In these days of increasing aggression in the workplace, patients, their relatives -- and sometimes other staff -- regularly invite renal healthcare professionals to “improve their skills in managing aggression”!

As a mental-health-nursing lecturer, I am often asked to teach these skills. I believe most staff are already experts in de-escalating aggression, owing to the amount of practice they get day to day, but they may be missing one important skill -- quick recognition of the kind of aggression with which they are being called upon to deal.

Based on experiences related to me by staff while I have been teaching this subject, I have drawn up a practical approach to correct this.

Don’t play pass the parcel

Most experts agree that aggression is an innate biological reflex, which needs an outside stimulus to trigger it.

Negative aggression -- the type we are looking at here -- is best viewed as a “parcel” of very negative emotions such as anger, fear, stress, hate, contempt, and disappointment. These emotions become unbearable to the person feeling them, and are then discharged at someone, or something, else.

In workplace aggression, the “someone else” is usually a healthcare professional -- you! Unfortunately, the “parcel” can then be carried, or experienced, by you and be why you do not always feel motivated to use the de-escalating skills you have.

Quick recognition of the type of aggression you are facing can help prevent this, so I have drawn up a way of classifying the different kinds of discharge of aggression, and suggested how you can manage these discharges.

Mr Lost It!

This kind of aggression includes all those who are beyond the reach of verbal interventions, for reasons such as confusional states, psychosis, alcohol and drug use, or simply the “red mist” of total loss of temper.

Most of these aggressors are not responsible for their actions. However, there is plenty of evidence to suggest that Mr Lost It! often “loses his temper” when he feels he can “get away with it”. If the consequences of “losing their tempers” are made clearly apparent to such aggressors, they often develop an astonishing ability to manifest self-control.

All categories of aggression can escalate to a Mr Lost It! if the situation is not brought under control.

The management of a Mr Lost It! is purely physical because the aggressor is beyond verbal intervention and your options are restraint or retreat.

Mrs Intimidator

This kind of aggressor may appear very similar to Mr Lost It! They may be behaving in the same way.

The difference is in their motivation and underlying emotion (contempt). Mrs Intimidator trying to force you to give her what she wants by threatening violence.

You can often determine the difference between a Mr Lost It! and a Mrs Intimidator through your emotional response to the situation. In both cases, you are likely to feel fear, but, with a Mrs Intimidator, you may also experience hate and rage. This is because, on a subliminal level, you are picking up that Mrs Intimidator is in control of her actions and that the behaviour is an attempt to manipulate.

The strategy for managing this kind of aggression is two fold. First, “name the game”; then “state the consequences”. For example, say: “You are behaving like this because you want X, but if this behaviour continues this is what will happen.” This strategy is easier said than done and you should never try it without first arranging proper back up: for example, from Security.

Master and Miss Communicator

This aggressor comes in two types. Master Communicator is reasonably and rationally distressed. Miss Communicator is discharging her “parcel” into inappropriate persons, so-called “dumping”.

Master Communicator has unbearable feelings which escalate from telling you how he feels, through showing you, to finally making you and other staff feel them by an act which violates others around him, such as violence. The escalation usually happens because you and others have been unable to demonstrate the right response.

At times of unbearable distress, the intervention which makes the unbearable bearable is an empathic one. Master Communicator needs you, not only to communicate to him that you know how he feels, but also that you understand why -- and care about it. When this is response is not forthcoming, Master Communicator must make the message clearer.

Miss Communicator, by comparison, is unconsciously making you feel her distress even though it has nothing to do with you. A common example of this is the patient who discharges all their distress about their condition onto you by making unreasonable complaints.

You feel that “this is not fair”, which is exactly what Miss Communicator is feeling about her illness.

The response which de-escalates Miss Communicator’s behaviour is an empathic one, but it is must also be one that sets limits on her behaviour.

Identifying the category of aggression you are experiencing helps in two ways. Firstly, it protects you against the effects of the “parcel”. You will find that you are no longer affected by an emotional load of negative feelings and can function more effectively in an emotionally neutral way.

Secondly, this strategy for management cuts down confusion and allows a quicker response, which is more likely to result in speedier control of the situation.