Angry patients An increasing number of health care staff are physically attacked or verbally abused by patients. During 2008-09, NHS trusts in England had one physical assault for every 61 primary care staff – 3,472 in total. 42% had experienced violence. A third thought the incidence of violence was increasing. A BMA survey of 400 GPs. 2006
Aggressive behaviour include: • Physical violence • Verbal or physical abuse, threats or gestures • Discriminatory abuse • Intentional damage to practice premises • Sexual or racial harassment • Stalking • Inappropriate emotional attachment to a doctor.
Causes:- • Not met or delayed, Patients expectations; • Aggression can often mask poor communication or interpersonal skills; • Delays in treatment, restrictions, mistakes, & lack of privacy;
Causes:- • Environmental factors, such as heating, noise or ventilation; • Personal problems, a history of violence, drug or alcohol abuse.
The anger/assault cycle Triggering events escalation crisis resolution. Be warned! • Conciliatory or diffusing actions only work during the triggering and escalation phases. • During the crisis phase your safety is paramount – get out!
Typical triggering events • Problems or perceived problems: • At home – financial, social, psychological, relationships etc. • With the surgery – no available appointments, unable to gain an appointment with the desired GP, mistakes by the surgery (perceived or real), no privacy at reception, poor communication etc. • Medical – psychiatric illness, intoxication, alcohol misuse, drug misuse, anxiety or fear. • Poor consultation skills e.g. missed cues, dismissive attitude etc.
Escalation • The upset patient may escalate to violence (crisis). • Indications of escalation are; • Symptoms– shouting, swearing, repeating themselves, threat etc. • Signs – clenched fists, wringing hands, pointing, pacing about, sweating, loss of eye contact or intimidating aggressive posture.
Escalation can be exacerbated • Poor communication with the patient - especially lack of explanation (by staff or GP). • Ignoring the patient (often happens at reception) • Failing to try and resolve the issue. • Confrontational or an aggressive response. • Failing to apologise when appropriate. • Poor consultation skills.
Escalation can be diffused: • Stay calm and remember their anger may not be directed at you personally. • Take a conciliatory approach – give them space and privacy and time to ventilate. • Express empathy, concern and support. • Apologise for their upset. • Listen to the patient’s distress and explore what has upset them and the contributory reasons for their anger.
Escalation can be diffused: • Then discuss how you can help - present the patient with realistic, achievable options and • Come to a shared agreed plan. • Check their understanding of what you have agreed. • Ensure you deliver your side of the deal. • Remember to address your emotional housekeeping.
2 Strategies: Reflection & legitimisation • e.g. of a reflection: 'You are upset because you think I do not really believe you are suffering.‘ • Then;legitimise the patient's anger. E.g. 'I can understand why you are upset. You came to me to find some physical cause for your pain. I cannot find any problem and now I am sending you to a psychiatrist. I might be upset also, if I were in your position.‘ - This expression of understanding and legitimising your patient's emotion is reassuring to them. It usually prevents any further problems and is a powerful method for establishing trust and rapport between the doctor and the patient.
Preparation is essential • Always ensure the arrangement of furniture in your consulting room does not block your exit. • Know where your panic alarm is and use it! • Ensure you and your staffs are trained as to how to respond to a panic alarm. • Consider attending ‘breakaway techniques’ courses. • Have a policy for seeking immediate police help.
Forewarned is forearmed Advance warning during the consultation: • Look out for agitation, • An angry tone of voice, • Clenched fists and • Finger pointing or abrupt movements
Signs of distress: • Speech ( becoming louder & quicker); • Facial expression (changing, flushed, loss of eye contact); • Manner (impatience or non-compliance) • Body language (closing in, sudden or expansive movements).
Forearmed • Take action to remove yourself from the situation if any of these warning signs occur. • “front-desk system” where alerts are recorded next to a patient’s name,
Actions speak louder than words • 80% of communication is non-verbal • Stay calm, speak slowly and politely • keep your voice at a conversational level • Maintain eye contact • Empathy can help. “I know you feel angry about your long wait, but I’d like to try and help you with your chest pain.”
Guidelines for dealing with the angry or aggressive Pts. • Is the Pt. agitated, restless or ready to explode? What does Pt. behaviour communicate to you? • Show willingness to talk & listen, acknowledge the Pt. anger or annoyance. • Keep a safe distance; neither too close, nor too far away. • Do not interrupt the patient’s outburst. • Ask open rather than closed Qs. Encourage the Pt. to talk.
Do not make agreements or promises that cannot be kept; be reasonable & honest. • Help the patient to feel he has choices. • Do not talk to the Pt. from behind; also do not attempt to touch the Pt. • Do not block the Patient’s path; ensure the Pt. has an escape route. • If security staff are summoned, try to supervised their actions.
Try to identify the cause of the aggression, you might be able to deal with it. • Maintain your distance from the patient • Never turn your back on a potentially aggressive patient, and always sit nearest to the door, in case you have to make a quick escape • Document all conversations and patient concerns carefully.