Skill List > Communication with Angry Patients through De-escalation
Clinical Alert
With some violent behaviour, for example, physical aggression, the nurse may not be able to defuse or de-escalate the situation. When this possibility exists, know whom to call for assistance, such as nursing colleagues or security staff. Some patients are disruptive to each other, especially those who are hyperactive, intrusive, threatening, or who exhibit bizarre behaviour. For these patients, first try the least restrictive measures before using more restrictive measures, such as seclusion.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Mosby Nursing Skills
Adapted by: Chris Brooker BSc MSc RGN SCM RNT
Updated by: Chris Brooker BSc MSc RGN SCM RNT
Last updated: July 2017
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of communication with angry patients through de-escalation.

Introduction

Anger is the common underlying factor associated with potential for violence. Patients become angry for a variety of reasons. The anger is often directly related to a patient’s experience with illness, or it is associated with problems that existed before the patient entered the healthcare setting. In the healthcare setting, the nurse has frequent contact with a patient so they often become the target of the patient’s anger. The nurse should understand that in many cases a patient’s ability to express anger is important to recovery. For example, when a patient has experienced a significant loss, anger becomes a means to help cope with grief. Some patients express anger towards the nurse, but the anger often hides a specific problem or concern. For example, a patient diagnosed with cancer may voice displeasure with the nurse’s care instead of expressing a fear of dying.

It is very stressful to deal with an angry patient. Anger often represents rejection or disapproval of the nurse’s care. The nurse’s efforts to satisfy an angry patient’s needs can result in a failure to meet the priorities of other patients. Allow patients to express anger openly, and do not feel threatened by their words; however, do not allow a patient’s anger to threaten or compromise care. Skills for communicating with an angry patient or a potentially violent patient enable the nurse to help the patient to deal with anger constructively and to refocus emotional energy towards effective problem solving. De-escalation skills are useful techniques that the nurse can use to manage a potentially violent patient; these skills range from using nonthreatening verbal and nonverbal messages to safely disengaging and controlling the aggressor (Lowry 2016).

Patients experiencing emotionally charged situations do not always comprehend instructions. Focus on understanding the patient, providing feedback, assisting in problem solving, and providing an atmosphere of safety, warmth, and acceptance.

Teaching the patient to identify possible factors that contribute to angry outbursts, such as inadequate coping skills, low frustration levels, illness, hospitalisation, knowledge deficits, or other known stressors, may give the patient a sense of control.

Once anger has been defused, help the patient to learn new adaptive methods of coping with anger.

Cultural considerations

Nurses face challenges when communicating with culturally and linguistically diverse patients. Effective communication between culturally diverse patients and nurses is essential to improving health outcomes (Al Abed et al. 2014). Research shows that providing both general and disease-specific information to patients in a culturally sensitive manner improves chronic illness self-management. 

The following factors are essential to effectively care for culturally and linguistically diverse patients:

  1. use of appropriate linguistic services, for example, an interpreter or bilingual healthcare workers, or other communication strategies
  2. a display of empathy and respect
  3. use of accurate health history taking for diagnostic and treatment purposes and health teaching
  4. use of patient-centred communication behaviour, including the patient's part in all decision making about their care. 

It is also helpful to speak plainly. Never mimic a patient’s accent or dialect. Understand that members of certain cultures use cultural phrases or slang common to their culture and this is not an indication that they do not understand English.

When nurses communicate with patients of diverse cultures, an interpreter is sometimes necessary. When using an interpreter, address the patient and family directly; do not direct questions or comments to the interpreter. Take care to make sure that the patient understands. Speak slowly in normal tones and avoid overly technical jargon or terms unique to a culture (Box 1). Adopting a flexible, respectful attitude that also communicates interest in the patient bridges any communication barriers that exist because of cultural differences between patient and caregiver.


 Box 1 Special approaches to patients who speak different languages. (From Giger J, Davidhizar R 2007 Transcultural Nursing: Assessment and Interventions, 5th edn. Mosby Elsevier, St Louis.)

  • Use a caring tone of voice and facial expression to help alleviate the patient's fears.
  • Speak slowly and distinctly, but not loudly.
  • Use gestures, pictures, and play acting to help the patient understand.
  • Repeat the message in different ways if necessary.
  • Be alert to words the patient seems to understand and use them frequently.
  • Keep messages simple and repeat them frequently.
  • Avoid using medical terms and abbreviations that the patient may not understand.
  • Use an appropriate language dictionary.

Not all cultures express anxiety, anger, and depression in the same way as in a Western culture. Sometimes people present with somatic complaints, such as loss of appetite or poor sleep. In addition, some patients internalise anger and it is expressed through somatic complaints of heat, indigestion, or tachycardia.

Children and anger

Set limits for inappropriate behaviour exhibited by children, such as a time out. Apply such limits immediately because children tend to have less internal control over their own behaviour (Hockenberry & Wilson 2015).

