and non‐verbal cues that could inform your decision regarding which de‐escalation strategy to use.
Use active listening to identify the patient's concerns.
Following initial assessment, suggest a quieter area if it is safe to do.
Use your fundamental communication skills, and ensure that you speak slowly and calmly using VAPER (volume, articulation, pitch, emphasis and rate; Nelson‐Jones 2014) to ensure that you communicate in a calm and caring manner.
Maintain an open, non‐threatening posture and encourage the patient to sit if currently standing, then ensure you follow SOLER (see Table 4.3; Egan 2014).
Adjust your body language to ensure that you are expressing concern and support for the patient (Figure 5.3).
Maintain appropriate social physical distancing; closeness could aggravate the aggression.
Engage in shared ownership of the problem and work towards attaining a solution together.
Once a solution has been found, reiterate your actions and the dates and times you will provide the patient with this information.
If a solution is not found, continue to monitor cues whilst attempting to gain a resolution.
If the patient then moves from early warning signs to danger signs of risk (Table 5.1), remove yourself from the situation and involve colleagues as appropriate.1
Red Flag
Sudden change in consciousness level should be escalated immediately.
If you perceive changes in behaviour to be threatening, remove yourself immediately.
References
1 Egan, G. (2014). The Skilled Helper: A Problem Management and Opportunity Development Approach to Helping, 10e. California: Brooks‐Cole.
2 Emergency Workers (Offenses) Act 2018 c.23. https://www.legislation.gov.uk/ukpga/2018/23/contents/enacted/data.htm (accessed 17 May 2021).
3 National Institute for Health and Care Excellence (2015). (NG10) Violence and Aggression: Short‐Term Management in Mental Health, Health and Community Settings. London: National Institute for Health and Care Excellence.
4 Nelson‐Jones, R. (2014). Nelson‐Jones' Theory and Practice of Counselling and Psychotherapy, 6e. London: Sage Publications.
5 Nursing & Midwifery Council (2018). Professional Standards and Practice of Behaviour for Nurse, Midwives and Nursing Associates. London: Nursing & Midwifery Council.
6 Sookoo, S. (2018). Identifying and managing risk of aggression and violence. In: The Art and Science of Mental Health Nursing: Principles and Practice, 4te (eds. I. Norman and I. Ryrie), 222–238. London: Open University Press.
Note
1 1 It may be that you feel it is outside of your skillset to reach a resolution. In this instance you may want to hand over care to a more experienced colleague. You may also find yourself in a situation where you feel risk is imminent. In this instance, extract yourself and call for help. This may involve using a silent panic button.
6 Communication – difficult conversations
Background
Working effectively in healthcare requires handling a wide range of conversations daily. Most people accessing the health services are experiencing stress and anxiety that come from uncertainty and loss. It is not always clear what will become a difficult conversation and, conversely, what will turn out to be easier to talk about than we would have expected.
Fear of the unknown regarding how a conversation might go is often the key factor that results in healthcare professionals avoiding initiating conversations they feel might be difficult. Preparing yourself and attentively listening can help you to approach and navigate these conversations.
Professional Approach: Preparing Your Self
Preparing for having these conversations is of fundamental importance. Ensure you are prepared for them to happen as a normal part of daily practice, observe others, and, as with any difficult skills, take the opportunity to practise whenever you can.
Engaging in healthcare communication is hard emotional work. Recognising this and understanding the need to develop ways of managing the emotion this causes are important. Suggestions include self‐care, developing relational skills, maintaining an empathic presence, taking a team approach, and retaining a professional identity (Luff et al. 2016).
Influencing Factors: What Conversations Might Be Considered Difficult?
Cancelled treatments.
Communicating with relatives.
Complex health promotion discussions.
Conversations around costs.
Life‐changing diagnosis.
Lost belongings.
Managing cultural differences.
Unexpected deterioration.
End‐of‐life conversations.
Influencing Factors: Requisite Qualities and Skills
1 The ability to listen.
2 A compassionate approach.
3 The courage to start or engage with conversation that maybe difficult.
4 The skills to manage a conversation that may involve a range of emotions.
5 An ability to be comfortable with silence.
Procedure: Breaking Bad News
In healthcare education we often talk about the need for “breaking bad news training”. It is important to be cautious with regard to making assumptions about what is bad news for another person. Sometimes a diagnosis can be a relief after months of uncertainty and symptoms. Sometimes the person has known for a while and it is a relief to be able to talk about it with someone else. Approaching these conversations can still create anxiety,
