Management of Assaultive Behaivor

Management of
assaultive behavior,
AB-508
CRITICAL CARE TRAINING CENTER
COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

Management of assaultive
behavior, AB-508
Violence Prevention Training in accordance with MAB® Policies and
Standards as well as California AB-508 Bill Requirements and Health
and Safety Codes; 1257.7 and 1257.8 Provider approved by the
California Board of Registered Nursing, Provider #CEP452, & Board of
Behavior Sciences Provider PCE#4518

Course Outline
The assault cycle
Aggression and violence predicting factors
Break (15 min.)
Verbal & other de-escalating maneuvers to diffuse and avoid violent behavior
General and personal safety measures
Lunch break (30 min.)
Strategies to avoid physical harm
Restraining techniques
Appropriate use of medications as chemical restraints
Break (15 min.)
Post crisis depression
Employee resources & incident debriefing

Workplace Violence on Healthcare
Workers

Workplace Violence on Healthcare
Workers
The National Institute for Occupational Safety and Health (NIOSH) defines
workplace violence as “violent acts (including physical assaults and
threats of assaults) directed toward persons at work or on duty.”

General Terms
Assault is defined as:
• an unlawful physical attack upon another;
• an attempt or offer to do violence to another, with or without battery,
as by holding a stone or club in a threatening manner. Thus, “threat”
– alone – can be considered an “assault”.
Management of Assaultive Behavior (MAB) is violence prevention and

de-escalation program, covering the essential and trusted methods of
crisis negotiation

Important to remember
It is essential that you respond to violence in a manner to protect injury
to yourself and the client.
You have to use techniques that are preventive and evasive. If you use
techniques that cause harm to the client, you may be liable for assault,
battery, loss of license and legal action.

Ten guidelines for avoiding assault
1. Is there Imminent Danger to Self or Others and to what degree?
2. Try to understand the Person or Situation that you’re faced with.
3. Try to understand your Reaction to the person or situation that you’re

face with.

(contd.)
4. Try not to focus on Behavior… Focus on what’s Behind the Behavior…
There’s usually something behind the Behavior that’s causing it.
5. Try Not to tell them what to do or demand their compliance… Try to

Ask for their compliance instead.

(contd.)
6. One Teamleader should be negotiating, not several… If more than
one person is trying to de-escalate the individual, it creates a Conflict
of Focus.
7. Try to initiate a Plan before entering into any potentially violent

situation.
8. Work as a Team… Everyone has a role to offer in helping to de-

escalate the situation.

(contd.)
9. Reactive Thinking always creates Primitive Responses… Critical
Thinking allows a person to help solve the situation by prompting you
to ask yourself questions of why the individual might be upset and
what you can do to help them communicate their needs.
10. Try to always focus on the power of De-escalation, rather than giving
into the weakness of Over-Reaction

Assault cycle
Baseline Behavior – the standard

behavior observed with the client

Assault cycle (contd.)
Remember, you and the client go through the same phases!
Trigger Event
 Observe to spot changes in the client
 Quiet person may pace
 Pacing person may sit still
 If the triggering event is not dealt with,
escalation occurs

Escalation
 Person thinks angry thoughts
 Body mobilizes for fight or flight
 Increased heart rate, respiration
 Person may pace, yell, throw things or
 Person may become tensely quiet
 If left unchecked may escalate to crisis

 During the escalation stage, assess the motive.
Is the person fearful, frustrated, manipulative
or intimidating?

Diffusing Techniques
Listening is the hero of good communication
Empathize with their situation
Understand their perception of the situation
What do they want that they are not getting?
Address their concerns
Offer a solution or alternative

Crisis
 Person cannot sustain this level of output
for long
 As crisis passes, person will enter a stage
of recovery
 During the crisis stage you must keep the
crisis communication ongoing and observe
the reasonable force guidelines. Remember
due to the tremendous output of energy, the
crisis will end.

