Beyond Customer Service
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ASSESSING AND MANAGING DISRUPTIVE PATIENTS
KATHRYN GIFT DNP, RN, CEN
Objectives
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 Discuss the 3 elements that interact in a violent
situation with emphasis on the most unpredictable
element.
 Summarize the different levels of stress and
intervention that can be used at each level of stress.
 Demonstrate customer service, verbal/nonverbal
interventions, and limit setting techniques that may
be deployed to de-escalate disruptive behavior.
Workplace Violence
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 “ Violent acts ( including physical assaults and
threats of assaults) directed toward persons at work
or on duty” National Institute for Occupational Safety and Health (NIOSH)
 2011-2013 workplace assaults ranged from 23,540
and 25,630 annually, with 70-74% occurring in
healthcare and social service settings.
 Assaults comprise 10-11% of workplace injuries for
healthcare workers compared to 3% in private sect0r
Bureau of Labor Statistics and National Crime Victimization Survey
(www.bjs.gov/content/pub/pdf/wv09.pdf)
Workplace Violence
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 Health Care workers are 16x more likely to
experience violence than other service workers.
 Over 50% of workplace aggression claims come from
the health sector.
Workplace Violence in the Health Sector- State of the Art
World Health Organization 2002
 24% of all female deaths in the workplace are the
result of homicide National Crime Victims Survey; Workplace Violence,
2006
Subtle Forms of Violence
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Predatory vs. Affective Violence
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Violence Risk Factors
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Decrease
 Values/beliefs against




violence
Intact thought
processes/ judgment
Appropriate emotional
control
Non-violent resolution
skills
Undesirable outcomes
Increase
 Predisposing Factors
 Internal qualities/
characteristics
 Things we bring into the
situation ( our baggage)
 Precipitating Factors
 Elements external to us in
the environment or
situation
Predisposing Factors
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 History of Past Violence
 Active Substance Abuse
 Weapons Accumulation
 Financial Stress
 Viewing the World as Hostile
 Social History, Past Experience
 Loss of Inhibition
 Confusion or Disorientation
Predisposing Factors
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 Inability to Bond with Others
 Misperception of Danger
 Problems Regulating Behavior
 Hopelessness or “Nothing Left to Lose”
 Means to an End
Precipitating Factors
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 Loss of Control
 Loss of Identity
 Loss of Privacy
 Loss of Dignity
 Loss of Independence
 Loss of Choices
 Fear of Pain
 Today’s Precipitating Factor May Become Tomorrow’s
Predisposing Factor
Ongoing Interactive Assessment
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Other’s Body Language: Non-Verbal
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 Fearful or Anxious Appearance
 Agitated or Angry Posture
 Lewd or Inappropriate Staring
 Acting Suspicious or Hostile
 Appearing Stressed or Threatened
 Angry or Sexually Inappropriate Gestures
 Behavior Doesn’t Match What is Being Said
Other’s Verbal Behavior
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 Talking Loudly/Shouting
 Cursing/Swearing
 Tone of Voice
 Claims of Mistreatment
 Sexually Inappropriate Comments
 Challenging, Threatening Others
 Blaming Others for Problems
 Stating a Plan of Intent to Harm Others
Stress Levels
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Stress Levels
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Normal/ Mild Stress Level
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Normal Stress Level Intervention
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Normal Stress Level Intervention
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 Allow Person to Express Concern
 Use Shared Problem Solving Approach
 Demonstrate Empathy
 Be Active Listener
 Avoid Being Defensive
 Apologize if Appropriate
 Follow Through with Their Problem
 Avoid Blaming Others or “Not My Job”
Moderate Level of Stress
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Signs of Moderate Stress
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 Looking Anxious, Lost or Confused
 Mild Voice Changes
 Higher/louder/faster speech
 Small Nervous Habits
 Drumming fingers
 Tapping foot
Moderate Stress Level Intervention
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Moderate Stress Level Intervention:
Verbal De-escalation
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 Encourage Person to Talk and Share Experiences
 Validate the Person’s Experience
 Ask Open Ended Questions
 Restate, Reflect, Clarify
 Suggest Collaboration
 LISTEN
Moderate Stress Level Intervention:
Verbal De-escalation
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 Present Reality Supportively
 Identify the Problem
 Focus on Problem Solving
 Give Information
 Provide Alternatives
 Summarize
 Create an Action Plan
Moderate Stress Level Intervention:
Verbal De-escalation- NON VERBALS
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 Remain Calm and in Control
 Maintain Personal Space
 Supportive Body Language
 Demonstrate Empathy
 Convey Willingness to Help
 Show Open Hands
 Non-threatening Eye Contact
Severe Level of Stress
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Signs of Severe Stress
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Non Verbal Signs
Verbal Signs
 Threatens others
 Approaching/avoiding
 Increasing loud or

boisterous behavior
 Cursing, swearing ,
argumentative




others, pacing
Invading personal space
Nonresponsive to directions
Uncharacteristic behaviors
Slamming doors/pushing
furniture
Behaving inappropriately for
the situation
Severe Stress Level Intervention
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Severe Level Intervention: Limit Setting
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Limits are:
 Simple and Direct
 Describe the Desired Behavior- Giving Options
 Appropriate to the Situation- Stating Consequences
if Needed
 Progressive in Nature
 Enforceable

You need to be clear, calm in demeanor, nonthreatening,
encouraging, firm yet supportive, respectful and civil, AVOID
POWER STRUGGLES
Severe Level Intervention: Limit Setting
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 Is an Advanced form of Verbal De-Escalation Skill
 Different than customer service
 Takes PRACTICE
 Requires keen self-awareness
Panic Level of Stress
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Panic Stress Level Intervention
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Panic Stress Level Intervention
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 Personal Safety Skills
 “Take Down”
 Follow facility policy/training
Tension Reduction
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Tension Level Interventions
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Tension Reduction Intervention:
Therapeutic Rapport
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 Support De-escalation/Calming
 Protect Dignity- help “Save Face”
 Monitor Stress Level
 Remember
 Even if you never see this patient again, SOMEONE ELSE
WILL!!
Scenario
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 A customer walks into your workplace. His/her face
is flushed and jaw is clenched. S/he states, “ I can’t
believe this place! My doctor tells me I may have to
go into the hospital for more tests & keeps me so late.
I need to go to the lab, bet anything it is closed or
another long line. I can’t even find it and no one will
help.
 What level of stress, What can be your response?
Scenario
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 You hear a loud voice in your workplace. You go to
see if you can help, and you see an angry person
pointing his/her finger at your co-worker’s face,
stating “listen, I don’t need a map, I just need to
know where my appointment is!! What is wrong with
you people? Can’t anybody find anything around
here?! Your co-worker appears frozen and stunned
by the outburst, unable to get the angry person to
calm down.
 What is the level of stress and what is your response?
Resources
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 Guidelines for Preventing Workplace Violence for
Health Care and Social Service Workers,
Occupational Safety and Health Administration
(OSHA), OSHA 3148-04R 2015
 Hills, D.J, Ross, H.M., Pich, J., Hill, A. T., Dalsbo,
T….. Martinez-Jarret, B. (2015). Education and
training for preventing and minimizing workplace
aggression directed toward healthcare works. The
Cochrane Library.