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De-Escalation of Techniques Back to Course Index

 

Before disruptive behavior turns to chaos, professionals with the necessary skills to de-escalate situations can help prevent catastrophes.

Stan is a client with a history of aggression.

Today, he’s been agitated since lunch, and now he just got cut off during group therapy because a staff member interrupted group with a new client’s arrival.

He then cuts off the staff member saying, “Yo, I was talking.  Don’t be an asshole.”

The staff member says, “​I apologize for interrupting but let’s welcome John to the group and be respectful.”​

The next thing everyone knows, Stan is tearing up the day room.

He’s breaking furniture and turning over chairs. He barrels down the hall into the acute unit, jumps over the nurses’ station, and starts stuffing charts in the garbage.

By the time you’re called to the scene, Mike’s in a corner, wielding a chair.

He looks like he could come at you with it.

But you know how to prevent that.

What you say is simple.

And you know it’s going to work because of HOW you say it.

Calmlynot showing panic that would contribute to the chaosyou say, Hey Stan, how can I help?”

Stan likes you because you have a good rapport with him. He likes your tone.

He tells you he wants a to be heard in group. You know you can’t make that happen right now, so you say, “What else do you want, Stan?”

Stan says he just wants to go lie down.

Another staff member says, “​No sleeping allowed midday! You’​ll sleep at night.”​

You see how this escalates Stan as he wields the chair higher. You signal for the staff to back away, and you say, “I can make a nap possible for you.”

You see how this calms Stan, so you say in a respectful tone, “But you can’t throw things.”

Stan lowers the chair very slightly, and you can see that his anger is starting to deflate. He’s almost done exploding. And your demeanor has calmed him. 

So you say, “Will you put the chair down?”

And Stan puts the chair down.

Because of you, the standoff is over.

Staff can’t believe your magic touch.

But it’s not magic.

It’s know-how. It’s knowing what escalates Stan, and what calms him. It’s knowing which rules are negotiable and which are not. It’s knowing how to assess risk, and which intervention to use and when.

 

Handled differently, this situation could have led to a physical struggle. The chair might have gotten thrown. Team restraint might have been necessary. Injuries and pain might have resulted. 

But the de-escalation skills used prevented an out-of-control situation from spinning more out of control.

When professionals are proficient in de-escalation, people get hurt less frequently and clients can learn how to manage their emotions.  They learn how to better be heard and how better to interact with those around them.

It’s far better to prevent behavioral incidents than to be thrust into the middle to manage them. It is important to train and to plan and take action well ahead of any escalation.

 

AGGRESSION

The best time to begin responding to an impending incident is right now.  Let’s take a look at what aggressive behavior is, how to recognize the warning signs and how to respond to help before it gets out of control.

Aggression in its broadest sense is behavioral, or a disposition or tendency to act in a particular manner that is either forceful, hostile or attacking (or some combination of the three). It may occur either in retaliation or without provocation. In narrower definitions that are used in social and behavioral sciences, aggression is an intention to cause harm or an act intended to increase relative social dominance. Aggression can take a variety of forms and can be physical or be communicated verbally or non-verbally. Aggression differs from what is commonly called assertiveness, although the terms are often used interchangeably among laypeople, e.g. an aggressive salesperson.

There are many theories on aggression.  Some describe these behaviors as instinct, others hone in on how frustration leads to overwhelming feelings and others that focus on aggression as a learned behavior.


Aggression as an Instinct

There are a number of theories (e.g. the Psychoanalytic Approach, the Ethological Approach and the Biological Approach) which attempt to explain aggression by suggesting that aggressive behavior occurs because each individual is born with an aggressive instinct. 

Such theories suggest that aggression is innate, i.e. inborn, and, therefore, unavoidable.  Outlets such as competitive sport and creative pursuits serve to reduce socially unacceptable aggressive behavior. 


Frustration as a Factor in Aggression

The Frustration-Aggression theory proposes that aggression occurs as a result of frustration.  The inference is that if individuals are frustrated in achieving their aims, the most likely response is aggression.  Such individuals are motivated to be aggressive towards whoever or whatever is standing in their way.  While frustration often leads to feelings of aggression, critics of this theory have argued that it does not explain all the causes of aggression. 


Aggression as Learned Behavior

The theory of aggression as a learned behavior is called the Social Learning Approach.  This theory argues that aggressive behavior is not inborn, rather it is something that is learned, either through direct experience or through observation or imitation of others.  The more that an individual’s aggression is rewarded, perhaps by getting what is wanted or by parental approval, the more likely that person is to be aggressive in the future. 

