Words mean different things in different contexts. When a phone is charging, it is doing something very different from what a rhinoceros does when it charges. Likewise, a technical term can mean different things in different professional fields.
In the healthcare profession, the term de-escalation has two different meanings. In one context, de-escalation of medical treatment means changing to a less aggressive course of treatment or lowering medication doses.
The more common meaning, though, is the use of de-escalation techniques to prevent conflicts involving patients, staff members, or family members of patients from escalating into physical aggression.
Thematic Analysis of Medical De-Escalation Techniques
Employees in many professions learn about the de-escalation process as part of their professional training, but instruction in de-escalation techniques should be even more widespread and more thorough than it currently is.
Conflict can occur in almost any situation, hence the need to prevent and resolve conflicts effectively before they turn into a crisis. Healthcare settings are stressful for patients and employees alike, hence the need for de-escalation training for healthcare workers.
Hospitals should not need to have a crisis intervention team on staff to maintain safety in a healthcare setting. Nurses, physicians, and office staff should learn how to manage a patient’s agitation and aggressive behavior to keep the healthcare setting safe.
An Ounce of Verbal De-Escalation Is Worth a Pound of Crisis Resolution
Emergency physicians, police officers, and other professionals who work in stressful, high-conflict situations know that most conflicts can be de-escalated. This knowledge enables them to remain calm even when someone is behaving aggressively toward them and trying to escalate a conflict.
Whether you work in the emergency department or a mental health clinic, your body language, nonverbal communication, and carefully chosen words can be effective at de-escalating conflicts with patients or with a patient’s family.
De-Escalation of Medical Treatment: What, How, and Why
In a medical context, de-escalation of treatment is a general term for reducing the intensity of therapeutic measures. It can refer to reducing medication doses or the frequency of therapy sessions.
One example is when a doctor tapers a patient’s dose of a drug, such as steroids or painkillers, to prevent withdrawal symptoms or reduce their severity. De-escalation can even be a euphemism for discontinuation of treatment, such as when terminally ill patients stop receiving parenteral nutrition or when a patient switches from treatment to palliative care in a hospice setting.
Medical de-escalation is not simply a matter of giving up on curing a disease. It often occurs in the context of chronic illnesses where the best-case scenario is for the disease to remain in remission indefinitely, for the patient to be asymptomatic for long periods of time, or for symptoms to be less frequent or less severe. In these cases, a true cure was never an option.
Doctors often consider de-escalation when the treatment itself is burdensome for the patient. Many effective medical treatments have side effects that make them feel uncomfortable, but patients are willing to accept these if it means getting rid of a painful or life-threatening disease.
When patients take medications long-term to control their symptoms, the side effects of the medications are a factor in determining the best strategies to treat the underlying cause of the disease and to manage its symptoms. Medical de-escalation is an effort to balance the effectiveness of treatment with the prevention of adverse effects from medications.
De-Escalating Cancer Treatment to Improve Patients’ Quality of Life
The American Society of Cancer Research (ASCO) encourages oncologists to focus on the patient’s overall quality of life, no matter how long or how short the expected survival time is for the person’s diagnosis.
Therefore, every patient receives a thorough assessment after a cancer diagnosis, so that the medical team can develop strategies to enable the person to experience the fewest possible adverse consequences of treatment.
Cancer research is always finding new ways of improving the effectiveness of therapies and looking for insights into cancer prevention. When studies in Richmond JS and other medical journals publish the results of clinical trials, the researchers care about other things besides how many or how few cancer cells the patient has at the end of the study. The extent to which the person can function is just as important.
For example, many studies on chemotherapy drugs and cancer surgeries show that, while these modalities are effective at getting rid of cancerous cells, they do not always extend patients’ survival time or improve their health. Lab tests are not the only way to measure a patient’s response to a drug.
The fact that chemotherapy can send many types of cancer into remission is not news to oncologists. Previously, doctors would give higher doses than necessary in order to prevent the cancer from recurring, even when these chemotherapy regimens caused debilitating side effects.
Five years after the treatment, patients might still be cancer-free, but they might also still be suffering from impaired concentration and from paresthesias in their hands and feet. The de-escalation approach favors giving enough chemotherapy to get rid of the cancer at least for a while. If the patient asks, “What if the cancer comes back?”, the response is, “We will cross that bridge when we get to it.”
Of course, oncologists must assess the risk of cancer recurrence before deciding to go with a lower dose. De-escalation in oncology is an individualized process. Doctors should consider how much the person can tolerate the drugs and which symptoms he or she finds the most bothersome.
The person you are treating now is not exactly like other patients you have treated, even if the patients’ lab test results look very similar to each other.
