Working with difficult patients/service users
Written by Ruth McGuire - 20th May 2022
According to the 2021 NHS’s staff survey, around ‘14.3% of NHS staff have experienced at least one incident of physical violence from patients, service users, relatives or other members of the public in the last 12 months.’ Similarly, in care settings, it is estimated that a health and social care worker is assaulted every 30 minutes in the UK. The figures are shocking. It is hard to imagine how employees can remain motivated to work, if they have to work in an environment where fear of being attacked is an everyday reality.
The Health Safety Executive (HSE) defines work-related violence as 'any incident in which a person is abused, threatened or assaulted in circumstances relating to their work.' In the case of health and care workers, the following are just some of the examples of violence highlighted by HSE:
- A carer bitten by a person with learning disabilities in the course of the normal care of that person.
- An irate visitor who considers that his relative has not been properly treated verbally abuses a ward manager.
- A nurse verbally abused and threatened by a patient who is unwilling to take prescribed medication.
- A catering assistant providing refreshments is hit by a confused elderly patient.
Behaviour support in the workplace
Employers have a duty of care towards their employees so are the first port of call when it comes to navigating the behaviour of patients/service users. Employers are legally obligated to protect employees from harm. This includes providing policies to support staff in navigating the behaviour of others, but more importantly, providing training so that staff are confident and competent to deal with anti-social or violent behaviour or at work. The most relevant policies provided by employers whose employees are at risk of being attacked whilst they work, will probably be a ‘Violence and Aggression Policy’ or a ‘Challenging Behaviour, Violence and Aggression Policy.’ However, before even getting to the stage of having to navigate challenging behaviour, there are some behaviours employees can adopt to minimise the risk of interactions with patients/service users becoming volatile.
Wherever possible, if staff can build up a positive working relationship with service users/patients, this puts them in a good position to identify trigger points that could lead to an eruption in their behaviour. Trigger points that could occur in health settings and which are identified by the National Institute for Clinical Excellence (NICE) include ‘refusing a service user's request, asking them to stop doing something they wish to do or asking that they do something they don't wish to do.’
In some cases, it might be possible to work with some service users/patients to identify their trigger points and to help them take responsibility for dealing with their own behaviour. This could result in a care/service plan that identifies and records possible trigger points and also identifies control measures and/or interventions to deal with these triggers.
The Crisis Prevention Institute in the US also has some helpful tips on how to respond to challenging behaviour. The Institute describes itself as ‘the worldwide leader in evidence-based de-escalation and crisis prevention training and dementia care services’. The approach it promotes is one where employees focus on their own behaviour first, before trying to support with the behaviour of others. The underlying principle of this approach is self-regulation of our own behaviour rather than regulation or control of the behaviour of others. For example, this includes controlling the way we communicate with angry patients/service users by controlling the way we speak to them and ensuring we do not use words or language that provokes them. It is also about ensuring that our tone of voice is mild and calm rather than loud and provocative, and ensuring our non-verbal communication such as our gestures or facial expressions are appropriate and of the right ‘tone.’
De-escalation techniques
One of the most important skills that employees can deploy when dealing with aggressive behaviour from service users/patients is ‘de-escalation.’ As the word suggests, de-escalation is the opposite of ‘escalation’ in that the process is about bringing a situation down from the height of volatility to a much lower level.
The National Institute for Clinical Excellence (NICE) recommends the following techniques for ‘de-escalating’ aggressive behaviour:
- If a service user becomes agitated or angry, one staff member should take the primary role in communicating with them. That staff member should assess the situation for safety, seek clarification with the service user and negotiate to resolve the situation in a non‑confrontational manner.
- Use emotional regulation and self‑management techniques to control verbal and non‑verbal expressions of anxiety or frustration (for example, body posture and eye contact) when carrying out de‑escalation.
- Use a designated area or room to reduce emotional arousal or agitation and support the service user to become calm. In services where seclusion is practised, do not routinely use the seclusion room for this purpose, because the service user may perceive this as threatening.
- It is also helpful if staff know their patients/service users well and are able to identify possible triggers that could lead to a deterioration in their behaviour.
Conclusion
By focussing on our own behaviour when we have to deal with an aggressive or violent service user/patient, we become better equipped to respond to their behaviour. Because navigating adult behaviour will not come naturally to most people, it is important to become familiar with workplace policies for dealing with aggressive/violent behaviour and in addition access training in how to apply techniques such as de-escalation.
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Further reading/research
Managing behaviour blog
https://www.psychologytoday.com/us/blog/the-management-behavior-challenges/202202/de-escalation-is-go-tactic-behavior-related-incidents?msclkid=fd8b6d68cf0911ec9ae9ab39f9c822cc
De-escalation tips
https://institute.crisisprevention.com/Refresh-De-Escalation-Tips.html
Reducing the risk of violent and aggressive behaviours - guide
https://www.nice.org.uk/about/nice-communities/social-care/quick-guides/reducing-the-risk-violent-and-aggressive-behaviours?msclkid=93ac69a9cfda11ec9898f00e342e1e09
Caring for a person who is aggressive or violent
https://www.health.qld.gov.au/__data/assets/pdf_file/0031/444586/aggressive.pdf?msclkid=744654d3cfdb11ecba08fc598551b1fb
NHS policies and plans for violence prevention
https://www.england.nhs.uk/supporting-our-nhs-people/health-and-wellbeing-programmes/violence-prevention-and-safety/
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Ruth McGuire has extensive experience in education as a lecturer/tutor and in the development of accredited courses within the further education sector. She is now involved in the inspection of education/social work courses. In addition, she has various roles as a patient advocate/representative within the NHS and is also an experienced writer/researcher.