We recently had the opportunity to sit down with the amazing Harriet Downing, Senior OVA Clinical Consultant and Neuropsychologist at Western Health, to learn more about the skills frontline workers can use to prevent occupational violence and aggression.

Reframe Your Response was a slogan that Elisa Ilarda generated and the idea was how do we recognise what we’re bringing to an interaction with somebody else and how do we realise that we’ve got more control than we might immediately think we have over the outcome of a situation.

There is a quote from Viktor Frankl that says something along the lines of ‘between stimulus and response is a space and in that space is our power to choose’. So what we’re trying to do in Reframe Your Response is to learn that behaviours of concern and occupational violence don’t come from nowhere. They exist in a relationship between, say patients and family members and staff.

So how do staff reflect and plan for what they’re bringing to a situation and use soft skills in order to minimise the chances of things escalating.

It can be difficult to demonstrate the impact that somebody has in their choices of interaction particularly in a conflict interaction. In an educational space, roleplay goes some way into practising these things, but I think one of the benefits of virtual reality is that you can track or make tangible where different responses can lead to different outcomes.

I’d say that there are multiple opportunities in any interaction for things to wobble and get back on track. There’s no perfect way to have a conversation or an interaction with somebody else. So sometimes we react automatically. That’s very, very human. Partly that’s about that human thing of mirroring somebody’s level of energy. If somebody’s really up and high, we get really up and high. If someone’s low, we’ll join them down there too. So, part of this is recognising when you have that automatic reaction, and then taking that space to say, okay, that’s this other person’s stress or distress, and shift from that empathic distress into compassion where we say, okay, I recognise the suffering of this other person. I’m going to hold a non-judgmental space and seek to connect and understand what’s going on for them and then help them to take action to relieve this. In terms of when you connect or disconnect with somebody, you might find that that’s partly because you’re reacting along the way automatically. Sometimes we just have to take steps to regulate ourselves or tone down our own stress response, so that we can maintain agency to have a goal and get where we want to go in that interaction.

So, one of the first things that we encourage people to do is to be aware of their own reactions. What are they thinking, feeling and how are they wanting to behave and so on? Then they can take steps to reduce their stress.

So, focusing on their breathing and their self-talk, “I’ve got this, I’m gonna say it from their perspective”. I’m noticing what I’m saying and what I want to say like “You’re overreacting!”. We use that as a cue to say “Okay, I’m bringing in judgement here. I need to step back and say it from their perspective”.

So, it’s about recognising when you’re reacting and creating that space, but it’s also about modelling the calm so that the other person can match where you’re at so you slow things down. You might slow down how quickly you’re talking and how quickly you’re moving. You focus on your body language, and it’s about sending ‘Signs of Safety’.

So, open body language, it might be about having your tone of voice and not even being super warm and super smiley but at least neutral, super non-threatening. We also lower our pitch because when we’re in that fight or flight state where the person has shown behaviours of concern or is likely to be in that state, our auditory system picks up on the lower frequencies frequencies, we can miss some of the higher ones so it’s about lowering your tone of voice as well when you speak. Then reflect back to the person some of the key words that they’re using and try to help them to identify what their main concerns are and how they’re feeling.

Yes, connection is key. One of the tendencies in the workplace is to get things done quickly. I don’t have time for this. I’ve got all these tasks I need to do. But actually what we need to do in this space where there’s a chance of things going pear shaped and having an episode of occupational violence and aggression, is to not rush people. That means giving the time that’s needed and we have a de-escalation model that’s starting with stay safe or is it safe to be here?

The next one is validation. So, connecting with the person taking as much time here as you need to connect with their emotional state and their understanding of the situation. You really need to spend time understanding this. And that will take as long as it takes. Often it won’t be, it really depends on the person but if you can show them that you’re there with them and that you’re wanting to understand, you are understanding and helping them to articulate what’s going on for them. Often that won’t take very long. But it’s not until you’ve sat with that person, and they can regulate as well. Then you move on to that collaborative problem solving.

