part 2 De-escalation techniques in #Nepal – eliminating the threat of “thrashing”


This is part two.

Here is the problem for MBBS docs who are doing a year-long internship:

In MBBS program, the curriculum has been science-based. They are rewarded for doing research on physiological problems related to medical diagnosis. They are always “junior” and not allowed to speak at rounds; they have not really counseled any patient during a crisis, instead deferring to the “senior.”

As a new intern, the situation continues. Unless somebody goes out of their way to challenge their interpersonal skill, the MBBS doc can stay in the comfort zone of the previous focus, not developing. this skill. “playing it safe” might be okay if you go into dermatology, but not for acute care.

After a year as an intern, the young doc ( who may still be 22 or 23) is posed to a rural area. All of a sudden, the responsibility in increased. It’s like jumping into the water – “sink or swim”

It doesn’t have to be that way. Every young doc needs to practice role play of the skills below.  The whole team – docs, nurses, security guards – needs this.

Here is another excellent resource  from USA. It’s directed toward police, but it applies to all of us.

http://www.crisisprevention.com/Resources/Knowledge-Base/De-escalation-Tips

The following article was written specifically for law enforcement professionals, but professionals in any field can better prevent crises and benefit from verbal de-escalation training in their workplace by using the five keys to empathic listening, as well as the five ways to remain in control of any situation.

Communication is the Key to Crisis De-Escalation

by Jerilyn Dufresne ( her twitter name is @Jerilyn65)

A difficult and potentially dangerous situation for officers involves being called to a scene and engaging with a person who may be mentally ill. Most individuals with mental illness are not dangerous, but a special set of skills is required to bring a mutually successful end to the encounter.

Although an officer’s inclination may be to intervene immediately, that may not always be the best response. As long as the individual isn’t an immediate danger to self or others, there’s time to make a quick assessment. CPI, an international training company specializing in violence prevention and crisis intervention, recommends evaluating the person’s behavior before acting, if at all possible.

How does an officer make the decision about how to treat that individual? Of course the answer is communication: talking to the person and evaluating the responses. But what if the person is unable or unwilling to speak? Again, as long as the person is not a danger to self or others, there is time. Use it to listen to what the person is saying—not only with words, but also with body language and tone of voice.

CPI stresses the importance of listening with empathy, trying to understand where the person is coming from. Like other skills, empathic listening can be learned. The five keys are: give the person undivided attention; be nonjudgmental; focus on the person’s feelings, not just the facts; allow silence; and use restatement to clarify messages.

Undivided Attention
When people are paid attention to they feel validated; they feel important. The converse is also true: people feel less important and sometimes feel they need to up the ante if they feel like they need attention. Paying attention doesn’t just mean saying, “I’m listening.” It means looking at the person, making eye contact if it’s culturally appropriate, and virtually listening with the entire body. By really listening, and conveying that through body language as well as words, an officer can take away the person’s reason for escalating the situation.

Be Nonjudgmental
If someone says, “The sewers are talking to me,” an officer’s immediate reaction might be to think that the person is crazy. That reaction, especially if verbalized, will probably upset the individual even more. Even if not said aloud, that attitude may be conveyed through the officer’s body language. If someone is psychotic, she may tune into the nonverbal communication much more than words. So besides paying attention to what is said, ensure that body language and tone are nonjudgmental as well. This will go a lot further in calming the individual.

Focus on Feelings
Going back to the previous example, if an individual says, “The sewers are talking to me,” a feeling response might be, “That must be pretty scary,” or even, “Tell me what that feels like.” This isn’t getting into a therapist’s bailiwick, but it is using a handy therapeutic tool. Most likely it will elicit a response that is positive, since the individual will know that the officer understands what’s happening.

Allow Silence
As people devoted to protecting and serving, officers are quite comfortable using silence during interrogations, but may not be quite so comfortable using it on the street. Officers want to make sure the incident is handled quickly and peacefully. However, sometimes allowing that moment of silence can be the best choice.

If the individual doesn’t immediately answer a question, it doesn’t mean he didn’t hear you. It may mean he’s thinking about his answer, or even that he wants to make sure he’s saying the right thing.

Allow a moment of silence. If the person’s face registers confusion, then repeat the question and let the silence happen again. Just as officers are taught in basic training, another good reason for silence is that no one likes it—and people tend to start talking when silence lengthens.

Clarify Messages
When a subject makes a statement, an officer may think he knows what the person means. The only way to be sure is to ask. Sometimes a question may be perceived as challenging and can make the subject defensive. So restatement is used instead.

For example, someone living on the street might say, “I don’t want to sleep here anymore.” The officer might think he knows what the person is saying, but instead of just making an assumption the officer could restate, “Oh, you’re ready to go to the shelter?”

The homeless person could say, “Yes.” Or perhaps, “No, I don’t want to sleep here anymore. I’m going to move over to Main Street where it’s safer.” In either case, the officer has shown an interest in the individual and has kept the lines of communication open.

One of the most important actions in any crisis is for the officer to remain in control of himself. This factor, which CPI calls rational detachment, will be the key to whether the officer helps de-escalate or escalate the situation. To rationally detach: develop a plan; use a team approach whenever possible; use positive self-talk; recognize personal limits; and debrief.

Develop a Plan
Devise a plan before one is needed. Decisions made before a crisis occurs are more likely to be more rational than those made when on the receiving end of emotional outbursts. Think about those things that are upsetting and practice dealing with those issues ahead of time. This is called strategic visualization and is effective in helping officers get through some stressful and even dangerous moments. Just as with other professional training officers receive, this training will kick in when needed.

Use a Team Approach
It’s easier to maintain professionalism when assistance is nearby. Support and back up are both crucial pieces when trying to rationally detach.

Use Positive Self-Talk
Positive self-talk has been the butt of many jokes. Picture Al Franken on Saturday Night Live saying, “I’m good enough, I’m smart enough, and doggone it, people like me.” Sure, that’s funny, but positive self-talk really can work wonders. Just as saying, “I can’t deal with this” might cause an officer to behave in one fashion, saying to oneself, “I’m trained, I know what to do” will cause another response.

Recognize Personal Limits
Being a professional doesn’t mean that a police officer must be able to excel at everything. That’s an unrealistic expectation. Know what your limits are. Know that sometimes it’s not easy to leave problems alone. Sometimes the most professional decision is to let someone else take over, if that’s an option.

Debrief
Be sure to debrief with coworkers, team members, or a supervisor after a major incident. Talking about it can relieve some of the stress and is also a good time to start planning for next time: what was done correctly, what could have been handled better, how could the response be improved the next time a similar situation occurs. This serves to assist in being able to rationally detach in the future.

Assisting someone with a possible mental illness is only one example of when an officer’s evaluation, assessment and negotiation skills come into play. There are many other examples: domestic disturbances, dealing with children, assisting victims, helping traumatized witnesses, and even calming down an out-of-control colleague. No matter what the situation, keeping the lines of communication open can help to de-escalate a potentially dangerous crisis.

Reprinted with permission from Law and Order Magazine, August 2003, www.lawandordermag.com.

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 2 De-escalation techniques in #Nepal – eliminating the threat of “thrashing”

  1. Pingback: part 1) What #Nepal doctors and Nurses need to know about “getting thrashed” | CCNEPal 2015

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

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

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

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