Phase 2 Defensiveness

The next level in the continuum of violent behavior is characterized by defensiveness. At this point, the patient's behavior is volatile and becomes verbally abusive and profane. These verbal attacks may be directed to staff members or others in the department and may include statements about age, gender, weight, or heritage. The patient's behaviors are irrational and often have nothing to do with why the patient presented to the emergency department. The patient is losing control and may feel helpless. A patient may present to the emergency department in this stage, having passed the anxiety stage outside the hospital. If the patient is restrained, such as a patient in police custody, feelings of helplessness may be further magnified.

Such patients will challenge emergency department personnel and their authority and will respond to staff with body posturing and movements. Emergency department personnel must remain professional and avoid power struggles and loss of patience. Appropriate responses to this phase are preventing total loss of control by the patient and thus deflecting physical aggression. One must be firm in tone and action. The patient must have reasonable limits set and be made aware of the consequences of such continued behavior. Limits must be simple, clear, enforceable, and consistent among all emergency department personnel. Giving the patient reasonable choices may help diffuse the situation and make him or her feel rewarded for good behavior. Emergency staff must not overreact or make counterthreats or false promises. If others are present, the patient and the situation must be isolated. A show of force by uniformed security personnel may be in order, keeping in mind that such a presence may cause further escalation; however, this is the exception, not the rule. It is important that no consequence be stated that is not readily enforceable. Let the patient make the choice.

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