11 Steps of Verbal De-Escalation

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Guiding Principle:
Trauma causes changes in brain structure and reactivity. Escalation is developed, not chosen.
• Verbal De-escalation Course Videos
• Verbal De-escalation Course Handouts

  1. Personal Response
    Self-calming to keep your fight-or-flight response at bay:
    • Focus on the breath for 3 breaths
    • Relax body
    • Soften gaze

    Body Language:  
    • Relaxed, open stance 
    • Body turned slightly
    • Hands open
    • Good eye contact
    • Concerned look

    Self-talk about this being an escalating situation:
    • You have the skills to manage this
    • The person is obviously feeling scared, out of control, powerless, or disrespected and you have the ability to help
  2. Personal Space
    • Anxiety increases a person’s personal space bubble
    • Move slowly and ask to enter space, even if you think it is assumed, (e.g. a patient who you have been caring for)
    • Steer clear of legs and arms
    • Sometimes the opposite side of the room is close enough
    • Ask permission before touching personal belongings 
  3. Establish Verbal Contact
    • Pleasant greeting to everyone
    • Use names. Find out what they like to be called
  4. Be Concise
    • Because the limbic system is firing, it may take extra time and effort for your patient to process information
    • Use few words and repeat the same words; do not change your words
  5. Identify Wants & Feelings
    • Sometimes the story a patient tells us has little to do with the emotion they’re feeling
    • Really listen for the emotion, not the story
    • Listen for fear, disrespect, or loss of control
  6. Active Listening
    • Allow silence
    • Let the person vent
    • Ask clarification questions
    • Give validation surrounding the emotion
  7. Set Limits
    State the inappropriate behavior that is occurring:
    • Be direct and firm but unemotional – tell the patient to stop the behavior if it is dangerous or inappropriate
    • It is important that you appear very indifferent
    • Maintain a quiet voice and calm demeanor

    When-then statements: 
    • When [positive behavior change happens], then [positive outcome] can happen
      Example: “When you put your clothes on, then we can get you a juice."
    • State as if you are on your patient's side and you know they will be able to change. You are rooting for their outcome
      The "then" has to be beneficial to the patient

    If-then statements:
    • If [negative behavior does not change], then [negative outcome] will occur
      Example: “If you don’t stop screaming, then we can’t have a conversation about your pain.”
    • This is a statement of consequence
    • It has to be stated as if you will be disappointed by the then as well
    • There can be no tone of authority or control when making this statement
  8. Agree or Agree to Disagree
    • Agree with the emotion
    • Give information, answer questions if related to care
    • Do not reinforce negative or potentially false statements
    • Do not argue or defend
    • Disregard lewd comments or cursing – continue setting limits to control situation
    TAKE ALL THREATS SERIOUSLY – if threatened, leave and report
  9.  Know When to Call for Help
    • When de-escalation efforts are exhausted 
    • When a threat occurs
    • Follow the Tiered Response Plan
  10. Debrief
    • This step must be done to break the cycle – the patient’s truth must be considered and respected-
       consider a plan with the patient’s truth
    • Wait for all involved to be calm
    • Get the story from everyone, including the patient
    • Everyone’s truth is valid, including the patient
    • Give the patient a job to do, take control of their situation, let you know well before they are out
      of control that they are escalating
    • Help patient identify triggers (Tool: My Health Passport)
    • Help connect the patient back to emotions and responses:
      - Ask what they were feeling, what they heard or saw that created the response
      - Ask if the emotion commonly causes that response
      - Ask what could be done next time
      -Tool: Behavioral Health (flipbook / pdf)
    • Document– this must be charted and passed on
  11. Reflection
    • Report all threats, violence or perceived violence through Veritas
    • De-brief with charge nurse, CSL, or other leader (Tool: TeamSTEPPS Debrief Checklist)
    • Take a mindful break, breath, stretch, leave unit if able to get coverage for patients (Tools: Work/Life Connections-EAP)

Verbal De-escalation Post Test