For nurses, de-escalation of conflicts is all in a day’s work. Nurses must resolve or prevent so many conflicts on any given day that, if they were heads of state, there would be world peace.
From dealing with crisis situations to helping an agitated patient through a stressful situation to dealing with the enormous egos of physicians, office managers, and everyone else who wants to be the star of the show in a healthcare practice, the task of conflict management falls on nurses. If you got through a doctor’s office visit or hospital stay without experiencing workplace violence, you can thank a nurse.
All of this de-escalation work goes underappreciated. Nurses in North America and in European countries have high rates of burnout, even when they are in well-paid positions.
This is especially true of hospital nurses whose work schedule is not conducive to getting adequate sleep or syncing one’s routine to that of other family members, but it is also true of nurses who work in outpatient clinics that are only open during normal business hours.
Why De-Escalation Techniques Are So Important for Nurses
No one goes to a doctor’s office or hospital for fun. Patients are, by nature, suffering from physical or psychological symptoms that bother them enough to make them seek treatment, or else they are worried about their own health.
The family members who accompany patients to medical visits are also worried and stressed. Some healthcare settings have even higher stress levels than others. Emergency rooms and mental health units are a perfect storm for conflicts and escalating behavior.
Nurses learn in nursing school to model calm behavior to make the treatment environment as low stress as possible, in order to prevent patient aggression. In especially tense situations, when patients are already stressed out, nurses and other health professionals must do more than simply not antagonize patients.
They must be even more deliberate about de-escalation. Even seasoned nurses could stand to learn more about de-escalation in healthcare settings.
Practical Tips for Handling Everyday Conflict Situations
From ordinary interactions at routine visits to scary encounters with violent patients in crisis, nurses should follow conflict management best practices in their dealings with patients. Many of the de-escalation techniques that nurses often use with patients also work in other work environments, from education to law enforcement, customer service, or social work.
Body Language Makes a Big Difference
Nurses are famous for keeping a calm demeanor, both in a busy doctor’s office or hospital situation or in the event of an emergency. De-escalating aggressive behavior by patients or by the relatives accompanying them begins before you speak.
Whether the patient is upset about something minor, like having to wait longer than usual to see the doctor, or something major, like an involuntary psychiatric admission, it is important to respect personal space.
Don’t get closer to patients than the situation requires for you to engage the patient in conversation. Don’t use closed body language, whether you are talking about treatment outcomes, helping address a patient’s complaint about a doctor, or dealing with any other matter related to the therapeutic relationship.
Read the patient’s cues about whether he or she wants you to make eye contact. Some patients see eye contact as a sign of honesty and friendliness, while others consider it threatening.
Listen Before You Speak
Nurses work in a state of perpetual time crunch, whether in emergency medicine or in outpatient offices. Despite the time pressure prevalent in the healthcare field, you will make things worse by rushing through conversations.
Even if the patient is complaining to you about a routine matter, such that you know the solution to the patient’s problem, it is important to let the patient finish saying what he or she wants to say. From the perspective of etiquette, interrupting people when they are speaking is rude. From a conflict management perspective, interrupting people when they are speaking is a recipe for conflict escalation.
It makes both parties more frustrated and makes each person feel as if the other one is not listening. This is especially important in the field of mental health care since by the time patients get to mental health settings, they have gotten used to people in their lives ignoring their requests and invalidating their feelings.
The HEARD method is a popular approach to de-escalation. HEARD is an acronym that stands for hear, empathize, acknowledge, resolve, diagnose.
In other words, the first step is to listen and the second and third steps are to accept what the other person said, whether you agree or not. You must go through three out of five steps of the de-escalation process before you have a chance to tell your side of the story. The nursing profession tends to attract people with excellent emotional intelligence, so nurses of all people are up to the task of practicing the HEARD method even when they are swamped with work.
Nurses Are the Ideal Mediators in a Healthcare Setting
Because nurses have become excellent listeners through a mixture of natural inclination and professional experience, they are the obvious choice of confidantes for patients. Establishing trust with healthcare professionals is good for patients’ mental health, and nurses are in an ideal position to prevent escalation of conflicts between patients and other members of the clinical staff.
When a patient is upset about something a doctor or member of the doctor’s office staff did, sometimes a nurse is the first person to hear about it, even before the patient tells a family member about the problem.
Nurses can actively listen to patients discuss their grievances about doctors while maintaining healthy limit-setting behaviors. The nurse can then bring up the patient’s concern when speaking privately with the doctor, so the patient does not have to confront the doctor directly about the problem.
Verbal De-Escalation of the Agitated Patient
The American Association for Emergency Psychiatry Project BETA recently published a consensus statement on the use of verbal de-escalation techniques with adult psychiatric patients when these psychiatric inpatients become agitated while receiving psychiatric services. The report appears in the Western Journal of Emergency Medicine (West J Emerg Med).
Background of the Psychiatry Project BETA De-Escalation of the Agitated Patient Consensus Statement
When patients become agitated, there is a risk of physical violence, and healthcare employees, especially in the mental health sector, recognize the importance of de-escalation to prevent violent behavior.
