Action

‘ACTION’

A practical approach and toolkit for managing conflict

Aims and Objectives

• Discuss background and development of guidelines and ‘tools’ for managing de-escalation.

• Have a framework for how to approach the challenges presented by patients who do not adhere to their management plan, refuse treatment or appear to be sabotaging attempts to help them.

Structure

• Presentation and discussion of some formal guidelines and tools for the management of agitation and conflict

• Discussion of their applicability and feasibility in your working environment

• What steps can you take to ensure their feasibility?

What is ‘challenging’ and where is ‘Conflict’

Eg. The angry, violent, aggressive, psychotic, difficult, challenging, sabotaging … etc ….patient

Spectrum of ‘challenging’ (active passive)

Context

• A move from traditional methods of restraint and involuntary medication to non-coercive approach.

• If done well, de-escalation to have significantly improved outcomes for all individuals involved in conflict in medical setting.

Limitations?

• Why might this field be under developed?

The basics: A three step approach to de-escalation

1- Verbally engage

2- Establish a collaborative relationship

3- Verbally de-escalate out of out agitated state

‘Calming the patient’ vrs ‘helping the patient calm themselves’

Which and why?

4 Objectives of de-escalation:

• Ensure safety of staff, patient and others in area

• Help the patient manage their emotions or distress or regain control of their behavior

• Avoid restraint if possible• Avoid coercive interventions that may

escalate agitation

Domains

• Environment

• People

• Preparedness

‘Environment, People and Preparedness’

1- Physical space and environment- Ensuring safety

2- Staff ‘qualities’ and ‘abilities’- Managing your own negative reactions and counter transference

3-Staff training – Akin to ILS/ BLS?

4-Adequate staff numbers

5-The role of ‘objective scales’Feasibility in your working environment?

Discussion- Barriers? Feasibility? Your experience?

• Guideline: Physical space should be designed for safety (How?)

• Guideline: Staff should be appropriate for the Job (Who- attitude?- stepping outside of yourself)

• Guideline: Staff must be adequately trained• Guideline: An adequate number of trained staff

must be available• Guideline: Use objective scales to assess agitation

(e.g ABCS/ BARS- helpful?)

10 domains of de-escalation to help practitioner's care of agitated patients• To think about prior to the session• ?• ?• ?• ?• ?• ?• ?• ?• ?

Summary

• 3 stages- engage collaborate de-escalate

• 5 domains- E,P,P

• 10 guidelines- A ‘toolkit’

Summary • Verbal de-escalation techniques have the

potential to decrease agitation and reduce the potential for associated violence, in the emergency setting.

• Paucity of work on verbal techniques + barriers to implementation

• Collaboration NOT coercion reduction of coercive measures

• Empowerment, stay in control, and build trust • Impact on future encounters, earlier help seeking

and reduction in future episodes of agitation

Core references

• Richmond et al Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine. Vol. XIII No.1: February 2012.

• Violence: The Short-Term Management of Disturbed/Violent Behaviour in Psychiatric In-patient and Emergency Departments Guideline NCC-NSC 22/02/05 http://www.nice.org.uk/CG25 FEBRUARY 2005 Clinical Practice Guidelines