Environmental management (adaption)

Environmental management (adaption) is key to de-escalation in all patients, but is especially so for children, those with cognitive impairment or communication difficulties, and older people. Optimising the clinician's approach and the physical environment, without restricting the patient's human rights, can positively influence the patient's behaviour, reduce the risk of escalation and avert significant harm. Use the least restrictive intervention necessary to ensure the safety of the patient, staff and others.

Ideally, provide a ‘safe place’ for the patient—a quiet, low-stimulus space, with someone who cares about them alongside for support. The physical environment (eg emergency department) may add to their distress due to unfamiliarity, fear or sensory triggers (eg noise, lights, handling). The patient should not be assessed alone; the clinician assessing the patient should have at least one other staff member in attendance. Maintain the patient's privacy and give them space and physical distance to move around if it is safe to do so.

If possible, consider the following environmental management (adaption) strategies:

  • orient the patient to the environment and to staff
  • use healthcare interpreters when required (eg for patients from non-English speaking backgrounds, and culturally and linguistically diverse patients) 
  • reduce environmental noise and avoid overstimulation
  • ensure the patient’s unmet needs are identified and addressed (eg pain, toileting, hunger, thirst)
  • identify and remove specific triggers for behaviours, if feasible
  • actively engage and promote contact with a friend or family member, if they are available
  • address comfort (eg offer a recliner and additional pillows)
  • optimise communication (eg ensure hearing aids, voice amplifier and visual aids are used, if indicated)
  • provide diversional activities
  • use soothing generation-appropriate music.

Children, older people and those with cognitive impairment are most likely to respond to environmental management (adaption) to defuse the situation.