Navigation and a Couple Tips for On-line Modules Navigation Instructions: Whenever you see words in this color and style in the module click on it for additional information De-escalation and Management of Aggressive Behaviors Module 2: Essential Concepts for De-escalating Aggressive Behavior This module presents key strategies for defusing agitation and managing verbally aggressive behaviors.

Effective De-escalation of Aggression is Built on Five Key Strategies: Situational Awareness and managing the stages of conflict Non-verbal Communication including approach and positioning Listening- Active and Empathic Assertive Verbal Communication Self-Management and Mental Preparation The application of these strategies will enable you to manage the majority of situations involving an angry or agitated person. We’ll look briefly at all the strategies, then more in depth at each. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Self Management Summary

Situational Awareness and managing the stages of conflict Situation Awareness is the ability to accurately assess what is happening and to predict what is likely to happen next. For Situational Awareness you need to know something about the nature of aggression and violence. You need to be aware of factors in the environment, in the patient in the staff that can escalate the risk of violence, so that you know which patients are most likely to act out physical, and under what circumstances Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

2. Nonverbal Communication A large part of communication is nonverbal. There are a number of components of nonverbal communication: Proxemics-- Managing space and position, approach Kinesics–- Gestures, facial expressions, eye contact, posture Prosody— The non-language part of oral communication Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

3. Listening Listening is the primary strategy for defusing anger and aggression. Most people prefer to resolve conflict through communication and cooperation, rather than through aggression. People want, sometimes desperately, to be heard. Listening (to both verbal and nonverbal) keeps the lines of communication open. Violence is the language of the unheard. Martin Luther King Jr. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

4. Assertive and Directive Communication Your responsibility is to use all non-physical means possible to manage aggression before applying physical interventions. The primary tool you have to use is communication Effective communication increases the likelihood that the angry or agitated person will cooperate. If you wish to win a man over to your way, first make him your ally. Abraham Lincoln Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

5. Self Management and Mental Preparation How do you manage your environment to reduce confusion, institutionalism, and other risk factors?   How do you manage your own response to anxiety and aggression?   How do you prepare for managing anxiety and aggression? All Interventions begin with you and how you manage your own responses. “Be the change you want to see in the world.” Mohandas Gandhi Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Situational Awareness 1/4- Why are People Violent? Aggression is behavior used to end or avoid an unacceptable circumstance. People resort to aggression when they do not perceive that their “problem” can be resolved through cooperation and communication. How quickly a person resorts to aggression depends on many factors, for example: Lack of personal resources (may be temporary or ongoing) Overwhelming personal demands, including physical condition Violence has worked in the past There are numerous conditions in healthcare that increase the potential for aggression, consequently, healthcare is a high risk environment for violence. The key fact to keep in mind is that the aggressive person is in distress and is seeking relief from that distress. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Situational Awareness 2/4- Stages of Conflict Aggression follows a predictable pattern. The stage of conflict will direct your response. Click on each term for a brief description. Baseline Anxiety Verbal Aggression Physical Aggression Resolution/Tension Reduction Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Situational Awareness 3/4- Stages of Conflict: An important difference The stages of conflict model applies to “expressive” or “relational” conflict, that arises because of distress. In these situations, the primary focus is on relieving the distress as early as possible in the process. This model does not apply to “instrumental” violence, such as criminal behavior. In these cases, security measures are needed to prevent violence. Recognize also that in many cases, both types of conflict may be present. Baseline Anxiety Verbal Aggression Physical Aggression Resolution/Tension Reduction Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Situational Awareness 4/4 - An awareness of risk factors and triggers for aggression allows for early intervention Risk factors and triggers can relate to the individual (patient or visitor), the environment or to staff members. While many of these factors can not be changed, be alert to those that you can control Individual Environmental Staff Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Nonverbal Communication 1/8- Whenever conflict arises, the preferred method of resolving the conflict is communication. Non-verbal communication is one of the most important aspects of communication. The section will look as three elements of nonverbal communication: Proxemics– how one manages space Kinesics- posture, gestures and facial expressions Prosody (or paraverbals) - Tone, volume, rhythm, rate and inflection. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Nonverbal Communication 2/8- Proxemics: managing personal space How space is managed is important for safety and to avoid further escalation of agitation. Care givers often enter another person’s personal space in order to give care. This places them in danger if the situation escalates to physical aggression. Ideally, you always protect your escape route. In a crowded hospital room this may not be possible . If you must give up your escape route, you must maintain your distance. An obstacle between you and an agitated person provides distance as well. When a person is anxious, maintain a minimum of 4 feet distance and a slightly angled position . Stand slightly to the side, not directly in front. When the person is verbally aggressive, keep a minimum of 6 feet distance. Again maintain a slightly angled approach. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Nonverbal Communication 3/8- Proxemics: managing personal space Cornering or positioning that crowds an agitated person can lead to increased agitation Avoid crowding and cornering an agitated person. This can make his agitation worse. Never stand directly in front of the agitated person, or between him and his escape route. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Nonverbal Communication 4/8- Kinesics: two equally important aspects The two aspects of nonverbal communications are 1) correctly identifying the nonverbal communications of others and 2) being purposeful in your non-verbal communication. The earlier you identify nonverbal signs of distress the earlier you are able to intervene. Intervention can be as simple as approaching and asking, “ Is there anything a can help you with?” Your own nonverbal behaviors must match you verbal interventions. We’ll look at the these two aspects in relation to the stages of conflict Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Nonverbal Communication 5/8- Kinesics: anxiety You will likely observe nonverbal indications of anxiety even if patients say nothing. Pay attention and respond to these nonverbal signs of distress. Your verbal response is supportive. Identify yourself and your role, and to express a desire to help (may be as a question). If the person is noticeable upset include your observation of this. For example, “ Hi, I’m Jim, the charge nurse. I can see you are have a difficult time here, is there anything I can do for you?” Meanwhile pay attention to you own nonverbal communication. Is it supportive, while maintaining safety and respecting personal space? Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Nonverbal Communication 6/8- Kinesics: Physical Aggressive Physical aggression is obvious. Less obvious are these nonverbal signs of immediately preceding violence. You primary response is defensive. Take immediate steps to protect yourself. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Nonverbal Communication 7/8- Kinesics: Tension Reduction Whether a person is verbally or physically aggressive, once the aggression stops you role is primarily supportive again. Be aware of these nonverbal signs of de-escalating agitation. Your primary response is once again is supportive. Your first task is to open communication with the individual, who may be fatigued or remorseful. Your nonverbal communication must demonstrate supportiveness. Movements stop or are more controlled If verbally aggressive verbalizations are quieter, softer Decreased eye contact Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Nonverbal Communication 8/8- Prosody: It’s not what you say, it’s how you say it. Through the anxiety and verbal aggression stages of conflict the most important thing is that one maintain a voice that is calm and confident. A voice that is neither too soft nor too loud, and neither too harsh nor too passive, sets the tone, while respecting what the distressed individual is going through. Remember that what the distressed person is experiencing is important to him or her. While you would never match the anger in that person’s voice, you do want to match the urgency or important in it. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

