MDS Alert

Knowing how to defuse situations is increasingly crucial to providing high-quality care.

When situations get tense, everyone involved is affected and may feel unsafe or distrustful. If you aren't already incorporating de-escalation techniques into staff training, start soon. Your staff will be better able to handle many different kinds of situations, and your facility will have a head start on the some of the practical aspects of providing trauma-informed care thatwill go into effect with Phase 3 of the Requirements of Participation.

"The first step is to recognize how common trauma is, and to understand that every patient may have experienced serious trauma," says Monique tello, MD, MPH, a physician at Women's Health Associates in Boston, in a recent blog post on the Harvard Health blog. "We don't necessarily need to question people about their experiences; rather, we should just assume that they may have this history, andact accordingly."

With that in mind, here are some key elements of the trauma-informed approach to providing care to residents, according to Kris Mastrangelo, president and CEO of Harmony Healthcare international in Topsfield, Massachusetts:

• "Realize that trauma is prevalent,
• "Recognize that all individuals within an organi­zation are affected by trauma,
• "Resist re-traumatization, and
• "Respond to the risk through incorporating knowledge in practice."

Skilled nursing facility staff can all have a hand in reducing the lived experience of trauma, so make sure you incorporate both the "theory" and practical strategies into your training. Helping staff better understand how the tone and tenor of their care can reduce trauma and then providing them with specific directives that can resolve tense situations can go a long way in helping residents.

Mastrangelo lists these five principles as the key to establishing and providing a trauma-informed a culture of care.

• "Safety: Keep residents (and staff) emotionally and physically safe.
• "Trustworthy: Make certain that tasks and boundaries are clear.
• "Choice: Offer control and choice as much as possible (the perception of control is as important as actual control).
• "Collaborate: Build in opportunities for participation.
• "Empowerment: Assure residents and staff feel empowered with decision-making and choice."

Use these techniques

With an understanding of the principles of trauma-informed care, prepare your staff with the following skills so they can navigate tense situations with residents.

"In a nutshell, listening to the individual with empathy is a primary skill in moving a tense situation to a better place, says Margaret Piccone, PhD, director of clinical innovation at Bradley Hospital in Providence, Rhode Island.

Give the resident your undivided attention

"Providing your full and genuine attention communicates respect and validation. Although verbalizing, 'I hear you,' or 'I'm listening' can be helpful, making eye contact and using body language that indicates that you are listening with your whole body may drop the crisis one small step," Piccone says.

Validate feelings, including anger or confusion

For many people, the reality of leaving home and entering a facility - regardless of the length of stay - is traumatic. Acknowledging the trauma inherent to the transition can go a long way in helping a resident feel understood and therefore more at home.

"Reflective feeling response is a simple skill to learn, but a challenging one to master," Piccone says.

While in a tense situation, listen to what the resident is saying and focus on understanding the underlying feelings behind whatever statements the resident makes, she advises.

For example, if a resident says something like, "I hate it here, I don't know anyone!" a staff member could respond with "I'm sorry you feel isolated and lonely. That must be so frustrating." to validate his feelings, instead of responding with something like "But that's not true, Mr. Smith! You know me!"

Tolerate - and invite - silences

"Silence is your friend! It can move confrontation to a gentler place all by itself," Piccone says. "If the patient does not immediately answer a question, he may be thinking or wanting to be sure he is communicating effectively. Research shows that most people tend to start talking when silence lengthens. The crisis often drops down one more step!"

Though this is great advice generally, instruct staff to be careful that they aren't misinterpreting a silence for a breakdown in communication. With many residents at an age where hearing loss is a reality, what may sound like silence could be a resident trying to evaluate exactly what the staff member just said.

Be accepting and nonjudgmental

"Whatever the person communicates to you, be sure that your words and body language communicate full acceptance," Piccone says.

If a resident is feeling frustrated by her slipping memory or feeling afraid of the future, help him feel empowered by his decision to confide in you by making sure your body language reflects acceptance. Keep shoulders back and relaxed; don't cross arms or turn away from the resident.

Reflect the communication

As a tense situation begins to dissipate, encourage the resolution and mutual understanding by reflecting the resident's own words back to him. "The only way to be sure what a person is trying to tell you is to ask," Piccone says.

For example, if the resident says he doesn't want to live in the facility any longer, clarify the statement by reflecting it back in a question: Ask him if he'd like to work together or with another team member on discharge goals. Though a discharge may not be realistic in the moment, allowing a resident to feel urgency about his future can bring hope and empowerment.

Remember these tips

"If you do something or say something to de-escalate a tense situation, and it makes the crisis worse, stop and try something else," Piccone says. "Crisis resolves one small step at a time! If your intervention brings some calm, you are on the right path. Try more of it!"

Part of maintaining resident and staff safety is having evaluating how any given situation may evolve and having a plan for each contingency.

"Know ahead of time how to keep yourself safe," Piccone says, whether that means having another team member nearby to help or leaving the room if you feel like you're getting too emotional in the moment.

Similarly, make sure you can contact another team member for help without upping the ante of a situation. "Know how to signal for help from other staff without escalating the crisis," Piccone says. "Keep a list of professionals across disciplines that you can readily access for consultation or referral."