unger de-escalation dem 2014
TRANSCRIPT
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De-escalation
De-Escalation Strategiesfor Dealing
with the Agitated Patient
Joachim Unger, MDGermany
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Aggressive behavior against health care providors
Why ?
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Aggression in Prehospital Care/ ED
Acute Pain Intoxication Limited informations Waiting time
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Kinds of Aggression
Instrumental-premeditated-
controlled-planned-proactive-cold blooded-hidden-
predatory-postitve/constructive
Emotional-hostile-impulsive-
uncontrolled-unplanned-reactive-
hotblooded-overt-affective-negative/
destructive
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Aggression in Health Care: Escalated Interaction
Escalation
Conflict
Anger/Fear
AdversiveStimulationEmpathy/
Theory of Mind
Violence
Social System
Interaction
Mental System
ExpectationRole
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NOW-modell
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Elements of violente situations
trigger – weapons – target – level of arousal
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Key Components
MANAGEMENT
YourselfMaintaining
personal control
situational awareness strategies for de-escalation
(when/where/how)
Communications Verbal and non-verbal
skills
Structure(environment)
safe conditions
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Basic Strategies
EmpathyEarly Intervention
Only one communicatorAssessment of emotional state
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Characteristics
of effective De-escalators
Open - Coherent - Confident Concern for the patient
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Maintaining Personal Control
Appearing calmAvoiding personal feelingsSupressing feelings of anger
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Identifying theEscalated Patient
High piched voice
Excessive
Sweating
Shaking
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Non-VerbalDe-Escalation
Keep an alert postureNeutral facial
expression
Never turn your back for any reason
Limit eye contact
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VerbalDe-
Escalation
Do not get loud
Be honest
Be respectful
Respond selectively
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Strategies
Find out the reason
Give guidance
Autonomy confirming vs.Authorative
Interventions
Establish rapportAssessment of emotional state
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Autonomy confirming
Interventions
Find aggreementsList consequences
Suggest alternativesEmpathize with feelings
Do not try to argue/ convince
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De-Escalating Aggressive Behaviour 1. Valuing the patient
2. Reducing fear 3. Enquiring about patient’s queries and anxiety 4. Providing guidance to the patient 4. Working out possible agreements 6. Remaining calm 7. Crosscheck: Take no risk
…brings the level of arousal down to a safer place
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ILO/ICN/WHO/PSI (2002). Framework guidelines for addressing workplace violence in the health sector. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector.
Di Martino, V. (2002). Workplace violence in the health sector – Country case studies Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand, plus an additional Australian study: Synthesis Report. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector, forthcoming working paper.
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Centre for Clinical PracticeReview of Clinical Guideline (CG) 25: Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments
NAU J. Et al. (2009) The De-Escalating Aggressive Behaviour Scale: development and psychometric testing. Journal of Advanced Nursing 65(9), 1956–1964.
RAMIREZ, J.M. Et al. Aggression, and some other psychological constructs (Anger, Hostility, and Impulsivity). NEUROSCI BIOBEHAV REV 21(1) 2005
Price O., Baker J. Key components of de-escalation techniques: A thematic synthesis International Journal of Mental Health Nursing (2012) 21, 310–319
Cowin L et al. De-escalating aggression and violence in the mental health setting. Int J Ment Health Nurs. 2003 Mar;12(1):64-73.
Hockenhull JC. A systematic review of prevention and intervention strategies for populations at high risk of engaging in violent behaviour: update 2002–8. NIHR Health Technology Assessment programme: Executive Summaries.
Walter G. Aggression und Aggressionsmanagement: Praxishandbuch für Gesundheits- und Sozialberufe. Verlag Hans Huber 2012