The art of 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 (OSHA, 2015). In 2013, 80 percent of the serious violent incidents reported were primarily caused by interactions with patients in the clinical setting (OHSA, 2015).
Since potential aggressive incidents is an acute behavioral emergency that frequently require immediate intervention, qualified nurses must be prepared to utilize 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 their 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 that is 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 utilize 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. Often times, nurses are 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 to ensue.
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 patient 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.
Once the patient is successfully de-escalated, the nurse is then responsible for settling any unresolved feelings or concerns the patient may hold. 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 all feelings and concerns are individually validated.
Overcoming adversity is a demanding task that requires a great deal of emotional resilience and mental toughness. While many people react to such circumstances with a flood of emotions and a sense of uncertainty, others may choose to adapt positively in response to their life-changing situations and stressful conditions. As a medical-surgical nurse, Jamie Davis, RN, understands the meaning of handling adversity both professionally and personally. In this Q&A interview, Davis discusses the importance of emotional resilience and how rising above adversity ultimately shaped her into the nurse that she is today.
Jamie Davis, RN
How did you become a nurse?
In 2006, I attended college in Michigan with a major in cosmetology. I met someone who was working as an LVN at the time who asked if I needed a job. During that moment, I did not have any intention of working in the health care industry. But during the interview however, I was asked, “how would you feel if you were unable to help someone you were caring for?” Surprised by this question, I simply responded, “I would feel horrible, but in the end, I would do everything in my power to assist them and make them feel better as a person.” It was at this moment that ultimately began my journey as a future nurse.
Why did you choose the specialty you currently work in now?
In 2007, I received a distressing phone call from my parents informing me that my brother was admitted into the ICU. After hearing the news, I booked a flight to California and headed straight to the hospital where he was staying at. When I walked into the room, I saw my brother lying lifeless in bed with machines hooked up to him. At that moment, so many memories rushed through my head and I began to have all these endless questions – What am I going to do if he doesn’t come out of this bed? How are we going to move on? How are we going to make it through this? Luckily, my doubts and fears went away when he began to improve so I decided to fly back home.
A few months later around Christmas time however, I received another troubling phone call from my mother telling me that my brother got readmitted again to the ICU but this time with worsening complications. As I rushed to the hospital, I distinctly remember seeing all the tubes hooked up to my brother and the nurses working tirelessly to save him.
Unfortunately, the following morning, I received the phone call that nobody ever wants to hear – my brother has passed away. It was a life changing moment that my family and I will never forget, but ultimately inspired me to become the nurse that I am today.
Therefore, although I currently work on the medical surgical unit, my dream is to one day work in either the ER or ICU settings to one day help those patients who are also in critical need.
How has your brother’s passing impacted the care you give for your patients?
Although my brother’s passing continues to affect me each and every day, I’ve learned to keep his memory with me every time I come to work and care for my patients. Despite his unexpected death, I’ve learned to understand that being resilient is learning how to not only live with those painful memories but also deal with it in a positive way.
What kind of advice would you give our readers on how to overcome tragedy as a nurse and develop resiliency?
One piece of advice that I would like to give the readers on how to overcome tragedy as a nurse is understanding that overcoming adversity is a personal journey. It’s okay to grieve from time to time, but it’s also important to take your sadness and create something positive out of it. Because of this, I have learned to become a more vocal advocate for my patients and their loved ones in times of need. By doing this, I am able to honor my brother’s spirit through my work as a nurse.
Do you have any parting words of encouragement for those interested in pursuing a career in nursing?
To anyone else who may be going through a difficult time, please don’t give up. Regardless of how difficult and emotionally challenging life can seem, personal success all depends on how you choose to deal with your given circumstances. Therefore, I am a living example that no matter what life puts you through, your dreams can become possible if you believe it.
The practice of meditation is used in many cultures to reduce stress and anxiety and to maintain optimal psychological and spiritual well-being. Meditation has been extensively studied as a treatment for not only improving cardiovascular health, but also anxiety disorders as well. Since burnout and anxiety are common conditions plaguing health care professionals around the world, nurses must understand the healing power that meditation has in assisting them maintain physical, mental, and emotional balance. By learning how to incorporate the complementary practice of meditation and mindfulness into their lives, nurses have the ability to learn advantageous coping skills to handle potentially stressful situations.
The Art of Meditation and Mindfulness
The ancient art of meditation and mindfulness was derived from ancient Buddhist and yoga practices around 1500 BCE. Mindfulness refers to a process that guides individuals in maintaining a mental state characterized by nonjudgmental awareness of the present moment. The basic premise underlying meditation and mindfulness centers on how experiencing the present moment nonjudgmentally and openly can effectively counter the effects of stressors, because excessive orientation toward the past or future can be related to feelings of depression and anxiety. It is further believed that by teaching nurses to respond to stressful situations more reflectively rather than reflexively, meditation can effectively counter experiential avoidance strategies, which are attempts to alter the intensity or frequency of unwanted internal experiences from the outside realm.
Mindfulness-Based Stress Reduction
Due to the incredible health benefits that meditation and mindfulness possesses, Kabat-Zinn conceptualized a highly effective and integrative approach for reducing the physical, emotional, and mental consequences of chronic stress and anxiety. Mindfulness-based stress reduction (MBSR) is an innovative therapy that blends various elements of different Eastern meditation practices with western psychology. MBSR is a formal eight-week evidence-based program that challenges the patient to cultivate a greater awareness of the unity of the mind and body as well as the unconscious thoughts, feelings, and behaviors that can influence their overall health. During MBSR therapy, the individual learns various coping skills and techniques aimed to reduce the physiological effects of stress, pain, or illness by participating in experiential exploration of stress and distress to develop less emotional reactivity.
Since the mind is known to play an influential role in stress and stress-related disorders, MBSR has been shown to positively affect a range of autonomic physiological processes, such as lowering blood pressure and reducing parasympathetic arousal and emotional reactivity. In addition to mindfulness practices, MBSR also utilizes yoga to help promote wholesome physical activity and prevent unhealthy complications associated with living a sedentary lifestyle.
Due to the many health benefits it possesses, MBSR has been shown to relieve pain and improve psychological well-being across the health care spectrum. Because of this realization, nurses should make a more concerted effort in incorporating mindfulness meditation practices into their daily lives to not only improve their own stress reactivity, but also imbue resiliency to stressful and arduous psychological challenges associated with working in the health care setting.
Due to the rising cost and complexity of health care, nurse practitioners (NP) are considered to be one of the most in demand professionals in contemporary society. According to the American Association of Nurse Practitioners (AANP), there are more than 205,000 NPs in the United States as of 2014, with an estimated growth to 244,000 by 2025. Nurse practitioners care for patients across the lifespan in a variety of settings and are one of the four recognized advanced practice registered nurse (APRN) roles, which also include Clinical Nurse Specialists, Nurse Anesthetists, and Certified Nurse Midwives. Since nurse practitioners provide high quality and comprehensive patient-centered care in the health care arena, standardized procedures are necessary to ensure that nurse practitioners not only have a clear understanding of their roles but also their responsibilities depending on their specialization and place of employment.
Roles and Specialties of Nurse Practitioners
According to the AANP, nurse practitioners (NPs) are licensed, autonomous clinicians focused on managing people’s health conditions and preventing disease across the lifespan. All nurse practitioners must complete a master’s or doctoral degree program and have advanced clinical training beyond their initial professional registered nurse experience which include comprehensive didactic and clinical preparation coupled with specialized knowledge and clinical competency to practice in primary care, acute care, and long-term health care settings. What sets nurse practitioners apart from other health care professionals are their unique emphasis on holistic healing which focuses on health promotion, disease prevention, and health education and counseling. By providing high-quality care, management, and advocacy, NPs guide patients in making smarter lifestyle choices, which lowers patients’ out-of-pocket expenses and provides innumerable solutions to the primary care shortage facing America today.
Standardized Procedure Requirements for Nurse Practitioners
Since NPs are considered to be vital leaders of the health care team, standardized procedures are required to ensure that they function within their scope of practice to meet the primary health care needs of their patients. According to the Board of Registered Nursing (BRN), standardized procedures are the legal mechanism for NPs to perform functions which would otherwise be considered the practice of medicine. Standardized procedures must be developed collaboratively by nursing, medicine, and administration in the organized health care system where they will be utilized. Since NPs work at various locations such as organized health care systems, acute care clinics, and home health agencies, standardized procedures must be formulated to ensure that the health care system functions competently and correctly.
Because of the nature of the Medical Practice Act and its strict authorization for physicians to diagnose mental and physical conditions, prescribe medications, and use other methods in the treatment of diseases, injuries, deformities, or other physical or mental conditions, standardized procedures are often required if any of these will be performed by a nurse practitioner. According to the BRN, a nurse practitioner may perform standardized procedure functions only under the conditions specified in a health care system’s standardized procedure and must provide the system with satisfactory evidence that the nurse meets its experience, training, and/or educational requirements to perform these functions competently. Since NPs provide services that frequently overlap the practice between nursing and medicine, standardized procedures include guidelines that require the nurse practitioner to seek physician consultation when clinically necessary. Because of this realization, only nurse practitioners that satisfactorily meet the standards delineated by the BRN are allowed to assume responsibility and accountability for the continuity of health care for all individuals seeking inpatient treatment and stabilization.
Although the scope of practice and demand for nurse practitioners are growing, written policies and protocols are still necessary in some states for advanced practice nurses to function safely and competently in the health care arena. As a result of this realization, NPs must understand that standardized procedures are not only necessary in providing uniformity but also consistency in protecting consumers from harm by meeting the mandatory requirements to practice safely in their area of employment according to state and legislative regulations.
Nursing education is the foundational pillar that enables future nurses to become competent and knowledgeable in their respective practices. This education was normally provided to nursing students through various didactic theoretical lectures and practical clinical training but recently, the use of advanced simulation technology as an adjunct educational tool has slowly become a significant addition to student centric learning.
History of Simulation
The concept of simulation practice can be traced back to the fields of military, aviation, and nuclear power (with military having used simulation the longest), dating back to the 18th century. Simulation was initially created as a cost-effective strategy for training professionals because it was considered exorbitant to train in these areas in the real world. As the years progressed however, the healthcare profession realized the practicality and usefulness of incorporating advanced simulation technology into educational practice and as a result, spurred the growing movement of simulation in healthcare training settings and educational establishments around the world.
The Impact of Simulation on Nursing Students
The emergence of computer technology has led to the development of innovative tools for healthcare professionals such as simulation technology and patient simulators Simulation technologies have had a profound effect on the nursing profession because it allows nursing students to apply their recently learned skills and knowledge to solve real life scenarios in a safe and structured setting.
In a typical simulation session, two students are often asked to participate and mimic the roles of a registered nurse or a certified nurse assistant (CNA). The rest of the remaining students are then asked to go to a separate room and observe the scenario through a one-way mirror and a live video stream. At the start of the session, the facilitator usually gives report on the patient, which allows the students to familiarize themselves with the patient’s situation, history, charts, and medications in order to successfully manage and implement high quality nursing care for the patient. As the simulation progresses, the facilitator controls the patient’s prognosis and provides cues to the team to enhance the realism of the situation. Once the simulation is completed, the students are then asked to head back to the debriefing room to discuss their experiences.
During the debriefing session, the students learn through self-reflection, group interaction, and questions asked by the facilitator. The use of group discussion engages students in reflective learning and enables the group members to consider a situation from multiple perspectives and consider other alternatives in order to broaden their scope of practice and clinical understanding. By performing simulation scenarios on a regular basis, students are able to develop better critical thinking skills, decision-making abilities, and application of theoretical knowledge in real-life situations.
Facilitating Simulation into Nursing Practice
According to the Institute of Medicine (IOM), approximately 98,000 people die every year from medical errors in U.S. hospitals, and a significant number of those deaths are associated with medication errors. This means that adverse events affect nearly 1 of 10 patients in the hospital setting. Based on this staggering number, the IOM called for a systematic change in healthcare practices and identified simulation practice as a resource to address the needed reform. By fostering experiential learning, simulation ingrains good nursing habits early, while discouraging bad nursing habits from forming before it becomes second nature.
In addition to allowing individuals to hone their nursing skills, simulation has also proven to increase student confidence and self-efficacy once they transition into the clinical setting. Nursing efficacy is an important aspect in nursing practice because it gives the students the confidence required to provide excellent nursing care to their patients. By incorporating what they have learned in simulation, more students are self-reliant in their capabilities, which are invaluable in ensuring that patient safety is implemented in the hospital setting.
Implications for Future Nursing Practice and Further Study
The shortage of availability of clinical sites is quickly becoming the norm for many nursing schools due to changing healthcare reform and the struggling economic crisis. One solution to combat the shortage of clinical sites however is to utilize simulation practice to replicate essential aspects of clinical situations for beginning nursing students. The National Council of State Boards of Nursing is currently conducting a landmark, longitudinal study to examine the knowledge and clinical competency outcomes of students when simulation technology is used in the place of actual clinical experiences. Although calls for additional research in these areas need to be performed, simulation is still quickly gaining momentum as the gold standard for effective learning practice in nursing education.