As a healthcare professional you are confronted with anger and aggression from patients. It is important that you know how anger and aggression can arise.
Anger is an emotion, a feeling. You get angry when people act unreasonably, when things are disappointing and you don't walk as you expect or find reasonable. Physical symptoms can also occur: high muscle tone, rapid breathing and heartbeat. You can deal with that feeling in different ways. You can express it verbally or show it in other ways that you are angry (behavior). That is not aggression yet.
There are many definitions of aggression, but they are all about (threatening) behavior: aggression is externally observable behavior, intentional (intentional) and non-intentional, that inflicts harm, is in conflict with prevailing rules and norms, which victims and / or others are perceived as threatening.
Dealing with anger
You can apply judo technique (entrainment and carry on) when you are dealing with an angry patient. This technique consists of the following four steps: purging anger (1), acknowledging anger (2), summarizing what the patient has told (3), and allowing a choice of possible solutions (4). In the first two steps you spring with the patient, in the last two steps you determine the direction of the conversation again.
In the first step, you let the patient tell his story (read it out). This way he can blow off steam and you will find out what he is so upset about. In the second step you show the patient that you see his anger and understand: "For you … is very annoying." In the third step you summarize what the patient has said. You name and acknowledge his emotion: "You told me … You are very angry about that. Did I understand that so well? "That is how you acknowledge the anger and what the patient is angry about. Moreover, this way the patient notices that you have listened well. Don't blame and stay respectful. Avoid discussions about the question of guilt or about substantive issues. The following box shows examples of anger in the pharmacy.
In the fourth step you show that you want to solve the problem as well as possible. If possible, offer the patient two solutions to choose from. For example: "I will find out for you. Shall I call you back, or would you prefer an appointment with the doctor about this? "That gives the patient some control over his situation.
If the problem cannot be solved immediately, or not completely, let us know that you are thinking along. Indicate in concrete terms what can and cannot be done. If necessary: "I cannot solve this for you now. What I can do … "or:" What you can do best now is … "" What could, is … "
Occasionally there is room in the conversation to provide business information that helps the patient to better understand the situation: "You see a patient ahead who came in later. It is not visible on the outside, but there may be a serious problem that requires the doctor to see it immediately. "However, the patient is usually not open to such information. The patient often becomes even more angry or a discussion arises.
Anger is often caused by the circumstances: waiting, uncertainty about the way things are going, not understanding that other people are ahead and so on. Sometimes people are angry because they have the feeling that they don't get care. Or they are angry because they have to wait a long time, while still paying a lot of money for their health insurance. Angry about a bill for a missed consultation: "because they had canceled in the morning". Angry that the costs of laboratory testing for STDs fall under the deductible. Angry about their own contribution for medicines, or that they suddenly receive other medicines (due to the preference policy). Angry that they have to pay information costs at the first issue of a medication. Or a patient is angry because he is allowed in between one assistant and now, with another assistant, not.
It helps to check in your team whether you can do something about waiting times at the doctor's office or about extended office hours. You can also think together about what you can do to make it less annoying for your patients. In addition, it is important to have agreements about having people intervene. You can also sometimes take measures to prevent annoyance and discomfort in patients (see the following box).
Forms of aggression and points for attention
There are roughly three forms of aggression: aggression from frustration, aggression consciously used as a tool (instrument) and explosive (pathological) aggression. The table below provides an overview of the characteristics and a specific approach to each form of aggression.
Forms of aggression and points for attention
|Frustration aggression||Instrumental aggression||Explosive or pathological aggression|
|Description||Out of powerlessness, due to different expectations, increasing frustration; the client is emotionally, unreasonably, currently unable to listen||Manipulative, calculating, intimidating; aggression is deliberately used to achieve something: commanding, belittling, bullying, threatening, intimidating, swearing; can exceed the emotional and physical limits of the other||Under the influence of drugs, alcohol, psychosis, after seizure; also neurological causes, such as with dementia, Huntington's disease|
|Purpose of aggression||Decrease in frustration||Dominant position||Discharging|
|Self control||Decrease self-control||Lots of self-controling||No self-control|
|Perceptible behavior||From his anger (verbal, behavior); physical signals (muscle tension, rapid breathing and heartbeat)||Conscious behavior||Fury, uncontrolled actions|
|Your first response and assessment||You can see it coming||Fright; your tendency to take a step back instead of taking a step forward and ask: what do you mean by this?||Fright; aggression comes like a thunderbolt in clear sky|
|Purpose of intervention||Calming down||Limit||Safety; handle the situation|
|Type of intervention||De-escalating techniques, so that the patient does not become increasingly angry, but calmer||Limiting techniques||Limiting techniques|
Phase 1: Room for the patient
A. Ignore the fight
B. Make contact, ask for the reason for the anger; allow the patient to unravel; ask on / reflect
C. Summarize what the patient has said; he must feel heard, otherwise it will start all over again
Phase 2: Room for the caregiver
A. Make your own point of view / interest clear
B. Make agreements; do not promise anything that you cannot deliver
Phase 1: Limiting
A. Confront; state the behavior and say what you think of it (annoying, not acceptable); indicate how the patient should behave
B. Give a choice: continue on your terms or stop the conversation (at the dentist: lie down comfortably or leave); possibly put the choice in an or / or sentence (or you keep threatening and then I stop this conversation, or you lie down quietly and then I can treat
C. Wait for response / agreement
D. If necessary, insert a time-out (sometimes with an excuse: call for consultation)
E. Stop the conversation if the aggressive behavior continues; if necessary, seek the help of a colleague or the security department
Phase 2: Room for the patient
A. Summarize the patient's question
B. Make a decision: meet the patient, within the limits of reasonableness, or stick to your point of view (refusal, costs, treatment proposal); the latter comes down to a bad news interview
A. Set limits
B. Try not to make the patient feel uncomfortable so as not to increase his anger. If the cross-border behavior is too serious or threatening, get help from your colleague or the guard; possibly use a (silent) alarm button, which alerts the police
Anger and aggression in people with mild intellectual disability (LVB)
People with a mild intellectual disability do not have much control over their situation. They can therefore become angry or aggressive faster (frustration aggression). Then it can sometimes help to choose a different strategy: do something very different from what the patient expects. This can change the situation in such a way that they get upset and therefore react differently. It requires experience and good assessment; with a wrong tone, the patient can become even more angry.
Try to reduce the causes of uncertainty. Do not blame, do not conduct substantive discussion. Stay respectful. Explain at the patient level. Possibly make a choice.
Setting limits can also work and, in the worst case scenario, you can stop the contact.
Proper preparation for the doctor or dentist visit can prevent behavioral problems and aggression. Involve the supervisor (s) in this. This is in line with the needs of the patient. Points of attention are:
- Explain and repeat
- Change language
- Pace, small steps
- Empower and motivate.