What Medical De-Escalation Is Not
De-escalation of medical treatment does not mean a complete cessation of medical treatment for cancer. It also does not mean choosing a shorter life with fewer drug side effects over a longer life with fewer drug side effects. It is simply a matter of treating each patient’s case individually.
In the field of emergency medicine, if the ER doctor determines that a patient’s infection is due to immunosuppression as a side effect of chemotherapy, then the oncologist who has been treating the patient might visit the patient during the patient’s infection-related hospital admissions.
Based on lab tests and on the emergency department doctor’s assessment, the oncologist might decide to de-escalate the treatment by postponing the next chemotherapy session until the patient’s white blood cell count has rebounded to a certain level.
De-escalating medical treatment also is not primarily about getting a patient to remain calm for treatment. Coping emotionally with the symptoms and interventions for cancer is certainly part of each patient’s care plan, but it is unrealistic to expect that all of the negative emotions that a person has about his or her experience with cancer can or should be de-escalated.
Mental health counseling for cancer patients and their families can be helpful, but the goal of it should not be to prevent conflict or negative emotions. In an oncology setting, an agitated patient may be one who is doing what he or she has to to be cured or to accept that the best-case scenario is to have a few months to say goodbye to the people that he or she loves.
Managing Aggression in Psychiatric Settings
Although there is more public discussion of mental health than ever before, and the stigma against mental illness is lower than it was a generation ago, stereotypes and misconceptions exist. The first thing that most people think about when they hear that someone is having a mental health crisis is potential violence.
In fact, people who have been diagnosed with a mental illness are at higher risk than the general population of being victims of domestic violence, but they are no more likely than anyone else to engage in violent behavior.
When police or emergency department staff respond to a mentally ill person in crisis, their goal is to ensure the safety of everyone in the environment. They take specific measures to prevent danger to other patients and to employees interacting with the person experiencing a mental health crisis.
The Medical Staff’s Response Can Make the Patient’s Distress Worse
Part of the stigma against mental illness arises from the fact that, in the past, psychiatric treatment was downright nightmarish. Coercive measures were the rule rather than the exception. Doctors often administered medications without patients’ consent, and in the worst cases, patients were forced to undergo surgeries or electroconvulsive therapy.
Today, the most coercive interventions are not as common, but the response by medical staff in an emergency room or psychiatric ward can make the patient feel more threatened. As a result, the patient becomes more agitated, and the situation escalates instead of de-escalating.
How to De-Escalate a Confrontation With an Agitated Patient Without Violence
In recent years, the mental health profession has witnessed a shift toward nonjudgmental interactions with patients seeking psychiatric care. This includes an approach that prioritizes verbal de-escalation and uses any kind of physical contact with an upset patient only as a last resort.
As a medical staff worker, you want to set limits so that the situation cannot escalate into violence, but it is possible to set boundaries without employees themselves behaving in a threatening or intimidating way.
When de-escalating a confrontation with an agitated patient in a psychiatric hospital, nonverbal communication and verbal de-escalation techniques are key. Respect the patient’s personal space and use eye contact to build rapport, not to show the patient who is boss. Use short sentences, and give the person a chance to talk. Just as when you are de-escalating any other tense situation, listening more than you speak is the key to crisis prevention.
The BETA Verbal De-Escalation Consensus Statement
Project BETA, which stands for Best Practices in the Evaluation and Treatment of Agitation, is a set of guidelines published by the American Association of Emergency Psychiatry. The guidelines were published in the 2012 issue of West J Emerg Med.
The principal author, Richmond JS is a social worker in the Department of Psychiatry at Tufts University School of Medicine. The other authors include psychiatrists who practice in Maine, California, Missouri, and Pennsylvania.
The authors searched the literature to find out how psychiatrists and psychiatric hospital staff respond to episodes of acute agitation and the consequences of their interventions, as shown by the long-term effects on patient health.
The data sources they examined, including systematic reviews, clinical trials, and case reports, were conducted in various countries and published in peer-reviewed journals such as Int J Psych and West J Emerg Med, among others. They used search terms such as “agitated patient,” “involuntary medication administration,” and de-escalation techniques.”
The authors found that physicians’ responses to acute episodes of agitation tend toward coercing the patient into calming down enough to comply with instructions. In other words, healthcare workers made the situation a matter of winning or losing, rather than keeping the focus on the wellbeing of the patient.
They found that this approach to agitated behavior was prevalent not only in emergency medicine but also in psychiatric wards of hospitals where patients were undergoing inpatient care. The use of physical restraint and administration of medications without the patient’s consent was very common.
