Sandra Ryan is a nurse educator for Ambulatory Care. She has led the CALM communication and de-escalation programme at Counties Manukau Health for four years.
Communication and de-escalation skills are essential for all frontline healthcare professionals.
Being in hospital can be stressful for patients and their families. Most are going through a crisis in their own health or that of a loved one. As a result, they are vulnerable to emotional escalation when faced with triggers and may not behave as they would normally.
De-escalation requires staff to understand the stress patients are under, recognise the signs of emotional escalation and manage it effectively when it occurs.
Patients who are reacting to stress triggers may alter their tone of voice, the way they speak to staff, and their body language. Shoulders hunch, fists clench, and the body and facial expressions become tense. Emotional escalation feeds into itself, creating a cycle of escalation. Recognising the beginnings of the cycle requires staff to be aware of what is considered to be normal tone and body language.
At Counties Manukau Health (CM Health), preventing and managing escalation involves a three-step approach.
First, staff apply organisational values to their communication with patients. These values are:
• Valuing everyone – reflecting the Māori core value of whakawhanaungatanga
• Kind – reflecting the Māori core value of manaakitanga
• Together – reflecting the Māori core value of kotahitanga
• Excellent – reflecting the Māori core value of rangatiratanga
Applied with AI2DET (Acknowledge, Introduce, Identify, Duration, Explanation, Thank you), which is a communication tool CM Health has adapted to improve face-to-face engagement experiences for patients and whānau, values-based communication effectively prevents emotional escalation most of the time.
If patients do become escalated, the skills taught in the CALM (Communication, Assertiveness, Look, Measured tone) programme come into play. CALM teaches staff to recognise the triggers of emotional escalation, identify it when it happens, and de-escalate the situation.
CALM de-escalation techniques include:
• Being aware of your own body language. Avoid defensive or powerless body language – hunched, eyes down, ‘closed’ postures with limbs crossed or held tightly against the body. Use assertive body language instead – stand erect, with shoulders back, and make eye contact.
• Giving people personal space. The need for personal space increases when people are emotionally escalated. This may extend to allowing people quiet time alone while you find the right person to talk to them. It also means protecting your own safety by ensuring you can get away if someone becomes threatening or violent.
• Listening. Feeling that healthcare staff don’t listen and are too busy with their own agenda is one of the most common frustrations for patients. Give patients your undivided attention when you speak to them and then summarise their key points back to them to show you’ve listened and check your understanding.
• Avoiding negative filters. There will be a lot of blame coming at you, but avoid becoming defensive. Instead, respond positively and aim for a win-win situation. De-escalation is not about giving up everything to the patient, but equally it’s not about healthcare staff always being in control either. Listen to what the patient wants and work towards a solution that all parties can agree to.
These techniques aim to manage conflict situations before it becomes necessary to take the last step of calling security or restraining the patient.
Finally, healthcare can be stressful for staff as well as for patients. Looking after ourselves through techniques such as mindfulness helps us to communicate compassionately and to develop the resilience needed to work through to a win-win situation when patients are under stress.