Exclusives, Patient Care, Training

Surviving Verbal Conflict: Verbal De-escalation Needs for EMS Personnel

When healthcare professionals develop verbal de-escalation skills, they feel more confident when handling hostile patients, hostile members of patients’ families, and confused patients in emotional crisis. (Photo National Highway Traffic Safety Administration)

You have been dispatched to an anonymous 911 call about an unconscious woman. When you and your partner arrive at the scene, it appears to be a house party with lots of drinking and potentially some drug use. When you reach the front door, you can see a woman lying face down on the carpet in the living room, but several partygoers are trying to block your entrance into the house. “She’s fine. All she needs is some sleep,” they say.

The woman does not appear to be breathing and you can see her skin tone turning blue. What should you do? Are you and your partner going to force your way into the house and risk being assaulted by the partygoers? Are you going to request assistance from the police? It may take the police a while to get there and the woman does not appear to be breathing. Are you really just going to stand there and wait? Is there anything you can say to potentially gain compliance from the partygoers?

Your rescue squad crew has been dispatched to an elderly man who was found lying unconscious on a sidewalk. When you arrive your crew finds the man conscious again, but he appears frightened and confused. He has a bleeding head wound, and you need to complete a primary assessment of the patient, but he is afraid and uncooperative. He is clenching his arms to his chest, unwilling to let you put on the blood pressure cuff or take his pulse. He keeps saying, “Look, I’m fine, really. I just need to go home. Everything is okay. I’m sorry to have bothered you people.”

A crowd has also gathered to watch what is going on. One of the man’s pupils is more dilated than the other, so obviously something is wrong. What are you going to do with this audience watching? Are you going to release him against medical advice without first trying to get him to cooperate? What will you say to get him to let you complete your primary assessment? How will you get his cooperation, and win his trust?

Most everyone within the healthcare field has encountered verbal hostility from patients, the family members of patients, or even coworkers. However, have you ever been trained how to successfully handle these situations with empathy, professionalism and tact? While significant attention is correctly placed on maintaining clinical skills, the evidence suggests that not enough attention has been devoted to equipping medical personnel with the skills to handle situations involving verbal conflict.

A Need for Verbal De-escalation Skills

Those who provide prehospital medical care are often exposed to aggression – both verbal and physical. A national survey of almost 3,500 emergency medical care workers revealed that 100% had witnessed both an act of violence and threats of violence at work within the last three years. Additionally, 20% reported dealing with verbal abuse almost daily.1 Another study that observed the behavior of patients transported to the emergency department revealed that one out of every six patients displayed verbal hostility towards medical staff.2

Unfortunately, research has also revealed significant deficits in verbal de-escalation skills within the healthcare field. While the healthcare profession attracts individuals with high levels of empathy for their fellow humans, only individuals who are driven and have strong leadership skills usually complete the training necessary to earn their positions as doctors, nurses, paramedics, and technicians. As a result, more than one study has suggested that the focus on leadership skills and technical proficiency has been at the expense of empathetic listening and verbal de-escalation skills.

In survey after survey, healthcare staff report feeling ill-equipped to handle situations involving hostility. Studies of doctors, nurses, paramedics, and intake staff have revealed that most feel unprepared and untrained to handle patient verbal hostility in an effective and professional manner.3 Even within psychiatric care units, where staff are more likely to have received training for the management of aggressive behavior, treatment staff have complained that their training often emphasizes policies and theoretical concepts rather than providing practical skills people need for calming individuals who are angry or upset.4

The Results of Verbal De-escalation Skills Training

Some healthcare staff are naturally gifted with outstanding communication skills that involve deflecting verbal abuse, empathetic listening, paraphrasing back statements, and offering options that guide individuals to a peaceful resolution of the conflict. Those who utilize these communication skills are rated as “more professional” by their patients and coworkers, receive fewer complaints about their demeanor and experience fewer violent acts.5 Unfortunately, these verbal de-escalation skills do not come naturally to most people.