There’s a tendency sometimes for us not to spend enough time just sitting with another person in their distress. We want to solve things with people. We want it to be okay but actually sometimes that’s not our job. Or sometimes we can’t do that completely and it’s just about showing up for someone and sitting in a difficult situation with them.

It’s not only that you have the time, but you have the permission to use the time.

At Western Health, there’s a policy that says it’s okay to step away and that comes down from the CEO. I think it’s tricky for some people to know when to step away and when not to and there are a lot of tasks and demands on nursing staff. Where there is a risk of OVA, staff need to know that they’re allowed to take the time and with some of these soft skills that we talk about, there are tangible ways to to use them and it seems like you might really disagree with this person and their perspective or not really like them, but you can still show up and use the skill of non judgement. You can show up and use the skill of respectful language. You can use the skill of validation and then at the end of that, when you’re safe you can debrief with appropriate set of professional supports as well.

I would probably have to look it up to give you a really accurate one but basically, it’s about their different levels of emotion, their primary emotion. There’s only about six or seven of those and then the secondary emotions and so on. Anger is what we consider to be a secondary emotion and often underneath anger is something else like fear or anxiety and so on.

It’s when we’re in that threat state that we show anxiety for example by becoming angry because that’s what’s easiest for us in the moment. Sometimes we’re not very good at being assertive and saying this is what I need for various factors. Maybe we’ve never had that skill or never been able to be assertive. So, we just communicate that need or that emotional state in the only way we know how.

Everybody has their triggers, right? There are things that set us all off but sometimes we’re triggered into a strong emotional reaction that might not seem to fit the reality of our situation. It’s because of stuff that’s happened in the past so that we might be showing up as an adult, we’re not acting at the age we are now because there’s something that’s brought us back to this previous point in time. So, when we’re absolutely not in our most mature space, that’s where that self-regulation piece comes in to help you get on top of that.

How do you communicate requests? How do you communicate boundaries? How do you check your expectations of people coming into the hospital? Where’s that conversation that’s happening to get to the expectations out there? Then you clarify things and provide the right information. There’s such a space for technology, for communication skills, for all these things just to clarify expectations and give people more control over a situation that is really destabilising.

It sounds obvious, but you’re absolutely right that communication is really hard. If we could just articulate our needs and feel comfortable in articulating them. Putting ourselves out there and being okay with a response that might be nice. Having some pushback and that be okay. Just being able to sit with a disagreement and that’s okay. It’s not a reflection that you’re a bad person or something.

Absolutely. I think in any human reaction, there’s a space for these sorts of discussions, this sort of training, even. In the Western Health setting, we have such a diverse population. So many different cultures, language groups, ages, socio economic background and things but we’re all humans. It’s that common humanity piece. How do we bring it back to that every day? We’re all people. Every person has worth and value and a right to be here.

I follow a bunch of people on Instagram, and I can recommend several different books. I’ve really liked Gabor Maté. So partly it’s about understanding diversity, understanding lived experiences that are different from your own.

So, for things like addiction, drug and alcohol problems, I really love Gabor Maté’s ‘In The Realm Of Hungry Ghosts’. He also has a fantastic book on ADHD called ‘Scattered Minds’ and the book called ‘Hold On To Your Kids’, which has themes that have come out in both his other books, that so much of what’s showing up for maybe dysfunctional adults is their life experiences and these people were all children at one stage. So, understanding what is it that’s important about childhood and attachment and how important that is, and how our society is structured in a way that’s really not conducive to really healthy relationships in a lot of situations. So, Gabor Maté is one.

I really have enjoyed the work of Brene Brown, she’s got her own research but also draws on a lot of other people’s research. So, she references people such as Kristin Neff, who is a researcher in self-compassion. And I think Paul Gilbert is another one in that space. I follow people on Instagram who work in the hostage negotiation space, people like Chris Voss. I try to read an eclectic mix of topics and various formats from books on communication to research papers on compassion and everything in between.