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OVERT - Classroom Version

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by

April Boyde

on 11 September 2014

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Transcript of OVERT - Classroom Version

O.V.E.R.T.
Please speak with an instructor if you have any physical limitations that will prevent you from participating fully in our physical exercises.

If your condition is temporary, please come back at a time when you are able to practice the techniques with the class.

If you are unable to practice and demonstrate more than 2 of the activities, we will notify Occupational Health (and from there your manager and HR).
At the end of the class, you should be able to:

-Understand the importance of effective communication techniques in the prevention and diffusion of potentially violent situations.


-Use a team approach to diffuse hostile situations.


-Describe the concept of perceived threat


-Demonstrate techniques for evading physical holds.
Objectives:
Early recognition
of the warning signs is the key to preventing or mitigating workplace violence.
Concept Refresher:

Prevention, Intervention and Response

Action Point

Flash Point
Type II & III Violence:
Action Point
Flash Point
An "action point" is the moment when an individual recognizes that a person may be on the path toward committing some type of violent act in the workplace and subsequently
takes action
to prevent it.
Prevention, Intervention, or Response?
Violence by non-employees or service recipients is often
unpredictable
.

Most strategies to curtail type I & IV violence are
preventative
.
Type I and IV Violence:
There are often warning signs that precede
instances of Type II and III
violence.

Communication
A two-way process of sending and receiving of messages.

Sending a message that is understood

Understanding the message that is sent
Communication is:
Sometimes the meaning is in
how
the verbal message was sent (or received).

This is called "Paralanguage"

Tone

Rate

Inflection

Pitch

Accent

Fillers

Volume
Is it important to identify Communication Barriers when attempting to deescalate? Why or why not?


Walls, Glass, Counters,
Beds...

Physical Barrier

Not just language!
Can be expressions, slang words, medical terminology, and other jargon.
Language Barrier
Gender Barriers
Differences between masculine and feminine styles of communication.
Interpersonal Barriers
Shyness, narcissism, mistrust,
perception of authority
Perceptual Barrier
Different views, ideas, or values
Cultural Barrier
Ethnic, religious, and social differences
Emotional Barrier
Psychogenic Shock,
Inability to control emotions.
L
isten
E
mpathize
A
sk questions
P
araphrase
S
ummarize
To put something in place to reduce a risk is
PREVENTION
An action that changes the course of something is
INTERVENTION
A physical or verbal reaction to something is
RESPONSE
ACTION POINT =

INTERVENTION
A "flash point," is the moment when violence occurs. It too late for an intervention or preventive strategy.
FLASH POINT =

RESPONSE
L.E.A.P.S.
Intervention during the
"Action Point":

Communication as a deescalation tool

Assault & Battery

"Reasonably necessary"

Least Restrictive Method

Equal Level of Force
If you are being assaulted or battered you have the legal right to protect yourself.

But you
must
respond with a lower or equal level of force
The force you use must be considered "reasonably necessary" under the circumstances,

EXCESSIVE FORCE IS NEVER AUTHORIZED!!!
So what is "Reasonably Necessary"?
Is your response reasonably necessary?

Imminent Danger

Protection of self or others

Least restrictive method

Least restrictive method of restraint
Intervention during the "Action Point"
The 10 principles of
de-escalation
Principle 1:

Respect Personal Space
Principle 2:

Do not Provoke
Principle 3:

Establish Verbal
Contact

Principle 4:

Be Concise

Principle 5:

Identify Wants
and Feelings
Principle 6:

Listen to What the Person Is Saying
Principle 7:


Agree
or
Agree to Disagree
Principle 8:

Lay Down the Law and Set Clear Limits
Principle 9:

Offer Choices
and Optimism
Principle 10:

Debrief the person and staff
Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup
Janet S Richmond, MSW,* Jon S Berlin, MD,† Avrim B Fishkind, MD,‡ Garland H Holloman, Jr, MD, PhD,§ Scott L Zeller, MD, Michael P Wilson, MD, PhD,¶ Muhamad Aly Rifai, MD, CPE,# and Anthony T Ng, MD, FAPA**
Occupational Violence Education and Reduction Training
Any type of restraint on a patient must be
MEDICALLY INDICATED.
The following must be documented by the attending physician:

The reason for restraints.

