Challenging behaviour has a variety of causes, including illness.
Consider whether a lack of resources is to blame.
Seek ways to protect yourself, colleagues and other patients.
Consult your local security management specialist (LSMS) for advice.

Why do patients become 'challenging'?

Patients, and sometimes their carers, become challenging, difficult, uncooperative or aggressive for a number of reasons:

being unwell or in pain
alcohol/substance misuse
fear, anxiety or distress
communication or language difficulties
unrealistic expectations
previous poor experience
frustration
guilt that they didn't bring a sick relative in earlier.

Their behaviour may take the form of:

being demanding or controlling
an unwillingness to listen/lack of cooperation
verbal abuse or threats
physical violence against people or property.

Identifying the problem

Is it the patient?

Always consider first whether the patient's behaviour is caused by a medical condition. If so, treat the patient as far as possible without putting yourself or others at risk.

Is it a lack of resources?

Long waiting times, lack of available appointments or beds, locums unfamiliar with the department, poor communication by staff and other factors can all contribute to a patient's deteriorating mood or behaviour.

Is it the doctor?

Competing pressures on the doctor (time, resources, personal) might affect their communication style and potentially exacerbate the situation.

Assessing the risk

Even if you're not in a position to determine the security policy at the trust or practice, you can seek ways to protect yourself, colleagues and other patients.

Identify high-risk situations: for example, Saturday night in the emergency department, when you have to deliver bad news, or when patients are kept waiting for a very long time.
Consider which staff may be vulnerable if a patient becomes violent. Reception area staff or doctors working alone in a clinic may be at greater risk.

Defusing a violent situation

Dealing with an aggressive patient takes care, judgement and self-control.

Remain calm, listen to what they are saying, ask open-ended questions.
Reassure them and acknowledge their grievances.
Provide them with an opportunity to explain what has angered them. Understanding the source of their frustration might help you find a solution.
Maintain eye contact, but not prolonged.
Keep an adequate distance from the patient, but keep away from corners. It is helpful if the furniture in your room is arranged in such a way that you can easily leave, but the patient doesn't feel trapped.
If the patient has a weapon, ask them to put it down. Don't ask them to hand it over.
Use the panic button or call for help.
Leave the room and call security or the police.
If possible, move the patient to an area away from public view.

What can you do?

Patients must not be denied necessary treatment even though they may be aggressive or violent. Treatment must be based on clinical need, however demanding the patient.

Nevertheless, you should assess and minimise the risks to yourself, the patient and others. In some cases it may be reasonable and necessary to consider alternative arrangements for providing treatment.

If systems, policies or availability of resources are compromising patient care, you must raise your concerns.

It's advisable to train staff in conflict resolution and dealing with aggressive behaviour.

Consider your security requirements. Your LSMS is responsible for security in your practice area and can advise you. If you have concerns about the safety of your environment, raise them with your security management director or the LSMS.

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Dealing with challenging patients

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