How to manage difficult and aggressive patients and their families
My experience working in health care has always reminded me of the extraordinary work that is carried out every day in providing care and support in the most challenging of work environments. Dealing with life-and-death situations and supporting patients and families experiencing unexpected illness or a health crisis means many healthcare workers may be subjected to higher levels of stress, emotions and aggression.
The distinction between difficult and aggressive behaviour is important. Difficult behaviour could be dealing with specific characteristics or emotions, whereas aggressive conduct can be defined as harassment, swearing, racial abuse, threats or violence.
Clear procedures need to be in place to manage aggression and support team members as well as setting clear expectations for patients and families. All healthcare providers have a duty of care to comply with work health and safety obligations — by identifying and mitigating potential risks towards healthcare professionals and protecting their safety and wellbeing at all times.
It is essential to develop and implement procedures including:
- Clear policies outlining management of aggressive behaviour.
- Actively and visibly promoting zero tolerance for aggressive conduct.
- Recommended wording or language that can assist in de-escalating conflict.
- Providing training on managing difficult behaviour and aggression.
- Escalation paths including hospital emergency codes, duress alarms or police.
- Video surveillance.
- Physical security presence.
Managing difficult behaviour and aggression is a skill and one that is paramount when dealing with heightened emotions or complex health issues.
The ACER model
The goal of every difficult interaction is to diffuse the behaviour while maintaining safety as the number one priority. Taking the time to understand why patients or families are expressing difficult behaviour is the first step in providing an empathetic response. This can be very useful not to excuse, but rather understand where the behaviour may be coming from. All behaviour has meaning. The following ‘ACER’ model is recommended to de-escalate difficult or abusive behaviour:
It is critically important to assess the state of the patient or family member. Being observant to signals of escalating behaviour is vital. Physiological signs may be observed including:
- Flushed face.
- Turning red.
- Clenching of face, fists or facial muscles.
- Sudden or jerky movements.
- Moving into your personal space.
- Grabbing your arm.
- Shouting or raised voice.
- Prolonged staring.
- Throwing items or pounding a fist on a counter.
You will need to recognise if the situation is escalating and if you or anyone else is in danger of physical harm. These signals may alert you to escalating behaviour and help to make a decision about what actions you need to take. Ultimately your judgement is critical in such situations.
Remain calm, focused and in control by focusing on your breathing. Where appropriate and safe — if a customer is exhibiting aggressive behaviour — set clear boundaries by letting the patient or family member know in a polite, respectful and non-threatening manner that aggression will not be tolerated and the outcomes for continued behaviour.
E: Exit or engage
You will need to make an immediate decision regarding your personal safety — if you are in immediate danger you may need to exit the situation straight away. If you are in a position to engage and have a conversation with the patient or family member, and if the behaviour moderates, work on resolving the issue. Speak in a calm, firm tone without raising your voice. Let the patient or family member vent their frustration and listen attentively and empathise with their situation. Display open and neutral body language and be conscious of not invading personal space. Work to resolve the issue in a calm and professional manner.
Depending on the severity of the situation, the incident may need to be escalated immediately by using the appropriate hospital emergency code, calling security, pressing a duress button or dialling 000 for police. A formal report should be prepared and documented for incident reporting and investigation.
Self-care is crucial immediately after an incident and also as part of your daily working routine. If you don’t take care of yourself, it is hard to take care of anyone else. While there are numerous approaches for self-care, it’s about finding what’s right for you. Strategies may include taking a physical break from your work environment where possible, making time for activities you find replenish you outside of work. Physical exercise, yoga or meditation may also be useful to de-stress.
Offer or seek additional support
In some cases of aggression where a team member may have been deeply affected (either post-incident or some time down the track), an EAP (Employee Assistance Program) should be offered. It is vital to recognise signs of mental and emotional impacts that require professional counselling in yourself and others and seek additional support when needed.
The significant role of healthcare professionals in our community must never be underestimated. Respect and courtesy must be shown at all times by patients and family members. When difficult behaviour or aggression arises, it is about demonstrating quality care while setting and implementing clear boundaries to ensure the protection and safety of the team.
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