Warning Signs

Regardless of what and where it comes from aggression needs to be diffused and fast.  Learning to de-escalate a situation before it is too late must include training on recognizing where, when and in what environment to watch for it.  Culture and gender play a role in aggression.  American men resorted to physical aggression more readily than Japanese or Spanish men, whereas Japanese men preferred direct verbal conflict to their American and Spanish counterparts. Within American culture, southerners were shown to become more aroused and to respond more aggressively than northerners when affronted. 

Behaviors like aggression can be learned by watching and imitating the behavior of others. A considerable amount of evidence suggests that watching violence on television, movies. Video games and social media increase the likelihood of short-term aggression in children.We are programming the youth on how to resolve conflict.

Gender is a factor that plays a role in both human and animal aggression. Males are historically believed to be more physically aggressive than females. This observation is validated by the result of studies that have found more males than females exhibit aggression. Further, aggressive behavior is exhibited more frequently or more intensely in adolescents and young adults. It usually declines in middle and later adult- hood. However, aggressive behavior is often very stable over time. This is one of the most robust and reliable behavioral sex differences, and it has been found across many different age groups and cultures.

Aggression is more likely in persons with one or more of the following attributes:

    • Greater degrees of intellectual disability;
    • Organic brain damage;
    • Sensory disabilities;
    • Difficulties in language;
    • Poor coping skills;
    • Poor problem-solving skills;
    • Limited social skills;
    • Weak or non-existing social support system;
    • Psychiatric disorders

 

With psychiatric and alcohol and other drug treatment populations you frequently have:

    • Limited social skills
    • Multiple legal and social problems and
    • A history of substance abuse

Each of these can exacerbate a tendency toward aggressive behavior.  None of these preclude the ability to diffuse the frustration and anger that is beginning.

 

Potential Triggers for Violent or Aggressive Behavior:

    • Recent relapse
    • Severe stress
    • Violent history
    • Social isolation
    • Significant loss or frustration (e.g. losing parental rights)
    • Receive a warning about their behavior
    • Believe they have been treated unfairly or disrespectfully
    • Failure to receive a privilege they expected or counted on
    • Have a hostile relationship with another client
    • Receive negative news (from courts or DCF)
    • Feel they have nothing to lose (total emersion into the present situation; nothing else matters)

 

Signs include:

    • Poor relationship with peers
    • Poor personal hygiene
    • Drastic changes in personality traits
    • Making threats of violence, getting back at someone, etc.
    • Intimidating others (bullying)
    • Getting very angry easily or often; loss of control
    • Using abusive language
    • Believing others are out to get him or her
    • Blaming others for their problems (playing the blame game)
    • Being rigid and inflexible (generally introverted)

Diagnosis That Frequently Have Impulse Control Issues and Aggressive Behaviors

There are diagnosis and conditions that go more frequently hand in hand with forceful and out of control behavior including conduct disorder, oppositional defiant disorder, behavior disorder not otherwise specified, intermittent explosive disorder, impulse control disorder not otherwise specified and some personality disorders, as well as can be seen throughout alcohol and other drug addictions. 

Physical Environment

Much of the crisis intervention strategies focus on predictive factors such as patient characteristics, as well as improvements to staff training and care processes.  There is another factor in reducing the risk of dangerous behavior in treatment facilities.  The physical environment plays a role too.  The lack of research on this piece of the puzzle has lead to limiting aggression reduction to security features and damage-resistant components: locks, observation windows and cameras, violence proof doors and walls, metal detectors, and isolation rooms.   These measures continue to be important, but the apparent continued high incidence of aggressive behavior and violence suggests that reliance on traditional architectural and clinical approaches is not enough.  Visibility such as good sight lines and overview, single rooms, reduction of over crowing that leads to over stimulation, quiet places with movable seating ample space that reduce stress where patients can feel a bit more alone even if they are still visible to the staff, the ability to foster a sense of control over their physical surroundings, gardens and even softer colors for the walls can lead to a reduction in aggressive behaviors.  

 

NON INVASIVE APPROACHES 

ag-bomb-2Frequently escalating behaviors such as yelling, using profanity and physically intimidating others are used to regain control when someone feels as though they have lost authority over their decisions or well-being.  The fastest way to diffuse these feelings are to give back options for feeling like the individual has options and the ability to make certain decisions.

