PRACTICE PARTNER Look Through the Patient’s Eyes First, consider what the environment is like for the patient. Henrietta Van Hulle, VP Client Outreach at the Public Services Health and Safety Association, reminds that health- care professionals navigate their settings and system every day. It makes sense to them. They’re comfortable there. But that is not necessarily so for patients. Patients can be anxious. They’re often deal- ing with the unknown. At the best of times, that can get the pot boiling. Now, add in whatever else is going on in the patient’s life. Or maybe they’ve had previous undesirable experiences with health care. All of this, even without aggression and vio- lence present, is reason enough for the health care team to pacify. In practice, that can mean providing enough information, speaking slowly and giving patients enough time to process what you’re saying, and making eye contact. “Keep a calm outer demeanour,” Ms. Van Hulle says. Sound too simplistic? Not really, says Dr. Brittany Poynter. She’s clinical head of the ED at the Centre for Addiction and Mental Health (CAMH) in Toronto, and an assistant professor in the Department of Psychiatry at the University of Toronto’s Faculty of Medicine. When patients are in a heightened state, some basic steps to build rapport and show understanding can go a long way. At CAMH, Dr. Poynter is part of a team working to de-escalate patients who are exhibiting a variety of psychiatric symptoms. Her advice, however, applies to a large swath of patients. Many individuals, in certain cases and at certain times, could potentially turn aggressive or violent. Consider, she says, some common patient experiences: wait times, absence of privacy, negative attitudes of staff, lack of respect or courtesy, not feeling heard, insufficient com- munication. These and other realities of being a patient can set people on edge. 30 DIALOGUE ISSUE 4, 2018 Dr. Poynter says it’s vital to be preventa- tive, i.e., act at the first signs of agitation. Even before it gets to that point, some de-escalation strategies are really just good proactive care interventions. For instance, introduce yourself, provide reassurance that you’re there to help, be clear and concise (short sentences, simple vocabu- lary), and identify the patient’s wants and feelings. Listen closely to what patients say, and acknowledge that you’re listening. Repeat information as necessary to ensure clarity. Set limits for safety, like acceptable behaviours, and do it in a respectful man- ner. Offer choices, even something as simple as where to sit. And perform little acts of kindness, like meeting a basic request or just providing hope. “It’s important to put yourself in the other person’s shoes and offer empathy,” says Dr. Poynter. These strategies can work, not all the time and not for everybody but even in quite challenging cases. In an article for the Toronto Star, Dr. Poynter wrote specifically about patients who are experiencing a mental health crisis. They’re probably scared, she said, and their actions are likely driven more by fear than a desire to harm. Some people can’t tell what’s real from what’s not. Look for something about the patient’s position to agree with – you could agree with their truth (even a bit of it), agree with the principle, or agree to disagree. Finding com- mon ground fosters trust, she said. What if someone is brandishing a knife? Dr. Poynter explained that rather than saying “No weapons allowed, give it to us or we’ll call the police”, she might try this approach: “I’m glad you’re at the hospital. You’re in a safe place now. We’re going to hold on to the knife for you, so that we can all be safe. Let’s sit down and talk.” It won’t always work and it’s not the only answer. Still, some of these communication fundamentals are the go-to protocols.