Realizing the need for verbal de-escalation skills training, some healthcare organizations have recently begun providing this training to their staff – with very positive results. One study involved providing nurses with a course in patient verbal de-escalation. A survey before and after the course revealed that after completing the course the majority of these nurses felt much more confident about their ability to handle stressful patient interactions.6

In another example, nursing students completed a verbal de-escalation training course just before beginning their clinical placements. Surveyed three months into their clinical placements, the nursing students reported they felt better prepared to handle their clinical placement experiences because they had completed the verbal de-escalation course.7

In a third study, a group of palliative care nurses received verbal de-escalation training and were surveyed six months later to determine the effects of the training. These nurses reported being calmer, and experiencing less stress, when communicating with patients, and patients’ families after having completed the training. They also reported feeling more confident about handling all difficult communication situations, such as making death notifications. Many of these nurses emphasized that the role-play portion of the training that allowed them to practice their new skills in a safe environment was the most beneficial part of the course.8

A study involving verbal de-escalation training for all student nursing students at one hospital revealed that, when compared to the two years before the training, acts of patient aggression fell by 25% over the 28 months after the training.9 Finally, a review of nine additional studies involving verbal de-escalation training within medical settings revealed that all nine studies saw increased staff confidence and improved skills in handling hostile patient behavior.10

It’s Time for Training

All EMS personnel sometimes face situations of verbal conflict or resistance in the midst of emergencies or serious injury calls. The problem is that most of us have not been trained how to handle this verbal resistance tactfully within the heat of the moment. Clearly, verbal de-escalation training offers many benefits for those working in the medical field, and who has a greater need than the prehospital staff who operate on the street with little support.

When healthcare professionals develop verbal de-escalation skills, they feel more confident when handling hostile patients, hostile members of patients’ families, and confused patients in emotional crisis. EMS professionals with strong verbal de-escalation skills also better manage conflict situations with their coworkers. They are perceived of as more professional by patients and coworkers and experience fewer aggressive acts or demeanor complaints from patients. As a result, EMS personnel should all receive verbal de-escalation training on a routine basis in order to improve personal staff safety, patient care and maintain the professionalism of the field.

References

1. Gacki-Smith J, Homeyer C, Juarez AM, et al. Violence against nurses working in U.S. emergency departments. J Nurs Admin. 2009;39(3):340-349.

2. Boyle M, Koritsas S, Coles J, et al. A pilot study of workplace violence towards paramedics. Emerg Med J. 2007;24(11):760-763; Mechem C, Dickinson E, Shofer F, et al. Injuries from assaults on paramedics and firefighters in an urban emergency medical services system. Prehosp Emerg Care. 2002;6(4), 396-401.

3. Boutin-Foster C, Charlson ME. Problematic patient-resident relationships. J Gen Intern Med. 2001;16(7):750-754; Brown T, Williams B, Boyle M, et al. Communication styles of undergraduate health students. Nurse Educ Today. 2011;31(4):317-322; Nordby H, Nohr O. Care and empathy in ambulance services: paramedics’ experiences of communicative challenges in transports of patients with prolonged cancer. J Commun Healthc. 2011;4(4):215-226; Ross L. Interpersonal skills education for undergraduate nurses and paramedics. J of Paramedic Practice. 2013;4(11):655-665.

4. Roberton T, Daffern M, Thomas, S. De-escalation and limit setting in forensic mental health units. J Forensic Nurs. 2012;8(2):94-101.

5. Apker J, Propp KM, Zabava-Ford, W, et al. Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. J Prof Nurs. 2006;22(3):180-189; Riggio R, Taylor S. Personality and communication skills as predictors of hospice nurse performance. J Bus Psychol. 2000;15(2):351-361; Zabar S, Ark T, Gillespie C, et al. Can unannounced standardized patients assess professionalism and communication skills in the emergency department? Acad Emerg Med. 2009;16(9):915-918.

6. Mullan B, Kothe E. Evaluating a nursing communication skills training course. Nurse Educ Pract. 2010;10(3):374-378.

7. Beech B, Leather, P. Evaluating a management of aggression unit for student nurses. J Adv Nurs. 2003;44(6):603-612.

8. Wilkinson S, Roberts A, Aldridge J. Nurse-patient communication in palliative care: an evaluation of a communication skills program. Palliat Med. 1998;12(1):13-22.

9. Nau J, Halfens R, Needham I, et al. Student nurses’ de-escalation of patient aggression: a pretest-posttest intervention study. Int J Nurs Stud. 2010;47(6):699-708.

10. Heckermann B, Zeller A, Hahn S, et al. The effect of aggression management training programs for nursing staff and students working in an acute hospital setting: a narrative review of current literature. Nurse Educ Today. 2015;35(1):212-219.