When a negative behavior occurs, do not enter the patient’s / individual’s personal space without their permission (unless there is an immediate risk of self-harm or harm to others) as this could escalate their distress, anger and / or behavioral disturbance.

Key points to remember:

  • Respect personal space
  • Do not be provocative
  • Establish verbal contact
  • Be concise
  • Identify wants and feelings
  • Listen closely to what the client is saying
  • Agree or agree to disagree
  • Set clear limits
  • Offer choices and optimism

When approaching the agitated client or patient, maintain at least 2 arm’s lengths of distance between you and them. This not only gives them the space they need, but also gives the clinician the space needed to move out of the way if the patient were to kick or otherwise strike out. The clinician may want to give himself more distance in order to feel safe; and, if a patient tells you to get out of the way, do so immediately. Both the patient and the clinician should be able to exit the room without feeling that the other is blocking his way.

The clinician must demonstrate by body language that he will not harm the patient, that he wants to listen, and that he wants everyone to be safe. Hands should be visible and not clenched. Avoid concealed hands, which imply a concealed weapon.  Knees should be slightly bent. The clinician should avoid directly facing the agitated patient and should stand at an angle to the patient so as not to appear confrontational. A calm demeanor and facial expression are important. Excessive, direct eye contact, especially staring, can be interpreted as an aggressive act. Closed body language, such as arm folding or turning away, can communicate lack of interest. It is most important that the clinician’s body language be congruent with what he is saying. If not, the patient will sense that the clinician is insincere or even “faking it” and may become more agitated and angry. It is also important to monitor closely that other patients or individuals do not provoke the patient further.

Do not challenge the client, insult him, or do anything else that can be perceived as humiliating.  

Multiple people verbally interacting can confuse the client and result in further escalation. While the designated person is working with the patient, another team member should alert staff to the encounter, while removing innocent bystanders.

A good strategy is to be polite. Tell the patient your title and name. Rapidly diminish the patient’s concerns about your role by explaining that you are there to keep him safe and make sure no harm comes to him or anyone else. If the patient is very agitated, he may need additional reassurance that the clinician wants to help him regain control. Orient the patient as to where he is and what to expect. If the patient’s name is unknown, ask for his name. Judgment is required in deciding whether to call the person by his first or last name. Although some prefer calling all patients by their last names, this formality, in some situations, can add to a patient’s suspicion and appear patronizing. When in doubt, it is best to ask the patient how he prefers to be addressed; this act communicates that he is important and, from the very beginning of the interaction, that he has some control over the situation.

Since agitated patients may be impaired in their ability to process verbal information, use short sentences and a simple vocabulary. More complex verbalizations can increase confusion and can lead to escalation. Give the patient time to process what has been said to him and to respond before providing additional information.

This involves persistently repeating your message to the patient until it is heard. Since the agitated patient is often limited in his ability to process information, repetition is essential whenever you make requests of the patient, set limits, offer choices, or propose alternatives. This repetition is combined with other assertiveness skills that involve listening to the patient and agreeing with his position whenever possible.

Attempt to find out what the client wants/needs, how he is feeling and how you can help.   Whether or not the request can be granted, all clients need to be asked what their request is.  A statement like, “I really need to know what you expected when you came here,” is essential, as is the caveat “Even if I can’t provide it, I would like to know so we can work on it.” 

“Free information” comes from trivial things the patient says, his body language, or even past encounters one has had with the patient.  Free information can help the examiner identify the patient’s wants and needs. This rapid connection based on free information allows the clinician to respond emphatically and express a desire to help the patient get what he wants, facilitating rapid de-escalation of agitation.

A sad person wants something he has given up hope of having. A patient who is fearful wants to avoid being hurt.  The aggressive patient has specific wants also, and identifying these wants is important for the management of the patient.

The clinician must convey through verbal acknowledgment, conversation, and body language that he is really paying attention to the patient and what he is saying and feeling. As the listener, you should be able to repeat back to the patient what he has said to his satisfaction. Such clarifying statements as “Tell me if I have this right…” is a useful technique. Again, this does not mean necessarily that you agree with the patient but, rather, that you understand what he is saying.

