Look for nonverbal cues to prevent violent episode
ID levels of behavior, expert says
The key to defusing a potentially violent situation in, say, a hospital emergency department (ED), lies in identifying the levels of behavior the disruptive individual is going through, advises Judith Schubert, executive director of the Crisis Prevention Institute (CPI) in Brookfield, WI.
Tuning in
Access personnel are familiar with the typical waiting room, Schubert points out, where being behind schedule and impatient behavior are the norm. What registrars should be attuned to in such a situation, she suggests, are verbal and nonverbal cues that the anxiety is escalating.
"The signs may be that someone who’s sitting and reading a magazine starts to just flip pages, and to stand up and sit down," Schubert says. Often, the way to prevent a more disruptive scene is simply to acknowledge the person’s wait by offering them something or just paying attention to their plight, she adds.
"Would you like a glass of water?" or "There are more magazines over here," Schubert notes, are comments that can calm the person. "In their own mind, they’re there by themselves, but you can let them know that you’re there with them. You’re not always able to take away the aspect that’s making them anxious — the long wait — but you can be supportive."
This response to early warning signs, she says, is one of the most effective strategies for health care personnel.
Although health care organizations have always been part of CPI’s client list, Schubert notes, "we’re seeing more and more health care professionals requesting training." That’s due in part, she suggests, to guidelines addressing workplace violence issued in 1996 by the Occupational Safety and Health Administration. "Training is a key component of those guidelines."
But when her company is asked to do "a two-hour training course because the organization is concerned about physical aggression," it’s more than likely to decline, Schubert says. Rather than a short course in "how to take someone down," she adds, CPI advocates a holistic program. "We do address issues of physical violence, but it’s a comprehensive approach rather than a quick fix."
Quoting Abraham Maslow, one of the founders of humanistic psychology, Schubert cautions, "If the only tool you have is a hammer, everything around you starts to look like a nail." With that in mind, she says, the focus is on how to prevent a situation from turning violent in the first place. Different responses, Schubert adds, fit different levels of behavior.
Suppose that impatient person in the ED, for example, goes up to the desk, loudly demands to be seen, and when the registrar asks him to sit down, says, "Why don’t you make me?" At that point, she says, the calming offer of a glass of water is no longer the best response.
The tough jobs
Instead, the registrar should become more direct with what she wants the person to do, Schubert adds, and offer a choice. The registrar might say something like, "If you can sit and stop yelling, you can continue to wait here, but if you’re disruptive you will have to leave."
If the person doesn’t comply and the registrar asks him or her to leave, or if he or she acts out physically — by throwing something, perhaps — it’s important that the health care employee "wrap it up" with that individual, she says. The registrar, Schubert adds, might say on the person’s next visit something like, "I want to talk to you about what happened on Thursday. I know you became anxious. What can we do so this doesn’t happen again?" Otherwise, she notes, the person might get frustrated again, or might wonder what the staff are thinking of him or her in view of the past behavior.
When there is physical aggression against an employee, it can be traumatic for the staff, Schubert points out. "They may have fears about not just that individual, but about the ED the next time it’s crowded after a particular event, for example." After such incidents happen, she says, it’s important to "debrief," by talking to staff about what occurred, how it occurred, what the patterns were, and how to prepare for next time. Different people may have different perspectives on the incident and the discussion can help put together the pieces as to what actually happened, Schubert adds.
Thoughts of the most extreme situations — those involving a weapon or a person who is physically aggressive — often prompt people to consider taking a training course, she says. CPI, however, wants people "to come together and to organize their thinking about a lot of things they already know about," Schubert notes. Those who are employed in a health care setting, she suggests, "already have a toolbox of things that work. We try to identify what those things are, and [determine] the best times to use those skills and strategies."
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