Behavioral Escalations — De-escalation Strategies — Clinical Pathway: Outpatient Specialty Care and Primary Care

Behavioral Escalations Clinical Pathway — Outpatient Specialty Care and Primary Care

De-escalation Strategies

Partner with Family If the patient is escalating, ask parents/caregiver what has helped during an escalation in the past. Ask parent/caregiver if there is anything that could cause further escalations.
Respect Personal Space and Establish Verbal Contact
  • When a person is in distress, consider maintaining two arms lengths distance, an open-nonthreatening body posture and positioning yourself off to the side to help support safety.
  • Limit the number of additional staff in the room.
  • Only one person should speak with an escalated child at a time.
  • Multiple people speaking can be overwhelming.
  • Speak calmly, slowly and moderate the tone of your voice.
  • Ask the question, “will you let me help you.”
Environmental Adjustment
  • Dim lights and minimize unnecessary noise.
  • Consider noise reducing headphones.
Set Clear Limits and Be Concise
  • Use simple and concise age-appropriate directions and explanations.
  • Allow time for the child to process your question or commands.
  • Limit choices and lower demands during an escalated event.
  • Consider communicating limits in matter-of-fact way, not as a threat.
  • Choose your limits wisely, be flexible and avoid setting unrealistic expectations. If they do not accept the boundaries, it is ok to end the encounter and get additional help.
Validate Feelings and Provide Specific Praise
  • Restate or Paraphrase what you hear the child in distress say.
  • “What I hear you saying is" (repeat back what they said to you).
  • “Please tell me more so I better understand how to help you.”
  • Reinforce importance of feelings with statements such as, “That must be scary.”
  • Identify a positive behavior and provide specific praise. “Great job holding onto your dad.”
Empathic Listening
  • Provide your undivided attention, no multi-tasking during an escalation. Ask eliciting questions and make uninterrupted time to listen to the escalated person.
  • Validate concerns. Remain neutral and calm. Engage in a non-judgmental manner. “Tell me if I have this right…” (summarize what they have said)
Agreement
  • Remain professional and agree, or agree to disagree with three ways to agree.
    • Agree in truth. “Yes, the phlebotomist has stuck you 3 times. Do you mind if I try?”
    • Agree in principle. “I believe everyone should be treated respectfully.”
    • Agree with odds. “There probably are other patients who would be also.”
    • If you cannot agree, then agree to disagree.