

7 Accept that sometimes de-escalation will not work

Staff must have boundaries to protect both themselves and other patients, says Ms Waddington. Always refer to their local violence and aggression policies and undertake appropriate training.

When a patient or carer becomes aggressive and violent, Ms Waddington advises:

‘About nine times out of ten, these steps will help calm a situation, but sometimes it doesn’t work, and that doesn’t mean we have failed,’ she says. ‘Many different aspects, often beyond our control, contribute to situations escalating.’

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