Violence and Aggression in the Health Care Sector
Main causes of violence in the health care sector, prevention of violence, verbal and non-verbal de-escalation.
3. Prevention of violence
Experience shows that it is possible to prevent violent situations through appropriate communication techniques and it is always worthwhile to make maximal efforts to prevent a conflict rather than to try to solve it subsequently (Fehlau, 2003). Also for extraordinary events in healthcare, many experts agree on the fact that if there was one single aspect in providing medical care that could bring effective improvement, it would be effective verbal communication (Škrla, 1998). Therefore, professional behaviour of health care staff plays a decisive role in the prevention of violence. It is erroneous to assume, that health care personnel have automatically inborn ability to communicate with empathy with all patients. Greetings and explanations have little or no tradition in our country and senior physicians’ don´t set a good example to junior colleagues.” But healthcare is 80% formed by communication. A patient, who is spoken to by a physician in a clear manner, is an informed patient. And such a patient cooperates better and recovers faster. It also influences cost, because faster recovery also means shorter incapacity to work” (Lánský, 2012). Communication includes not only information transfer and hearing, but above all our behaviour whilst communicating with a patient.
The practical skills of injections or surgery require training to perform and develop these skills. It needs to be reinforced if it is to become effective. The same applies to communication skills. Reciprocal relations between healthcare staff and patients are literally charged with emotions. These are just emotions that govern our non-verbal behaviour, and this part of our communication is much more accentuated than the word content. Patients can remember (not only) their own emotions very well and for a very long time. Health care personnel also have a right to their emotions. Unfortunately, most patients’ don´t know healthcare work and any emotional stress of healthcare staff (”You are again here?, So come in.”,”What do you want again?”“, I have just explained it to you, so why are you doing something else?“), can be perceived as unprofessional behaviour (Ptáček, 2011).
From the point of view of conflict prevention, it is crucial not to get into a violent clash with a patient at all and to de-escalate maximally any prospective conflict. We consider the prevention in relation to violent patient in two steps:
The first effective step of conflict prevention is such behaviour that neutralises initial stress and other negative emotions accumulating at the first contact between the healthcare professional with the patients (or his/her relative). Paternalistic relations between the general nurse and the patient is so replaced by a partner relation. It is not necessary to exaggerate our professional activity in the first contact, it is quite sufficient if we focus on prevention of factors (as discussed in the chapter 3. 1.) that deepens stress for the patients and increases the risk of their unwanted actions.
The primary factor that can prevent conflicts is (very often neglected) interest for the patient. The Halo effect can be evident for the patient also, not only for general nurses in their relation to patients. The first impression of a patient is, in addition often impaired by his first visit of the surgery, his first stay at the hospital, whereas for a general nurse it is her/his everyday work that can become a routine which can appear to be the reason for the lack of interest. The healthcare professional cannot rely on patient knowing in advance what he/she shall expect – or more importantly – what a healthcare professional is thinking about. Only one gesture or one word can engender his/her favour or dislike. It is suitable to introduce yourself to avoid negative emotions already in the first contact with the patient or his/her relative. Introduction signalises interest, dampens the fear and means leaving the anonymity that is there ever since the ground for wrongdoing (Fraser, 1974; Zimbardo, 2008). Thanks to the introduction from a healthcare professional, the patients gets the feeling that he/she is important to them. The introduction is an important step for confidence building by the patient. Subsequently, the patient perceives the general nurse as a partner in care and is not ashamed to speak not only about his/her health problems, but also feelings or emotions. If the nurse gains the confidence of the patient, a short-term or a long-term relationship begins to be created and starts the foundation for mutual collaboration. It is necessary to hold the relationship for as long as possible, because it is enough when a certain negative situation arises and the patient looses his/her confidence and it is easier to establish a relationship again from the beginning. Only then if we have a relationship with other people, we do not see them only as objects. Then there are no illnesses, but only ill people (Urbánková, 2013). If healthcare professionals can see their patients in this way, patients will be more tolerant of waiting and they will follow doctors’ advice and provide necessary information. Also healthcare personnel will be protected from burnout, if they work like this. The difficulty for the professionals is that they cannot always expect from ill patients reciprocity in relationship, but they must strive for such a relationship. The person who has the power is responsible. The introduction and establishment of confidence from a healthcare professional towards the patient is thus a fundamental measure for conflict prevention. Also patience, an effective communication style and an appropriate intervention into patient´s violent behaviour (the patient doesn´t come always calm and balanced) have to be implicit. Very often the patient is violent already during the first contact without any action for the part of healthcare personnel.
The second effective step is therefore the knowledge of phases of violent behaviour. The ability to recognize the phase which the patient is in, makes it possible not only to reliably react but it also increasesthe security of healthcare personnel.
Novák and Capponi describe the development of a conflict situation in five phases:
- Triggering phase (the person leaves his/her normal non-aggressive behaviour).
- Escalation phase.
Also, the victim very often doesn't react in the phase thoughtfully.
- Crisis phase
The aggressor is already physically, emotionally and psychically excited; a small impulse is enough for him to attack his/her counterpart.
- Recovery phase
- Post-crisis depression phase
The aggressor regains physical/emotional control, and is taken aback by what has happened. This elevated adrenalin level of an aggressor persists 90 minutes after the attack, then follows a stepwise reduction of this tension.
This phase comes as the last one. Distress, a sense of anxiety and blame, despair are evident. Sometimes, it is typical to want to give reasons for something that cannot be justifiable, and at other times comes pleas for forgiveness and regrets.
It is not possible to ensure that everything will go off without a hitch. It is an optimal measure not to allow the trigger phase to come over into the escalation phase and then into the crisis phase – a healthcare professional can use de-escalation communications techniques. The healthcare professional has to bear in mind that angry people (Crisis phase) don´t think rationally. The attempt to calm such an angry person by calm arguments can have in the crisis phase a contrary effect. Due to the stress response that goes with the crisis, it is necessary to proceed from the assumption that 80 % of blood is gathered in muscles – is in preparation for an attack or escape. Cognitive centres in the brain are in this phase supplied with blood at the very minimum, it means that the attacker we want to pacify, doesn`t hear, doesn´t perceive and has a limited visual field. Any long sentences, explanations or calming doesn´t help in this situation or may even worsen it. What to do in the given phase and how to use concrete effective communication techniques of de-escalation is described in the following chapter (Benett, 2012).