Managing Angry and Violent Patient Encounters

Angry and violent patient encounters can contribute to physician burnout. The effective management of these encounters with challenging patients can help reduce the impact they have and help maintain a safe work environment. Although many of the triggers of patient anger are avoidable or at least can be moderated, managing violent patient encounters may require different strategies.

Angry Patient Encounters

Understanding what is causing a patient’s anger can enable a constructive follow-up to an outburst and help de-escalate the situation. However, it is important to individualize your response to an angry patient based on the potentiality of danger.

For example, de-escalation strategies may be too dangerous if the angry patient is threatening violence or has a weapon. On the other hand, a patient who is angry because of a perceived service failure or unanticipated outcome might be successfully calmed to a degree that the basis for their anger can be discovered and remedied. Successful service recovery and apology protocols have been linked to increased physician wellness and burnout reduction. Preparation is the key to preventing and successfully managing patient anger that can lead to burnout. Having a disruptive patient policy in place can provide structure to an otherwise stressful patient encounter.

Avoiding Anger Triggers

Anger and agitation can be triggered by many different factors. Some triggers are avoidable (e.g., interrupting the patient) others are not (e.g., denying cigarettes to a hospitalized patient). Some examples of avoidable triggers are:

• Sharing confidential information without the patient’s permission
• Being sarcastic, rude, hostile, patronizing, or untruthful to the patient
• Arguing with the patient
• Interrupting the patient
• Using negative or aggressive body language; for example, eye rolling, pointing, deep sighs, throat clearing, checking your watch, fidgeting, taking a phone call, standing in the doorway, clenching your fists, hiding your hands, folding your arms, or turning away
• Getting too close to or touching a patient with physical boundary issues
• Making a patient wait
• Failing to follow through with promises

De-escalating Angry Patients

Obtaining de-escalation training can reduce the risk of escalating a patient’s anger and restore peace with a minimum amount of stress and practice disruption. Consider the following de-escalation strategies when dealing with an angry or agitated patient: ^1,2

• Keep two arms’ length of space between you and the patient, stand at an angle and maintain an open posture.
• Use body language that is congruent with your words to avoid sounding insincere.
• Keep your composure.
• Avoid statements that seem judgmental; for example, do not ask questions that begin with “why.”
• Do not interrupt unless it is to clarify.
• Use short, concise sentences and simple vocabulary.
• Discover what has triggered the undesirable behavior and how the patient wants the situation resolved.
• Don’t say, “I understand,” if you do not or could not understand the patient’s problem.
• Respond to what you hear in the patient’s voice instead of the content, for example, say, “You sound very angry.”
• Effectively use silence, which can encourage the patient to provide more information and can allow the patient to calm down.
• Use “I” messaging to show the patient how you feel, why you feel this way, and how the patient can change to remedy the situation; for example, say, “I feel frustrated when you yell at me because I am having a hard time understanding what you are trying to tell me. I would like you to stop yelling.”
• Find aspects of the patient’s position with which you can agree.
• Offer options for reducing agitation, for example, “We can give you a pill or a shot to help you to calm down” or, “Would you be more comfortable in an examination room?” or, “Can we start this conversation over? I feel like we got off on the wrong foot.”
• Express optimism by using positive language, and avoiding words like “but,” “can’t,” and “don’t.”

De-Escalation Resources

• “Verbal De-Escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-Escalation Workgroup” (Western Journal of Emergency Medicine)
• “CPI’s Top 10 De-Escalation Tips” (Crisis Prevention Institute)
• “Doctor Patient Communication: The Universal Upset Patient Protocol in Healthcare Communications” [video] (The Happy MD)
• “3 Tips for Calming Agitated Patients” [video] (Jennie Byrne, MD, PhD)
• “Managing Difficult Patients” [podcast] (Emergency Medicine Cases)

Angry Patient Follow-up

Terminating treatment of patients who are angry because of a service failure or unanticipated outcome of treatment can increase a patient’s propensity to file a lawsuit. The nature of the event prompting the anger should direct the response. Service recovery and unanticipated outcome programs can help turn a frustrated, angry patient into a loyal one who is more likely to comply with treatment recommendations and less likely to file a malpractice suit, make a report to the medical board, or write a negative online review.

Service Recovery and Unanticipated Outcome Resources

• Service Recovery in Healthcare (The Beryl Institute)
• Responding to Unanticipated Outcomes: First Conversations (NORCAL)
• Communication and Optimal Resolution (CANDOR) Toolkit (AHRQ)

The Threat of Violent Patients

Workplace violence, “the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty,” contributes to physician burnout. Physicians and other healthcare workers are frequent victims of violence by patients, their family members, and visitors. Violent patients disrupt a physician’s control over their environment, a frequently cited cause of physician burnout. Knowing how to respond when a patient becomes violent is a way for physicians to maintain this control.

