We live in an increasingly demanding and vociferous society and incidents of conflict and aggression are sadly commonplace. Kate Taylor, Clinical Risk Manager at the Medical Protection Society offers advice on how to deal with the problem Working in general practice is busy and demanding, with increased workloads, stretched time and some patients having greater expectations of care. At times, when expectations are not met, we can find ourselves in conflict with patients – and in some situations this can turn to aggression. As nurses, how should we deal with potentially difficult situations? This article aims to increase our understanding of conflict and provide strategies to deal with it effectively. It also includes practical tips to reduce risks associated with managing conflict and aggression.
Conflict means different things to different people. The Health and Safety Executive defines workplace violence as ‘any incident where staff are abused, threatened or assaulted in circumstances relating to their work, involving an explicit or implicit challenge to their safety, well-being or health’.1 Non-physical violence can be defined as the ‘use of inappropriate words or behaviour causing distress and/or constituting harassment.'[ 2] The scale of the problem
There is limited documentation relating to violence against nurses working in general practice. However, a recent survey carried out by the British Medical Association, to which 20% of doctors responded, found:[ 3] * Violence is a problem in the workplace for half of doctors (same for GPs and hospital doctors). * 1 in 3 respondents had experienced some form of violence in the workplace in the last year (same for hospital doctors and GPs). * 1 in 5 doctors reported an increase in violence in the past year, but the level remained constant for the majority. * Among doctors who reported some experience of violence, most had been the victim of verbal abuse in the past year while more than half had received a threat, and a third had been physically assaulted. Most injuries were minor, but 5% were serious.
In April 2011, NHS Protect was set up. It is responsible for leading on work to protect NHS staff and resources from crime in England.[ 4] According to its statistics, physical assault against NHS staff is steadily increasing. However, these statistics do not capture the incidents where staff have been subjected to non-physical violence. In general practice, members of staff are more likely to be subjected to non-physical violence. Imagine working as a practice nurse and an unhappy patient threatens you, telling you ‘I know where you live?’ We cannot underestimate the impact that such non-physical violence can have on individuals.
* Members of the general practice team are particularly vulnerable as they often consult with patients alone. Doctors and practice nurses often work in small numbers.
* Home visits are usually carried out alone.
System and Organisational Problems
* Delays, restrictions and mistakes such as lost prescriptions or delays in test results
* Lack of appointments
* Patient disappointment often results from unmet expectations, whether realistic or unrealistic. Environment
* Waiting room (heating, lighting, noise and seating)
* Cramped consulting rooms without easy exit for health professionals
* Lack of privacy
* Availability of potential weapons.
* Increased expectations and the difficulties in meeting these demands. Dissatisfaction with the care provided is perceived as the most common cause of aggression and violence * Strong patient emotions e.g. uncertainty, frustration, stress and anxiety. Anger is often secondary to emotions such as anxiety or grief * An underlying medical condition such as hypoglycaemia or psychotic illness
* Physical symptoms including pain, headache or over-tiredness
* Mental health problems such as
* Personal problems e.g. financial, relationship, stress at work
* Drugs and alcohol.
* Under pressure staff-working in noisy cramped rooms, unable to trace or contact staff
* In adequate staff numbers
* Escalating the situation by confrontation, over-reacting, poor ccmmunication, inconsistencies in handling patients, patronising behaviour, ignoring a situation or falling to apologise.
Good communication with patients is likely to reduce the risk of conflict and violence. As nurses, how we communicate with our patients can have an impact on how difficult situations develop. We need to think about what we say and how we say it. We should rely on our strong communication skills to determine with our patients what they can expect from the services we provide. A study by American psychologist, Albert Mehrabian, determined that non-verbal communication represents over 50% of an interaction.[ 5]
Being aware of your own body language can be the first step to understanding how it is perceived by our patients. Listening and empathising with patients are essential skills for nurses-so how do we ensure our patients know we are listening?
* Give the patient your undivided attention
* Don’t trivialise the patient’s issue
* How is the patient feeling – are they angry, afraid, frustrated? Respond to the emotion as well as the words
* Allow the patient to finish what they are saying
* Ask questions, paraphrase and reflect to ensure you understand the message.
Challenging interactions with patients can be a significant cause of stress for nurses, yet the nature of most clinical jobs makes these encounters unavoidable. It can be difficult to communicate your point of view effectively for fear of generating conflict, which can lead to frustration and dissatisfaction, and may affect your ability to give good care. It is vital to build a trusting relationship with the patient in these circumstances; ensure you listen attentively, empathise and avoid confrontation. Maintain eye contact and try to establish a shared understanding of the patient’s problem. Having acknowledged their perspective, respectfully inform them of your position.