Miller’s law states, “To understand what another person is saying, you must assume that it is true and try to imagine what it could be true of.”  If you follow this law, you will be trying to understand. If you are truly trying to imagine how it could be true, you will be less judgmental, and the patient will sense that you are interested in what he is saying and this will significantly improve your relationship with the patient. For example, if the patient’s agitation is driven by the delusion that someone is following him and intends to cause him harm, you can imagine how this is true from the patient’s standpoint and engage the patient in conversation as to why this is happening to him and who would want to harm him. This will convey your interest and will result in the patient engaging in conversation about that which is driving his agitation. By engaging in conversation, the patient will begin to see that you care, which in turn, fosters de-escalation.

Fogging is an emphatic behavior in which one finds something about the patient’s position with which he can agree.  It can be very effective in developing one’s relationship with the patient. There are 3 ways to agree with a patient. The first is agreeing with the truth. If the patient is agitated after 3 attempts to draw his blood, one might say, “Yes, she has stuck you 3 times. Do you mind if I try?” The second is agreeing in principle. For the agitated patient who is complaining that he has been disrespected by the police, you don’t have to agree that he is correct but you can agree with him in principle by saying, “I believe everyone should be treated respectfully.” The third is to agree with the odds. If the patient is agitated because of the wait to see the doctor and states that anyone would be upset, an appropriate response would be, “There probably are other patients who would be upset also.” Using these techniques, it is usually easy to find a way of agreeing, and one should agree with the patient as much as possible. Clinicians may find themselves in a position where they are being asked to agree with an obvious delusion or something else the clinician can obviously have no knowledge of. In this situation, acknowledge that you have never experienced what the patient is experiencing but that you believe that he is having that experience. However, if there is no way to honestly agree with the patient, agree to disagree.

It is critical that the patient be clearly informed about acceptable behaviors. Tell the patient that injury to him or others is unacceptable. If necessary, tell the patient that he may be arrested and prosecuted if he assaults anyone. This should be communicated in a matter-of-fact way and not as a threat.

Set limits demonstrating your intent and desire to be of help but not to be abused by the patient. If the patient is causing the clinician to feel uncomfortable, this must be acknowledged. Often telling the patient that his behavior is frightening or provocative is helpful if it is matched with an empathetic statement that the desire to help can be interrupted or even derailed if the clinician feels angry, fearful, etc.

The bottom line is that good “working conditions” require that both patient and clinician treat each other with respect. Being treated with respect and dignity must go both ways. Violation of a limit must result in a consequence, which (1) is clearly related to the specific behavior; (2) is reasonable; and (3) is presented in a respectful manner.

Some behaviors, eg, punching a wall or even breaking a chair, may not automatically indicate the need for seclusion or restraint, and the patient can continue to be de-escalated with some increase in limit setting and consequences. Reassure the client that you want to help him regain control and establish acceptable behavior.

Once you have established a relationship with the client and determined that he has the capability to stay in control, teach him how to stay in control. Use gentle confrontation with instruction: “I really want you to sit down; when you pace, I feel frightened, and I can’t pay full attention to what you are saying. I bet you could help me understand if you were to calmly tell me your concerns.”

For the patient who has nothing left but to fight or take flight, offering a choice can be a powerful tool. Choice is the only source of empowerment for a patient who believes physical violence is a necessary response. In order to stop a spiraling aggression from turning into an assault, be assertive and quickly propose alternatives to violence. While offering choices, also offer things that will be perceived as acts of kindness, such as blankets, magazines, and access to a phone. Food and something to drink may be a choice the patient is willing to accept that will stall aggressive behaviors. Be mindful that these choices must be realistic. Never deceive a patient by promising something that cannot be provided for him.

Be optimistic but in a genuine way. Let patients know that things are going to improve and that they will be safe and regain control. Give realistic time frames for solving a problem and agree to help the patient work on the problem. When the patient states, “I want to get out of here,” the clinician can respond, “I want that for you as well; I don’t want you to have to stay here any longer than necessary; how can we work together to help you get out of here?”

Redirecting

Before things escalate staff can verbally redirect and assist the patient to a quiet area of the facility that is free from all stimuli, and is away from other patients or residents. Also, redirecting the patient’s attention to less distressing topics, and even using humor, may be appropriate. Shift the conversation to the future, create hope, and you make yourself less threatening.  Using “what” and “we” helps include the person in those future plans.

“I’m sounds like it was frustrating that someone came in right when you were beginning to open up.  When we visit the garden this afternoon we can all listen to the rest of your story and maybe some of the other clients will have suggestions for how to help.  The garden is always one of my favorite places to chat.  What are some of your favorites?”