Recovery
 Body and mind return to baseline levels
 Person is still vulnerable and can re-escalate
 During the recovery stage, avoid lengthy
conversations
 Do not blame or chastise the person
 Honor requests for being alone (with

observation). The person could still re-ignite
and start back into the crisis stage
 This is a poor time for medication because of
the post-crisis depression that follows

Post Crisis Depression
 Person is exhausted, body is below the baseline level
 Pulse and respiration lower than normal
 Depression accompanies fatigue
 More engaging verbal techniques can be used. Some people
will not want to talk.
 Close supervision is required

 Medication could place a person at risk of too low of
a blood pressure or respiration
 Return the person to the treatment plan

Incident De-briefing
Review the incident with the team
Perform a debriefing with the client
Try to determine what could have been done differently

Self-Care
Ensure you are taking care of yourself physically and mentally
Know when to seek help
Find time for you

12 Elements of Active Listening
1. Emotional Labeling allows the client to see that you see their
perspective by attaching a tentative label to the feelings expressed or
implied by the person’s words and actions.
e.g. “This must be very frustrating for you” or “I understand, you must be
really angry over this”
2. Paraphrasing provides evidence of your attention to the client’s

words
e.g. “So what you’re saying is you believe I could’ve said what I said
differently… Alright, I think I understand”

3. Mirroring is repeating only the most important concepts, or the last
few words to gain better understanding of their core issues and
developing more effective rapport.
e.g. “You were promised to be on this unit… I understand what you’re
saying”
4. Minimal Encouragement – brief, well-timed vocal replies, such as

“Alright,” “O.K.,” or “I see” provide evidence that you are actually
listening and understanding, rather than hearing.

5. Open-Ended Questions helps focusing on what the person is really
thinking and feeling, what’s his intent, so that you can develop a
roadmap of actions.
e.g. “I’d like to help you and in order to do that, I need more information on
just how you feel.”
6. Directive “I” Messaging portrays level playing field. Make up “I”

messages of 3 main elements: (1) the problem or situation, (2) your
feelings about the issue, (3) the reason for your concern.

7. Effective Silence uses people’s reflex to speak to fill gaps and spaces
within conversations. Even the most emotionally-charged individuals
find it uncomfortable to stay in one-sided argument and will
eventually calm.
8. Perception Checking helps understanding feelings and emotions

behind the words or tap into the root cause of the issue. The issue
can be deeper behind what’s at hand and trying to discover it may
serve to satisfy an emotional need and help the person to trust you
and open up.

9. Clarifying is following up to understand the content and context of
the words or feelings expressed, to clear up any misperceptions that
may occur.
e.g. “Can you tell me again what you meant when you said that you don’t
feel like you’re being heard by administration?”
10. Structuring is necessary to create guidelines or parameters for

conversation and give the person a sense of purpose.
e.g. “Which one of these issues would you like to talk about first?”

11. Pinpointing is used to re-direct the conversation back to the most
important issues (when the person is dealing with too many internal
and external emotional topics).
e.g. “I hear you saying you’re feeling better now, but I’m still seeing some
tears” or “Is everything really okay now?”
12. Body Language and Posturing can either validate, or discount the
message you are trying to convey and can sabotage even the best
intentions.
Negative body language would be checking your watch, working on an
unrelated task, interrupting, fidgeting, sighing, taking a phone call, or
standing at the doorway instead of face to face while listening

Methods for a Successful
Negotiation: L.A.S.T
• LISTEN
• to a person’s complaint or point of view with genuine concern
L.
• APOLOGIZE
• on behalf of the Organization and that you’re sorry to see them go
A. through this
• SOLVE
• by formulating in your mind of how to tactfully explain how you will
S. try to assist them
• THANK
• the person for bringing their concerns forward and allowing you to
T. assist them

Negotiation: 4-E’s
• Approach with an official and “interested”
ENGAGE manner, then introduce yourself
• Listen to their concerns and repeat them

EMPATHIZE back, apologizing when necessary
• Explain what you can do for them at the

EDUCATE moment, limits you may face, but that you
will try your best to help
• When formulating a compromise, ask their
help in making this into a Win-Win
ENLIST situation. E.g. “If I do [this] for you, will you
agree to do [this] for me?”

