1. Action

2. ‘ACTION’ A practical approach and toolkit for managing conflict

3. Aims and Objectives Discuss background and development of guidelines and ‘tools’ for managing de- escalation. Have a framework for how to approach the challenges presented by patients who do not adhere to their management plan, refuse treatment or appear to be sabotaging attempts to help them.

4. Structure Presentation and discussion of some formal guidelines and tools for the management of agitation and conflict Discussion of their applicability and feasibility in your working environment What steps can you take to ensure their feasibility?

5. What is ‘challenging’ and where is ‘Conflict’ Eg. The angry, violent, aggressive, psychotic, difficult, challenging, sabotaging … etc ….patient Spectrum of ‘challenging’ (active  passive)

6. Context A move from traditional methods of restraint and involuntary medication to non-coercive approach. If done well, de-escalation to have significantly improved outcomes for all individuals involved in conflict in medical setting.

7. Limitations? Why might this field be under developed?

8. The basics: A three step approach to de-escalation 1- Verbally engage 2- Establish a collaborative relationship 3- Verbally de-escalate out of out agitated state

9. ‘Calming the patient’ vrs ‘helping the patient calm themselves’ Which and why?

10. 4 Objectives of de-escalation: Ensure safety of staff, patient and others in area Help the patient manage their emotions or distress or regain control of their behavior Avoid restraint if possible Avoid coercive interventions that may escalate agitation

11. Domains Environment People Preparedness

12. ‘Environment, People and Preparedness’ 1- Physical space and environment- Ensuring safety 2- Staff ‘qualities’ and ‘abilities’- Managing your own negative reactions and counter transference 3-Staff training – Akin to ILS/ BLS? 4-Adequate staff numbers 5-The role of ‘objective scales’ Feasibility in your working environment?

13. Discussion- Barriers? Feasibility? Your experience? Guideline: Physical space should be designed for safety (How?) Guideline: Staff should be appropriate for the Job (Who- attitude?- stepping outside of yourself) Guideline: Staff must be adequately trained Guideline: An adequate number of trained staff must be available Guideline: Use objective scales to assess agitation (e.g ABCS/ BARS- helpful?)

14. 10 domains of de-escalation to help practitioner's care of agitated patients To think about prior to the session ?

15. Summary 3 stages- engage  collaborate  de-escalate 5 domains- E,P,P 10 guidelines- A ‘toolkit’

16. Summary Verbal de-escalation techniques have the potential to decrease agitation and reduce the potential for associated violence, in the emergency setting. Paucity of work on verbal techniques + barriers to implementation Collaboration NOT coercion  reduction of coercive measures Empowerment, stay in control, and build trust Impact on future encounters, earlier help seeking and reduction in future episodes of agitation

17. Core references Richmond et al Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De- escalation Workgroup. Western Journal of Emergency Medicine. Vol. XIII No.1: February 2012. Violence: The Short-Term Management of Disturbed/Violent Behaviour in Psychiatric In-patient and Emergency Departments Guideline NCC-NSC 22/02/05 http://www.nice.org.uk/CG25 FEBRUARY 2005 Clinical Practice Guidelineshttp://www.nice.org.uk/CG25