Until recently, psychiatric settings were notorious for their use of coercive measures to deter violent behavior. Physical restraint by security personnel and other members of the therapeutic alliance was the norm. Sometimes several staff members would have to work together to restrain an individual patient and regain control of the situation.
Administering medication without the patient’s consent was also common; combined with widespread restraint use, it made for a terrifying psychiatric ward climate. At best, these restrictive measures did little to improve patients’ prognosis. At worst, they amounted to physical assault and abuse and made the public hesitant to seek psychiatric treatment even when doing so would have improved their mental health.
Project BETA Proposes a Collaborative Approach to De-Escalation With Agitated Patients
Project BETA is a set of guidelines for best practices in the Evaluation and Treatment of Agitation. The guidelines are based on a literature review that includes systematic review articles, clinical trials, and case reports from many European countries as well as some countries in North America, Asia, and Oceania.
The guidelines identified risk factors for physical aggression in a psychiatric setting. Researchers have found that the approach that hospital staff and psychiatrists used to routinely take in regard to agitated behavior actually makes patients more agitated instead of helping to de-escalate the situation.
Employees would resort to coercive measures such as restraint and threats to dominate the patient instead of making him or her feel comfortable which would further precipitate the agitation.
The de-escalation tips proposed by Project BETA assume that, in a psychiatric hospital as in any hospital setting, employees should strive for mutual respect with patients. They should respect the personal space of the patient. Nonverbal communication is the first step to successful de-escalation.
The BETA de-escalation workgroup also cautions staff members against using medical jargon with each other in front of patients, because this often has the effect of making patients more anxious instead of less.
Workplace Conflict Among Healthcare Professionals
Workplace violence is only the worst-case scenario of what can happen when conflicts escalate in a healthcare setting. Conflict between a staff member and a patient is usually not the type of conflict that detracts the most from the job satisfaction of employees in healthcare settings and contributes to burnout.
Except in hospitals and nursing homes, the amount of time that any given staff member spends with any given patient is very limited. Instead, the most troublesome conflict that nurses face at work is often with a doctor, a medical assistant, or another nurse.
Common Causes of Conflict in the Healthcare Workplace
Hospitals are some of the most stressful work environments possible. There are plenty of opportunities for misunderstandings and inconsiderate behavior to occur, and it is virtually impossible to find the time to resolve the conflicts.
Therefore, doctors and nurses sometimes work together in a dysfunctional relationship that goes on for years. One nurse may fault another for problems in the work environment, and they may show their resentment indirectly without ever addressing the conflict directly.
Verbal De-Escalation Among Staff Members Leads to Better Patient Care
Every nurse is only one person, and each person’s emotional reserves are finite. Professional ethics and common sense dictate that, if you have to choose between staying calm in front of a patient and losing your temper at another nurse or the other way around, the patient is the one who most deserves your best self.
Of course, it is hard to be attentive to patients if you are still steaming mad about something your colleague just did. When you are scrambling from one patient to the next, you do not have time to go through all of the steps of the HEARD process or engage in a full-fledged mediation session.
It is important, however, to address the issue with the other nurse so that you can prevent the conflict from escalating. An angry and frustrated nurse is a distracted nurse, and dealing with conflict effectively can prevent medication errors and other mistakes by nurses and improve patient care.
No one has time for active listening while all the nurses on duty are rushing from one patient to the next. This is true in an adequately staffed healthcare facility, but it is even more noticeable in an understaffed one. Therefore, using verbal de-escalation techniques such as saying to your colleague, “Let’s talk about this at the end of our shift” can help you free up emotional resources to resist distraction and concentrate on your patients.
Practical Tips for De-Escalating a Confrontation With a Colleague
The five modes of conflict management are competing, collaborating, compromising, avoiding, and accommodating. In the fast-paced environment of a doctor’s office or hospital, your goal is to stop your conflict with a fellow nurse from escalating to the point where it interrupts the workflow.
Other industries might require employees to work under time pressure but rarely is briefly diverting one’s attention from one’s work a matter of life and death except in healthcare.
Therefore, at the moment, the goal is to de-escalate the conflict as quickly as possible so that you can resolve it more thoroughly when there is time to do so. Avoiding and accommodating are not effective means of conflict resolution if your goal is to achieve a long-term solution.
They are, however, among the fastest ways to de-escalate. In other words, the best way to deal with a problem in the middle of a busy shift is to not deal with it until you are less busy.
If the problem is that another nurse constantly bullies or harasses you, then the long-term solution may not be to confront your troublesome colleague directly. It may be better to discuss the issue with human resources first.
If you decide to file a formal complaint about your colleague’s treatment of you, then de-escalation is not the ultimate goal. It is, however, important to de-escalate daily conflicts to give yourself more time to think about a long-term resolution.
Your employer may eventually want you to engage in conflict mediation with your colleague, or you may be able to change your schedule or work location so that you are no longer in direct contact with the colleague as often as you were before.
Contact Defuse About De-Escalation Training for Nurses
It is in the interest of nurses and patients if the nurses at your hospital, doctor’s office, or staffing firm are skilled in de-escalation techniques. Defuse offers de-escalation training programs designed especially for nurses and other stakeholders in the healthcare profession.
Contact Defuse today to find out more about our course offerings!
