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

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.

Aggressive behaviour include:

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.

Causes:-

 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!

The anger/assault cycle

  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, ignoring ICE,

dismissive attitude etc.

Typical triggering events

 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

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 exacerbated

  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.

Escalation can be diffused:

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.

2 Strategies: Reflection & legitimisation

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.

Preparation is essential

Advance warning during the consultation:

Look out for agitation, An angry tone of voice, Clenched fists and Finger pointing or abrupt movements

Forewarned is forearmed

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).

Signs of distress:

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,

Forearmed

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.”

Actions speak louder than words

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.

Guidelines for dealing with the angry or aggressive Pts.

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.