Patients who are angry or aggressive

If a patient becomes angry, says Dr Peter Havelock , there might be any number of stressors to consider

It is important in managing anger in other people to be aware of the vicious cycle of anger that causes the overt behaviour. The initial and stated cause might only be the last straw; there might be underlying problems such as debt, housing, relationships, previous history with doctors, fear or any of a number of stressors.

These issues are controlled and managed appropriately by the majority of people but for the angry person the internal management of these stressors can change to thoughts of persecution, victimisation, lack of respect, or blocking by the other person. Their mood deteriorates, their pulse races, a ‘red cloud’ fills their vision and normal control is lost. It is this aggression that healthcare workers sometimes have to manage and they need the understanding and skill not to escalate the vicious circle and enable the patient to retain self-control.

Reducing the causes of anger
If you want to appreciate why some patients get angry it is important to look at the stressors that the doctor’s surgery might create: rudeness or lack of respect; long delays without any explanation; receiving unexpected bad news; delay or perceived delay in providing a service; losing control or being disempowered.

Identification of anger
Try to notice the early warning signs of anger, both verbal and non-verbal. The jaw thrust forward, the slight narrowing of the eyes and the flushed cheeks all might indicate internal anger. The voice inappropriately too loud, or too soft and controlled, the invasion of body space and inappropriate arm movements might also be warning signs.

It is essential for the doctor to resist the instinctive reaction and get cross in response; control of your own emotions and calmness are important. To achieve this calmness requires a degree of disassociation from the situation, you need to be an observer of the situation that you are part of. When you look at the situation as an observer your emotions will diminish and become less intense and it will enable you to then formulate the next stage, which should be curiosity about the reasons for the anger.

Acceptance, acknowledgement and exploration Let the patient know that you recognise the extent of their emotion and that you wish to understand it. The skills to do this are those of active listening: keep eye contact, ask open questions, ask why they feel like this, non-verbal listening (nodding, smiling), acknowledge responses, explore reasons behind the anger.

If there are legitimate reasons why the patient is angry, acknowledge it, and perhaps apologise, without apportioning blame, and offer further exploration of the cause if appropriate.

Try to avoid admonishing the patient for their behaviour or language, touching them or trying to control them physically, talking without eye contact or from behind, trying to defend the situation or being defensive. Most importantly, do not respond with anger yourself.

Channelling of the anger
When the emotions eventually settle down it is important to conclude with a plan. The issues need clarity and acknowledgement by both of you that the situation should be avoided in the future. There might be something that you wish to do differently: run a significant event discussion, change a system or communicate differently.

It might also be possible at this stage to share your thoughts about the patient’s behaviour and offer other ways they could express their frustrations, taking care not to fan the flames of their anger.  

Dr Havelock is a GP trainer in Wooburn, Buckinghamshire 

Case study Anxiety is making a patient angry
I was called to reception because a patient was abusing the staff and causing chaos in the waiting room. I found Mrs Smith, a 72-year-old woman, shouting at the staff, obviously very upset and demanding an appointment.

I was able to get her into the office and told her that I recognised that she was very upset. She continued to be angry but, by remaining calm, I discovered that that morning she had lost the hearing in her good ear and was very scared that she was going to go completely deaf and wanted something done urgently.

Slowly she settled down and I was able to make a plan for an urgent ENT appointment.

She apologised to the staff for her behaviour as she left. 

Learning points
Dealing with patients who are angry or aggressive

  1. Prevention of situations causing anger in the surgery is essential.
  2. Early recognition of the signs of anger aids management.
  3. Do not become angry yourself — stay calm. Take a detached view of the situation to be objective about its causes.
  4. Explore the reasons why the patient is angry.
  5. If there are legitimate reasons for the patient’s anger, acknowledge them and apologise if appropriate.
  6. Devise a shared plan to try to avoid this situation in the future.

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