De-escalation Techniques

SJT Textbook: De-escalation Techniques (Deep-dive)

De-escalation Techniques MSRA

This guide provides a deep-dive into De-escalation Techniques MSRA scenarios. While general communication skills are important, this specific topic requires a “Safety-First” mindset. In the SJT, you must demonstrate that you can manage high-risk aggression without endangering yourself or others.

🎥 Video Lesson (YouTube)

🎧 Podcast Lesson (Spotify / Apple / Amazon)

🎯 THE CORE PRINCIPLE

De-escalation is a safety-led communication approach that reduces anger, agitation or distress while preserving dignity. You use non-threatening posture, calm language and empathic listening to lower arousal, then set clear limits around behaviour and agree practical next steps.

In the MSRA SJT, high-scoring answers protect safety before conversation (distance, exits, colleagues), show you genuinely hear the concern, and offer realistic, time-bound options instead of threats, avoidance or empty promises. Proportionate escalation to senior staff, security or police is expected if risk continues to rise.

The examiner is looking for a structured pattern: Safety → Empathy → Limits → Choices → Record/report. You score well when your actions are predictable, fair and consistent with GMC guidance, and when you look after staff safety with proper documentation, incident reporting and debrief.

⚡ HIGH-YIELD ACTIONS (What Scores Points)

1. Scan the environment for risks, maintain distance and a clear exit, and invite a colleague early when concerned.
2. Reduce stimulation: move to a quieter, safer space where possible and avoid an audience gathering.
3. Use calm, low, slow speech, open posture and visible hands to signal non-threat and control.
4. Acknowledge and name the emotion (“I can see you are very frustrated about the delay”) before problem-solving.
5. Set clear, neutral behaviour limits (what is and is not acceptable) without criticising the person.
6. Offer 2–3 practical, time-bound choices (e.g. senior review now vs timed call-back) to restore a sense of control.
7. Escalate proportionately: pause/timeout, senior review, then security/police if risk persists or escalates.
8. Protect confidentiality by moving away from public spaces and keeping discussion discreet.
9. Record a factual account of behaviour, risks and actions taken, including threats in the person’s own words.
10. Complete an incident report and ensure staff support/debrief, especially after threatening or abusive incidents.

Trap themes: loudness, threats, appeasement with dishonest promises, abandonment and confidentiality breaches. Any option that sacrifices safety, honesty or dignity to make the noise stop will usually score poorly.

💬 MODEL PHRASES (Use These in SJT Logic)

* “I will keep my voice calm. I need you to keep some space between us and lower your voice so we can continue.”
* “Right now I can offer two options: a senior review today, or a timed call-back to resolve the booking. Which would you prefer?”
* “I am going to ask a colleague to join us so we can sort this out safely for everyone.”
* “I want to understand what has happened from your point of view; tell me what is worrying you most.”
* “If the behaviour continues like this, I will need to pause this conversation and arrange a safer review.”

C = Check safety (space, exits, colleague)
A = Acknowledge feeling
L = Limits stated clearly
M = Minimise noise and crowd
C = Choices that are practical
H = Help from senior or security if needed
O = Outline agreed plan and timeframes
I = Incident-report and record facts
C = Chart threats in their own words
E = Exit safely and ensure staff debrief

📋 QUICK FAQ

When should I end the consultation?
End the consultation when there is continuing risk despite clear limits and choices, or you no longer feel safe. Summarise what has been agreed, give alternatives (time-out, new appointment, senior review), move to safety, and escalate to senior staff or security. Document and incident-report.

Should I report verbal abuse if there was no physical harm?
Yes. Threats, racist or targeted abuse and near misses should all be reported via local incident systems. This supports prevention, security planning and staff wellbeing.

What if difficult clinical news triggered the anger?
First validate the emotion and allow some venting. Then calmly re-explain the information in clear language, check understanding, and offer a senior review or written summary. De-escalation complements, rather than replaces, honest communication.

How do I manage de-escalation in a crowded waiting room?
Invite the person to a quieter, safer space with a colleague if possible. Avoid discussing confidential details in public. If they refuse to move and risk remains high, focus on safety, call for help, and prioritise the safety of other patients.