Negotiation
Win
Win
Creating a mutual compromise between two adversaries resulting
in a beneficial outcome for both parties. Keep this in mind for
every customer contact you have.

General Safety Measures
Don’t make the situation worse
Allow the client/ patient to regain self-control
Treat the person respectfully
Preserve the client/ patient’s rights
Assess and remove potentially harmful items in the environment

(Contraband)

General Safety Measures
Common Contraband items What else might be Contraband?
Compacts with glass mirrors Scissors
Glass containers Staples
Picture frames with glass Pencils

Pens
Hair dryers
Comps
Curling irons
Eating utensils
Razors
Mouthwash or cleanser containing
Keys alcohol

Position Yourself For Safety
Personal Space – maintain a distance of at least 2 arms’ lengths between
you and the aggressor, to have reaction time from attacks such as grabs,
strikes and lunges.
Stance – angle your body about 45 degrees in relation to the individual,

to reduce your target size if attacked and prepare for escape when
necessary.
Hands – in front of your body in an open and relaxed position, to appear

non-threatening.

Personal Safety
✓Don’t wear items around your neck
✓Don’t divulge personal information about yourself
✓Give yourself access to exit
✓Have others around you
✓Inform co-workers if there is a potential threat
✓Isolate agitated persons (e.g. client, family, visitors)

Clinical Risk Factors
Patients at risk of perpetrating violence include those who:
✓Are under influence of drugs or alcohol
✓Are in pain
✓Have a history of violence
✓Have cognitive impairment
✓Are in the forensic (criminal justice) system
✓Are angry about clinical relationships
✓Have certain psychiatric diagnoses and/ or medical diagnoses

Organizational Risk Factors
✓Careless management an staff attitudes toward workplace violence
prevention
✓Inadequate security procedures and protocols
✓Lack of staff training and preparedness
✓Low staffing levels, extended shifts, overtime requirements and etc.

Verbal & Other De-escalating
Maneuvers
3 Main Listening Skills
1. Attending: giving your physical attention to another person
2. Following: making sure you’re engaged by using eye contact, non-

intrusive gestures (e.g. nodding your head, saying okay)
3. Reflecting: paraphrasing, reflecting back using the feelings

Maneuvers (contd.)
Defusing a Situation
Note when the situation first escalates
Fidgeting, verbal sounds
Build-up of energy
Be proactive, not reactive

Attend to the client before it gets out of hand
Be in control by actively defusing the client, family or visitor

Maneuvers (contd.)
Defusing Techniques
Avoid arguing or defending previous actions
Avoid threatening body language
Calmly but firmly outline limits
Watch for the Defense Phase

If escalating, the client will give more physical cues
Staff interventions
Reduce stimulation from setting – move to quieter area
Communicate information about delays or areas of concern

Maneuvers (contd.)
Rules for Open Communication
Allow the distressed person to state the problem
Hear the person out
Request behavior changes only. Be specific/ non-threatening!
Don’t ask to feel differently or to change the attitude
Remember the Rule of Five – five words or less/ five syllables or less

Patterns Leading to Assault
✓Approach from the side angles, ✓Confident speech
not head on or from back ✓Good eye contact
✓Calm & reassuring voice
Fear ✓Approach directly but outside striking range
✓Eye level not above will fight if ✓Use broken record technique
✓Short & direct speech safety ✓Avoid communication that demonstrates
concern loss of control
Intimidation
Uses
calculated
Frustration
threats to get Assault Splotchy skin,
what they loud voice
want
Manipulation
Tantrum to ✓ Use little eye contact
escalate the ✓ Use a broken record type
✓ State consequences of their choices situation
✓ Be clear & direct of speech
✓ Don’t present ultimatums ✓ Act detached & relaxed
✓ Use sparing eye contact
✓ Have an escape route
Principles to Reduce the Threat
Match your level of response to the dangerousness of the threat
If an assaultive person is alone kicking and screaming, fatigue will

eventually win and intervention might not be needed
Short, direct statements, calm voice
No open ended question
Evade
Restraint (at last resort)