LISTENING 1/1 This section will discuss listening, a key skill for de-escalating aggression. As long as person believes his or her problem will be resolved through communication and cooperation there is a chance of resolution without resorting to aggression. You responsibility is to Listening attentively Listen empathically Listen Actively Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Assertive and Directive Communication 1/2 Effective communication increases the likelihood that the angry or agitated person will cooperate. When a supportive response does not reduce agitation, your right , and the right of others in the care environment, to safety and well being may be threatened. Verbal and nonverbal communication must become more assertive. Set reasonable, clear and enforceable limits . State the consequences of further aggression. Give options. Appeal to the distressed person’s self interest. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Summary Self Management

Assertive and Directive Communication 2/2- Additional Verbal Intervention tips Every situation is different, and when you are face-to-face with an agitated person the more options you have for how you respond the better. Here are additional verbal dos and don’t: Frequently use “I’m sorry”, “thank you”, and the person’s name. Avoid the use of the word “but”, as in, “I’m sorry to keep you waiting but were really swamped.” Find points of agreement whenever possible. Avoid, “I know how you feel.” Instead of “You need to..,” try, “ I need you to…” Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Self Management Summary

Self Management 1/3- The most important skill of all While you are attempting to influence the behavior of a distress person, except through force, you can never control it. You can only control how you respond. As a person goes into flight or fight mode his or her ability to relate rationally to other decreases. Just as a distressed person goes into flight or fight mode, so do you as you are involved in a situation of escalating agitation. In order to respond appropriately it is important to maintain a certain level of professional detachment. In other words, keep a caring attitude, but don’t allow yourself to take it personally. This section will present a number of strategies you can use to self-manage your responses. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Self Management Summary

Self Management 2/3-It all comes down to preparation, planning and practice   Preparation is building the base of knowledge and learning skills needed to respond to a behavioral crisis. This module, and additional learning about de-escalation is essential preparation. Planning is thinking through how you will apply the principles and use the strategies presented here and from other resources in your own work situation. For frequently occurring situations in your work setting, you can prepare and plan how you will respond. Practice is actually using the principles and strategies in real life (all the communication skills presented here are applicable to home and work interaction), in simulations and in mental rehearsal. Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Self Management Summary

Self Management 3/3-What Navy SEALs Know   The Navy SEALs are considered by many to be the most elite combat unit in the world, both in terms of physical skills and mental toughness. The Navy has the SEALs train for stressful often combative situations over and over again. These men learn skills and develop strategies to manage their reactions in situations more intense and deadly than any we are likely to face. We can learn important self management strategies from them. Their training for self-management of their response focuses on four key areas: Arousal Control via proper Breathing Mental Rehearsal Positive Self Talk Short Term Goals Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Self Management Summary

SUMMARY- Key principles and strategies   Situational Awareness and managing the stages of conflict Non-verbal Communication including approach and positioning Listening- Active and Empathic Assertive Verbal Communication Self-Management and Mental Preparation Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Self Management Summary

Overview Situational Awareness Nonverbal Communication Listening Assertive Communication Self Management Summary About this Module. This module is provided without charge as a service of Change Dynamics for use by individuals and organization wishing to enhance their effectiveness in the topics presented. We believe that the information in this and other modules in this series is a small part of complete training in the topics covered. Complete training requires further explanation and clarification of the principles, and demonstration of and practice in the skills presented. Change Dynamics provides consultation and instructor led training in the following: Preventing and Responding to Workplace De-escalation and the Management of Aggressive Behavior: Verbal De-escalation and Physical Intervention (Train-the-trainer training available) Reducing the Use of Seclusion and Restraints in Healthcare Settings Conflict Resolution Stress Management This module with additional supporting material, is available in a variety of formats for purchase by organizations wishing to modify it, or make use of it according to organizational requirements. This module also available with audio. For information on consulting and training for your organization, or to purchase this module contact: John Lundholm, M.A., RN: lundholm@juno.com (208)691-4468