 

Active Listening

The ability to listen is an important therapeutic skill.  It improves inter-personal relationships by:

  • reducing conflicts
  • strengthening cooperation
  • fostering understanding
  • calming others (it is comforting to be understood)

Active listening is a structured way of listening and responding to others. It focuses attention on the speaker. It is important to observe the other person’s behavior and body language.

Having heard, the listener may then paraphrase the speakers words. It is important to note that the listener is not necessarily agreeing with the speaker simply stating what was said.

The benefits of active listening include getting people to open up, avoiding misunderstandings, resolving conflict and building trust

Utilizing these techniques help to create a safe environment and space for a client to calm down.  Staff should always treat the patients with respect. Judgmental attitudes, authoritative directives will likely result in anger and shame, feelings that in turn can result in negative behaviors.

As mentioned previously, communication is crucial for effective treatment and for the patients compliance, as well. Staff members should  explain who they are, what they are going to do and why it is necessary. Speak to the patients about their treatment and offer them choices wherever practical.   Staff should frequently check with the patient or client about their level of comfort with the physical surroundings and so forth. If it is impossible to comply with a patients request, explain why.

Keep in mind that it is important to:

  • Return the feeling of control, as much as possible, to the individual acting out. They have a choice as to how this situation will play out. Allow them to be a part of the solution when possible.
  • Help the patient determine self-capacities, strengths and resources.

Always, present the facts without making judgments or getting emotional, state expectations calmly and simply. If you are directing the patient to change a behavior, be specific and clear as to what you are requesting of them to end the situation. End with a question to gain agreement. Allowing the patient to be a part of the solution is always best, but the safety of the unit must be at the forefront of any discussion.

 

POST INCIDENT PROCEDURES

The occurrence of a behavioral incident begins the task of preventing the next one. Participants learn to involve the agitated person (when appropriate) and involved others in assessing what happened and developing plans to prevent future incidents.  Interdisciplinary teams can help look at the situation from different perspectives.  Documentation is important.  Use the agency’s incident report and follow established protocols and procedures.

When writing the incident report:

  • Be as specific as possible
  • Do not use vague pronouns or emotional language
  • Do use concrete language
  • Write in simple, straightforward sentences
  • Identify the perpetrator and victim/s
  • Explain behavior clearly
  • Identify any known precipitating events

Be sure to communicate with the next shift.   Patients who were victims or witnessed the event may be upset or agitated. Aggression often leads to more aggression; therefore staff on subsequent shifts should be alert.

  • Supervisors or managers should process the event (be aware of what happened and follow-up as appropriate)
  • Identification of precipitating events is important
  • Root cause analysis may be done
  • If possible, identify steps to take or changes to make to prevent a similar incident from happening again

Once a crisis situation is over it is important to assess the other patients. An aggressive incident can lead to problems with other clients such as:

  • Aggression/violence
  • Sadness
  • Grief
  • Anxiety

It is also important to keep in mind going through a situation like this can take a toll on staff.  They need the time and opportunity to calm themselves down after an event, as well.  

 

THE USE OF RESTRAINTS

Physical intervention on psychiatric inpatient units remains a highly controversial ethical issue.  Professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients in regard to personal safety and patient rights have changed the mental health and addiction fields.

Many facilities do not employ restraints. However, in an effort to inform we will briefly discuss these.

The term restraints include the use of seclusion, physical restraint, mechanical restraint and chemical restraint.

The only indications for the use of seclusion and restraint are to prevent dangerous behavior to self or others and to prevent disorganization or serious disruption of the treatment program. The use of restraints must be in accordance with the facilities policies and procedures.

Seclusion and restraint should not be used as punishment for patients, for the convenience of the program, where prohibited by state guidelines, to compensate for inadequate staffing patterns, or instituted by untrained staff. In facilities that employ these measures, for the safety and well being of the patients, the autonomy and dignity of the patient must be preserved as much as possible.

The decision on when to seclude or restrain a patient must be made by the professionally trained staff working with the patient at the time of the aggressive behavior in consultation with a physician. Seclusion, physical restraint, and chemical restraint should not be ordered on a prn (pro re nata = as the occasion may arise) basis. All patients in seclusion or restraint must be monitored continuously. There are strict requirements for the monitoring of pulse, blood pressure, range of motion, nutrition, hydration and comfort. With a release in place, the patient’s family should be informed of use of seclusion or restraint.