Physical Maneuvers – Last Resort
Intervene early, don’t think if you ignore them they’ll go away!
Keep others away from angry people
Alert staff members & security to be close by
Allow angry people time and space
Physical maneuvers are used as the last resort & only when all tactics
have failed.
Never plan to fight an attacker & win; do only what it takes to get away
from them.

Evasive Techniques: Basic Defense
Techniques
Arm Grab (One handed)

Techniques (contd.)
Arm Grab (Two handed)

Techniques (contd.)
Bear Hug (Front, Under arms)

Techniques (contd.)
Bear Hug (From behind, Over arms)

Techniques (contd.)
Bear Hug (From behind, Under arms)

Techniques (contd.)
Biting (Pushing in)
Biting (Pinching nose)

Techniques (contd.)
Biting (Balance leg push)

Techniques (contd.)
Biting (Balance hip/leg push)

Techniques (contd.)
Chair disarm

Techniques (contd.)
Choking (Front)

Techniques (contd.)
Choking (From behind)

Techniques (contd.)
Choking (From behind using rope)

Techniques (contd.)
Choking (On floor)

Techniques (contd.)
Choke hold (Lift up)

Techniques (contd.)
Choke hold (Shoulder drop)

Techniques (contd.)
Hair pull (Top behind)

Techniques (contd.)
Hair pull (Top front)

Techniques (contd.)
Hair pull (Long hair or pony tail)

Techniques (contd.)
Kicking

Techniques (contd.)
Punching

Techniques (contd.)
Rushing

Techniques (contd.)
Stick/ Club swing

Physical Apprehension, Escort, &
Takedown Techniques
Escort (Two person)

Takedown Techniques (contd.)
Escort (Three person)

Takedown (Two person)

Takedown (Four person)

Standing directly in front of the attacker

Appropriate Use of Medication as
Chemical Restraints
Seclusion – involuntary confinement of a person in a room or an
area where the person is physically prevented from leaving
Restraint – any manual method or physical or mechanical device,

material or equipment attached or adjacent to the client’s body
that cannot be easily removed and restricts freedom of movement
or normal access to one’s body
Chemical restraint – medication used to control behavior or to

restrict the client’s freedom of movement and is not a standard
treatment for the client’s medical or psychological condition

Chemical Restraints (contd.)
Chemical Restraints Guidelines
1. Sedative agents may be used to provide safe, humane method of
restraining the violently combative client, presenting danger to
themselves and others, and to prevent the violently combative client
from further injury while secured by physical restraints

Chemical Restraints Guidelines
2. These clients may include but are not limited to the following:
✓Alcohol and or drug-intoxicated clients

✓Restless, combative head-injury clients
✓Mental illness clients
✓Physical abuse clients (more humane than physical restraint)

Chemical Restraint Suggested Procedures
1. Assess the possibility of using physical restraint first; evaluate the
personnel needed to safely attempt to restrain the client
2. Have sedative medication prepared for injection; prepare for possible

hypotensive side effects
3. Contact Physician prior to administration and clearly state the need

for sedation if you think it is necessary for safety or client care

4. Administer medication as ordered
✓Vital signs should be assessed within the first five minutes and
thereafter as appropriate
✓Haldol is often the drug of choice
✓If necessary, contact the Physician for additional sedation

5. Assess the need for sedation carefully
✓The violently combative client stands a lesser chance of injury when

sedated
✓Clients who are physically restrained and aggressively fighting their

restraints and head injury clients who are combative and compromising
their airway and C-spine may be candidates for sedation

