Conflict resolution and de escalation

Cue 1 Causes of aggression wheel with pain, infection and toileting needs at the top.

AMARA 00:00 I want to start somewhere uncomfortable. A lot of care staff are told that aggression is just part of the job.

NADIA 00:08 And it is not. Let me separate two things, because they get confused and the confusion causes harm. Understanding why aggression happens is useful. Being expected to absorb assault is not the same thing at all.

AMARA 00:22 So why does it happen?

NADIA 00:24 Very rarely malice. Fear. Pain. Delirium. Dementia. Intoxication or withdrawal. Frustration at waiting or at not being heard. And the humiliation of having lost control over ordinary things, like when you eat and who sees you undressed.

AMARA 00:39 And you say that is practical, not just compassionate.

NADIA 00:43 Deeply practical. If the cause is unmet pain, then paracetamol changes the behaviour and no amount of de escalation technique will. If the cause is being told what to do by a stranger, a genuine choice changes it in about five seconds. So before you manage behaviour, exclude pain, infection, constipation, needing the toilet, hunger, thirst and overstimulation.

Cue 2 Assault cycle graph with the escalation phase highlighted as the intervention window.

AMARA 01:06 Tell me about the assault cycle, because I have heard the term and never had it explained.

NADIA 01:13 Five phases. Baseline. Trigger. Escalation. Crisis. Recovery. And then a post crisis phase where the person is often exhausted and full of remorse.

AMARA 01:22 Which one matters most?

NADIA 01:23 Escalation. That is where de escalation works. In crisis it barely works at all, and this is the single most useful thing in this module.

AMARA 01:33 So if somebody is already in crisis and I am talking them down?

NADIA 01:39 You are probably prolonging it. Once a person is in crisis your objective changes. It is no longer talking them down, it is keeping everyone safe until the arousal falls. Reasoning with somebody in crisis is like reasoning with somebody who is drowning.

Cue 3 Recovery phase warning showing a second trigger relapsing to crisis.

AMARA 01:56 What about recovery? That sounds like the safe bit.

NADIA 01:59 It is the bit that catches people out. Arousal comes down slowly, so a second trigger during recovery sends the person straight back to crisis from a much lower starting point. Give time and space before any conversation. Do not go straight in with we need to talk about what just happened.

AMARA 02:20 Right. De escalation. What actually works?

NADIA 02:23 Reduce the audience. Reduce the noise. And reduce the number of people talking to exactly one. Three staff all speaking at once is escalation, not help.

AMARA 02:33 And physically?

NADIA 02:34 Give more space than feels natural. Lower your voice instead of raising it, which is counterintuitive and it works, because people match your volume. Slow your speech. Keep your hands visible and open.

Cue 4 De escalation posture diagram: angled stance, space, hands visible, exit behind you.

AMARA 02:47 What do I say?

NADIA 02:49 Short sentences. Their preferred name. Acknowledge the feeling out loud: I can see you are angry, and I want to sort this out. Do not argue about facts, because you will win the argument and lose the person.

AMARA 03:04 And what should I never say?

NADIA 03:06 Calm down. It has never calmed anybody in the history of the world. Also you need to relax, and there is no need for that. All three tell the person their feeling is illegitimate, which is a fresh trigger.

AMARA 03:22 You mentioned offering a choice.

NADIA 03:24 Two real options. Not an instruction dressed up as a question. Would you rather sit here or come through to the quiet room. Choice restores control, and lost control is usually what caused this in the first place.

Cue 5 Phrase bank: what to say in gold, what never to say crossed out.

AMARA 03:39 Let us talk about my safety. Where do I stand?

NADIA 03:43 At an angle rather than square on. Square on is confrontational and it also means you cannot move. Stay beyond arm's reach and out of kicking range. Never let the person get between you and the door, and know where the second exit is before you need it.

AMARA 04:02 Anything to move?

NADIA 04:03 Ligature and weapon risks within reach, where you can do it safely. And that includes things people forget. Your own lanyard. Scissors. A hot drink.

AMARA 04:13 When do I leave?

NADIA 04:15 When the risk exceeds what you can manage. And I want to say clearly that leaving is a professional decision, not a failure. Summon help, follow the escalation route, and if you are a lone worker, use the check in system and the agreed distress phrase.