Then work on achieving a mutually agreeable solution or way forward rather than focussing on points of disagreement, which can otherwise degenerate into an argument. Then help and support the patient to achieve the agreed solution. After challenging interactions that have required you to state your position, ensure there is effective communication with other members of the practice clinical team, along with a clear record of the discussions held. This will ensure consistency should the patient approach a different clinician seeking to re-negotiate an alternative plan or outcome.
Practices should consider:
* Providing a side room or separate area to deal with upset/aggressive patients or those who need more privacy.
* Providing good temperature and ventilation control, adequate seating and clear signage
* Providing calming measures to reduce frustration, anxiety or boredom such as distractions in waiting room e.g. toys for children, magazines for adults * Adding an agreed marker to the summary of a patient’s record who has a history of violence (and ensure it is factually accurate)
* Having a protocol for involving the police and removing patients from the list
* Using CCTV
* Ensuring all practice staff have access to panic alarms
* Providing locks for all areas where patient access is restricted
We can and will experience conflict in general practice due to the sheer volume of patient contacts that occur every day. The key to managing a conflict situation is to try to de-escalate it as much as possible.confidentiality is central to the trust between nurses and their patients – think how easy it may be to breach confidentiality when you have a situation with an aggressive patient. The Nursing and Midwifery Council Code of conduct clearly states ‘you must respect people’s right to confidentiality’.[ 6] As a last resort you can remove a patient from the practice list. However, this can be seen as an emotive issue, risking criticism from bodies such as the Parliamentary and Health Service Ombudsman, the GMC and the media. You can find useful information on how to go about it in the MPS factsheet, Removing patients from the practice list (September 2013).[ 7]
Nurse E is about to start her clinic when she notices Mrs S on the list of patients for the day. Her heart sinks. Mrs S often presents with one or more complaints, talks nonstop and does not listen to advice provided. She knows from experience that interactions with Mrs S will be challenging. Mrs S is called in 20 minutes later than her planned appointment and she lets Nurse E know that she is not happy. Nurse E admits that her clinic is running late but tells Mrs S that she had an unavoidable emergency.
She proceeds to take Mrs S’s blood pressure and other vital signs. Mrs S then asks Nurse E for a prescription for antibiotics as she is going on holiday and wants them ‘just in case her chest flares up’ while away. Nurse E advises her that she will need to make an appointment to see the GP. Mrs S, now increasingly unhappy, begins to raise her voice and bang her fist on the desk, demanding a prescription before she leaves. Nurse E, staying calm, advises Mrs S that she is unable to give her a prescription as she doesn’t have any active symptoms. Mrs S storms out of the consultation room pushing past Nurse E. Understandably upset, Nurse E calls the practice manager to report the incident. How could this situation have been dealt with better?
* Apologise when mistakes occur or when clinics are running late. Some practices ask reception staff to inform patients when they are checking in if clinicians are behind schedule
* Ensure patients are well informed about how systems at the practice work to try to reduce unrealistic expectations
* Acknowledge the patient’s emotions and allow them to express them, which can take time. Ask the patient to tell you about their concerns. Listen actively using comments such as ‘I see’, or ‘go on?’, and nodding your head. Summarise their experiences, feelings and concerns back to them
* Work with the patient to resolve the situation. Agree a plan for dealing with their concerns and moving forward.
* Try to offer an alternative solution to demonstrate that you are keen to help them. For example, ‘I’m sorry Mrs S, but I am unable to give you a prescription. However, if you wish to make an appointment with one of the GPs you can discuss this with them’ * Consider the layout of the consulting rooms and reception area to ensure you can leave the room if the situation escalates. Aggression in healthcare settings is becoming all too common
1. Health and Safety Executive: work related violence www.hsegov.uk/violence 2. NHS Business Services(2012) Not part of my job http://www.nhsbsa.nhs.uk/Documents/ SecurityManagement/NP0J1 .pdf 3. British Medical Association (2008). Violence in the workplace. The experience of doctors in the UK. http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/ PDFviolence08/$FILE/Violence.pdf 4. NHS Protect 2013 http://www.nhsbsa.nhs.uk/Protect.aspx
5. Mehrabian, A(1971) Silent messages Belmont, CA:Wadsworth 6. NMC(2011)The code: Standards of conduct, performance and ethics for nurses and midwives http://www.nmc-uk.org/Documents/Standards/ nmc TheCodeStandardsofConduct PerformanceAndEthicsForNursesAndMidwives%5FLargePrintVersion.PDF 7. MPS Factsheet removing patients from practices list September 2013 http://www.medicalprotection.org/uk/england-factsheets/removing-patients-from-the-practice-list ~~~~~~~~