Tips and Strategies for De-Escalating Aggressive, Hostile, or Violent Patients

Laura M. Cascella, MA, CPHRM

Managing patient complaints and dissatisfaction is an unpleasant but certain reality in healthcare. Despite best efforts, situations will occur in which patients are unhappy and feel compelled to voice their displeasure and concerns. In some cases, patients’ emotions might escalate, and they may become aggressive, hostile, or violent.

Violence in healthcare is an unfortunate reality, and healthcare workers should be prepared to handle tense and potentially violent situations if they occur. Understanding the risks of violence and learning strategies to address such behavior is an imperative safety measure.

Foremost, recognizing that no single response will work in every situation is crucial. You should consider the individual patient, the circumstances, and the broader context of the situation when responding to escalating behavior. An article from the Western Journal of Emergency Medicine notes four main objectives when working with an agitated person. They include:

1. Ensuring the safety of the patient, staff, and others in the area
2. Helping the patient (a) manage their emotions and distress, and (b) maintain or regain control of their behavior
3. Avoiding the use of restraint when possible
4. Avoiding coercive interventions that escalate agitation¹

Using de-escalation techniques might be appropriate if confronted with aggressive or hostile behavior. The aforementioned article lists 10 domains of de-escalation, as follows:

1. Respect personal space while maintaining a safe position. If a situation begins to escalate, make sure that both you and the patient have adequate personal space. No one should feel trapped or cornered in a room or space. Maintain a safe distance from the patient in the event that they try to physically lash out.
2. Do not be provocative. Keep a calm demeanor, and make sure your body language reflects that you will not hurt the patient and do not want a confrontation. Avoid excessive staring, clenching or concealing your hands, and closed body language that insinuates judgment (e.g., crossing your arms).
3. Establish verbal contact. Do not involve multiple people in de-escalation efforts. Only one person, who is properly trained, should talk with the patient in an attempt to de-escalate the situation. Speak calmly and politely to the patient and assure them that your goal is to help resolve the issue and keep everyone safe.
4. Be concise; keep the message clear and simple. Use clear, short sentences and simple vocabulary to help the patient comprehend messages without further agitation. Give the patient time to process information and respond. Repeating key information — such as requests, options, and limitations — is essential in de-escalation.
5. Identify wants and feelings. Try to determine what the patient expects, wants, or feels. Doing so is crucial to resolving outstanding issues or identifying alternative options that might help the patient regain control of their behavior. Responding with empathy and compassion, even if the patient’s expectations are unrealistic, can help establish trust and rapport.
6. Listen closely to what the person is saying. Actively listen to the patient’s complaints or concerns and give verbal and physical indications that you hear and understand the patient’s message. Repeating key information back to the patient is a helpful approach.
7. Agree or agree to disagree. Try to find common ground with the patient and identify opportunities for agreement, whether the agreement is based on facts, principles, or odds. When an agreement can’t be reached, agree to disagree, but acknowledge the patient’s feelings.
8. Lay down the law and set clear limits. Negative behaviors have consequences, and you should calmly, but clearly inform the patient about unacceptable behaviors and potential consequences (e.g., alerting security or law enforcement). This information should be communicated in a factual but nonthreatening manner. Explain that mutual respect is necessary to work together and help resolve issues.
9. Offer choices and optimism. Consider realistic choices and alternatives to violence that you can offer the patient. Doing so can help empower the patient and potentially de-escalate aggression. You also should consider whether other small gestures might help comfort the patient, such as the offer of a beverage or time to make a phone call. Staying optimistic but realistic during these encounters also can help manage the patient’s expectations and work toward solutions.
10. Debrief the patient and staff. Once a situation has been de-escalated, work with the patient to discuss what happened, understand the patient’s perspective, and devise strategies for controlling aggressive and hostile behaviors in the future. Additionally, talk with staff members to determine what went well during the intervention and potential areas for improvement.²

For more detailed information and strategies related to each of these domains, see the full article from the Western Journal of Emergency Medicine.

In the most serious cases, patient aggression can turn harmful or deadly. A patient might attempt to physically attack, stab, or shoot a healthcare worker, another patient, or a bystander. If this occurs, immediately try to isolate the aggressor in as limited an area as possible (such as locking the waiting room door to prevent access to patient care areas), and evacuate patients, staff, and visitors as quickly as possible by all means of egress available.

Notify law enforcement as soon as possible to allow police time to respond to the scene. Ideally, notification to law enforcement should occur before the situation turns violent.

Resources

To learn more about preventing workplace violence in healthcare, see the following MedPro resources:

• Active Shooter Preparedness and Response for Healthcare Practices
• An Uncomfortable Reality: Dealing With Domestic Violence in the Workplace
• From Verbal Insults to Death: The Reality of Workplace Violence in Healthcare
• Risk Considerations: Ensuring Safe Discharge of Disgruntled Patients
• Checklist: Planning and Response for Active Shooter Situations

Endnotes

¹ Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman, G. H., Zeller, S. L., Wilson, M. P. . . . Ng, A. T. (2012, February). 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, 13(1), 17–25.

² Ibid.

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