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Special Report: Proxemics Training Can Prevent ED Violence (In English Don't Let Things Escalate)

Johnson, Anne, MD

doi: 10.1097/
Special Report

Dr. Johnson is the medical director of Aurora Sinai Department of Emergency Medicine in Milwaukee. She tries verbal defense tactics on her teenager with occasional success, practices taekwondo, and serves in the Army Reserve. Her first novel, Room Four, a dramedy of emergency medicine, won a Best of 2012 Kirkus award. She wants everyone to have a safe shift. She blogs at



Is your method for handling conflict something like this: Ignore it, kill them with kindness, and when all else fails, yell for security? These methods might get us through the shift, but it leads to low morale, poor staff retention, and injuries. You can help your organization recruit and retain staff by creating a safer workplace. You can even—stay with me—change your workplace culture in the long run.

It is a myth that people under stress have a fight-or-flight reaction; there is actually a third response: freeze. That's the most common one, and it gets people hurt. We have protocols in emergency medicine for high-risk, high-stress situations. Cardiac arrest, seizures, arterial bleeds, open fractures—we handle things that would send an untrained person running from the room. We do ourselves a disservice without protocols for conflict.

Under stress, very few people will rise to the occasion. It is more likely that they will fall to the level of their training. That is not a bad thing, but it means training is important.

Physicians are rightfully skeptical of the latest initiative from administration. It usually gets rolled out in a death-by-PowerPoint method, we check the box, and go back to what we were doing. Disney does not run my hospital, and I don't do group hugs. That's why I became a verbal defense and influence instructor when I heard my hospital had partnered with a company called Vistelar to solve our workplace violence problems. Full disclosure: I've been in the Army for 20 years, I'm a martial artist, and my dad was a cop, so I have a lifelong interest in conflict resolution. Vistelar has roots in police and military training. I was intrigued by their methods, but did not want to see them watered down to slides.

I finished the training convinced these are teachable skills, so I developed a one-hour course for physicians. Students have to role-play, which initiates groans until they realize they get to act as irate patients. We have Academy Award-winning physicians by the end of the class. It is not “be nicer” training nor is it hand-to-hand combat.

The role play is essential to get certain phrases hard-wired; otherwise we fall back on blurting out words of frustration. In the history of calming down, no one has ever calmed down after being told to calm down.

Just as in EMS, scene safety comes first. Every patient (and visitor) is assessed at 10 feet and five feet away before any physical contact is made. This is proxemics training: Where are you relative to the other person, and where is the exit? Gateway behaviors (pacing, staring, rapid breathing, fist-clenching, mumbling) are a warning to stay back. What if you are alone at the end of the hallway and someone storms toward you?

Part two of proxemics is hand position. I don't recommend teaching cool takedown moves as part of institutional training. They seem deceptively easy on a padded mat with a cooperative instructor, and that can lead to a false sense of security in your staff. That training is also not scalable. I just want to deflect the drunk guy's sloppy punch and get away to safety; I don't want to dislocate his elbow. Some simple postures, however, can keep your hands ready to protect your face without looking like a boxer. My favorite is the thinker's stance. It keeps my hands out of my pockets and looks natural. The time-out is a universal pause signal. The two-hand stop is also effective. (See photos.) These three postures keep your hands in position to block if needed.

Personal space varies among people, but everyone has a limit. A confident posture with hands out will buy you some buffer space. It is helpful to teach the postures and verbal role play simultaneously so your staff learns to do both at once.

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Stop Saying I'm Sorry

Every patient receives a universal greeting. “Hi, sir, I'm Dr. Johnson. I'm the emergency physician tonight.” It sounds pedantic, but we tend to barge in and get right to work in the ED. Acknowledge the wait if your patient perceived it to be too long (whether it was 20 minutes or six hours). “We're having a busy flu season/have you seen the news/this is a tough situation/thank you for waiting.”

Note we can acknowledge this without saying “I'm sorry.” I find saying “I'm sorry” over and over during a shift just leads to a sorry state of mind. I'm not sorry about a 20-minute wait, but I can acknowledge that the patient isn't feeling well. And this is about respecting the patient and maintaining your morale for the long haul. When conflict arises, we give choices, context, and avoid the parental finger.

How do the following phrases feel to the person on the receiving end?

  • Calm down or what's the matter?
  • Come here or excuse me, sir, may I talk with you?
  • You wouldn't understand or I'll try to explain.
  • Because it's the rule or can you work with me?
  • It's for your own good or it's for your safety and mine.
  • What's your problem? Or what can I do to help?
  • I need you to... or you seem like a reasonable person.