Cue 6 Reporting loop showing under reporting leading to unchanged conditions.

AMARA 04:33 What about restraint?

NADIA 04:35 Not from this course, and not from any online course. Restraint carries a real risk of death, particularly prone restraint or anything restricting the chest or airway. It requires in person training under a recognised framework, it is a last resort, for the shortest possible time, and it is always recorded and reviewed.

AMARA 04:56 Afterwards. What should happen and what usually happens?

NADIA 04:59 What usually happens is nothing. People do not report, especially verbal abuse, because they have decided it is normal.

AMARA 05:07 And the cost of that?

NADIA 05:09 The staffing level never changes. The waiting time never changes. The layout never changes. The individual's unmet need never gets found. Under reporting is precisely why nothing improves. So report everything, debrief the team, and where it is appropriate debrief the person too, because many are ashamed afterwards and will tell you exactly what set them off if you ask at the right moment.

AMARA 05:34 And the colleague who was on the receiving end?

NADIA 05:38 Check on them properly, not in the corridor. And take the cumulative effect seriously. One incident is an incident. Being shouted at every shift for two years is an injury, and it is the one nobody writes down.

Cue 1 Four part lone working system, with the flag feeding back into the rota.

AMARA 05:53 Most of my work is alone, in people's houses, often in the dark.

NADIA 05:58 Which is the highest risk part of care, and it is the part with the least training attached to it. Employers have duties under the 1974 Act to assess and control that risk, and a lot of them discharge it with a policy nobody has read.

AMARA 06:17 What would a real system look like?

NADIA 06:19 Four things. Somebody knows where you are and when you are due out. You can raise an alarm without being seen doing it. There is a defined response if you do not check in. And you can flag a property as higher risk.

Cue 2 A flag raised and a rota returning unchanged, marked as a document not a system.

AMARA 06:37 We can flag things.

NADIA 06:38 Then here is the test. You flag a property, and the following week the rota comes back unchanged. What have you got?

AMARA 06:47 A document.

NADIA 06:48 A document. A flag that does not change how a visit is staffed is a filing exercise, and workers stop using it within a month because they can see it does nothing.

Cue 3 Environmental cues in a room: extra person, locked door, seating rearranged.

AMARA 07:01 Are there warning signs? Or does it just happen?

NADIA 07:04 It very rarely just happens. And this is the difficult part: people who are hurt usually say afterwards that they noticed something and talked themselves out of it.

AMARA 07:15 What should I be noticing?

NADIA 07:17 Environment first. Somebody in the house you were not expecting. A door locked behind you. A dog loose that is usually shut away. And the room rearranged so you are the one furthest from the door.

Cue 4 Situational trigger: a benefits letter on the mat before the visit.

AMARA 07:32 That last one is subtle.

NADIA 07:34 It is subtle and it is deliberate when it happens. Then behaviour: pacing, clenched hands, rapid speech or a sudden silence, standing too close, blocking the doorway, not letting the conversation end.

AMARA 07:47 And situational?

NADIA 07:47 The most reliable predictor of all. Bad news that arrived before you did. A care package cut this week. A benefits letter that morning. An eviction notice. You have walked into somebody's worst day and you are the nearest representative of the system that caused it.

Cue 5 Leaving the house and escalating from the pavement.

AMARA 08:06 What do I do?

NADIA 08:07 Leave. Not after the call, not after explaining. Leave, and escalate from the pavement.

AMARA 08:13 It feels rude, and I would feel stupid if I was wrong.

NADIA 08:18 Then say something neutral. You need something from the car. That is all. And hear this clearly: nobody has ever been disciplined for leaving a house that felt wrong. Several people have been seriously hurt for staying to be polite.

Cue 6 Delayed reaction curve: fine on the night, shaky at three days.

AMARA 08:34 And afterwards?

NADIA 08:35 Report it, including verbal abuse, because under reporting is exactly why the visit arrangements never change. And get a real debrief, not a corridor conversation on the way past.

AMARA 08:46 I would probably say I was fine.

NADIA 08:49 Most people do, on the night. And then they are shaky three days later, which is a completely normal delayed reaction and not weakness.

AMARA 08:59 What should a manager do?

NADIA 09:01 Ask more than once. A single how are you on the day gets a fine from almost everybody. The honest answer usually arrives about a week later, and only if somebody bothers to ask again.