Joint Commission Issues De-escalation Guidebook for Healthcare Facilities and Workers

By John Palmer

As patient violence in hospitals becomes more of an issue yet continues to lack a clear solution, healthcare administrators have begun to realize the need to teach workers how to prevent violence and defend themselves.

The Joint Commission has joined the effort by releasing a guide for healthcare workers designed to help them learn how to de-escalate aggressive behavior before it turns into violence.

The January publication, titled Quick Safety 47: De-Escalation in Healthcare, acknowledges that violence in healthcare settings is on the rise, so frontline staff need to know de-escalation techniques and solutions to quell potential violence and aggression.

“This issue focuses on managing aggressive and agitated patients in emergency departments and other inpatient settings,” according to a written statement from The Joint Commission. “For this Quick Safety issue, de-escalation is defined as a combination of strategies, techniques, and methods employed to reduce a patient’s agitation and/or aggression.”

The Joint Commission says de-escalation techniques can include communication, self-regulation, assessment, and safety maintenance to lower the chance of harm to patients, caregivers, and healthcare staff. In addition to explaining the importance of de-escalation, the guide presents de-escalation models and safety actions. It also provides workplace violence–related resources for staff training.

The problem of violence toward healthcare workers, and facilities in general, has heightened in recent years with increased incidence of active shooters in hospitals and gang violence. Workplace protection agencies and accreditation agencies have begun to take notice.

A 2014 report from the ECRI Institute found that as many as 80% of hospital staff have been “physically assaulted at least once during their career,” with nurses “at the greatest risk” for such assaults.

In 2015, the Occupational Safety and Health Administration (OSHA) issued an update to its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, known to many in the healthcare safety field as OSHA Rule 3148. The update was published to help facilities improve their preparations for violent incidents.

In addition, a study released in October 2018 by the American College of Emergency Physicians (ACEP) shows that violence in America’s emergency departments (ED) is increasing, causing harm to physicians, staff, and patients. Nearly half (47%) of emergency physicians report having been physically assaulted while at work, with 60% saying those assaults occurred in the past year, according to ACEP. Almost eight in 10 also say that patient care is being affected, with 51% of those saying that patients have been physically harmed.

The survey polled some 3,500 emergency physicians across the United States and painted a picture of violence against hospital ED staff that is growing worse. The trend is alarming, if not surprising, as healthcare safety experts have known for years that ED violence has been increasing, largely a byproduct of the opioid epidemic as well as the closings of mental and behavioral health facilities.

Assaults against nurses in particular have also been well documented. The Joint Commission literature cited a report from the CDC that indicated the greatest increases of violence have occurred against nurses and nursing assistants. In addition, a three-year study published in the American Journal of Nursing found that 25% of nurses reported being assaulted by patients or a patient’s family members.

The new de-escalation guide points out that there is no single best set of de-escalation tactics for every facility, and healthcare safety experts are divided on what should and should not be taught, as well as whether healthcare workers should be armed. That said, The Joint Commission contends that proper use of de-escalation tactics can have positive effects, including the following:

• Preventing violent behavior
• Avoiding the use of restraint
• Reducing patient anger and frustration
• Maintaining staff and patient safety
• Improving staff-patient connections
• Enabling patients to manage their emotions and regain personal control
• Helping patients to develop feelings of hope, security, and self-acceptance

Tips and advice for reducing violence

The Joint Commission’s advice notes that each area of the hospital has its own types of patients, and therefore potentially aggressive patients can have different signs. In the mental health setting, for instance, aggressive patients may be an everyday occurrence, including patients who exhibit risk-prone behaviors such as verbal or physical aggression, elopement attempts, self-harm, or refusing to eat or drink. In the ED, patients may present while hallucinating, hearing voices, or under the influence of unknown substances. The Joint Commission recommends that a triage nurse assess the patient on entry.

Most anti-violence training for healthcare workers centers around de-escalation techniques that focus on recognizing the signs of imminent violence, which could be as easy as reading a person’s body language. Most experts agree that 50%–70% of communication is non-verbal, so there’s a good chance that if someone is going to get aggressive, his or her actions will show it first.

Training for staff members has largely focused on learning verbal de-escalation tactics and providing staff members with logistical reminders, such as never letting a potentially violent patient get between them and their escape route.

While the Joint Commission literature stops short of recommending any one school of thought when introducing de-escalation tactics into a facility, the guide offers several examples of models in development. First is the “Dix and Page” model, which consists of three interdependent components: assessment, communication, and tactics. Next is the “Turnbull, et al.” model, which requires the de-escalator to continually monitor and evaluate the aggressor’s response to de-escalation skills.

“The authors stress that flexibility in individual cases is more important than basing de-escalation on a few well practiced skills, or using those skills in a pre-determined order, since what may be de-escalatory for one person may be inflammatory for another,” the guide reads.

Still another is the “Safewards Model,” which instructs moving the aggressor (or other patients) to a safe area and maintaining a safe distance; clarifying the reasons for the anger using effective communication; and resolving the problem by finding a mutually agreeable solution.

Most safety experts agree that effective interventions for de-escalating potentially violent situations include the following:

• Recognize nonverbal body language known as “behaviors of concern” that can precede actual violence. If caught early, de-escalation tactics can be used to nip the situation in the bud. Keep alert for telltale signs of stress and anxiety, including raised voices or fast talking, clenched fists and teeth, glaring eyes, and fixed or darting stares. These behaviors of concern work on a sliding scale and can usually be defused with simple tactics such as calming talk, offering a glass of water, or allowing the person to sit in a quieter area to relax.
• Use clear and calm verbal communication, maintaining a non-confrontational attitude and using words that are easy to understand—that means no abbreviations or healthcare terms.
• When approaching the patient, use non-threatening body language and demonstrate empathy and respect.
• Use risk assessment tools for early detection of potential violent or aggressive behavior and intervention. Many violent acts against healthcare workers are from “frequent flyers” who have committed such acts before. By tracking these individuals and keeping up-to-date records, healthcare workers can have the advantage.
• Practice and provide staff education on de-escalation techniques. Staff members should participate in drills that simulate violent acts so they can practice before violence happens for real.
• Respond to the patient’s expressed problems or conditions to help create a sense of trust. Teach healthcare professionals that they don’t always know better than the patient, even if they do have more training.
• Set clear limits for patients to follow, and don’t tolerate it when those limits are breached.
• Implement environmental controls such as minimizing harsh lighting, noise, and loud conversations. Many hospitals are creating behavioral health units—and more patient treatment areas in general—that boast high ceilings, open areas, and large windows that allow more natural light to come in. Some hospital waiting rooms are being designed with a living room feel, with comfortable furniture and fireplaces, as well as showers and video game areas, to create a less-threatening environment for those who may be subjected to longer stays.

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.