Although maintaining a safe environment is primarily the responsibility of healthcare entities, physicians can protect themselves and the people around them by engaging in training, recognizing the signs of impending violence, preparing with the healthcare team for patients with violent tendencies and employing de-escalation strategies, and, when necessary, retreating to somewhere safe and calling security or the police.

Nonverbal Cues of Imminent Interpersonal Violence

Swearing, using abusive language, and threatening violence are direct indications of an impending attack, but patients may also signal they are getting ready to lash out through nonverbal communication, including the following:^3,4

• Body movements: pacing, gesturing in an exaggerated or violent manner, assuming a boxer’s stance, removing excess clothing, clenching fists, tensing the body, trembling, shaking, stretching to relieve tension, invading your personal space
• Facial expressions: jaw clenching, scowling, sneering
• Voice signals: speaking loudly, chanting, talking to themselves
• Eye contact: glaring or avoiding eye contact
• Physiological changes: flushing, pallor, sweating, extreme fatigue, rapid breathing

Of course, all of these nonverbal cues may indicate something other than imminent violence. One of the challenges of healthcare violence prevention is successfully anticipating it without unjustly profiling a patient who is not prone to violence. It is important to judge a situation by the totality of circumstances and not just on nonverbal cues.

Violent Patient Preparation and Management Strategies

Unfortunately, violent patient encounters are common. Successful management of an incident depends on developing the skills necessary for recognizing risks, keeping everyone safe, and tending to your own stress following a violent patient encounter. Consider the follow recommendations.

• Be familiar with your healthcare entity’s workforce violence and disruptive patient policies and procedures.
• Do not work alone, particularly at night.
• Be prepared for a patient with violent tendencies.
  • Determine the behavioral past of new or transferred patients.
  • Huddle (clinicians, nurses, risk managers, social workers, security personnel, and behavioral therapists) and determine the best plan for a potentially violent patient.
• Treat known aggressors in relatively open, easily accessible areas that still reasonably maintain privacy (e.g., rooms with removable partitions).
  • Consider having more than one person in the room if an easily accessible area is not available.
• Learn to identify predictive behaviors and violence triggers.
• Excuse yourself, leave the room or move away from the patient, and then contact security or the police if your safety is threatened.
  • Know how to summon security or the police.
• Share information about a patient’s agitation or assaultive tendencies at hand-off using communication tools, for example, the Agitated Behavior Scale
• Alert and, when appropriate, evacuate individuals in danger.
• Create an incident report for each incident.

Workplace Violence Resources

“Practical Tips for Managing the Agitated Patient: Avoiding Violence in the Clinical Setting” (Psychiatric Times)

“The Agitated Patient: Steps to Take, How to Stay Safe” (Journal of Family Practice)

“Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers” (Occupational Safety and Health Administration)

“Guiding Principles for Mitigating Violence in Workplace Toolkit” (American Organization of Nurse Executives and Emergency Nurses Association)

“Workplace Violence Prevention for Nurses” [course] (Centers for Disease Control and Prevention)

“Sentinel Event Alert 59: Physical and Verbal Violence Against Health Care Workers” (Joint Commission)

“Workplace Violence Best Practices for the Worst Case” [webinar] (American Hospital Association)

“Active Shooter Planning and Response in a Healthcare Setting” (Healthcare and Public Health Sector Coordinating Council)

Behavioral Agreements and Warnings

Although termination of the physician-patient relationship with disruptive patients may be the easiest way to follow up an incident, if the behavior is the result of dissatisfaction, in many cases the better strategy is to understand the patient’s complaint, empathize, apologize, and then re-establish behavioral expectations for moving forward in the physician-patient relationship with a patient behavior warning or patient behavior agreement.

References

1. The Joint Commission. “Sentinal Event Alert 59: Physical and Verbal Violence Against Health Care Workers.” Sentinel Event Alert Newsletters, April 17, 2018;59, Revised June 2021.

2. Richmond JS, et al. “Verbal De-Escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.” Western Journal of Emergency Medicine, 2012;13(1); 17-25.

3. Canadian Centre for Occupational Health and Safety. “Violence and Harassment in the Workplace – Warning Signs.” OSH Answers Fact Sheets.

4. Dawn M. Sweet, Rebecca G. Burzette. “Development of the Nonverbal Cues of Interpersonal Violence Inventory: Law Enforcement Officers’ Perceptions of Nonverbal Behavior and Violence.” Criminal Justice and Behavior, 2018;45(4):519-540.