De Escalation And Managing Violence.pptx

De escalation of violence

1. DE-ESCALATION AND MANAGING VIOLENCE A training program for health care settings 1

2. Learning Objectives Understand different types of violence  Understand situations where violence can escalate Identifying violence triggering situations  Understand de-escalation tactics to control violence  Understand the method of breaking a bad news, step wise Understand the emotional stress that comes with breaking a bad news  Develop coping strategies for different levels and types of stress 2

3. Learning Outcomes Stepwise bad news delivery,  Recognize associated emotional stress,  Develop coping strategies for varying stress levels/types. 3

4. Violence World Health Organization (WHO) defines violence as " the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment , or deprivation ."  According to the International Federation of Red Cross (IFRC), the basis of any violence is misuse of power. 4

5. Participants experienced violence (2909/ 8,579) 5

6. Facts about Escalation Things escalate because someone is trying to win an argument Things escalate when someone is judgmental Escalation happens because two people are in conflict  Escalation happens because both people are trying to convey what they mean and neither one is listening When someone attacks you, your first response is to defend yourself; this causes stress and an adrenaline rush. The aggressor is experiencing the exact same reactions. So this makes two dysregulated persons. If you remain calm, this will automatically lead to de-escalation 6

7. Escalation: What are the Early Signs? Tense body language (yours or the other person’s) Taking up personal space Touching or grabbing to emphasize your point Raised voice Rapid speech Excessive sweating Excessive hand gestures: clenched fists, hands on the hips etc. 7

8. De-Escalation: bringing the level of anger down in a situation Reasoning with an angry person is not possible The first and only objective in de-escalation is to reduce the level of anger so that discussion becomes possible De-escalation techniques are impulsive . Our mind prepares the body to fight, flight or freeze when scared However, in de-escalation, we can do none of these. We must appear centred and calm even when we are frightened 8

9. Signals of Aggression and Escalation Recurrent or frequent queries Shoulders pulled back and dominating  Tight jaw with clenched teeth Clenched fist or pointing fingers Staring Be polite and appear calm Stand adjacent - not in front Open your hands Be consistent and empathetic Break eye contact 9

10. Signals of Aggression and Escalation (contd..) Invading private space  Using offensiveness  Shouting Walking here and there Fast breathing Give space Do not be provocative Use a calm tone of voice Use gentle instructions to sit down Allow the person to relax 10

11. MODULE 2 Patient communication protocol 11

12. Basics of patient communication: Active listening How can you show your patients that: 12

13. Normal protocol of communication Greet and introduce yourself to them Tell them that you are going to talk to them right after you have examined the patient (FOR ATTENDANTS) Examine the patient and then communicate your assessment They need to receive clear explanations and instructions about their condition; it is reasonable Share adequate information .i.e. clinical management 13

14. Use active listening Tell them about available treatment options and avoid medical terms Help them decide; do not decide for them right away (WHERE POSSIBLE). This will make them feel more empowered. Go through important information slowly; be especially careful not to rush through negative information. If you have to repeat yourself, that is fine 14

15. Empathize with your patient: What is empathy? Ability to feel other’s pain and happiness No judgment (You ate fast food last night; that’s why your stomach hurts) Perspective taking (seeing things from other’s point of view) Recognizing emotion and communicating that (e.g. “You look really worried.”) Offering help rather than solutions (Instead of saying, “ roney ka koi faida nahin hai ,” you can say, “How can I make you feel better?”)  Avoid giving explanations or your opinion on the issue Don’t force positivity (e.g. “You should think about your blessings, be positive.”) 15

16. Breaking Bad News 16

17. What is bad news? “Information likely to drastically alter a patient’s view of his or her future.” (Beckman, 1992) “…situations where there is either a feeling of no hope, a threat to one’s mental or physical well-being, a risk of upsetting an established lifestyle, or where the message given conveys fewer choices in his or her life…” 17

18. How bad news is given is important “…some unhappiness is caused by what the client is hearing, but dissatisfaction with the way they hear it is most commonly caused by:  The doctor not listening or not appearing to listen The doctor using medical terms The doctor blaming the patient 18

19. Emotional Reaction To Trauma 19

20. Emotional reactions to traumatic news This may take the form of any one or more of the feelings listed below: Shock and disbelief Fear Sadness Helplessness Guilt Anger Shame 20

21. Arrange for important family members to be present; try to get a separate, private place (select a place with no access to sharp instruments or any hazardous material which can be used against you in case of escalation of aggression or violent behavior ) Ideally you should have another healthcare team member with you (if that is not possible let the other doctors/ nurses/ receptionist/guard know that you are with the patient/attendant to break the bad news) Be respectful; use appropriate names, keep a comfortable distance, pay attention to your own body language, make eye contact. Be conscious of patients/ attendants body language be watchful for signs of escalation of aggression or signs of violent behaviour (Make sure that you are sitting/ standing at a place with easy and safe access to exit to door( so you will be able to take off if patient/ attendant gets violent). Step 1: Setting up the meeting Always remember !!! Identify the sensible person in case of death or serious condition of patient Take him/her to a separate area (if at scene) Delay the bad news (if the attendant seems violent) and first tell them to pray as the patient’s condition is serious (even if the patient is dead). This will divert their attention, and you will get time to organize security to be able to deal with the consequences In case of a high risk situation .i.e. death of public figure, always call security forces/guards to the location before you break the bad news 21

