1. The Cognitively Impaired Patient and De-Escalation skills.

2. The Recipe.
When we talk about aggression and Violence in healthcare we talk about the recipe:
The Ingredients:
The Client.
The Staff member.
The environment.
The interaction.

3. Client Factors.
Frustration. Unable to have needs met due to numerous reasons, inability to communicate effectively, Poor speech ability etc.
Pain, being too hot or too cold, uncomfortable.
Paranoia, Hallucinating or Delusional.
Feeling confused, loss of control or empowerment.
Fear. Trigger of bad memory or event from the past. Uncertain about what is currently happening or about to happen.

4. Staff Factors.
Staff-Staff behaviour is a crucial point where the prevention of Aggression and Violence is initiated. Many health professionals will experience huge workloads, pressures and can be highly stressed. (Duxbury and Whittington 2005)
Often general ward type settings can be very task orientated and can more often then not revolve around the ward routine as opposed to the routine of the client. In a designated dementia unit routine is important but it must be patient centred where possible.

5. For many staff their choice of response could greatly determine the safety of themselves and others and profoundly affect their relationship with those they care for and their colleagues. (Linsey 2006)
It is very important that if a staff member has been assaulted or hurt in the past that they have been adequately looked after e.g. supervision, time off etc as this can impact they way the react in future similar situations e.g. Under-react or over-react.

6. The Interaction.
Although many aggressive states are influenced by a persons mental state many violent incidents are not caused by the fact that someone is unwell mentally but that ‘normal’ interactional process stimulate both parties and conflict arises. Whittington and Richer
The humour/mood the staff member and the patient when the patient approaches them or when they approach the patient will often determine how that interaction will go.

7. The Environment.
Noise levels in a ward or unit can greatly impact on both staff and patients particularly if patients are hard of hearing or have cognitive difficulties.
The Decor: If a ward or unit has loud bold colours or paintings and furnishings can over stimulate people.
Try to use calming relaxing colours and furnishings, bed linen and curtains etc, aromatherapy or relaxation or music on low in the background can instil a calming atmosphere on the ward for everybody presant.

8. De-Escalation is defined as:
“To reduce the level or intensity of (a crisis,etc)”
“To decrease in intensity, magnitude” (Collins 2015)

9. De escalation for Cognitively Impaired Patients.
Knowing your patients full history likes and dislikes and triggers for frustration or anger should be communicated effectively among the people working with the patient daily e.g. nurses care staff possible cleaning staff if going into a room alone....Prevention and care planning is better than dealing with the aftermath.
Personal space varies from person to person but we normally advise arms length or double that if a person has a history off aggression or hitting out.

10. De-Escalation for Cognitively Impaired Patients.
Body posture and Movement.
Observe for the patients facial expressions and hand positions. Be aware of your own. All movements should be slow and gentle if someone is becoming very agitated.
Distraction techniques, talking, reminiscence, looking at photos etc.
If two people or three are required to safely and effectively deliver personal care to a patient who becomes very agitated and violent towards staff then staff need to be made available for that amount of time to complete bathing/changing/shaving/dressing etc as this can be both distressing for the patient and staff if trying to manage a patient who is fearful and lashing out and going against staff.

11. Non -Verbal techniques.
Lowered, uncrossed arms with open hands. A relaxed appearance- given by head posture and gaze of eyes. Upright position of the head- subtle tilts to the left and right. Active and empathic listening. All gestures should be slow and gentle. Distance should be provided and space if necessary.

12. Resolving conflict using models of communication PALMS
Position.
Attitude.
Look and listen.
Make space.
Stance.

13. Further De-escalation techniques.
Assess the patients emotional state.
Identify trigger factors.
Reassure to reduce anxiety.
Talk/Listen. Watch the rate and tone of your voice.
Problem solve.
Keep a relaxed and alert posture.
Allow space and time back of for a while if needs to be...can the task be done later??
Stand side on to protect yourself when in close proximity.
Breakaway techniques or emergency responses if required. (Practical part of the course)

14. DO NOT!! Show hostility. Use provocative language.
Show signs of irritation.
Adopt a square on stance.
Behave in an overly authoritative manner.
Sometimes you need to be the bigger person if a patient has a particular dislike to you or another staff member than maybe it is better if that staff member swaps with another member to deliver that particular piece of nursing care....we don’t always get on with everyone its human nature and personality clashes happen in all walks of life even if we have done nothing and the patient just happens to have taken a dislike or are paranoid about someone sometimes we just have to accept that for what it is without taking it personally.

15. Important to note.
As a patient becomes very aroused and agitated their body changes physiologically when responding to a perceived threat.
This is known as the flight or fight response.
These responses may inhibit the ability for effective communication such as verbal de escalation.
It also impairs information processing and decision making.
When the arousal peaks they can lose control of their impulses resulting in physical aggression.
Space and time and adequate staffing if personal care is to be provided during this time.

16. Any questions??