part 1) What #Nepal doctors and Nurses need to know about “getting thrashed”


Young doctors worry about this in Nepal. A lot.

Sooner or later, every nurse and doctor in Nepal has confronted a situation in which a family member threatens violence. It’s a fact of life, here. It happens to the junior doctors on night or evening duty when there are fewer backup  persons.  It’s the junior doctors who need the skills to deal with this,  the most.

This series of blog posts will explore ways to mitigate the problem. There are things that can be done.

(please share widely, and subscribe to this blog so you don’t miss future entries)

IF YOU ARE A CONSULTANT OR SENIOR DOCTOR READING THIS

my advice is to be sure to address how to act,  not just to how to diagnose and treat, when you meet with your entourage. Lead your team in role play.

IF YOU ARE A FOREIGNER READING THIS

A guy who comes frequently to Nepal to go trekking heard about this and he said “That’s preposterous, it’s just not the Nepal I know.” for non-medical foreigners it’s hard to believe that such a wonderful country has this problem. It’s because they shield you from it when you are here.

For medical foreigners volunteering in Nepal – as soon as anything like this happens, the Nepali professionals will generally shunt you away from it. It’s dirty laundry. Paradoxically, the only way to improve the climate is to bring it out into the open.

Future blogs will deal with building security and the like. Here is something I found on the web.

NOTE: this is adapted nearly verbatim from the source cited, in Massachusetts USA. The only part that is mine is the indents – the indents are my comments!

from http://www.naswma.org/

For Defusing or Talking Down an Explosive Situation

When a potentially violent situation threatens to erupt on the spot and no weapon is present, verbal de-escalation is appropriate.

In other words, if somebody has a weapon, get out and away. this is Number One Priority!

There are two important concepts to keep in mind:

  1. Reasoning with an enraged person is not possible. The first and only objective in de-escalation is to reduce the level of arousal so that discussion becomes possible.
  2. De-escalation techniques are abnormal. We are driven to fight, flight or freeze when scared. However, in de-escalation, we can do none of these. We must appear centered and calm even when we are frightened. Therefore these techniques must be practiced before they are needed so that they can become “second nature.”

Note: MBBS students advance on the basis of their science knowledge. To execute the above requires a skill set that also must be studied and practiced.

THERE ARE 3 PARTS TO BE MASTERED IN VERBAL DE-ESCALATION

  1. The Worker in Control of Him/Her Self
  2. Appear calm, centered and self-assured even though you don’t feel it. Relax facial muscles and look confident. Your anxiety can make the client feel anxious and unsafe and that can escalate aggression.
  3. Use a modulated, low monotonous tone of voice (our normal tendency is to have a high pitched, tight voice when scared).
  4. If you have time, remove necktie, scarf, hanging jewelry, religious or political symbols before you see the client (not in front of him/her).
  5. Do not be defensive-even if the comments or insults are directed at you, they are not about you. Do not defend yourself or anyone else from insults, curses or misconceptions about their roles.
  6. Be aware of any resources available for back Know that you have the choice to leave, tell the client to leave or call the police should de-escalation not be effective.
  7. Be very respectful even when firmly setting limits or calling for help. The agitated individual is very sensitive to feeling shamed and disrespected. We want him/her to know that it is not necessary to show us that they must be respected. We automatically treat them with dignity and respect.

Note: when you read about this, it sounds like common sense – “I already do those things!” you say to your self. You need to videotape yourself and practice the way a professional actor would. And by the way, the reason for #4 is to avoid being strangled.

