The combination of pain, stress, uncertainty, and a lack of control can be a recipe for conflict. Think about the times in your career you’ve heard things like, “What are we waiting for? Why aren’t you helping me? Do you know what you’re doing? When is the doctor coming? This is ridiculous.”

We encounter difficult patients and experiences all the time. Because of the additional stress that the medical or hospital setting can induce, small stressors can become escalating and potentially dangerous situations. When patients are scared, anxious, or in pain, otherwise benign miscommunications can be amplified. Conversations can quickly become confrontations.

Therapeutic conversations are part and parcel of a nurse’s daily work. One of the most important things we do for our patients is communicate. As the nurse, we often act as liaisons between family, patients, and physicians. Good communication can be the difference between a good interaction and a poor one. Preventing escalating behavior before it starts can keep everyone safe.

Naturally, you cannot control other people’s behavior, but you can control your response to it. Below are some tips for how to defuse and de-escalate conflict interactions.

Start with empathy. When someone first starts to become anxious or upset, try to start by considering why. Are they in pain? Are there precipitating factors that are contributing to their outburst? Try to use your active listening skills to show the person respect. Reflect back to the patient, repeat what they are saying, and really put yourself in their position.

Stand back. Have you ever heard that communication is 7% verbal and 93% nonverbal? Uncross your arms, use an open body stance, and position yourself in a respectful and non-confrontational pose. Approach patients from the side, and try not to back anyone into a corner. Maintain a safe talking distance. Most people are more comfortable with about three feet of buffer.

Be mindful of how you say it. Verbal communication encompasses tone, inflection, and volume. When someone begins to escalate a situation, be sure to use a slow, calm, and low volume for communication. Matching their aggression does not help defuse a situation.

Set limits. When patients get upset or defensive, sometimes it is because they are seeking information. Try to provide information about their care or answer their questions within the context of limits. For example, a statement such as, “When you keep your voice down, I will be able to tell you why we are waiting” can help set expectations of behavior.  

Drop your own defensiveness. When a patient starts to get anxious or upset, he or she tends to act irrationally and become very defensive. When someone lacks a sense of control, he or she may start yelling or start actively refusing the plan of care. When you in turn become defensive, this only matches their energy and leads to even greater irrationality. Try not to take actions or words personally and remember to maintain professionalism.

Know when to remove yourself from a situation. There are many reasons that you may need to get a coworker or teammate to “tap in” and help you with a situation. If you are ever truly feeling threatened, do not handle the situation alone. Keeping yourself and your patient safe at all times should be your main priority. 

De-escalating anxious or tense situations helps prevent violence or conflict and keeps everyone—staff and patients alike—safe. There are several courses available for certification in therapeutic interventions and crisis prevention. Visit the Crisis Prevention Institute to learn more.

Laura Kinsella

Laura Kinsella, BSN, RN, CEN, is an emergency room nurse in Washington, DC.

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