- – – –
- Doctor: Dr Ramesh Mehay
- Nurse: –
- Admin: Chris Rushton
12th June 20202
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 click the panic button box on the S1 main menu at the top horizontal navigation menu
- Please read the advice note below about the use of the panic button.
Frequently Asked Questions (FAQs)
To activate the panic button…
- press CTRL+SHIFT+ENTER on Systm1 or
- alternatively select panic button from the SYSTM1 horizontal user menu
All clinical rooms at the surgery are kitted out with a panic button. This alerts all members of staff that you are in difficulty – who will then run to your rescue (hopefully). However, please consider how you use this button very carefully.
- You should try to calmly diffuse all situations down using your communication skills first rather than reach for the panic button. In fact, reaching for the panic button might alert the aggressor who may then panic even more and will then be able to throw a punch or even stab you by the time other staff get there.
- What sorts of things can you do before the panic button?
- If you are standing up, sit down. Adopt a submissive position.
- Ensure that the patient doesn’t come between you and the exit, in case the situation escalates and you need to leave quickly
- Apologise to the patient for the upset (whether you are at fault or not).
- Keep regular brief eye contact BUT do not stare. Do not constantly stare at them too directly in the face (this is one instance where constant eye-contact can be seen as an act of aggression rather than a tool for building rapport).
- Back down and aim to either get yourself out of the room or them.
- Only reach for the panic button if physical assault is imminent and you can feel it coming and there is no way out. But remember -most situations can be diffused by speaking nicely in a nice tone, using helpful and positive words (including an apology). Back off from becoming an alpha-male; and be the submissive and friendlier omega-male.
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.
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.
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.
Ashcroft Surgery has a zero tolerance for aggressive behaviour. A person does not have to be physical to be aggressive. The simple way to think of it is to remember that if someone is making you feel intimidated, then they are being aggressive. So, people can be aggressive by their behaviour OR simply by the way the words they use and how they say them. If you feel that a patient may end up being very aggressive to you need to…
- Protect yourself. Get behind a protected screen counter, in a protected area (like reception area) or near a safe exit point.
- Call another member of staff to be with you (do not be on your own) or even to take over.
- Now politely and firmly tell the patient:
- (i) how they are making you feel, (ii) ask them to stop and (iii) that you want to help them but only if they calm down.
- ‘Mr X, please would you lower your voice and calm down. You are making me feel very uncomfortable. I really would like to help you but it is difficult when you’re shouting at me’.
- If they continue… ask them to leave the premises.
- ‘Mr X, I’ve asked you politely to calm down but you’re still shouting at me. I’m sorry but I need you to leave the premises.’
- If they fail to leave, tell them that you will be calling the police if they don’t.
- ‘Mr X, I’ve asked you politely to leave the premises and you have not. You are leaving me with no choice but to call the police. I don’t want to call the police but I will do if I have to. Now, I will ask you politely one more time to leave the premises. It’s up to you…’
- You may wish to involve the Practice Manager, the Assistant Practice Manager or a GP to help you.
In common law, assault is the act of creating apprehension of an imminent harmful or offensive contact with a person – in other words, a sense of threat of violence. Put another way, assault is an “attempt, threat or offer to apply unlawful force sufficient to create fear that actual violence may ensue”. If a person feels intimidated or fearful that something awful might have happened, then that is enough. Therefore, assault may result in either criminal and/or civil liability. The term is often confused with battery. Battery applies when physical contact is involved.
Being physical to another patient or person is simply unacceptable. The physical act doesn’t necessarily need to be throwing a punch. Even pulling someone’s glasses of their face can be a aggressive physical act – depending on the context and whether the recipient consented to that act. If they didn’t consent, then the act could indicate an act of battery. In these situations…
- Call another member of staff to be with you (do not be on your own).
- Make sure you are behind a protected screen, in a protected area or near a safe exit point.
- Call the aggressive person over to the screen and ask them to leave the premises. Explain why you are asking them to leave and conclude by saying that their behaviour is not acceptable.
- If they refuse to leave, tell them that you will call the police if they don’t.
- Once they have left, go to the victim and ask them how they are and whether they wish to file an assault charge.
- If they do, call the police.
- Whether the patient makes an immediate assault charge or not, please make a written record of what went on. A person can make a claim of assault up to 6 months after the event!
- You may wish to involve the Practice Manager, the Assistant Practice Manager or a GP to help you.
- Yes, definitely!
- Please warn the doctor, nurse or any other member of staff who is due to see a patient that you either know to be aggressive or has been aggressive with you. You have a duty to protect your colleagues.
Ensure that you have a personal system of safety:
- We would never recommend going alone to patients who are known to be aggressive – instead, take a colleague with you or better still, encourage them to come to the surgery.
- If you do visit (because you think the level of threat isn’t so high), make other staff members aware when you are on a visit to a potentially risky patient and when you are expected to come back. Therefore, if any incident happens, this is more likely to be spotted by colleagues by your absence and in a timely way. When you are there, make sure you are near an exit point at all times. Any slight worry – get out!