Violence and Aggression in the Health Care Sector

Communication as an effective tool for calming patients was approved in one pharmacology study (Isbister, 2010). Agitated patients were given calming medication (midazolam), nevertheless, some of the study patients had to be excluded, because the personal were able to de-escalate through communication and the drug administration was not necessary. 

 Communication is still the most important connecting link of medical care. Health-care facilities are not an exception in this regard. The technical development (equipment, pharmaceuticals, etc.) of contemporary medicine was very remarkable in the last years. It strongly influenced the communication relationship between the healthcare professional and the patient. Communication has ceased to be the focus of interest. The patients who were mostly concerned have registered this change. Nowadays, the patient requires the best services, modern devices and modern equipment and wants to understand “all”. Only an informed patient who understands what happens with him/her is willing to have confidence in members of a health care staff. Such a patient feels safe and has no reason to try to get the power on his/her side, because the general nurse can through their “professional approach” not let the patient feel powerless. If the patient feels safe, the patient does not normally put an affront upon the general nurse and doesn't accuse or assault them. 

 The answer to the violent situation (extreme stress) is complicated by the necessity of fast decision and the necessity of an immediate reaction. It is well known that communication should prevent the provocation – the verbal and non-verbal part must be in balance. Nevertheless, in a stress situation the communication form changes: The non-verbal part forms 50 % of communication content, 40 % is tone of voice and only 10 % is the verbal part. Said words are not so important, the most important aspect is the behaviour of medical staff members that can in the violent situation de-escalate or in contrary escalate. On the basis of practical experience and special literature, the health professional is in opposition and should defend himself. In the next text, a recommendation that we called verbal self-defence is presented. Literature excerpts and proficiency have practically proven that it can help to solve violent situations.  We are aware that every violent situation is unique and variable.

Nevertheless, techniques were created that were proven as effective in real situations. 

The non-verbal part has to be harmonised with the verbal part. The voice (tone) of our communication gets other voice colour in stress situations and can sound completely differently. Men very often “bark and bellow”and  women “screech”. The voice helps us in a violent situation if it is calm, relaxed but yet unfaltering. The right breathing is also an important part of the vocal expression as we speak when breathing out. A long and deep breath is suitable for speaking. It is better to breathe through the nose in stress situations – it is possible to breathe out the stress literally. Controlling the situation can also, help to stabilise the verbal expression when there are more people.  In this case, the principle is that only one person speaks with a violent patient – one health professional (more voices only increases situational stress). From the de-escalation point of view, it is suitable that the health professional introduces themselves and asks the patient how they would like to be addressed (Nöllke, 2011).

Following formulations are possible: 

 “Hello, I am nurse Jitka “What is your name?”

 “How can I address you?” I am Jitka, and you?  

Even though we know, the patient's name from paramedics or from his/her relatives, asking about his/her name is more personal and shows the interest (Lánský, 2012). 

Also the information about where the patient is and what follows is very important. 

 “Now you are in a hospital”.

”We are going to do all to finish your examination as fast as possible. “ (For your security feeling. “). 

“I will take care of you so as nothing happens to you”. 

 

The patient who is informed, doesn't mostly complain and doesn't cause violence (Lánský, 2012). It is better to speak with a patient in brief sentences (a sentence should not have more than 13 words). It is more suitable to use simple sentences, questions and well-known words (“You are in a hospital.) I am nurse Jitka. I will take care of you. First, we will do the CT examination.  CT doesn't hurt, it is something like X-ray and takes 5 minutes”)  

 Difficult words, questions or long instructions often confuse the patient and can increase their irritability (especially if they were waiting for a very long). Explaining each situation dealing with the patient, that health professional performs, calms the patient and avoids pointless misunderstandings. The patients has the right to get comprehensible sufficient information (Law No. 372/2011 Coll., dealing with health services). The health professional should not forget to let enough time for patients’ answers (not to interrupt him) to absorb information. The health professional repeats necessary and important information and checks to see if the patient has understood him (Nöllke, 2009).  Following questions are suitable:

 “What do you want to ask about?”

 “Is there anything you don´t understand?”

 “How do you understand it?” 

"What did I forget?"

Health professionals as well as patients are controlled by their negative emotions in a violent situation. To be aware of his/her own wishes (what I want to achieve) and the possibility to ventilate his/her emotions has a de-escalating effect (Ptáček, 2011). To find out the goals of the patient the health professional can ask: 

“I really have to know what you want to achieve now ?”

“You can really help me if you tell me why you are here?”

“If I understand it well, you are angry, because ...?” 

Questions regarding verbal communication are very effective. A question is like stroking. If it is well chosen, it doesn't provoke and provides us with time for our next reaction. The health professional should speak with a crying patient on his tone level (loud, firm) and he should use the situation to ask questions. The health professional shouldn't give instructions and advise him what to do. It is much more effective to describe patient's behaviour or the health professional can describe his/her feeling:  

“I can see that you are angry!” Who annoyed you? 

"You are furious! What happens?”

 “It would be better, if we sit down. When you are crying at me, I am afraid of you  and cannot concentrate on your needs."  

 

The concept of patient's involvement by MacYoung (2011): 

The nurse: “I don't think it is a good idea to hurt me”

The patient: “What do you mean?” The nurse: “Let us find it out”

 

In order to understand what the patient is saying, the health professional should assume that the patient is telling the truth. Also in the case, that it won't be the truth, the health professional should try (pretend) that he perceives it in this way. The interest for the patient decreases the tension at a violent situation and helps to deescalate it. In addition, when we confirm that the patient is right, we acknowledge that we have never experienced what the patient is experiencing now, but we think that their  feelings are righteous. 