People with cognitive impairment and anger

Older people with dementia and some people with a learning disability who have cognitive impairment may exhibit tantrum-like behaviour in response to real or perceived frustration. Apply distraction techniques to remove a cognitively impaired adult patient from distressing stimuli, or redirect the patient to activity that is enjoyable. 

Care in a person's home

Personal safety for the nurse against a potentially violent patient or family member extends to all healthcare settings, including a patient’s home. The nurse may be in a potentially dangerous situation while giving care to a patient at home because they may be doing so without the support of other staff members. Be aware of physical surroundings, including possible exits. If de-escalation does not occur and the nurse’s personal  safety is threatened, they should call for assistance or remove themselves from the situation.

Preparation and safety

  • Are you competent to provide this care? Should you summon an experienced colleague to help?
  • Assess the situation. Can you safely intervene?
  • It is vital that you do not put yourself or others in any physical danger.
  • Observe for behaviour that indicates the patient is angry, for example, pacing, clenched fist, loud voice or throwing objects, and expressions that indicate anger, for example, repeated questioning of the nurse, not complying with requests, abusive language, aggressive outbursts or threats.
  • Assess factors that influence the communication of the angry patient, such as refusal to comply with treatment goals, use of sarcasm or hostile behaviour, becoming easily frustrated, or being emotionally immature.
  • Consider resources, such as the healthcare team or family, available to assist in communicating with a potentially violent patient.
  • Prepare for interaction with an angry patient:
    • pause to collect own thoughts, feelings, and reactions
    • establish what the patient is saying
    • attempt a calm, firm, assertive approach. Try to talk in a comfortable, reassuring voice.
  • Prepare the environment to de-escalate a potentially violent patient:
    • encourage other people, particularly those who provoke anger, to leave the room or area
    • maintain an adequate distance
    • make sure gestures are slow and deliberate, rather than sudden and abrupt
    • maintain an open exit. Position yourself nearest the door to facilitate escape from a potentially violent situation. Do not block the exit; if the patient feels escape is unattainable, this may cause a violent outburst
    • reduce disturbing factors in the room, such as noise, draughts  or inadequate or very bright lighting
    • take care of the patient’s physical and emotional needs and discomforts, for example, offer analgesic for pain.

Procedure

  1. Perform hand hygiene.
  2. Check the patient’s identity, verbally or using the name-band, according to local policy. In this situation only ask to see the name-band if it is safe to do so.
  3. Maintain nonthreatening verbal and nonverbal communication when interacting with an angry or potentially violent patient.
    RationaleA relaxed atmosphere will prevent further escalation and create a climate of acceptance for the patient.
  4. Use therapeutic silence and allow the patient to express their feelings.
    RationaleOften de-escalates anger. Anger expends emotional and physical energy; the patient runs out of momentum and energy to maintain anger at a high level.
  5. Answer questions as appropriate; if the patient asks a challenging or confrontational question, then redirect and set limits by giving clear, concise expectations. Inform the patient of potential consequences without sounding threatening, and follow through with consequences if the patient does not change their behaviour.
    Rationale Setting limits on challenging and confrontational questions provides structure and helps defuse anger.
  6. If the patient is making verbal threats to harm others, remain calm yet professional and continue to set limits on inappropriate behaviour.
    Rationale – Angry patients lose the ability to process information rationally, so they may impulsively express anger through intimidation.
  7. Maintain personal space and safety with the patient who is making verbal threats of violence directed at others. Maintain nonthreatening position and behaviour, with appropriate body language, position, and cadence.
    Rationale –  Avoiding sudden movements and loud tones prevents giving the appearance of an attack.
    A potentially violent patient can be impulsive and explosive, so keep personal safety skills in mind. In this case, avoid touch.
  8. If the patient appears to be calm and anger is defused, then explore alternatives to the situation or feelings of anger.
    Rationale Processing the situation with the patient may prevent future explosive outbursts and will teach them effective ways of dealing with anger.
  9. Perform hand hygiene.

Ongoing care, monitoring and support

  • Report technique used to deescalate and patient’s response.
    Rationale – Communication with other healthcare providers will enhance patient care.
  • Monitor for continuing verbal expressions of anger.
    Rationale – Indicates success or failure of communication efforts.
  • Note the patient’s ability to answer questions and problem solve.
    Rationale – Determines whether anger has lessened so that the patient is able to focus on alternative coping skills.

Documentation and reporting

  • Document the event in the patient’s nursing notes and include:
    • the cause of the patient’s anger (if known)
    • the patient’s behaviour
    • how you dealt with the patient’s anger and de-escalated the situation.
  • Complete an incident form in accordance with local policy.
  • It is important to talk to colleagues following the incident. Think about whether you need further support (Watkins 2009).
Your email :


Recipient: (email address)
To multiple recipients, separate email addresses with commas.


Note : (optional)