Is it ever appropriate to “give in” to demands to keep the peace?
No. Offering inappropriate investigations, queue-jumping or dishonest promises to stop shouting is unsafe and unfair to others. Instead, explain what you can reasonably offer and why, and escalate if the behaviour remains high-risk.

📚 GMC ANCHOR POINTS

* Communicating clearly, listening and treating people with kindness and respect (GMC Good medical practice 2024, communication domain).
* Keeping patients and colleagues safe and raising concerns about risk, including violence and aggression (GMC Good medical practice 2024, safety and quality).
* Maintaining clear, accurate and timely records after incidents, including decisions and actions (GMC Good medical practice 2024, records and information).
* Looking after your own health and wellbeing and supporting colleagues after distressing events (GMC guidance on caring for yourself and colleagues).
* Respecting confidentiality and discussing patient information in appropriate settings (GMC confidentiality guidance).
* Following local policies on violence, aggression, zero tolerance and incident reporting (GMC expectation to follow local rules and national law).

💡 MINI PRACTICE SCENARIO

A patient in a small consulting room becomes increasingly angry about a cancelled scan. They stand up, step towards you, swear loudly and move between you and the closed door. You are alone and feel unsafe.

Best action: Position yourself near the door, open it to create an exit, call a colleague for support, acknowledge their frustration, set clear limits on behaviour, and offer realistic options (for example, senior review now or a timed call-back from radiology).
Why: This prioritises immediate safety, brings help early, validates emotion, uses calm limits and choices, and prevents escalation or abandonment. Documentation and incident reporting should follow.

🎯 KEY TAKEAWAYS

✓ Safety positioning and early backup are more important than getting through the history.
✓ Empathy plus calm limits and realistic choices is the core de-escalation pattern.
✓ Never trade honesty, fairness or confidentiality to make the shouting stop.
✓ Terminate consultations safely and escalate if you or others remain at risk.
✓ Factual notes, incident reports and staff debrief are part of good care.
✓ The exam strongly rewards structured, proportionate responses over bravado or avoidance.

🔗 RELATED TOPICS

* → Dealing with Angry or Distressed Patients
* → Active Listening
* → Working with Relatives and Carers
* → Duty of Candour (Openness and Apology)
* → Self-awareness and Insight
* → Incident Reporting and Raising Concerns

📖 FULL PRACTICE QUESTIONS

Example SJT — Best of 3 (8 options; choose three)

A 54-year-old man is in the ED waiting room, shouting about long delays and claiming he has been “forgotten”. Other patients are watching, and a child nearby is crying. He is standing, gesticulating and demanding to see “the manager now”. You are an FY2 doctor nearby and staff look to you for help.

Options:
A. Raise your voice so you can be heard over him and firmly tell him to sit down and be quiet.
B. Invite him to a quieter, safer area with a colleague, acknowledge his frustration, set calm limits on behaviour, and explain what you can realistically do next.
C. Promise he will be seen immediately, even though this is not true, to calm him down and sort the queue later.
D. Ignore him and continue with your current task, hoping reception will deal with it.
E. Ask security to remove him from the premises without attempting to speak with him.
F. Ask a colleague to call security while you calmly approach, introduce yourself, acknowledge his concerns and invite him to talk in a quieter space.
G. Start explaining the four-hour ED target loudly in the waiting room so everyone understands the delay.
H. Quietly ask reception to bring him straight through to the clinical area to avoid a scene, even though other patients have been waiting longer.

Example SJT — Rank 5 (best → worst)

You are in a small clinic room in outpatients. A patient becomes angry about a cancelled scan, stands up, steps towards you, swearing and pointing, and is now between you and the closed door. You are alone and feel unsafe.

Options:
A. Position yourself with space and an exit by opening the door, invite a colleague, acknowledge their frustration, set clear limits and offer two practical options (for example, senior review now or timed call-back from the booking team), then document and incident-report.
B. Raise your voice and threaten to remove them from the clinic list if they do not calm down immediately.
C. Continue typing and ignore the behaviour, hoping they will settle on their own.
D. Promise an immediate scan you cannot realistically arrange to stop the confrontation.
E. End the consultation by leaving abruptly without explanation, closing the door behind you and not informing anyone.