22. Step 2: Discuss the patient`s/attendant`s understanding of disease and its probable outcome Utilize your full concentration and listening skills to get to know their (patient/attendant) understanding of the situation. Let the patient/attendant know that you are trying to listen and that you are interested in what s/he thinks is going on Be alert for signs of escalation of aggressive behavior such as: I- Recurrent or frequent queries II- Shoulders  dominating  III-Tight jaw with clenched teeth IV- Clenched fist or pointing fingers V-Staring VI- Assaulting personal space VII-Using offensiveness VIII- Shouting IX- Wandering X- Fast breathing  XI- Abrupt or NO reply 22

23. Step3: Sharing the Information To develop their confidence align the information that you are going to provide with what the patient or attendant already knows Use small sentences and pause frequently  Do not use medical terms and difficult words Allow time for silence Allow time for tears; offer tissues to convey the message that crying is allowed 23

24. Step 4: Identify and acknowledge the patient’s reaction. Offer realistic hopes but avoid trying to be overly reassuring If the patient/attendant becomes violent or tries to harm you, immediately exit the room (push the safety alarms if available) 24

25. Step 5: Demonstrate an understanding of the patient’s/attendant’s problems. Arrange for all possible help in the case the patient has not survived Provide comfort, a place to sit and water  At all times, demonstrate compassion and respect for the attendants’ loss 25

26. MODULE 3 POST TRAUMATIC STRESS DISORDER (PTSD) 26

27. How does being exposed to violence affect you? 27

28. What happens to the body? The nervous system releases a flood of stress hormones, including adrenaline and cortisol, which stimulates the body for emergency action The heart beats faster Muscles tighten Blood pressure rises, breath quickens All of these changes prepare you to either fight the threat or run away to save yourself 28

29. What happens to the brain in a fight/flight response? The emotional centre of the brain senses the threat Fear-based responses overcome you Your critical thinking is impaired (not working) Judgment is impaired The power to make decisions is weakened The frontal lobe that is responsible for logical thinking and decision making shuts down, and the “limbic system” (the emotional brain) takes over 29

30. What happens to the body afterwards ? When the threat has passed, the body tries to regain its natural balance Heart beat, blood pressure, muscle tension all come back to normal Is your body always able to regain its natural balance? 30

31. NO 31

32. What happens when the balance is not restored? The excessive energy that is released in the threatening situation often stays in the body and later appears as symptoms of stress Your blood pressure still stays high even if the threat has gone You stay alert without any reason (cannot sleep or relax) The body experiences pains for no reason The immune system is compromised 32

33. If the exposure to violence continues and threat is present; you might develop stress or Post Traumatic Stress Disorder depending on the extent of the impact on you 33

34. Post Traumatic Stress Disorder Definition 34

35. Post-Traumatic Stress Disorder Any physical, emotional, or psychological anxiety continued to be experienced after safety has resumed 35

36. Trauma can get stored in your body; WHAT THE MIND FORGETS THE BODY REMEMBERS Babette Rothschild 36

37. What are the symptoms of PTSD? Isolation Negative mood Negative thoughts Alertness without threat Avoidance of reminders of the incident Bad memories Nightmares 37

38. Normal Emotional Reactions to Traumatic Events Shock and disbelief Fear Sadness Helplessness Guilt Anger Shame Racing thoughts 38

39. Look at the graph and tell us if you think health care professionals in Karachi might be experiencing PTSD 39

40. Relational Trauma When your trauma is not understood When people around you say things about your job, such as “Why are you even bothered by what happened? Let it go,” it makes you feel misunderstood and may lead to isolation and/or not sharing your feelings 40

41. What can you do? Meditation Exercise (it helps release the stored energy) Mindfulness 41

42. Recovery tips Spend time with loved ones Connect with other survivors Take advantage of support groups, especially at your workplace Don’t try to force the healing process Sharing your experience helps Please reach out for professional help if symptoms persist 42

43. Activity Develop your own coping strategy: please write down two ways that you can reduce stress and the effects of violence on yourself and at the workplace 43

44. MODULE 4 Rights and Responsibilities of Health Care Providers in Violent Situations ) 44

45. Rights of Health Care Providers in Violent Situations These include the right: To be respected and protected To not be punished for performing your responsibilities according to protocols To not be forced to act in a manner opposite to the law and/or health care ethics To not be punished for disobeying an illegal or unethical order To maintain your general well-being; you should do everything to ensure your own safety, to not take unnecessary risks, get enough rest and know your limits 45

46. Responsibilities of Health Care Providers in Violent Situations “You must” in all circumstances: Not take unnecessary risks while performing your duties Provide effective care for the patient without any discrimination Respect every patient’s wishes, with confidence and dignity Refuse to obey orders that are unlawful or that force you to act opposite to health-care ethics 46