Managing conflict in general practice

Read this article to:

• Find out why conflict and aggression is a prevalent issue in general practice.
• Learn strategies to avoid aggression escalating.
• Discover tips for effective communication.

All members of the general practice team have the right to work in an environment that is free from harassment and threat; nobody should have to tolerate verbal or physical abuse. Unfortunately conflict and aggression do occur in general practice – the environment is busy and demanding and involves contact with a wide range of people in varying circumstances. Patients sometimes have unrealistic expectations of care and when these expectations are not met, a conflicting situation may arise.

Most episodes of conflict or aggression start with a minor disagreement that may then escalate. The key to managing these situations is to de-escalate them effectively to avoid a more serious incident.

The scale of the problem

In 2015 Medical Protection surveyed 254 GP members and found that 52% experienced challenging interactions with patients on a weekly basis. This was mostly attributed to unrealistic patient expectations (72%), followed by alcohol/drug misuse by the patient (41%). It also found that one in three GPs had considered leaving the profession due to stress and anxiety caused by an experience with a challenging patient.¹

It is more likely that staff working in general practice will be subjected to non-physical violence, but we must not underestimate the impact that violence of this nature can have on an individual. It can result in a loss of confidence and increased fear, as well as feelings of insecurity and a loss of control or panic, all of which can ultimately have an impact on staff morale.

Conflict means different things to different people – some people may enjoy a heated discussion where others may find it upsetting. The Health and Safety Executive describes workplace violence as, “Any incident in which a person is abused, threatened or assaulted in circumstances relating to their work.”²

Why is there a risk of violence within general practice?

Aggression does not usually develop suddenly or in isolation.  Violence and aggression in healthcare can differ greatly from other workplace environments. As healthcare workers we interact closely with patients and their loved ones, often in very challenging circumstances. Patients may respond aggressively due to their medical condition, medication, psychological factors or disability. Members of the practice team are particularly vulnerable to violence as they are often consulting with patients alone, working in small numbers within the premises and may be undertaking home visits on their own. There are also other contributing risk factors that may aggravate or escalate conflict situations.

System issues

• delays in appointment times or test results
• errors, such as lost prescriptions
• difficulty accessing other services such as secondary care
• lack of appointments.

Environmental

• waiting room factors such as heating, ventilation, lighting, noise and seating
• cramped consulting rooms without easy exit for health professionals
• lack of privacy in areas like reception.

Patients

• unrealistic expectations
• dissatisfaction with the care provided
• underlying medical conditions, such as hypoglycaemia or psychotic illness
• communication issues and language barriers
• strong patient emotions such as uncertainty, frustration, stress and anxiety (anger is often a secondary emotion toanxiety or grief)
• physical symptoms including pain, headache or fatigue
• mental health problems which lead to confusion and anxiety
• personal problems or worries, such as financial or relationship problems, stress at work
• drugs and alcohol.

Staff

• working under pressure
• working alone
• working in noisy cramped conditions
• inadequate staff numbers
• escalation of the situation, eg: by confrontation, over-reacting, poor communication, inconsistencies in handling patients, patronising behaviour, ignoring a situation or failing to apologise.

Key strategies to manage conflict and avoid escalation

Good communication and attention to patient experience is essential in reducing the risks of conflict and aggressive behaviour. Practice staff with a patient-friendly and focused approach that values the patient, acknowledges their individual situations and demonstrates a willingness to help can go a long way to reducing the stimuli for aggressive behaviour. Remaining focussed on addressing the individuals’ needs and aiming to achieve a mutually agreeable solution will make the patient feel safe and less distressed.

A study by American psychologist Albert Mehrabian (1971) determined that our non-verbal communication represents over 50% of an interaction, therefore being aware of your own body language can be the first step to understanding how you may be perceived by your patients.³

Top ten tips for effective communication

1. Make a conscious effort to stay calm.
2. Approach in a warm, friendly, open manner, avoiding confrontational body language such as crossed arms and standing too close.
3. Pay attention, show you are listening, give the patient your undivided attention and where possible avoid distracting activities such as writing or looking at the computer.
4. Avoid patronising behaviour.
5. Read the patient; observe the emotions behind the words. Is the patient angry, afraid, frustrated or resentful? Respond to the emotion as well as the words.
6. Avoid interrupting and allow the patient to finish what they are saying.
7. Communicate understanding, ask questions, paraphrase and reflect to ensure you understand the message.
8. Try to find out what the problem is from the patient’s point of view. Ask open-ended questions such as “what can I do to help?”
9. Acknowledge frustration and the importance of the issue for the person.
10. Give clear messages that demonstrate you want to help and you understand their point of view (which does not necessarily mean you agree with it). Apologise if errors have occurred as this goes a long way in defusing a situation and is not an admission of liability.

Achieving a solution

Once a problem has been highlighted, the key to a successful outcome is finding a mutually- agreeable solution. Remember, do not promise what you can’t deliver. Acknowledge the patient’s position, inform them about your position and together discuss a way forward. Provide choice and use timeframes where possible. Always offer an alternative rather than a refusal.

Practical tips for practices

• Use a side room or separate area to deal with upset/aggressive patients or those needing more privacy.
• Ensure good temperature and ventilation control, adequate seating and clear signage.
• Ensure patients are well informed about how systems at the practice work to try and reduce unrealistic expectations.
• Introduce calming measures to reduce frustration, anxiety and boredom, and consider providing distractions in the waiting room, such as background music, TV screen and magazines.
• Add a practice-agreed marker to the summary of a patient’s record who has a history of violence. Ensure it is factually accurate.
• Have a practice protocol for involving the police and subsequent removal of patients from the list.
• Ensure good external lighting and consider whether CCTV might be appropriate.
• Ensure the practice has access to panic alarms and a plan in place for what to do when they are activated.
• Ensure that locks are in place to areas where patient access should be restricted.

Advice for home visits

• Inform staff at the surgery where you are going and your anticipated time of return; during out of office hours advise the driver.
• Carry out a risk assessment before agreeing to see any patients with a history of violence, alcohol or substance misuse or mental illness. If there is a potential risk to your safety it may be important to inform the police and have them support you on your visit.
• Have access to a mobile phone with speed dial to emergency services.
• Consider carrying a personal alarm.
• Park as near to the destination as possible to minimise the risk of being attacked and facilitate a quick exit if necessary.
• Consider the safety of prescription pads and narcotics. When possible keep medications locked away.

We can and will experience conflict at many times in our lives, including in general practice due to the sheer volume of patient contacts that occur every day. Early detection and aiming to de-escalate a situation is crucial to preventing violent behaviour. The aim is always to reach an effective solution for both parties. Remember your personal safety is the highest priority.

References

1. Medical Protection Society. Half of GPs face challenging patients on a weekly basis, says MPS survey. Available from https://www.medicalprotection.org/uk/articles/half-of-gps-face-challenging-patients-on-a-weekly-basis-says-mps-survey
2. Health and Safety Executive. Violence in health and social care. Available from http://www.hse.gov.uk/healthservices/violence/
3. Mehrabian A, Silent Messages. Belmont, CA:Wadsworth; 1971.