What measures have been taken to avoid restraints.

The type of restraints being employed and why.

A plan for removal of the restraints.
A response that is deemed prudent and sensible under the prevailing circumstances.
Reasonably Necessary is:
We legally may not restrict someone’s freedom any more than we must.

Use the minimum amount of force to necessary to maintain a safe environment.


Least Restrictive Method
Restraint
Protection of self
If you are being battered, you have the legal right to defend yourself.

HOWEVER

Your actions must be reasonably necessary under
the circumstances.
Protection of Others
If a person is attempting to cause physical harm or threatening to kill someone the
hospital
has a legal responsibility to either detain that patient for medical evaluation, or notify law enforcement.
Imminence is...
Immediate (expires within 10-30 minutes)
Unavoidable
Witnessed
Imminent Danger is....
The legal criteria that must be met before you engage in self defense or the defense of others.
Approximately
90%
of all emotional information and more than
50%
of the total information in spoken English is communicated
non-verbally
.
In almost all cases, verbal
de-escalation must be attempted prior to the use of restraints.
Are these examples of restraint?


Grabbing an arm

Holding someone down

Denying discharge

Seclusion in an isolation room

The use of behavior modifying medication

Detaining a person for observation
CONTACT
attempts to
verbally
de-escalate the agitated person.
COVER
provides
presence
and assists in the event of physical violence.
Critical
Communication
Concepts:

1. Non-Verbal
2. Paralanguage
3. Barriers
A
lowered
voice level

may set a tone of anger which could create fear or challenges.

A
raised
voice may set a tone of anticipation or uncertainty which may promote excitement or disruption.

Speak slowly -- This is usually interpreted as soothing.

A
controlled
voice is one of calm and firmness which promotes confidence in both parties.
What do these non-verbal actions say to you?

Finger pointing

Shoulder shrugging

Rigid walking

Jaw set with clenched teeth

A fake smile

Crossed Arms

Hands on Hips
An assault is an unlawful attempt, coupled with a present ability, to commit
violent injury
on the person of another.

This includes verbal threats that place another in
APPREHENSION
of an offensive and imminent bodily contact (a battery).
ASSAULT
A battery is any willful and unlawful use of force or violence upon the person of another.

A victim must be physically touched for a battery to occur.
BATTERY
Becoming skilled at verbal de-escalation requires:

Practice, Communication skills,
and an understanding of your:

-vulnerabilities
-tendency to retaliate
-tendency to become defensive

Choke from front


Choke from behind


Headlocks


Headlock Choke (lift technique)


Headlock Choke (shoulder drop technique)
General principles with Biting


Biting on the arm


Biting a finger


Biting the shoulder or back


One-Handed Grab


Two-Handed Grab (on one arm)


Two-Handed Grab (one hand on each arm)


Fingernails dug into the arm
Grabs
Your goal is to escape to safety

Turn an attacker’s attention inward

Move in rather than pulling away

Activate your larger muscles

Weak points in a grasp

Angles that will force release

Bear Hug – front over arms


Bear Hug – front under arms


Bear Hug – behind over arms


Bear Hug – behind under arms
Bear Hugs
General principles with Hair Pulling


Hair pulling – top from the front


Hair pulling – top from the back


Hair pulling – ponytail or from behind
Hair Pulling
Plant your feet apart, with one foot forward and your knees slightly bent. This will lower your center of gravity and increase your balance.


Before doing anything physical, try to talk the aggressor into letting you go.


As soon as you feel a grip releasing, continue the motion to make your escape.
Physical Maneuvers:
First Steps
All of these physical maneuvers are evasive. Your goal is always your personal safety.