When a patient e.g. claims: “You have a mess here; I have been waiting here for more than two hours! - The health professional can answer: “Yes, you have already been waiting very long; you should be treated with more respect.”

The patient in stress struggles for power (he/she is helpless) and the form of his/her reaction (also defensive) can be an attack or an escape. The patient can also react in this way when he/she tries to achieve a certain goal (pain reliever, immediate examination, disease symptoms, long waiting). In such a situation, the offered alternative can be perceived as goodwill – offering water, a magazine, go smoking to an appointed place, information about the examination, phone call possibility, offering another appointment date – and at the same time the distraction of attention that is a part of de-escalation (interruption of the decreasing tension at a violent situation). However, we should not promise something to the patient that is not possible (e.g. smoking in his room) (Richmond, 2012).  

Also, the communication technique called the absurd theatre can serve as a distraction of attention (Nöllke, 2009). The principle of this technique is simple sentences that are not related to the concrete situation at all. The technique is based on the theory of the absurd theatre, when we surprise the patient with our absurd reaction. It means that things are said which are not connected to what was said before. The reaction surprises the aggressor and can also stop the violent reaction. 

When the patient asserts: “You have a mess here, I have been waiting here for more than two hours! “ 

 The health professional can answer nonsensically: “And with which car did you come?” 

The patient may answer: “With a car???” --- PAUSE --- What, what ... has it to do with it?

The health professional may answer to it: “Nothing at all, I only deviated from the theme a little bit.  

So now your requirement."

 

It is an effective way to involve the patient into the communication by means of the word “we” in the case of a very angry patient. By using the words ”I“ (”I don't know more how to explain it to you?“) or ”you“ (”You don't understand it, do you?“) cannot help the health professional involve the patient in the situation, so that he/she perceives that he/she is a part of it. By using the word “we” (“I don't know, where we are making a fault, that it is still not clear to us?”) we involve the patient into the situation – we show him that he is not a “thing” and that he participates in this situation and can decide it  (Nešpor, 2012).  

A big problem with communication can arise with intoxicated patients. In such a situation, it functions very well, when the health professional enables them to become their relatives for a certain time. The health professional and patient have more tolerance for one another if they feel they are like relatives and will lead to led aggression. It is only then  possible to get the concrete situation under control, because if the intoxicated patient realises that they don’t  have an opponent, they don’t  attack any more. It is important on the other hand to inform the patient clearly about acceptable behaviour limits.  The health professional should inform the patient that their behaviour - reaction - would be unacceptable. If it is necessary, the health professional will tell the patient that the can be arrested and prosecuted if they attack. The information should be formulated as a matter of fact and not as a threat:

“I don't want anybody to call the police. Possibly, we can come along. “   (Richmond, 2012).

 

When it is not possible to de-escalate the patient any more by means of communication, the health professional can in collaboration with other health staff members offer pharmacological calming to the patient. In this case it is necessary to persuade the patient that it is in his favour (his security, the security of other patients). The health professional can choose: 

 “I can see you aren't doing well. Aren't you feeling well?  Can I offer you any medicine?”

 “We have to agree our next progress. For our better communication it is better to take some medicine for you to feel well. Do you agree, please?”

 

It is also suitable to ask the patient if they already have any calming drug in the past.   If it is necessary to give drugs, the health professional informs the patients the rationale for it.  It is important to continue respectful communication and option possibilities: 

 “From the view of your security we give you now some drugs for your calming.”

 “Do you prefer intramuscular administration, intra-arterial administration or would you like to take the drug as a tablet taken with water?”

“If you agree with a pill, we don't need an injection.” “We have here three sorts of pills - which one do you want?” 

  (Richmond, 2012). 

 

In the case of a real threat from the patient, the health professional has always to take in account that they may be physically attacked.  It is very often about the violence arising from fear and in such a case the health professional can react verbally: 

 “Why do you want to hurt me?” Do you feel secure? I want neither violence, nor injury!”

(Fishkind, 2008).  

 

The founder of assertive communication Smith (1975) offers other alternatives reflecting the health professional’s emotions:  

 “If you look at me like that, I am afraid of you”.

“I don't want somebody to get hurt, we certainly can make us understand”.

"I am am afraid of you! Please, I don't want to be afraid of you."

 

It is always necessary to keep in mind that physical and pharmacological interferences into the behaviour of a violent patient are  dangerous processes and it is necessary to use them as a last possibility for solving this extraordinary event (Zampieron, 2010.) Either kicking a door or breaking a chair doesn't necessary mean a need of restriction or pharmacological calming.  In the case where all possibilities of a calm de-escalation are exhausted, then it is necessary to restrict the patient. It is always necessary to perform a written entry into the care documentation. As well as the usual information, the entry should also contain the opinion of the patient on the performed restriction (Richmond, 2012). 

The modern clinical thinking support less serious compulsory interventions that ask the patient to cooperate as a partner (although they behave violently). These attitudes can have many advantages in comparison with traditional restrictive attitudes. We don't occupy ourselves with the patient's restrictions means, because we support communication as a de-escalating technique and the item of patient's restriction goes beyond the appointed range of our work and its goals.  We are stating in this context that since 2012 the Law dealing with health services No. 372/2012 Coll. can a general nurse according the § 39, paragraph 3 letter d) restrict the patient by restrictive means without a physician's presence (grasp, restrictive interventions). This action is possible only then, if a patient's violent behaviour endangers himself or his environment, all available calming interventions are depleted and there is no physician present. As soon as a physician appears, it is his duty to assess the whole situation (further using of restrictive interventions or their cancelling) and to confirm the legitimacy of the situation in the medical documentation.