Physical and mechanical restraints that cause airway obstruction must not be employed, such as choke holds or covering the patient’s face with a towel, bag, etc. With supine (face up) restraints, a patient’s head must be able to rotate freely. With prone (face down) restraints, the patient’s airway must be unobstructed at all times (i.e. not buried), and the patient’s lungs must not be restricted by excessive pressure on the patient’s back.

Physical Restraint

Physical restraint, the most frequently used type, is a specific intervention or device that prevents the patient from moving freely or restricts normal access to the patient’s own body. Physical restraint may involve:

  • applying a wrist, ankle, or waist restraint
  • tucking in a sheet very tightly so the patient can’t move
  • keeping all side rails up to prevent the patient from getting out of bed
  • using an enclosure bed.

Typically, if the patient can easily remove the device, it doesn’t qualify as a physical restraint. Also, holding a patient in a manner that restricts movement (such as when giving an intramuscular injection against the patient’s will) is considered a physical restraint. A physical restraint may be used for either nonviolent, non self-destructive behavior or violent, self-destructive behavior. 

 

Restraints for Nonviolent, Non self-destructive Behavior

Typically, these types of physical restraints are nursing interventions to keep the patient from pulling at tubes, drains, and lines or to prevent the patient from ambulating when it’s unsafe to do so—in other words, to enhance patient care. For example, a restraint used for nonviolent behavior may be appropriate for a patient with an unsteady gait, increasing confusion, agitation, restlessness, and a known history of dementia, who now has a urinary tract infection and keeps pulling out his I.V. line.

 

Restraints for Violent, Self-destructive Behavior

These restraints are devices or interventions for patients who are violent or aggressive, threatening to hit or striking staff, or banging their head on the wall, who need to be stopped from causing further injury to themselves or others. The goal of using such restraints is to keep the patient and staff safe in an emergency situation. For example, a patient responding to hallucinations that commands him or her to hurt staff and lunge aggressively may need a physical restraint to protect everyone involved.

 

Chemical Restraint

Chemical restraint involves use of a drug to restrict a patient’s movement or behavior, where the drug or dosage used isn’t an approved standard of treatment for the patient’s condition. Chemical restraint is to be distinguished from the pharmacological management of a patient’s underlying illness.  For example, a provider may order haloperidol in a high dosage for a post surgical patient who won’t go to sleep. (If the drug is a standard treatment for the patient’s condition, such as an antipsychotic for a patient with psychosis or a benzodiazepine for a patient with alcohol-withdrawal delirium, and the ordered dosage is appropriate, it’s not considered a chemical restraint.) Many healthcare facilities prohibit use of medications for chemical restraint.

 

Seclusion

With seclusion, a patient is held in a room involuntarily and prevented from leaving. Many emergency departments and psychiatric units have a seclusion room. Typically, medical-surgical units don’t have such a room, so this restraint option isn’t available. Seclusion is used only for patients who are behaving violently. Use of a physical restraint together with seclusion for a patient who’s behaving in a violent or self-destructive manner requires continuous nursing monitoring.


Mechanical Restraint

Mechanical restraint refers to the use of a mechanical device to restrict a person’s movement in an emergency situation of aggressive behavior, where the person is at an immediate risk of harm to self or others. Examples of manufactured mechanical restraint devices include (but are not limited to) belts, harnesses, manacles, straps and mittens.

The use of seclusion and or restraint should be followed by a debriefing discussion that allows the patient to process and understand what has happened. The staff should review with the patient the events that triggered the seclusion or restraint; discuss with the patient alternate strategies to avoid similar incidents and arrange whenever possible for the patient to make amends or do restitution to those who have been injured.

Every episode of seclusion and restraint must be documented in the patient’s medical record. The Joint Commission requires that patients be allowed written comment about the experience. Staff participating in a seclusion or restraint should review the episode in a separate debriefing session and document recommendations and findings for the facility’s committee that reviews seclusion and restraint reports.

Strong clinical leadership is essential in the management of aggressive behavior in order to minimize the need for seclusion and restraint. Facilities must have a committee that provides oversight of the practice of seclusion and restraint. This may include a review of restrictive interventions; restraint equipment; staff training; staff retention; and peer review of the application and use of seclusion, mechanical and chemical restraint, and restraint equipment. A patient and family ombudsman should also be available to review concerns about restrictive interventions if a facility wishes to employ these methods.

 

CHANGE

We have moved as a profession away from using restraints and seclusion to reduce aggressive behavior to de-escalation techniques to prevent aggressive behaviors.  Non violent crisis intervention and de-escalation training is an integral part of any mental health or substance abuse professional’s education.  It is important to continue to evolve with new techniques to meet changing standards.  What was once a normal response is now a last resort. 