This led to patients experiencing more anxiety about receiving psychiatric care and to a breakdown of trust between patients and healthcare personnel. Doctors and nurses in psychiatric hospitals tended to act more like a crisis intervention team than as a source of support for a person trying to manage symptoms of a mental illness. The more coercive the personnel in the psychiatric ward were, the worse the patient’s outcomes were.
By contrast, when the medical staff viewed the situation as a de-escalation process, the outcomes were better. Nurses and other professional caregivers were able to build a rapport with the person and help him or her manage symptoms such as acute anxiety and agitation.
Project BETA found that doctors, nurses, and other stakeholders were open to taking a non-coercive approach to dealing with anxiety, but they lacked additional resources on de-escalation techniques.
Compassionate De-Escalation Can Prevent Violence, Even in the Midst of a Mental Health Crisis
After assessment of the strategies that clinical staff often use, the authors of the consensus statement recommended an approach to agitation in psychiatric patients where the focus is on the person in crisis and not on the staff trying to control the situation.
They encouraged professionals who interact with patients suffering from acute mental illness to prioritize de-escalation. This recommendation applies to physicians, nurses, police, social workers, and anyone else whose job duties may involve helping a person through a mental health crisis.
Limit setting remains important when dealing with patients who have recently arrived at a psychiatric ward in an agitated state. What you may see as reasonable limit-setting strategies may come across as attempts at intimidation and control. Healthcare staff should be mindful of their body language and should respect patients’ personal space.
They should be nonjudgmental even as they set boundaries. Project BETA cautions that patients will be more receptive to de-escalation techniques when they feel that you respect their bodily autonomy and let them have as much control as possible over their personal space.
When you treat an inpatient in a psychiatric hospital as a person instead of a problem or a threat, it is much easier to prevent violence and avoid having to call the police.
Other Situations Where You Need De-Escalation in the Healthcare Industry
It is obvious to everyone that the emergency room is a high-pressure situation. Hospital nurses, with their 12-hour shifts, also operate under a lot of stress and must deal with the anger and frustration of the people they are supposed to help.
Nursing homes rank up there with hospitals as workplaces with a high incidence of employee burnout. These are not the only professional settings in the medical field where it is important to know how to manage conflict. De-escalation and conflict resolution are just as important in a primary care doctor’s office as they are in the emergency room.
The Billing Department Is a Minefield for Conflict
Medical bills are expensive, and most households cannot afford the burden of an additional medical expense. Employees who work in the billing departments of doctor’s offices and hospitals are as aware of this as anyone is. They are also an easy target for the ire of stressed-out patients who are faced with medical bills that equal a quarter of their monthly income, or even more.
Unfortunately, there is no simple solution that an employee in the billing department of a hospital can use to avert America’s medical debt crisis. The best solution is to empathize with each patient who calls you about a bill and to be as helpful as you can.
Your response should not show your frustration, because, at the end of this interaction, you are a few minutes closer to your next paycheck, while the patient is still stuck with a debt for a visit that may or may not have improved the patient’s health.
Several recent policy developments have helped reduce the amount that a patient must pay for certain medical bills and offer protection from harm to the patient’s credit score. For example, the No Surprises Act has reduced the amount that a patient must pay for emergency medical services, regardless of whether the patient has insurance.
Likewise, medical creditors must wait at least six months before reporting unpaid portions of medical bills to credit reporting bureaus. Neither of these developments can make a patient’s medical bill go away, but you can cite them as a de-escalation tactic.
Although the nationwide medical debt crisis is outside your control, de-escalation in the medical billing department is no better than platitudes unless you offer solutions. If you work for a small medical practice, being flexible with patients about payment is in your interest.
Selling unpaid medical debts to collection agencies just makes you into a villain. It is better to offer patients interest-free or low-interest installment plans without reporting the debts to credit reporting bureaus, to offer financial aid to financially distressed patients and to negotiate directly with patients about settling debts for a lesser amount if they cannot pay the full amount.
You would only be doing what insurance companies and collection agencies do, except without harming consumers’ credit scores.
Dealing With Patient Complaints
There are two sides to every story, but when a doctor and a patient don’t get along with each other, the whole Internet only hears the patient’s side of the story in the form of a negative online review.
When you miscommunicate with a patient during an appointment, or when the patient’s response to something you said or the way you said it seems to indicate that he or she is upset, try to make amends by the end of the appointment.
This is much better for your reputation and your relationship with the patient in the long term than writing a response to a negative review or contacting the patient after the fact and trying to persuade him or her to change the text of the review. If you do this, you run the risk of making the patient even angrier. This is the antithesis of de-escalation.
