Calm your farm! De-escalation strategies for potentially violent situations in the emergency department

Karen Thompson1

1 RN, Grad Dip (Emergency) Certified instructor (Non-violent Crisis Intervention) | North West Regional Hospital, Burnie TAS 7320

A common public perception of nursing is “the caring profession”, yet ironically, nurses are at ever-increasing risk of exposure to violence in the workplace, and the emergency department is identified as a high risk environment. Indeed, a study conducted by in 2006 found that 63.5% of Tasmanian nurses reported being subjected to some form of work-place violence in the previous four weeks and it is documented as a major stressor contributing to challenging working environments and high turnover.

Today, I’m going to discuss a situation which is challenging from both an environmental and personal perspective, how one challenging situation generated another and the strategies employed to address both.

Obviously action was needed to address this problem and research led to the adoption at my workplace of a program known as Non-violent Crisis Intervention (NVCI). In a perfect world this would seem to be the answer, however the introduction of the program created challenges in itself. Once the preliminary structure of the program was in place, all staff were emailed and either appointed or invited to attend a session – a method which created immediate resistance in many quarters. The primary concern expressed by many nurses was that they would be engaging in some form of hand to hand combat, generated by the historical mindset that Code Black = forcible take-down. They, quite reasonably pointed out that these situations were outside their scope of practice.

Paradoxically this unfavourable situation provided unexpectedly positive outcomes, as it challenged me to find cohesion and acceptance of the program. I used servant leadership theory to support pace-setting leadership as I assured my colleagues that I too am disinclined to be wrestling with aggressive individuals

A full-day workshop format was developed and with no pre-reading or preparation required, staff attend with, hopefully, an open mind, although this is often not the case. During the workshops, interactive learning sessions are presented, covering stages of agitation, the verbal escalation continuum and identifying precipitating factors for deteriorating situations. We focus on understanding and intervening appropriately to certain behaviours rather than making the individual cease the behaviour. Role playing and activities complement the sessions, enabling the staff to experience the situation from the perspective of the person in crisis and learn and practice personal safety techniques. All sessions are underpinned with the message of Care, Welfare, Safety and Security of all, reminding staff at all times that the acting-out individual is a person in crisis; they have no control so the staff member must maintain control of him/herself.

Given that increasingly violence is a global problem – think road-rage, trolley-rage and similar phenomena – the challenge of being faced with violence in the workplace is not going to disappear overnight. As more staff complete the NVCI program, with overwhelmingly positive feedback, the objectives that staff will be equipped with advanced de-escalation skills and more likely to report incidents, leading to a safer workplace environment, are being met. This has generated several recommendations, primarily that NVCI training be adopted for all staff – clinical and non-clinical – as part of mandatory credentialing, and that the name be changed from Code Black Training to NVCI Education


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Karen has a varied background over the past 35 years, beginning her nursing career as a mental health nurse under the “old system” in the early 1980s. She returned to study at the University of Canberra in 2000, to complete a Bachelor of Nursing.  She has worked in the emergency department for over seven years after extended stints in remote health and ICU nursing. She has also practised in women’s health, general practice and drug and alcohol programs. Karen has recently diversified into teaching as a certified instructor in non-violent crisis intervention and works as a sessional teacher of the Diploma of Nursing at TasTAFE. Her other qualifications include Grad Certs in both Critical Care and Rural and Remote Health, as well as a Grad Dip in Emergency Nursing and expects to complete her Masters of Clinical Nursing degree in October 2016. Karen’s clinical interests are education, crisis intervention and an intense fascination with the pathophysiology of trauma, particularly brain injury.Her personal interests include a passion for travel and study of languages, animal welfare, playing netball, volleyball and softball, loud rock music and maintaining an organic mini-farm. Not least, she enjoys spending time with her family and spoiling her four grandchildren, and her greatest supporter through all her academic achievements is her husband David.