Defusing Conflicts With Aggressive Patients

PARIS — The rise in violent incidents at hospitals and doctors' offices has led clinicians to be on constant lookout for ways to keep themselves safe while caring for patients. At SantExpo 2023, well over 50 hospital workers attended a session led by psychologist Yves Peiffer, director of clinical practice and development at the Crisis Prevention Institute (CPI), a provider of evidence-based de-escalation and crisis prevention training. In his presentation, Peiffer gave an overview of the tools that can be used to handle aggressive patients and defuse conflict situations.

This was a timely subject, as the day before SantExpo began, a nurse had been stabbed by a psychiatric patient at the University Hospital of Reims. She died the following day. The tragedy was a cruel and stark reminder that hospitals, though already under stress, also must confront violence.

Since its creation in 2005, the French Ministry of Health's National Observatory on Violence in the Healthcare Sector (ONVS) has collected voluntary reports of attacks against people and property at hospitals and doctors' offices. In 2021, there were over 19,000 reports of nearly 37,500 incidents or acts of varying severity.

The ONVS' most recent report, which came out in November, noted, "The relationships between medical personnel and patients and/or medical personnel and patients' caregivers can very quickly deteriorate after a disagreement or even just a simple misunderstanding. The balanced nature of the therapeutic alliance and the relationship of trust are thus upset, and this, de facto, affects the quality of care."

Improving Well-Being

Personnel — for the most part nurses, nurse's aides, and paramedics — don't always know how to react or respond when faced with an aggressive patient. "Aggressiveness has repercussions not only for the individual staff member, but also for the organization as a whole, be it through absenteeism or the quality of patient care," said Peiffer.

Violence also has a significant impact on a staff member's motivation and desire to stay in the profession. So it is important that management tackle the issue head on and come up with strategies for improving their employees' well-being — particularly now that healthcare facilities are struggling with recruitment.

Peiffer, who works primarily in psychiatry wards and emergency departments, shared several tips for identifying violent behavior and preventing volatile situations.

Kindness Is Key

"There are people who use aggressive behavior to express themselves, to be heard. It's this idea that 'I have to scream and yell to get someone to take care of me.' "

Conflict prevention is not taught formally. Yet, according to Peiffer, it's a proven strategy "based on scientific research and professional experience."

Surprisingly, the main piece of advice was pretty straightforward. "Let's all be kind! After all, behavior influences behavior," Peiffer explained. "There's no switch we can flip to stop someone from being aggressive. The one thing we do have control over is our own behavior — and we can use it to calm the person in front of us."

It's essential to have a kind and caring attitude and to take a person-centered approach, he added. "Ensure that the person feels safe," Peiffer advised. "The physical environment, any interactions, all should instill a sense of security."

He also emphasized the importance of being transparent and reliable. "Be consistent. Establishing trust is all about saying what you're going to do and doing what you say you're going to do."

Body and Words

Because 57% of information is communicated nonverbally, it's important to be mindful of physical gestures and facial expressions. Peiffer gave common-sense advice about verbal expression. "Instructions, orders, directions — these should be short, simple, clear, and they should be given in a respectful, upbeat manner. Instead of saying, 'You shouldn't be here,' say, 'You seem lost. Can I help you?' And pay attention to your voice — its tone, its volume, its cadence."

Medscape French Edition spoke to Peiffer at the end of his presentation. "There's a great need for training on this topic," he said. He went on to tell a story from when he gave a training session to healthcare professionals in Saint-Denis, a suburb just north of Paris. The attendees told him that they were literally spat on every single day. They ended up considering it the norm. "When they come face to face with violence and aggressiveness, healthcare providers tend to react by mirroring the other person. Today, a lot of them are looking into ways they can physically protect themselves, asking their employers to provide self-defense classes. In fact, a nurse in Saint-Denis said that she was learning Krav Maga, a martial arts [form] that's taught in the military!"

CPI makes it a point not to build on that mirroring tendency. None of its interventions employ gestures that could be construed in any way as violent. "Indeed, de-escalation is the main focus — and helping people get to a point where they feel they have the necessary skills to put the techniques into practice confidently in crisis situations."

Into the Curriculum?

After the tragic event in Reims and given the rise in the number of (mostly verbal) attacks that private practitioners have reported to the Observatory of France's Board of Physicians, people are again thinking about how to get control of the violence being committed against those who work in the healthcare system.

"As more and more of these incidents come to light, we're seeing a mentality shift, such that decision-makers may want to place a higher priority on training medical staff on the issue of violence," said François Schimmer, a country manager at CPI France.

For about 20 years, nurses in the United Kingdom have been required to take a course to learn to manage aggressive patients. "It's a prerequisite for anyone who wants to work in a department where there's aggressiveness," said Schimmer. "Recently, the French Minister of Health announced that reforms are going to be made in the field of nursing. The hope is that a course like the one they have in England will be included in the revised curriculum."

This article was translated from the Medscape French Edition.

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