Reactions to Distressing Medical News
Having to tell a patient that he or she must live with a certain diagnosis in the long term is an unavoidable risk of practicing medicine, and it is one of the hardest parts of your job in the healthcare field. The patient is entitled to have an emotional response, as are the family members who accompany the patient.
Whether patients cry, or whether their initial response is to act as if the situation is your fault, is not within your control. You cannot police other people’s emotions. In this regard, the best approach to de-escalation is simply not to escalate and to let the patient control the interaction with you.
Give the patient a chance to process the news before you start talking about which avenues to pursue in the subsequent appointments.
Bullies Can Show Up in Any Workplace, Including Healthcare
You might find yourself wanting to sharpen your de-escalation skills, not to help a patient through a distressing situation, but rather, to get along with your coworkers. Workplace harassment and bullying can happen in almost any work environment where two or more employees interact, including doctors’ offices and hospitals.
The problem might be that a doctor with a big ego tries to boss around all the nurses, medical assistants, and other employees in the office, even when they can do their jobs better without all of this constant micromanaging.
In other situations, the problem might be a “mean girls” dynamic among nurses who work together in the same hospital ward, doctor’s office, or nursing home. In either case, conflict management is a necessity, and de-escalation of the present conflict is a prerequisite to finding a long-term resolution.
Using the HEARD Method for Healthcare De-Escalation
Whether in healthcare or in other settings, the HEARD method is a reliable approach to de-escalation of conflicts. It is applicable no matter who the parties to the conflict are. They can be a patient and a doctor or nurse, two employees in the same workplace, or a doctor’s office staff member and a family member of a patient.
Unlike simple de-escalation techniques such as using non-threatening body language, the HEARD method requires a whole conversation. However, it is not as elaborate as a formal mediation session. During a tense phone call, you can initiate the HEARD de-escalation process at any time.
If you are trying to de-escalate a conflict with a co-worker in a busy doctor’s office or hospital environment, it is a good idea to set up a time to talk things out, or at least go to the break room and talk at the end of the workday, so you are not keeping patients waiting while you work to resolve your conflicts.
Hear the Other Person Out
HEARD is an acronym for Heard, Empathize, Acknowledge, Resolve, Diagnose. The first step is to hear the other person’s side of the story. Give the person a chance to tell you why he or she is upset and what the problem is from his or her perspective.
Do not interrupt the person, even if it takes the person a long time to get through the description of the problem. Try to remain calm even if it seems like the person does not completely understand the situation or if the person is making untrue accusations or is unfairly placing blame. You will eventually have a chance to tell your side.
Empathize With the Person’s Feelings
Even if you think that the other person is being unreasonable, do not try to police the other person’s feelings. Empathize with his or her frustration. Repeat back the person’s account of the conflict in your own words to show that you understand.
Acknowledge Your Role in Contributing to the Conflict
Your response to the other person’s account of the problem should not be defensive. After you show that you have heard what the person is saying, acknowledge the role that you or your organization has played in causing the problem.
The original formulation of the HEARD approach says that A stands for apologies, but apologizing is only sometimes appropriate. Even if you do not apologize, you should not make the other person feel like the problem is all his or her fault. You should also not send the message that you are unwilling to help.
Resolve the Issue
The fourth step of the HEARD method is a response to the problem and not merely to the person’s description of the problem. Propose solutions. This may mean that you need to involve other parties to mediate the conflict or to refund some of the money that the patient has paid.
Diagnose the Underlying Causes of the Conflict in Order to Prevent Recurrences
It takes time to get through the first four steps of the HEARD method. Time is already tight in a healthcare workplace, so if you have to keep responding to the same kinds of conflicts again and again, this will be costly for your doctor’s office and will make it less productive.
Diagnosing the underlying cause of the conflict you have just resolved also takes time, but it is time well invested. It may or may not be appropriate to include the patient in the de-escalation process if the conflict and others like it were between a patient and a staff member. Leaders within the organization should play a role in the policy changes that aim to prevent conflicts that have been plaguing the workplace.
Conflict Management Is an Important Part of Healthcare
If you are a doctor, a nurse, or a member of the office staff in a clinic, then people do not come to see you when everything is fine. Dealing with conflict is part of working with healthcare. If you are not prepared for the kinds of conflicts that can arise, then it will make life more stressful for everyone who works in your doctor’s office and you will have a harder time providing quality patient care.
De-Escalation Training for Healthcare Practices
The sooner you start building de-escalation training into your employees’ job descriptions, the more smoothly your practice will run. Defuse De-Escalation Training offers in-person and online training sessions on an individual and group basis, specifically for healthcare professionals. Contact Defuse today to find out more about our de-escalation training courses.
