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					                                                    Initiated 03/2001; Revised 04/2004; Revised 06/2005



                          ECHO Community Health Care, Inc.
                               Policy and Procedure
          CARE PROVISION GUIDELINES FOR AGGRESSIVE PATIENTS

PURPOSE: To outline proper guidelines for handling situations with aggressive patients.

POLICY: Staff safety is ECHC’s top priority at all times for both clinic and outreach staff.
In order to maintain staff safety, ECHC is committed to providing guidelines to enable all
staff to handle situations with aggressive patients in a professional and sensitive manner.

PATIENT STRESS AND SPECIAL EXTENUATING CIRCUMSTANCES: ECHC patients
often experience adverse conditions on a daily basis. Many patients have experienced these
conditions since they were young and have been exposed to a variety of things from an early
age. Stressful living situations break down morale and social behaviors such as courtesy and
patience. It can be challenging to work with patients who have experienced these
circumstances.

Many patients have also interacted frequently with private and public agencies to have their
basic needs met. This process is often long and frustrating. The patients have to answer a
series of personal questions and provide documentation regarding their household and
income. Due to these circumstances, by the time they arrive at ECHC they may react
negatively towards requests or instructions.

Although a patient’s negative behavior may appear unwarranted, this behavior may be a
learned survival technique and a way of coping with daily living. Some patients have found
that aggressive, demanding behavior will get their needs met. ECHC staff members must
interact with these patients in a professional and sensitive manner while adhering to the
policies and procedures as set forth by ECHC.

It is important not to take a patient’s behavior personally. Regardless of the patient’s actions,
it is imperative that the reaction of staff members does not encourage further negative
behaviors or responses. Staff shall employ the simple intervention strategies set forth in these
guidelines when a patient begins to act inappropriately in either the clinic or outreach
environment.

GUIDELINES FOR ADDRESSING AGGRESSIVE PATIENTS: Strategies for dealing with
aggressive individuals are best formulated around the principle of the least restrictive
measure. This means beginning with the least invasive tactic for subduing the aggressor and
not advancing to the next level of restriction unless absolutely necessary.

The three levels of intervention are:
       1. Prevention - anticipating the behavior and taking measures to prevent the
           escalation of negative behavior. This can be done by an early assessment of the
           situation at hand. ECHC staff members may ask the following questions:
           a. What are the patient’s needs?
           b. Can ECHC meet these needs?

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                                                                                         Section 4-5
                                                   Initiated 03/2001; Revised 04/2004; Revised 06/2005


          c. If not, what options can ECHC offer the patient? (i.e. speaking with the
              supervisor)
          d. Is there another facility that can assist the patient? (i.e. make a referral for the
              patient at that facility)
          e. Would a different appointment time better suit the patient’s needs?
       2. De-escalation of tension – the listening skills of therapeutic communication are the
          most effective tools in decreasing a patient’s level of anger and averting
          potentially violent behavior.
       3. Action aimed toward safety of all individuals involved – decreasing the patient’s
          sense of powerlessness or helplessness in order to minimize the patient’s
          frustrations.

ECHC’s goal of preventing violent behavior can be achieved by effectively employing four
skills:
        1. Observing the patient’s behavior
        2. Skilled listening when listening to the patient’s concerns
        3. Discussing the patient’s concerns with him/her
        4. Taking action to address the concern as appropriate

WARNINGS THAT SIGNAL ESCALATING TENSION:

   Defiant attitude
   Excessive swearing
   Aggressive motions
   Unusual demands
   Increase or decrease in voice volume
   Challenging demeanor
   Tightening of jaws
   Deep sighs
   Fidgety movements
   Rapid pacing
   Clenched fists
   Advance or retreat actions

TIPS FOR EFFECTIVE LISTENING:

ECHC staff members shall:
 Tune in to their personal anxiety levels and be aware how their anxiety level will
  negatively affect the situation at hand.
 Listen to what the patient is saying.
 Acknowledge the patient’s feelings by using statements such as:
      - “You seem very upset.”
      - “I can see your situation is very difficult.”
      - “I’m concerned that your behavior is affecting others.”
      - “I’m concerned that you might hurt yourself or others here.”



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                                                                                        Section 4-5
                                                    Initiated 03/2001; Revised 04/2004; Revised 06/2005


   Ask open-ended questions to elicit more informative responses than a simple yes or no
    answer.
   Identify the patient’s anxiety or anger by defining the real issue and determining what is
    causing the anxiety or what is behind the anger.
   Demonstrate the appropriate affect by being sincere and assertive.
   Convey calmness, control, and a willingness to help.

TIPS FOR DISCUSSING A PATIENT’S CONCERNS:

   Demonstrate a positive regard and respect for others.
   Keep a low voice tone that is calm and soft, yet firm.
   Simply state the facts by using simple, direct statements and, if necessary, repeat them.
   Do not offer lengthy explanations or excuses.
   Ask, “What can I do to help?”
   Ask the patient what he/she would like to have done so the issue can be resolved.
   Offer the patient choices and alternatives when possible.
   Encourage the patient to verbalize anger rather than acting out.
   Express limitations when a patient’s language becomes offensive.
   Provide reassurance while setting limits.
   Identify behavioral expectations in a kind manner.
   Do not offer placating responses such as: “Everything will be ok.” or “You are not the
    only one.”
   Do not make promises that can not be kept.
   Never challenge, criticize, or laugh at the patient.

TIPS FOR TAKING ACTION REGARDING A PATIENT’S AGGRESSIVE BEHAVIOR:

   Communicate to the patient that he/she is responsible for his/her own actions.
   Follow instinct and intuition.
   Use common sense.
   Detect danger signals.
   Maintain safety for all those involved by leaving doors open, identifying an escape route,
    keeping furniture positioned with safety in mind, and accessing the environment for
    potential weapons.
   Protect others in nearby surroundings.
   Ask the patient to sit down.
   Establish and maintain eye contact.
   Observe social distance. Do not touch the patient or make any threatening gestures.
   Decrease environmental stimuli by minimizing the presence of staff, other patients, and
    distractions.
   Promote quiet voice tones.
   Promote privacy.
   Meet the patient’s requests as appropriate.
   Do not analyze or interpret the patient’s motivation.
   Do not ignore the patient.



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                                                                                         Section 4-5
                                                    Initiated 03/2001; Revised 04/2004; Revised 06/2005


PROCEDURE:

A. ECHC staff shall interact with all patients in a professional and sensitive manner.
B. If a patient shows signs of aggression, the staff member will make arrangements for
   conversing with the patient in a private setting, away from the lobby or any other public
   area.
C. The staff member will attempt to de-escalate the situation by utilizing the tips set forth in
   these guidelines.
D. If the patient’s aggression level does not decrease or if the aggression increases, the staff
   member will contact his/her supervisor to assist with the situation.
E. If at any time the staff member feels his/her safety has been threatened, the staff member
   will alert others for additional help by identifying the Code (Hazel) in the walkie-talkie,
   phone, or in a loud voice. The staff member shall also identify the location so others
   know where to respond.
F. The authorities will be called as appropriate.
G. The situation will be reviewed by those involved and a case conference will be held as
   necessary.
H. Staff will refer to the policy on TERMINATING THE PATIENT RELATIONSHIP AT
   ECHC as necessary.




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                                                                                         Section 4-5

				
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