- Doctors: Ramesh Mehay
- Admin: Chris Rushton
26 May 2016
Date of Next Review
People usually become angry or difficult when their needs are not met. Think of the last time when you got really angry - can you recall a situation which made your blood boil? This tells us that all of us at some point have become really annoyed or angry but that in itself does not mean we are bad or horrible people on the whole. In a similar way, people who are angry or difficult with you are not usually horrible or bad people (and don't forget that in their lives, they have people who like and love them too). So, we’ve constructed this page to give you all some ideas on how to approach the aggressive, angry or difficult patient and diffuse the situation.
Actually, most of this stuff will work with any difficult person you encounter. And you don't always need to go to your line manager to help sort this situation out - you have the power within you to diffuse the situation – but only if you will let yourself try. Believe in yourself!
Two Basic Rules
1) Always keep yourself safe.
If you feel threatened or intimidated by the other person, make sure there is a good distance between you two and where possible, keepbehind a protective counter or be sure to be near a safe exit point. Remember, if you want to ask the patient to leave, you can still do so from behind a counter: 'Mrs. YYY please can you come up to the desk.' ; and once they are there 'I'm sorry Mrs XXX but I'm going to have to ask you to leave the premises because of ............ which is not acceptable in this practice.' If you said this face-to-face to Mrs. YYY - you might get a punch!
2) Change to a positive mindset.
Remember that most angry people are not horrible people. Like we said before, people are upset when they don't get what they want.
- So, instead of thinking...'Oh no, I've got a horrible nasty person',
- Change your thoughts to:'I've clearly got a person whose needs are not being met. Most people aren't horrible people. Let's see if I can help this person and get them in a better place and better frame of mind'.
Signs that a patient is kicking off
- Obviously, a patient will show that they are vexed through what they say and how they say it. They will use harsh words expressed in a harsh tone.
- You should be able to read from their facial expression that they are displeased.
- If they start shouting, this could be a sign that if you don't diffuse the situation soon, they could start to become aggressive.
- If they then start tapping or banging on a desk or other piece of furniture, it could mean that they are about to become physically aggressive.
In the last two instances, you need to act quickly - apologise for upsetting them, be polite, be nice and use positive language to calm them down. For example, 'I'm really sorry for upsetting you Mr XXX but I didn't mean to. Please can I politely ask you to calm down so that I can try and fix things and help you as best as I can?'. Of course, these sorts of phrases need to be said with genuine meaning.
What is defined as violence or aggression at the work place?
Any incident where staff are verbally or physically abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well being or health. This includes:
- Loud or intrusive conversation or shouting
- Threatening or abusive language involving excessive swearing or offensive remarks.
- Racial or sexual remarks
- Malicious allegation relating to members of staff, other visitors or patients.
- Abusing alcohol or drugs whilst on the Practice premises
- Drug dealing
- Wilful damage to Practice or staff property
- Threats or violence and or threatening behaviour
Four Simple Rules
- Nicely ask the offending person to calm down,
- Nicely ask the offending person to stop doing the undesirable behaviour and
- Advise them that we are only trying to help them.
- Keep yourself safe at all times - for instance, keep behind the glass screen at reception or be close to a point of exit.
If they continue we will politely ask them to leave and return when they have calmed down. Aggression is not tolerated in this practice. Both verbal and physical aggression will result in dismissal because we need to safeguard the health and safety of our practice staff.
To activate the panic button
- press CTRL+SHIFT+ENTER on Systm1 or
- alternatively select panic button from the User Menu
- Please read the advice note below about the use of the panic button.
Staff must look after their own health & safety first.
DO NOT BE CONFRONTATIONAL AND WITHDRAW IF NECESSARY
- Decide whether you feel you are able to cope with the situation, if not seek help from other colleagues, Assistant / Practice Manager. If the behaviour continues, staff should inform the Practice Manager, Assistant Practice Manager or a Doctor. The patient will be asked to leave the premises if the behaviour continues.
- If the abusive behaviour is taking place by telephone, inform the person that you are trying to help then, but if they continue to speak to you in this way you will put the telephone down.
- The SystmOne PC panic alarm should be used if the individual fears a situation may be becoming out of control or violent.
- Where urgent Police response is required for a violent situation, staff should ring ‘999’ informing the operator the nature of the call and use the code words “GP ASSIST”, giving the surgery and location details.
- Staff should not continue to deal with a person if they feel that their personal safety, or that of anyone else, is in jeopardy. The police should be called immediately using the ‘GP Assist’ process if they feel that this is the case.
- If an incident occurs, the critical incident procedure will be followed by the Practice Management. This involves the Practice recording the incident, reporting to the relevant authorities, PCT and possibly other local Practices to help avoid the situation in future. Therefore it is vital all incidents are reported. It will form part of the practice significant event reviews process.
How to diffuse the angry situation
Diffuse means to disperse or calm down. So, this section is about how to calm down the angry situation.
- Keep safe - don't directly approach an overtly aggressive patient face-to-face without the protection of a barrier or being close to an safe exit point.
- Change your attitude - see the patient in a more positive light – that aggression is simply a manifestation of someone not getting their needs met. If you are feeling worked up, take some deep breaths and calm yourself down.
- Apologise for the upset – even if it is not your fault. ‘I’m sorry Mr X for upsetting you.’
- Be positive – both with your mouth and your behaviour. ‘I’m sorry Mr X for upsetting you. Shall we see if I can make things right?’
- Your speech – use a steady, calm and clear voice, positive language.
- Eye contact – keep regular contact but do not stare
- Face – show attentiveness, use nods to signal interest and relax facial muscles
- Your behaviour and posture – should be non-aggressive, open and gentle. Sit down if you are standing. Adopt a submissive position.
- Your attitude – should reflect a sincere ‘wanting to help’ the other person
- Acknowledge feelings in the other people and empathise. 'I can see why that would upset you' or 'I can see that you're finding this very upsetting'
- Encourage a good conversation between you and the other person to
- Help understand the difficulties
- Help you understand what need is not being met
- Help you appreciate each other's feelings
Make sure that the person is aware that you are listening for their feelings, concerns and intentions. Both of you need to see each other's perspective. In doing so, hopefully the other person will apologise for their behaviour too
When to back down: if these simple de-escalation techniques are not working after 5 minutes, it may be best to back off and ask another member of staff to intervene as it could be that the staff-patient relationship has broken down.
After the incident...
Any member of staff involved in an incident should have a discussion with the Assistant / Practice Manager as soon as possible after the incident has taken place. The purpose of this is to:
- Discuss the incident in order to support the worker
- Discuss the need for further / expert counselling for the member of staff if necessary
- Evaluate the actions of staff involved to see if any system has failed
- To take any steps to ensure protective actions need to take place following an incident to staff or property.
The Manager or Assistant Manager with at least two doctors will decide on the required action to deter the patient from future similar behaviour. This will either be:
- A warning (last chance) to the patient advising that they will b e removed from the list if the unacceptable behaviour continues.
- Removal of the patient(s) from the Practice list. This would also include any other patients for who they are a guardian, carer or likely to have a future input for them. This is only used when it is felt that the warning is unlikely to stop the behaviour or the actual incident has undermined the doctor-patient relationship and a doctor is not then willing to treat the patient. The practice patient removals policy must then be followed. Even this action should serve as a warning for the patient not to behavior in an appropriate manner with a new practice.
The PCT has contracted with Shipley HC for them to provide GP services to patients removed from a practice list due to violent behaviour. Therefore the practice should be contacted.
If a patient remains on the practice list, the member of staff has the right to see the patient with another staff present.