If we invest a little in non-escalation, it is much easier than de-escalating later. If things escalate anyway, try giving a choice. “Being in the ER is frustrating. But the yelling has scared other patients. We have some very sick elderly folks here. You've got some good options. You can stay in the room, and keep your friend company, you can go to the waiting room, or you can take a break outside. Which would you like to do?”

A choice may be the only sense of empowerment for someone for whom violence is the only other option. And for some of our ED patients, it might be the first time in a long time that someone has spoken to them with respect.

Emotions and volume tend to equalize. If you get louder, they get louder. When you get even louder, they get even louder. Try the “reverse-yell.” This is fun to role play. A colleague shouts, “You didn't do anything for me!” in the class, and I reply softly, “Ma'am, I want to hear more about this. Will you walk with me over here?” The shouter invariably leans in and says, “What?” They have lowered their volume to match mine.

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Sticks and Stones

This exercise also trains staff not to take it personally. We aren't offended at the arterial bleed hitting the ceiling. Why do we feel gut-punched by the patient who calls us a name? (Because we are human, of course). But working conflict like an ACLS algorithm keeps it clinical and objective.



Along these lines, never argue with A, B, or C. What are those? If you are a parent, they are: It's not fair, everybody else gets to, I never get to. If you work in an ED, it's something like: You didn't do anything for me, I hate this hospital, I waited forever. The logical clinician in you really wants to say, “I ran three labs and an x-ray, this hospital is a fine institution that has served this community for decades, and the national mean wait time is three hours and 23 minutes, and you only waited for two hours.”

Don't. Say. That.

Be careful about saying “I understand” or “I know” because it can come across as insincere. Try, “This is a tough situation. It's hard to have your condition. Can we go over the discharge plan again?” Many times after they vent, the anger balloon deflates, and we have a better conversation.

This is more than scripting. It is having a few arrows in your quiver that sound natural and work for frequent situations. It is not a bad thing to have a phrase or two memorized in situations that predictably get heated, such as demands for narcotics.

Give a second chance, but not a third chance and a fourth chance. Verbal defense is not endless venting. You are always moving toward closure and resolution of the situation. Closure usually means the situation resolves, and you and your patient go on with the plan.

When words fail, it is important for your staff to know they have backup. Closure might mean you intervene early with an order for IM ketamine. It might mean building better processes for security to escort patients or visitors out. It might mean calling the police more often. I call it tactical civility, and consistency is the key.

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Repeat Offenders

Crisis communication is a different flavor of verbal defense. Crisis is a step beyond conflict. When your computer screen freezes, do you keep tapping at it frantically as if that will work? We do the same thing to patients in crisis. “Calm down, hold still, you'll be OK” comes from four different directions. It is critical to reduce stimulation, minimize extra staff in the room, and adapt to a slow telegraphic communication that comes from one voice only. Pause here, and wait 15 seconds. You'll need to check your watch. It feels like an hour. That's how long it may take a person in crisis to “reboot” and answer your question if they don't get any other stimulus in the interim.

Several other things went into place at my hospital this year. We streamlined reporting for violent incidents. Our security are the liaison between the caregiver and police to help with paperwork as much as possible. We created a violence alert best practice advisory within our EMR. Patients with a documented episode of verbal abuse, physical violence, or inappropriate sexual behavior will have a pop-up on their chart once per caregiver per 24 period. We vetted the process with our legal and compliance teams and review the alerts regularly to see if they should stay or be removed. We also have discreet signage for rooms if patients have an alert to protect housekeeping and other nonclinical staff.

A name pops up on the tracking board. You know the feeling. He's back. Homicidal ideation. Hearing voices. I tell myself that it's show time and sign up for the patient. The security guard, who is fighting off a stomach flu that shift, has already searched the patient for weapons, and had him change into a gown. The patient is intermittently swearing at the security guard and talking to skeletons.

I introduce myself, stand in the thinker pose, address the swearing, and say he has the choice of an injection or a pill to help him feel better. He chooses a pill (and I do an internal happy dance that this verbal stuff worked), and I tell him I will be back in 20 minutes to check on him and talk more.

About 20 minutes later, I hear violent gagging sounds coming from the patient's room. I fear he is strangling the security guard. But what I see instead is my chronically homicidal patient standing behind the security guard, gently patting his back, and saying “I got you, man. You'll be all right,” while the security guard vomits into a trash can.

Perhaps antipsychotics and verbal defense is an ideal marriage. But I like to think that giving the patient respect led to him respecting us back. Maybe I'll change my stance on group hugs.

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