Tips and Strategies for De-Escalating Aggressive, Hostile, or Violent Patients

Managing patient complaints and dissatisfaction is an unpleasant but certain reality in healthcare. Despite best efforts, situations occur in which patients are unhappy and feel compelled to voice their displeasure and concerns. Unfortunately, in some cases, patients’ emotions might escalate, and they may become aggressive, hostile, or violent.

Violence in healthcare is all too common, particularly in the wake of the COVID-19 pandemic, and chiropractors and staff members need to be prepared to handle tense and potentially violent situations if they occur. Understanding the risks of violence and learning strategies to address such behavior is an imperative safety measure.

First and foremost, recognizing that no single response will work in every situation is crucial. You should consider the individual patient, the circumstances, and the broader context of the situation when responding to escalating behavior. An article from the Western Journal of Emergency Medicine notes four main objectives when working with an agitated person. They include:

  • Ensuring the safety of the patient, staff, and others in the area
  • Helping the patient (a) manage his/her emotions and distress, and (b) maintain or regain control of his/her behavior
  • Avoiding the use of restraint when possible
  • Avoiding coercive interventions that escalate agitation1

De-escalation might be one appropriate technique that you can be trained to use if confronted with aggressive or hostile behavior. The aforementioned article lists 10 domains of de-escalation, as follows:

  1. Respect personal space while maintaining a safe position. If a situation begins to escalate, make sure that both you and the patient have adequate personal space. No one should feel trapped or cornered in a room or space. Maintain at least 2 arm’s length of distance, and make sure you are out of striking distance from the patient in the event that he/she tries to lash out.
  2. Do not be provocative. Keep a calm demeanor, and make sure your body language reflects that you will not hurt the patient and do not want a confrontation. Avoid excessive staring, clenching or concealing your hands, and closed body language that insinuates judgment (e.g., crossing your arms).
  3. Establish verbal contact. Do not involve multiple people in de-escalation efforts. Only one person, who is properly trained, should talk with the patient in an attempt to de-escalate the situation. Speak calmly and politely to the patient and assure him/her that your goal is to help resolve the issue and keep everyone safe.
  4. Be concise; keep the message clear and simple. Use clear, short sentences and simple vocabulary to help the patient comprehend messages without further agitation. Give the patient time to process information and respond. Repeating key information — such as requests, options, and limitations — is essential in de-escalation.
  5. Identify wants and feelings. Try to determine what the patient expects, wants, or feels. Doing so is crucial to resolving outstanding issues or identifying alternative options that might help the patient regain control of his/her behavior. Responding with empathy and compassion, even if the patient’s expectations are unrealistic, can help establish trust and rapport.
  6. Listen closely to what the person is saying. Actively listen to the patient’s complaints or concerns and give verbal and physical indications that you hear and understand the patient’s message. Repeating key information back to the patient is a helpful technique.
  7. Agree or agree to disagree. Try to find common ground with the patient and identify opportunities for agreement, whether the agreement is based on facts, principles, or odds. When an agreement can’t be reached, agree to disagree, but acknowledge the patient’s feelings.
  8. Lay down the law and set clear limits. Negative behaviors have consequences, and you should calmly, but clearly inform the patient about unacceptable behaviors and potential consequences (e.g., alerting security or law enforcement). This information should be communicated in a factual but nonthreatening manner. Explain that mutual respect is necessary to work together and help resolve issues.
  9. Offer choices and optimism. Consider realistic choices and alternatives to violence that you can offer the patient. Doing so can help empower the patient and potentially de-escalate aggression. You also should consider whether other small gestures might help comfort the patient, such as the offer of a beverage or time to make a phone call. Staying optimistic, but realistic during these encounters also can help manage the patient’s expectations and work toward solutions.
  10. Debrief the patient and staff. Once a situation has been de-escalated, work with the patient to discuss what happened, understand the patient’s perspective, and devise strategies for controlling aggressive and hostile behaviors in the future. Additionally, talk with staff members to determine what went well during the intervention and potential areas for improvement.2

For more detailed information and strategies related to each of these domains, see Verbal De-Escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

In the most serious cases, patient aggression can turn harmful or deadly. A patient might attempt to physically attack, stab, or shoot a chiropractor, staff, another patient, or a bystander. If this occurs, the immediate response should be to try to isolate the aggressor in as limited an area as possible (such as locking the waiting room door to prevent access to patient care areas), and evacuating patients, staff, and visitors as quickly as possible by all means of egress available.

Law enforcement should be notified as soon as possible to allow police time to respond to the scene. Ideally, notification to law enforcement should occur before the situation turns violent.

To learn more about preventing workplace violence in healthcare, see ChiroPreferred by MedPro Group’s article From Verbal Insults to Death: The Reality of Workplace Violence in Healthcare.


Endnotes

Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman, G. H., Zeller, S. L., Wilson, M. P. . . . Ng, A. T. (2012, February). Verbal de-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, 13(1), 17–25.

Ibid.

This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions. 

MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and may differ among companies. 

© 2022 MedPro Group Inc. All rights reserved.