By Jonathan V. Llamas, DNP(c), BSN, RN-BC, PHN

De-escalation is an invaluable tool developed primarily to defuse hostile individuals and situations. In its original usage, the concept of de-escalation implies the existence of both verbal and non-verbal skills and techniques, which, if used selectively and appropriately, may reduce the level of an aggressor's hostility and emotional reactivity.

Although violent incidents may come from a variety of different sources, aggressive and hostile patients appear to be the largest source of workplace violence in the healthcare setting. In 2013, 80% of the serious violent incidents reported were primarily caused by interactions with patients in the clinical setting.

Since potential aggressive incidents represent an acute behavioral emergency that frequently requires immediate intervention, qualified nurses must be prepared to use the following de-escalation skills and techniques to promote patient safety and staff protection.

1. Maintain a Calm Demeanor

Maintaining a calm demeanor and intervening early with less restrictive measures, such as verbal and non-verbal communication, reduced stimulation, active listening, diversionary techniques, and limit-setting can help relax the patient and promote a culture of structure, calmness, negotiation, and collaboration, rather than control. If nurses remain calm and cooperative, the patient will most likely mirror that behavior.

2. Practice Active Listening

While most nurses are often tempted to retaliate when dealing with an aggressive patient, active listening and watching for nonverbal cues may be helpful in the de-escalation process. Active listening is pivotal in pre-empting an angry outburst by looking for or listening to "paraverbal" communication -- i.e., tone, inflection, and volume.

Since most patients that arrive at the hospital are fearful or anxious, it is not uncommon for some patients to utilize anger or aggression as a coping mechanism. Therefore, nurses should use active listening as a tool to help comfort and reassure patients that they are invested in their safety and recovery.

3. Provide Patients an Opportunity to Vent

After actively listening to the patient, nurses must be able to offer thoughtful comments that demonstrate an awareness of the patient's unique feelings and concerns. By offering patients an opportunity to vent, it allows the nurses and patients to work collaboratively and address underlying issues.

When a patient appears to be upset or is demonstrating early signs of anger, it is imperative for nurses to substantiate what they see or hear, so that the patient feels validated. Oftentimes, nurses are so accustomed to telling patients what to do that they forget to provide patients an opportunity to sufficiently express themselves. Therefore, when nurses provide patients a chance to vent, it not only provides patients an opportunity to voice out their frustrations but also diminishes the likelihood of physical violence.

4. Display a Non-Defensive Posture

Another important technique that must be considered when de-escalating an aggressive and hostile patient is displaying a non-defensive posture. By keeping the hands in front of the body, open and relaxed, and maintaining appropriate eye contact, it illustrates authenticity and compassion towards the individual. While proper eye contact is subjective, however, it is imperative not to stare.

Since a nurse's reaction can greatly influence the emotional reactivity of highly dysregulated patients, the nurse must maintain a neutral expression at all times. By remaining calm and sustaining a neutral appearance, patients are less likely to overreact, allowing nurses to regain control of the situation.

5. Impart Empathy and Compassion

Lastly, nurses should also be able to properly express their concern by conveying empathy and compassion towards the patient. The art of empathy and compassion helps reassure patients that they are not alone. Paraphrasing can be an effective tool in de-escalating a situation because it not only communicates empathy but also demonstrates understanding. By using phrases such as "I understand how difficult this can be for you," nurses can connect with patients much more effectively, which can help facilitate the healing process by re-establishing trust and rapport.

Resolution Stage

Once the patient is successfully de-escalated, the nurse is then responsible for settling any unresolved feelings or concerns the patient may have. During the resolution stage, the nurse should identify how the patient would like their anger to be dealt with if and when a similar situation recurs. During this time, the nurse should work collaboratively with the patient to re-establish therapeutic rapport and ensure that all feelings and concerns are individually validated.