The Physical Stance

  1. Never turn your back for any reason.
  2. Always be at the same eye level. Encourage the client to be seated, but if he/she needs to stand, you stand up also.
  3. Allow extra physical space between you – about four times your usual distance. Anger and agitation fill the extra space between you and your client.
  4. Do not stand full front to client. Stand at an angle so you can sidestep away if needed.
  5. Do not maintain constant eye contact. Allow the client to break his/her gaze and look away.
  6. Do not point or shake your finger.
  7. DO NOT smile. This could look like mockery or anxiety.
  8. Do not touch – even if some touching is generally culturally appropriate and usual in your setting. Cognitive dysfunction in agitated people allow for easy misinterpretation of physical contact as hostile or threatening.
  9. Keep hands out of your pockets, up and available to protect yourself. It also demonstrates non-verbal ally, that you do not have a concealed weapon.
  10. Do not argue or try to convince, give choices i.e. empower.
  11. Don’t be defensive or judgmental.
  12. Don’t be parental, join the resistance: You have a right to feel angry.

The De-Escalation Discussion

  1. Remember that there is no content except trying to calmly bring the level of arousal down to baseline.
  2. Do not get loud or try to yell over a screaming person. Wait until he/she takes a breath; then talk. Speak calmly at an average volume.
  3. Respond selectively; answer all informational questions no matter how rudely asked, (e.g. “Why do I have to fill out these g-d forms?” This is a real information-seeking question). DO NOT answer abusive questions (e.g. “Why are all social workers ___ ?) This question should get no response what so ever.
  4. Explain limits and rules in an authoritative, firm, but always respectful tone. Give choices where possible in which both alternatives are safe ones (e.g. Would you like to continue our meeting calmly or would you prefer to stop now and come back tomorrow when things can be more relaxed?)
  5. Empathize with feelings but not with the behavior (e.g. “I understand that you have every right to feel angry, but it is not okay for you to threaten me or my staff.)
  6. Do not solicit how a person is feeling or interpret feelings in an analytic way.
  7. Do not argue or try to convince.
  8. Wherever possible, tap into the client’s cognitive mode: DO NOT ask “Tell me how you feel. But: Help me to understand what your are saying to me” People are not attacking you while they are teaching you what they want you to know.
  9. Suggest alternative behaviors where appropriate e.g. “Would you like to take a break and have a cup of coffee (tepid and in a paper cup) or some water?
  10. Give the consequences of inappropriate behavior without threats or anger.
  11. Represent external controls as institutional rather than personal.
  12. Trust your instincts. If you assess or feel that de-escalation is not working, STOP! You will know within 2 or 3 minutes if it’s beginning to work. Tell the person to leave, escort him/her to the door, call for help or leave yourself and call the police.

There is nothing magic about talking someone down. You are transferring your sense of calms and genuine interest in what the client wants to tell you, and of respectful, clear limit setting in the hope that the client actually wishes to respond positively to your respectful attention. Do not be a hero and do not try de-escalation when a person has a gun. In that case, simply comply.

This document was developed by: Eva Skolnik-Acker, LICSW, evaskolnikacker@comcast.net

HOW to use this knowledge

Reading is not enough. you need to role play it and get personal feedback about how you perform.

Click here to go to Part Two!

Every family member needs to be assessed for stress level.

Note: if you got this far, please click here to take a look at the reviews of my book, available at Vajra Books in Thamel.

About Joe Niemczura, RN, MS

Experienced nursing educator and problem-solver. I have fifteen years of USA nursing faculty background. Add it with fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. I travel outside of Kathmandu Valley as well. When the recent violence happened, I knew the cities - I had trained people in those locations. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011. Global Health Nursing is not all sweetness and light; not solely milk & honey and happy moms and babies.
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4 Responses to part 1) What #Nepal doctors and Nurses need to know about “getting thrashed”

  1. Pingback: part 3 about “thrashing” of healthcare workers in Nepal – building design | The Sacrament of the Goddess – a Novel of Nepal

  2. Pingback: part 3 about “thrashing” of healthcare workers in Nepal – building design | CCNEPal 2015

  3. Pingback: part 4) De-Escalation skills for Critical Care nurses and doctors in #Nepal March 31st 2015 | CCNEPal 2015

  4. Pingback: Two doctors thrashed at Patan Hospital Sept 10, 2015 and what to do about it | CCNEPal 2015

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