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

Sept 28 2016 update

I wrote a blog specifically about the recent incident in Charikot – read this:

Update May 7th 2015

I wrote the blogs on this subject prior to the earthquake. Now, post-earthquake, there’s lots of speculation as to the mental health needs of the population after such a massive event. So far I’ve seen things posted, in an attempt to be helpful, on the general subject of bereavement counseling. They seem to me to be generic adaptations of western ideas on the subject. they do not take into account the cultural factors that reflect the actual way people deal with it here. I have a lot of boots-on-the-ground experience dealing with this specific problem in the clinical setting, and my general assessment is, that a widespread focus on de-escalating anger in needed as a central part of the armamentarium.  Anger is part of depression. Anger is an important, and extremely destructive, part of Nepal healthcare these days, even before the earthquake. Frankly if you don’t think so, it proves that you are out of touch.

Every nurse and doctor in #Nepal needs to be protected against the possibility that an angry family member will harm them.

This is a major fear. It prevents people from wanting to get involved in emergency care. So, CCNEPal teaches skills that will raise awareness of the problem. The first step is to develop “street smarts” – predicting a problem and taking  steps to prevent it.

Note: the words in blue are hyperlinks – click on one and see what happens!

Fourth in  a series

I already wrote three blogs on this topic. The first was about some beginning techniques in dealing with a person who is enraged and not able to be reasoned with. Another one expanded on this, sharing the concepts of  “de-escalation techniques” that are useful. A third blog was about the design of a secure building. In the future I will  write one about  debriefing after an incident, and also about doing drills with the security guards.

Sometimes the only thing that will prevent a problem is to put the hospital on “lockdown”.

If unruly visitors have a weapon and/or make threats to use it, the first duty of staff is to get away, even if it means abandoning the patient.

Not all hospitals are designed in a way that makes it easy to lock down, but many are. It’s important to limit access.

And now I’ll tell you a secret.

The secret is, ever since 2011 CCNEPal has included a role-play of family counseling during cardiac arrest, as part of the course. I never made a big deal about publicity for the role play, because I wished to preserve an element of surprise.   I decided to do it serendipitously in June 2011 with my very first session. Usually it involved asking some members of the class to role play the distraught relatives of a young victim. The role play created a space where people could share their concerns, and I have included role play of family counseling in every subsequent session, more than fifty times since the beginning.

Role play is not new for nurses in Nepal. Most schools of nursing, B Sc or Bn or PCL, do it as part of training in interpersonal skills, and for that reason, we have had excellent portrayal of this scenario.

Not all medical schools in Nepal use role play. My impression is that role play is very new for medical schools in Nepal,  and that few MBBS programs use it as a teaching tool. Here is an area where the medical education authorities in Nepal could profitably spend some time, if you ask me. There are many applications of role play. In the USA, the USMLE step 2 CS exam consists of role play, and every medical student in USA is evaluated according to their ability to do role play. Why not Nepal?

How we do the role play for dealing with families under severe stress

It’s live improv  theater and there is an element of immediacy. The key actresses are usually given a day in advance to plan out their role, and to bring a costume to wear during the event. We plan it out, and make sure every one understands the objectives. Then we do it.

Debriefing =reframing

The role play is theatrical and “fun” and also intense. The most important aspect of the exercise is the discussion and debriefing afterwards. At the debriefing, we accomplish several tasks.  We go over specific strategies to prevent a situation; we talk about ways to de-escalate; we talk about how to assess the family in advance when that is possible; and we share stories of episodes from among the class participants. But some of the most important parts of the debriefing are when the senior nurses talk about overcoming their own fear, or how to address the existential threat posed when the victim needing resuscitation is the same age and from a similar background. This kind of exercise can be an important step in building resilience in critical care nurses.

The benefits of role play in exploring cultural context

We are able to do this because CCNEPal does not run a “sterile” course.  These days, the course from AHA is DVD-based, and an American ACLS course would not be allowed to add a scenario that was not on the script.  It’s my opinion that any course which fails to address the issue of family counseling  does not meet the needs of Nepali nurses and doctors.

Here is a present for those who read this far.

I have allowed people to video the way that CCNEPal uses role play, usually it’s been the scenarios involving resuscitation. But for the scenario involving counseling, I previously asked participants never to post to Youtube or to FaceBook. Why? Because I have been worried about the way it might be misinterpreted. For example, sometimes during the role play, the participants or onlookers laugh.  On the one hand, laughter in the face of a critical situation involving death despite efforts to save a person’s life, could be construed as not taking it seriously – being disrespectful.  On the other hand, laughter in this context is actually a sign that the person is anxious about the topic.

It is important to me that  people know we are serious in using this technique to pursue excellence in family counseling during this kind of crisis, and I do not want to get flamed on this by a non-professional person who stumbles across it not knowing the context.

Here they are

The first video shows a step in the role-play, during which the team is being instructed as to how to prepare.

The next one shows the rest of the group, preparing the various roles and explaining how it will go.

I think these are a good start. I am not ready to post the next one, where we actually do the role play, yet. I will post that one, as well one which shows the debriefing, soon.

I should note, this issue is partly what prompted me to write my second book about hospital care in Nepal, and the book explores the way that Nepali people act as a group. You can get my book at Vajra books on Jyatha in Thamel, or if you are not in Nepal, on Amazon.

In the meantime, I am eager to hear from the readers as to their impressions of this…… please feel free to reply below….


About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it 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. 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.
This entry was posted in medical volunteer in Nepal and tagged , , , , , , , , , , , . Bookmark the permalink.

4 Responses to part 4) De-Escalation skills for Critical Care nurses and doctors in #Nepal March 31st 2015

  1. sani adhikari says:


    Sent from my Windows Phone ________________________________

  2. Pingback: Grief in Nepal, a short introduction post-earthquake, May 6th 2015 | CCNEPal 2015

  3. Pingback: part two of debriefing video is now on YouTube July 25th 2015 | CCNEPal 2015

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

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s