The practice of medicine is often referred to as a blend of science and art. Nowhere is the art more evident than in our communication with patients and families. Until recently, medical education used to be lacking in communication skill training.1 Over the past few decades, there has been a renewed focus on interpersonal and communication skills in medical education across the world.2

When it comes to difficult patient encounters, the educational focus is often on scenarios such as breaking bad news, disclosing medical errors, etc. A domain where we often get little training and education is on handling aggressive patients and families. When it comes to physical aggression, the solution is straightforward and involves alerting security or law enforcement, safeguarding of the staff involved, and removal of the offending party from the clinical premises. Verbal abuses on the other hand are often much more difficult to deal with. This is especially true if they fall short of the threshold where one needs to alert security or law enforcement.

Our objective is to provide a brief framework on how to navigate these aggressive patient encounters. This roadmap can easily be remembered as the three B’s—Barriers, Boundaries and Behavioural agreement.

In this context, barriers refer to our own predispositions that we bring towards a conflict that hinders an amicable resolution. These barriers include tendencies to get defensive, jumping to conclusions before gathering all the facts, inability to empathize with families when you perceive them to be wrong, difficulty in remaining calm in the face of hostility, and dismissal of certain concerns and topics as irrelevant. It is imperative that we reflect upon our own nature and identify which of these barriers tend to accompany us in conflict situations. Overcoming these barriers is often enough to de-escalate many verbally aggressive encounters, and engage with families and patients in a healthy dialogue.

Being a patient or a caregiver is a highly stressful experience. Therefore, it is imperative that we are constantly mindful of this fact and show abundant patience and understanding. However, there needs to be clear and firm boundaries on behaviour that cannot be accepted in a clinical setting. This might include yelling, threatening, intrusion of personal space, etc. At the time of such an incident, it needs to be clearly stated that such actions will not be tolerated and there will be consequences if it continues. The consequences have to be specific, e.g. ‘If you continue to yell at me, I will have to leave your room. I will come back in one hour to re-discuss and hopefully we can have a peaceful dialogue at that time.’ Although different providers are likely to have different thresholds of tolerance, we recommend a discussion among colleagues to adopt a set of uniform standards. It is important that you and your colleagues strictly enforce these boundaries each time, and you follow through on the consequences. Consistency is essential for successful behaviour modification.3

For patients or families who repeatedly violate the boundaries that you set, a behavioural agreement would be the next step (see Box for sample behavioural agreement). The overarching goals of such an agreement are three-fold:

Formally communicate that the staff at your institution has the right to work in a safe and respectful environment which allows them to provide the highest level of care for all their patients.

Outline inappropriate patient behaviours and their effect on patient care (both for that individual patient, as well as for other patients).

Document the consequences for actions that violate the dignity, safety and/or well-being of staff.

Being presented with an agreement often allows the other person to step out of their shoes and see how their actions are affecting the delivery of care in that clinical environment. It also serves as a formal notice which can prevent excuses that they were unaware that certain actions were not acceptable and had specific consequences. It has to be clearly communicated that even if they refuse to sign the agreement, they will still be expected to abide by its terms and that the consequences that are outlined will still be enforced if the terms are breached.

Aggressive behaviour continues to be a major drain on the healthcare field and its prevalence spans both geography and specialties.4 It consumes time, cognitive bandwidth, mental and emotional well-being, and a variety of other finite resources. This roadmap of the three B’s—Barriers, Boundaries and Behavioural agreement—can hopefully serve as a framework that healthcare providers can utilize across a variety of disciplines and settings to navigate these difficult situations in their workplaces.

BOX

Sample behavioural agreement (paediatric)

I, [insert individual’s name], agree to enter into an agreement with [insert hospital name] (‘the hospital’) based on the following conditions.

As a condition of the hospital agreeing to continue my child’s treatment, I promise that I will not while I am in the hospital:

swear at staff or in the presence of other patients

shout or make offensive remarks

make verbal or physical threats

enter doctor’s work room and disrupt/disturb the workflow of the team

act in a manner that is likely to cause harassment, alarm, or distress to others in the hospital

[insert other applicable conditions if needed].

If I breach this agreement, I understand that:

I may be asked to leave the hospital,

police attendance may be requested by hospital staff, and

my future attendance at this hospital may be permanently discontinued.

DECLARATION

I confirm that I understand and agree to the conditions of this undertaking.

I also acknowledge that the consequences of breaching the conditions of the acceptable behaviour agreement have been explained to me.

PARENT NAME:        WITNESS 1:       WITNESS 2:

SIGN:                           SIGN:                  SIGN:

DATE:                           DATE:                 DATE: