Non-Violent Crisis Intervention

1. Non-Violent Crisis Intervention Occupational Health, Safety and Wellness 2017

2. Objectives At the end of this course, you will: • Have a basic understanding of the different stages of escalating behaviour • Understand interventions and techniques for deescalating behaviours • Know what to do when the crisis is over

3. Definitions Escalating Behaviour: Undesirable or unwanted behaviour that increases in frequency, intensity or magnifies over a course of an interaction or interactions and may lead to a behavioural crisis. Behavioural Crisis An escalating episode of emotional upsets involving anger and verbal threats, which may lead to dangerous situation of environmental destructiveness and/or physical aggression towards staff and others.

4. Phases of Escalating Behaviour Physical Aggression hitting, kicking, biting, throwing things, hair pulling etc. Imminent Explosive speech, physiological changes i.e. heavy breathing, verbal and/or physically threatening gestures Escalating Increase in volume and rate of speech, resistant to care, signs of physical tension Subtle Changes in interaction style, language used, energy level

5. Common Patient Triggers • Disrespect (real or perceived) • Unmet needs (pain, hunger) • Frustration / Inability to communicate • Fear • Anxiety • Change in routine • New setting/environment • Repeatedly being told to wait • Frequent medication changes • Feeling unheard or diminished • Rude comments • Loss of dignity • Frequent interruptions • Excessive noise • Unanswered call bells

6. De-escalation Techniques Physical Space Allowing personal space (3 feet) tends to decrease a person’s anxiety and can help prevent acting-out behaviour. If you must enter someone’s personal space – e.g.to provide care, explain your actions to decrease confusion. Body language is important. Turn your body to a 45% angle from the person you are talking to. You look smaller and less threatening. You are also providing less of a target. Asses the layout of the space and potential weapons that could cause an injury.

7. De-escalation Techniques Communication • Be empathic and non-judgemental. Whether or not you think those feelings are justified, they are real to the other person. Pay attention to them. • Focus on feelings. Facts are important, but how they are feeling is what is important in this kind of situation. • Supportive words let the person know you understand e.g. “that must be frustrating/scary” etc., validate their feelings ”

8. Eye Contact is “a soft gaze with the eyes of an eagle, not the glare of a hawk”Elder Vern Harper

9. De-escalation Techniques Power and Equity • Don’t get into power struggles. • Disregard challenging questions, it will only result in a power struggle. Ignore the challenge but not the person. Bring their focus back to how you can work together to solve the problem. • Offer options and flexibility to avoid unnecessary altercations. E.g. If someone does not consent to receiving care right now, you cannot force it on them. Try again a little later. Remember to respect a patient’s right to refuse care.

10. De-escalation Techniques You Have Time You may be in a hurry but responding to a code takes up more time than a successful de-escalation. Slow down your speech and don’t rush the person. Use active listening skills. Allow periods of silence for reflection. Silence can be a powerful communication tool. Give them time to make decisions. It is hard to think when someone is upset and their stress level will rise if they feel rushed. Let them think and process what you are saying.

11. De-escalation Techniques Negotiating Set limits. If someone’s behaviour is belligerent, defensive or disruptive, give clear simple and enforceable limits e.g. “I want to help solve this but I need you to lower your voice” Give respectful choices e.g. “Would you like me to help you transfer from bed to chair now or should I come back a bit later?”

12. De-escalation Techniques Keep ego out of the situation Defuse yourself before you try to defuse others If you are not being successful de-escalating someone, let someone else speak to them. Don’t make the situation about you, make it about what the patient/family member needs. The situation is not about you being “right” or getting someone to do what you want. It is about finding a solution to a problem. Make it win-win. Be aware of your own level of agitation. If it increases to the point you are not being effective, let someone else speak to the patient/family member.

13. De-escalation Techniques Other Factors to be Aware of • Pay attention to cross-cultural communication. Culture, beliefs and language skills may play a part in the interaction. • People who have experienced trauma may have a higher state of arousal and be more reactive when they perceive a threat. Consider this may be a factor in their behaviour.

14. De-escalation Techniques Do NOT: • Raise your voice, swear, interrupt Cross your arms, make a fist, tap your foot or show impatience • Challenge the person’s thoughts/comments • Argue with the person • Issue threats • Put yourself in harm’s way • Make judgements about the person’s behaviour DO: • Recognize escalating behaviours • Lower your voice and speak calmly • Be respectful • Be patient – it can take time • Allow them their dignity, offer choices • Get help if you need it • Speak clearly • Offer reassurance

15. Keep Each Other Safe • If you observe a colleague trying to de-escalate a situation, stay in the area to assist if needed • Ask if they need your help • Move others away from the area to reduce noise and distractions

16. When the crisis is over… • Check in with the staff immediately to ensure that everyone is safe and feels supported • Complete a SLIP for the near miss/incident • Document – it is important to keep track of what the triggers were and what worked to calm the situation • Check in with the patient regularly • Debrief with the patient or family after some time passes to get their perspective on what happened and why

17. Debriefing an Event • Debrief as soon as possible after the event occurs with the team • Discuss and reflect on the incident and allow staff to share how they feel about the event • Identify strategies that were used during the event and speak about what went well and what can be improved • Discuss what was learned and how this can be used in the future

18. THANK YOU Thank you for completing the non-violent crisis intervention course