Compliancy-based means we are trying to create a release-response

Give enough resistance as the attacker to understand the efficacy of the maneuver without hurting your partner.
Compliancy-Based
Physical Maneuvers:
Choke Holds
CODE GRAY
A Code Gray is used to alert hospital staff to a disruptive or potentially violent employee, patient, visitor, or other service recipient.
Rate & Pitch
INTERVENTION
Biting
The key is to preventing this type of violence is to intervene
before the person becomes violent.
When approaching an agitated person, maintain at least 2 arm’s lengths of distance.

Do not touch the person.

Both parties should be able to exit the room without feeling the other is blocking the way.
Attempt to identify and resolve possible barriers to communication.

Stand at an angle and minimize eye contact.

Maintain a calm demeanor and voice.

Keep a neutral facial expression.

Keep your hands visible.

Let the person know you are and why you are there

Ask
how they would like to be addressed.

Ask
for compliance

Give options & choices
Give the person time to process what has been said.

Allow the person to respond before providing additional information.

Persistently repeat your message to the person until it is heard.

Actively listen to the patient and
agree
with his/her position

whenever possible.

Do not make assumptions regarding why the person is agitated -ASK THEM

Communicate your desire to understand

Use
non-verbal cues
to determine unspoken needs.

Acknowledge the person is having difficulty conforming to what is expected of him/her.

Is their behavior a symptom of a medical issue? Personality disorder?


Actively Listen

Empathize vs. Sympathize

Try to imagine how the person’s beliefs could be true

Make an attempt to understand what he/she is saying by asking questions

Do not dismiss the persons concerns or contribute to delusions


Use the "fogging" technique to find something about a person’s position with which you can agree.
Tell the person that injury to them self or others is unacceptable and they may be arrested if he assaults or batters anyone.

Present consequences, which are:

Clearly related to the specific behavior
Reasonable
Legitimate

Be prepared to follow through with the consequences you have given.

Do not give idle threats or discuss consequences that are not directly related to the behavior.
Be assertive

Propose alternatives to violence.

Offer things that will be perceived as acts of kindness

Give choices that may stall aggressive behaviors.

Do not deceive by promising something that cannot be provided.
Class Discussion:

Give two examples of
excessive force
and two examples of
appropriate force
in a clinical setting.


Questions?
Paralanguage
Barriers
What are people
actually
saying when they communicate?


Words don't always matter!
What's your name?
or
What would you like me to call you?


I'm here to help
or
I need your help

Do you want?
or

Would you like?

You will...
or
Can you...

You are...

or
It seems...

That may be but...

I understand however...

I see your point and...
You seem upset


or
Are you upset

I can't understand you
or
I want to understand you

You need to calm down right now
or
I know you're doing your best to be calm right now


RESPONSE
CODE GRAY
OR
CODE SILVER?
Action and
Flash Point

Class Discussion Questions:

Describe at least 3 warning signs that may signify an "Action Point" .

Do you believe use of communication and intervention techniques can prevent violence from occurring? Why or why not?
Class discussion question:

Agree with the truth
"That's true, you have been waiting for a long time"

Agree with the principle
"
You know, you're right. Nobody should have to wait to be seen when they have a sick child."

Agree with the odds
"I agree. If we weren't so busy you would probably not have to wait as long."
Fogging involves agreeing with any truth that may be contained within statements, even if critical.

By not responding in the expected way, (being defensive or argumentative), the other person will cease confrontation as the desired effect of their words is not being achieved.
I've been waiting here for an hour! My daughter is sick and I want her seen RIGHT NOW!
When a CODE GREY is called, the team leader MUST establish

TEAM ROLES

and who will be doing the talking

Contact vs. Cover
Note!
Response during the
"Flash Point":

Use of force and self defense

Escaping the Flash Point:

Evasive Maneuvers
Full transcript