Lowering the temperature in hostile patient encounters

A DENTAL professional in Ipswich describes daily abuse from patients as “soul destroying” to staff. A practice in Pontefract installs a panic button at its surgery after facing a torrent of abuse on informing patients it can’t offer routine check-ups for the foreseeable future. A dentist in Manchester calls the police twice in the last six months to deal with violent threats to staff. Another dentist in Hull begs patients to be polite with her "tired and battered" team who are doing their best.

Such stories are appearing regularly in newspapers across the UK, with healthcare professionals reporting a steady increase in abuse and aggression directed towards practice staff as the pandemic lingers on. Frustration is boiling over for a variety of reasons, including patients being unable to book check-up appointments, requirements to wear face masks while in the practice, and also unavoidable delays in treatment.

Conflict situations can quickly escalate, not only face to face and on the telephone but also with patients venting their anger against practices on social media or by making formal complaints. All of this can have a serious effect on staff, who may feel unsupported and unable to cope with the stress of being exposed to hostile patient encounters.

Dental practice employers must treat the potential of such encounters as a health and safety at work matter, with a legal obligation to take reasonable steps to mitigate and minimise the associated risks. The focus should first be on actions that can prevent conflict situations arising in the first instance, or to reduce their frequency. This includes establishing related policies, safe systems of working, carrying out risk assessments and providing staff with necessary training.

Here are some approaches to consider.

Ensure your staff feel protected

There are various strategies you can use to protect your team. These include providing guidance and training on how to prevent conflict escalating, typically the effective use of interpersonal skills such as defusing and calming strategies, or team tactics to de-escalate and control a conflict situation. Specific training is likely to be required in this respect, as dealing with hostility does not come naturally to most people.

You should also review and update your practice’s unacceptable patient behaviour policy, as a reference for reception staff, practice managers or clinicians. Signs or posters can be put up on the front door of the surgery and in the waiting room, and notices posted on your website and other social media platforms, reminding patients you have an unacceptable behaviour policy that prohibits aggression, threats and violence towards staff and other patients. This should provide examples of behaviours that cannot be accepted, along with the potential consequences.

Practice staff should be reminded that such behaviours should be distinguished from patients simply experiencing anger or annoyance, which are legitimate emotions that arise from frustration and anxiety. Unfortunately, some individuals are unable to express these feelings constructively and resort to becoming aggressive, which should not be tolerated.

Other practical measures can include providing detailed information about your current appointment booking system and other related pandemic arrangements on your practice’s website, recorded telephone message or other social media platforms.

Exit strategy

Ensure all team members have a viable safety strategy to rely on if faced with an aggressive or violent patient. It is vital to ensure that consulting rooms offer staff an uninterrupted pathway to the exit. Make sure there is no furniture blocking the way to the door and, ideally, the dental treatment chair should not impede your exit. Check the layout of your consulting room in advance with this in mind.

The consulting room may have a panic button so check where it is and find out what happens if you press it. The practice should have a protocol for what to do if a staff member presses the panic button, and everyone should be familiar with it.

Practices may consider terminating the practice-patient relationship if unacceptable behaviour cannot be managed in any other way. See page 12 of this issue and contact MDDUS for advice on how to go about this correctly.

Understanding why conflict arises

Having a practice discussion about potential sources of patient frustration and how to minimise the flash points that may act as triggers for patients will help everyone’s understanding of the problem. Consider how to keep patients involved and engaged in their journey through your practice. This can be as simple as explaining to them how long they will have to wait to be seen.

Formulate safe systems of working

Developing an agreed verbal script for staff to follow (both over the phone and at the reception desk) can provide reassurance and also consistency of approach in challenging patient encounters. This may assist in reducing complaints that some patients are being given preferential treatment over others.

Developing and encouraging the use of clear communication channels with your patients can assist in preventing challenging situations arising and help quickly calm a difficult face-to-face situation. This should certainly include providing an explanation of the causes behind a frustrating situation and an apology for any inconvenience.

More specifically, in the context of Covid-19, your staff can try to place the patient’s frustration in the broader context of the immense challenges of the pandemic. This approach can help develop empathy, which in turn can reduce tension when providing factual explanations behind perceived “bad news”.

In the most extreme situations, your staff should be empowered to make it clear that aggressive behaviour or violence will not be tolerated, in line with your unacceptable behaviour policy. This should be calmly communicated while attempting to manage the situation, for example by acknowledging that a complaint has been made and will be acted upon in accordance with your complaints policy.

You should also consider supporting staff by organising conflict management training, preferably using scenario-based learning directed at managing difficult patient encounters. MDDUS can assist members in this respect.

Listening to patients concerns

Even if a patient’s behaviour is inappropriate, it can help if practice staff take the time to listen carefully to their concerns and offer appropriate solutions where possible. Simply cutting a patient off without an explanation or apology may only lead to a situation escalating out of control.

Check that staff are supported

This should encompass guidance on actions to take after an incident has occurred to support staff and prevent or reduce the potential for recurrence. Attention should be focused on the effect of single or cumulative instances of conflict on individual staff, including psychological harm. It is important to allocate protected time for all staff to debrief and de-stress following serious incidents.

Do you provide access to an independent employment assistance program (EAP) offering wellbeing or mental health support to your team? Individuals often find approaching managers or colleagues difficult as they worry about appearing weak or unable to cope.

Remember that developing a strategy to prevent and reduce patient conflict will help reduce frustrations for both your patients and staff, ultimately reducing the risk of complaints, claims or regulatory action.

MDDUS has developed online workshops on managing patient conflict details. Email risk@mddus.com to find out more.

Alan Frame is a risk adviser at MDDUS