 

THE JOINT ACCREDITATION

The Joint Accreditation revised their regulations ‘to restrict the uses of restraints and seclusion to emergency situations in which there is imminent risk that the individual may physically harm himself or others.’ 

Standard PC.03.05.01: The [organization] uses restraint or seclusion only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others.

Element of Performance: 
1. The hospital uses restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others.
2. The hospital does not use restraint or seclusion as a means of coercion, discipline, convenience, or staff retaliation.
3. The hospital uses restraint or seclusion only when less restrictive interventions are ineffective.
4. The hospital uses the least restrictive form of restraint or seclusion that protects the physical safety of the patient, staff, or others.
5. The hospital discontinues restraint or seclusion at the earliest possible time, regardless of the scheduled expiration of the order.

 

Standard PC.03.05.03: The[organization] uses restraint or seclusion safely.

Element of Performance: 
1. The hospital implements restraint or seclusion using safe techniques identified by the hospital’s policies and procedures in accordance with law and regulation.
2. The use of restraint and seclusion is in accordance with a written modification to the patient’s plan of care.

 

Standard PC.03.05.05:  The [organization] initiates restraint or seclusion based on an individual order.

Element of Performance: 

1. A physician or other authorized licensed independent practitioner primarily responsible for the patient’s ongoing care orders the use of restraint or seclusion in accordance with hospital policy and law and regulation.
2. The hospital does not use standing orders or PRN (also known as “as needed”) orders for restraint or seclusion.
3. The attending physician is consulted as soon as possible, in accordance with hospital policy, if he or she did not order the restraint or seclusion.
4. Unless state law is more restrictive, orders for the use of restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others may be renewed within the following limits:

– 4 hours for adults 18 years of age or older
– 2 hours for children and adolescents 9 to 17 years of age
– 1 hour for children under 9 years of age

Orders may be renewed according to the time limits for a maximum of 24 consecutive hours.
5. Unless state law is more restrictive, every 24 hours, a physician or other authorized licensed independent practitioner primarily responsible for the patient’s ongoing care sees and evaluates the patient before writing a new order for restraint or seclusion used for the management of violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others in accordance with hospital policy and law and regulation.
6. Orders for restraint used to protect the physical safety of the nonviolent or non– self-destructive patient are renewed in accordance with hospital policy.

 

Standard PC.03.05.07:The [organization] monitors patients who are restrained or secluded.

Element of Performance:

1. Physicians or other licensed independent practitioners or staff who have been trained in accordance with 42 CFR 482.13(f) monitor the condition of patients in restraint or seclusion. 

 

Standard PC.03.05.09:  The [organization] has written policies and procedures that guide the use of restraint or seclusion.

Element of Performance:

1. The hospital’s policies and procedures regarding restraint or seclusion include the following:

– Physician and other authorized licensed independent practitioner training requirements
– Staff training requirements
– The determination of who has authority to order restraint and seclusion
– The determination of who has authority to discontinue the use of restraint or seclusion
– The determination of who can initiate the use of restraint or seclusion
– The circumstances under which restraint or seclusion is discontinued
– The requirement that restraint or seclusion is discontinued as soon as is safely possible
– A definition of restraint in accordance with 42 CFR 482.13(e)(1)(i)(A–C)
– A definition of seclusion in accordance with 42 CFR 482.13(e) (1)(ii)
– A definition or description of what constitutes the use of medications as a restraint in accordance with 42 CFR 482.13(e (1)(i)(B)
– A determination of who can assess and monitor patients in restraint or seclusion
– Time frames for assessing and monitoring patients in restraint or seclusion

2. Physicians and other licensed independent practitioners authorized to order restraint or seclusion (through hospital policy in accordance with law and regulation) have a working knowledge of the hospital policy regarding the use of restraint and seclusion.

 

Standard PC.03.05.11: The [organization] evaluates and reevaluates the patient who is restrained or secluded.