✓Chemical restrain precautions: side effects of Haldol may include
hypotension, tachycardia, and acute dystonic reactions. Treat symptoms
of dystonic reaction with Benadryl as ordered. Watch for increased
sedation

Post Crisis Depression
Close supervision required
Depression accompanied by fatigue
Person exhausted, body below the baseline level
Pulse and respiration lower than normal
Medication could place the person at risk of too low blood pressure or
respiration
Return to the treatment plan

Employee Resources & Incident
Debriefing
Post Incident Debriefing
Review the incident with the team
✓Discuss the incident
✓Meet in a quiet place
Perform a debriefing with the client

✓Assess safety
✓Discuss the triggering event
✓Look for pattern

Debriefing (contd.)
Post Incident Debriefing
Try to determine what could have been done differently
Discuss with your manager or HR if you need additional assistance (e.g.

employee assistance)

Debriefing (contd.)
Complete an Incident Report
Document the event completely
Documentation of the event is a legal record. It is important to be clear

and accurate. Use words and descriptions within your scope of practice.
Include what part of care didn’t work, what plan “B” were attempted.
Describe the event and what was done to return the client to the primary
treatment plan.

Debriefing (contd.)
If you have to give a deposition or go to court about an assaultive event,
your documentation is the legal record of it. Read it! Do not rely on
memory. Documentation will demonstrate your efforts at preserving the
client’s civil rights.

Debriefing (contd.)
After an assaultive episode, you must recover, relax and re-gain your
thinking ability.
Take care of your physical, mental and emotional health.
Self-care is unique for everyone.

The Do’s & Don'ts of Self-Care
Do Don’t
Express yourself. Try building Don’t bottle up your anger to
bridges, not barriers frustration. This can lead to
destructive behavior. Shout, scream
or punch a pillow, if necessary
Pamper yourself. Take time out Don’t overeat or use drugs, drinks or
during the day just for you tobacco as ways to running away
from problems
Talk to your supervisor Don’t be afraid to ask for help from
family, friends or professional
Seek professional help, if necessary. Don’t allow work to take over your
Recognize the danger signs and take life.
actions

The Do’s & Don’ts of Self-Care
(contd.)
Always
remember
about

Management of Assaultive Behaivor

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Management of

COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

Aggression and violence predicting factors

Break (15 min.)

General and personal safety measures

Lunch break (30 min.)

Strategies to avoid physical harm

Appropriate use of medications as chemical restraints

Break (15 min.)

Post crisis depression

Employee resources & incident debriefing

COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

Management of Assaultive Behavior (MAB) is violence prevention and

COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

2. Try to understand the Person or Situation that you’re faced with.

3. Try to understand your Reaction to the person or situation that you’re

COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

5. Try Not to tell them what to do or demand their compliance… Try to

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7. Try to initiate a Plan before entering into any potentially violent

8. Work as a Team… Everyone has a role to offer in helping to de-

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COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

Baseline Behavior – the standard

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 If left unchecked may escalate to crisis

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 Honor requests for being alone (with

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 Close supervision is required

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2. Paraphrasing provides evidence of your attention to the client’s

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4. Minimal Encouragement – brief, well-timed vocal replies, such as

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6. Directive “I” Messaging portrays level playing field. Make up “I”

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8. Perception Checking helps understanding feelings and emotions

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10. Structuring is necessary to create guidelines or parameters for

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COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

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• Listen to their concerns and repeat them

• Explain what you can do for them at the

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COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

Allow the client/ patient to regain self-control

Treat the person respectfully

Preserve the client/ patient’s rights

Assess and remove potentially harmful items in the environment

COPYRIGHT©2018. LOS ANGELES CAREER COLLEGE. ALL RIGHTS RESERVED.

Compacts with glass mirrors Scissors

Glass containers Staples