Violence and Aggression in the Health Care Sector

Both the health professional and the patient can misconstrue non-verbal communication if the situation is not correctly interpreted. This can happen by lack of awareness, without intention, by mistake - either by a false interpretation or influenced by situational or personal factors. Based on communication analysis (70 % non-verbal component), it is necessary for the health professional in the case of violence to involve effective non-verbal communication and to control him/herself. Respecting personal space of a patient increases the safety of the health professional.  It is recommended to stay at a distance of two extended arms. Any further approach (there are stronger reactions of homeless or drunk people) decreases patient's space, which automatically increases tension and negative emotions. This recommendation is the same for health professionals when the patient comes near to the health professional. If it is impossible to keep this distance, it is better to turn a little sidewards or escape around the patient and not backwards. Physical contact can be also dangerous as it can escalate a violent situation.  

If we want to support the patient and to touch him/her, it is necessary to connect this non-verbal motion with a verbal question and to tell the patient the reason for this contact.  After the determination of personal space boundaries, the health professional should try to avoid an unnecessary provocation (Richmond, 2012).

The health professional mustn't be provocative in their non-verbal behaviour. Their behaviour should signalise safety and neither danger nor uncertainty. Upper limbs shall be visible, and fists should not be clenched – holding arms between one's waist and chin in a position prepared for “praying” or “thinking” is considered as nonconflicting. These positions are not provocative and provide a possible fast defensive reaction in the case of physical violence. It is necessary to consider our gestures and it is important that the movements are not exaggerated and negative. Shrugging shoulders, shaking the head, hands placed behind the back, hands in the pockets, flighty motions of arms or legs are regarded as negative gestures. The use of improper gestures (flipped off middle finger, forefinger), lifting your hands over your head, clenching your fists, fast and inappropriate motions of your upper limbs should be avoided. It is always better to avoid these gestures for a safe situation (Nöllke, 2011). 

Facial expression of the health professional is very important.  The health professional should avoid staring eyes, lifting his eyebrows, dropping corners of the mouth or opening the mouth for too long as it can escalate potential violence. It is right to keep eye contact when you begin speaking and when you finish a sentence or an idea (Nöllke, 2009). A calm view inspires confidence, but long eye contact can be provocative. The eye contact should be for a maximum of six seconds and then, it is necessary to change your view to other places (it is possible to catch the beginning movement of the patient), the movement towards us, a kick or a punch. We can show interest in the patient by a looking directly into their eyes of the patient or it make us appear self-confident. The patient may avert his eyes as our view is too uneasy for him, (he feels the dominance) and this decreases his tension. An even better technique is called “the third eye” – we imagine the eye in the middle of the forehead of the patient. By watching this point, we don't look straight in the patient’s eyes and we can see the whole face of the patient. We fundamentally avoid any humiliation of the patient by our non-verbal communication (frowning, laughter, gestures of lack of interest, supercilious behaviour), that would only increase the potential of violence. Through watching the expression of the patient, the health professional can see the non-verbal elements of a violent patient: clenched fists, raised voice, moving cheekbones, dilated nostrils, rapid breathing / raising chest, blushing or pale face, stamping, toing and froing, dilated pupils, big muscle groups moving (Skellern, 2013).  

The health professional should after the initial examination focus their attention on attitude. The attitude of the health professional should be firm, self-confident but relaxed at the same time. It is possible to attain this by ensuring that our feet are not too close to each other and are shoulder width apart. The forefoot of the health professional is oriented towards the patient and the hind foot supports the health professional by having a broad stable base. The health professional inspires confidence and can breathe much better if in an upright pose. It is important to avoid many changes of this pose because it has a nervous and restless effect on the patient.  It is possible to avoid this by shifting the weight from one leg to another. This movement should be accompanied by a deep expiration, as it will lead to a reduction of any possible tension and to an increase of self-control (Nöllke, 2011). 

The health professional may also be attacked when sitting. If the patient is leaning over the health professional, he/she has a bigger space for his/her attack than the health professional has for their defence. Ideally, it is best to stand up (without bending, if possible). When standing up, it is safer to put a barrier between you and the aggressor (a chair which is possible to hide behind  or it can be used to drive back an aggressor. If it is not possible to stand up (stress reaction) or the patient does not allow it, the health professional should try to relax by exhaling and lying back in an armchair to enlarge the personal zone. If sitting, it is more dangerous to rest legs on the chair. A straight look and putting one leg forward looks more self-confident and enables a fast standing up position. If a table is between a health-professional and a patient, then all objects should be put away (or at least aside) which the aggressor could use as a weapon. It is necessary after a partial orientation to the situation and after a check of the non-verbal communication of a health professional, to assess the environment for any objects (such as sharp edges, objects etc.) that could in the course of a conflict escalation conduce an injury to the health professional or a patient (Nöllke, 2009).