Element of Performance:

1. A physician or other licensed independent practitioner responsible for the care of the patient evaluates the patient in-person within one hour of the initiation of restraint or seclusion used for the management of violent or self destructive behavior that jeopardizes the physical safety of the patient, staff, or others. A registered nurse or a physician assistant may conduct the in-person evaluation within one hour of the initiation of restraint or seclusion; this individual is trained in accordance with the requirements in PC.03.05.17,EP 3.
2. When the in-person evaluation (performed within one hour of the initiation of restraint or seclusion) is done by a trained registered nurse or trained physician assistant, he or she consults with the attending physician or other licensed independent practitioner responsible for the care of the patient as soon as possible after the evaluation, as determined by hospital policy.
3. The in-person evaluation, conducted within one hour of the initiation of restraint or seclusion for the management of violent or self destructive behavior that jeopardizes the physical safety of the patient, staff, or others, includes the following:


– An evaluation of the patient’s immediate situation
– The patient’s reaction to the intervention
– The patient’s medical and behavioral condition
– The need to continue or terminate the restraint or seclusion

 

Standard PC.03.05.13: The [organization] continually monitors patients who are
simultaneously restrained and secluded.

Element of Performance:

1. The patient who is simultaneously restrained and secluded is continually monitored by trained staff either in person or through the use of both video and audio equipment that is in close proximity to the patient.

 

Standard PC.03.05.15: The [organization] documents the use of restraint or seclusion.

Element of Performance:

1. Documentation of restraint and seclusion in the medical record includes
the following:


– Any in-person medical and behavioral evaluation for restraint or seclusion used to manage violent or self destructive behavior
– A description of the patient’s behavior and the intervention used
– Any alternatives or other less restrictive interventions attempted
– The patient’s condition or symptom(s) that warranted the use of the restraint or seclusion
– The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention
– Individual patient assessments and reassessments
– The intervals for monitoring
– Revisions to the plan of care
– The patient’s behavior and staff concerns regarding safety risks to the patient, staff, and others that necessitated the use of restraint or seclusion
– Injuries to the patient
– Death associated with the use of restraint or seclusion
– The identity of the physician or other licensed independent practitioner who ordered the restraint or seclusion
– Orders for restraint or seclusion
– Notification of the use of restraint or seclusion to the attending physician
– Consultations

 

Standard PC.03.05.17: The [organization] trains staff to safely implement the use of
restraint or seclusion.

Element of Performance:

1. The hospital trains staff on the use of restraint and seclusion, and assesses their
competence, at the following intervals:

– At orientation
– Before participating in the use of restraint and seclusion
– On a periodic basis thereafter

2. Based on the population served, staff education, training, and demonstrated knowledge focus on the following:

– Strategies to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of restraint or seclusion
– Use of nonphysical intervention skills
– Methods for choosing the least restrictive intervention based on an assessment of the patient’s medical or behavioral status or condition
– Safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia)
– Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary
– Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including, but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the in-person evaluation conducted within one hour of initiation of restraint or seclusion
– Use of first-aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification (See also PC.03.05.07, EP 1)

 


3. Individuals providing staff training in restraint or seclusion have education, training, and experience in the techniques used to address patient behaviors that necessitate the use of restraint or seclusion.
4. The hospital documents in staff records that restraint and seclusion training and demonstration of competence were completed.

 

Standard PC.03.05.19: The [organization] reports deaths associated with the use of restraint and seclusion.

Element of Performance:

1. The hospital reports the following information to the Centers for Medicare & Medicaid Services (CMS):

– Each death that occurs while a patient is in restraint or seclusion
– Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion
– Each death known to the hospital that occurs within one week after restraint or seclusion was used when it is reasonable to assume that the use of the restraint or seclusion contributed directly or indirectly to the patient’s death


2. The deaths addressed in PC.03.05.19, EP 1 are reported to the Centers for Medicare & Medicaid Services (CMS) by telephone no later than the close of the next business day following knowledge of the patient’s death.  The date and time that the patient’s death was reported is documented in the patient’s medical record.

 

SUMMARY

Aggression, including yelling and throwing items, kicking and hitting are behaviors that are frequently preventable by being watchful of warning signs and knowledgeable regarding individuals triggers for these behavior.  It is important to understand how to communicate, most importantly listen, because everyone has an inherent need to be understood.  Good communication plays an important role in avoiding arguments and escalations.

The tone we use, what we say, as well as active listening and redirection all can help to reduce potentially dangerous behaviors.  When individuals have control over elements of their situation they don’t need to become as hostile.  

If an incident does occur, employ crisis intervention techniques, notify supervisors immediately and complete an incident report.

Repeated training in the management of aggressive behavior is necessary to develop a high degree of competence this work requires. Good training promotes the retention of qualified staff, safety of patients and staff and better treatment outcomes.

 

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