The Risk Management and Patient Safety Department at the Cooperative of American Physicians (CAP) has recently received an increased number of requests for assistance with managing disruptive patients.
While the physician’s first inclination may be to discharge the patient, this action may not always be the optimal solution. De-escalation techniques and protocols can help equip you and your staff with strategies for navigating these challenges to minimize potential disruptions.
Learning to recognize when a patient is upset is an important first step. Minor verbal complaints (e.g., “The wait is too long,” “There are too many people in the waiting room”) may serve as initial signs of worsening behaviors, like yelling, expressing degrading comments, swearing, or threatening statements in a belligerent tone of voice.
STAMP is an an easy-to-remember acronym to help identify five specific behavior elements characteristic of potentially disruptive patients. It is an effective risk assessment tool that can help health providers recognize an aggressive patient.
STAMP:
- Staring and eye contact: looking directly at the provider or away from the provider;
- Tone and volume of voice: speaking loudly in a sarcastic or aggressive tone;
- Anxiety: showing signs of restlessness, irritability, or agitation;
- Mumbling: not speaking with the provider, but to themselves; and
- Pacing: moving about without clear direction.”¹
Recognizing when a situation may escalate allows you to be prepared to manage the behaviors and de-escalate the matter.
The following scenario is based on a compilation of facts from various cases but demonstrates an effective approach to mitigating a potentially disruptive situation.
A well-known patient named Tom arrived at the physician's office only to be informed that his appointment was scheduled for two days later. Despite his mistake in arriving on the wrong day, Tom, who typically conducted himself in a calm manner, was upset that he couldn't be seen immediately and grew increasingly agitated at the situation. It is worth noting that he had been living away from his home and had driven for over an hour to reach the office. Upon hearing the commotion, the office manager promptly went to the waiting room to address the situation. She approached Tom in a calm and composed manner, and asked him to accompany her Although still upset, Tom reluctantly followed the office manager to the designated space. Sensing his distress, she inquired about the reason behind his agitation. Tom explained that he was feeling overwhelmed because recent personal events had turned his life upside down. He acknowledged that he knew he had an appointment but was uncertain of the exact date. Expressing sympathy, the office manager assured Tom that she would explore potential ways to assist him. She requested Tom wait in her office while she looked into the matter. She proceeded to the front desk to review the schedule, which was fully booked for the day. Additionally, she informed the physician about Tom's situation. The physician, understanding the circumstances, agreed to see Tom during his lunch break. The office manager approached Tom with this option, asking him if he wouldn't mind waiting an hour to see the physician. Tom's agitation resurfaced as he struggled to comprehend why he couldn't be seen immediately. In a calm and empathetic tone, the office manager expressed her sincere apologies for his situation and acknowledged that she understood his frustration. She invited Tom to stay in her office for lunch and continued to lend an ear. Tom gradually calmed down and patiently waited for the physician, who eventually completed his visit with Tom. |
The office manager in the case above used several techniques found in Dr. Dike Drummond’s “Universal Upset Person Protocol” for de-escalating a disruptive situation.
- STEP ONE: Acknowledge the emotion.
Tell the patient that they look or sound upset and that you’d like to help.
- STEP TWO: Hear them out.
Ask the patient what is wrong. Listen to their story and try to find the real intent behind their words. Patients may have a variety of issues and concerns and come to their visits with anxiety or worry about the cost, transportation difficulties, their potential diagnosis, treatment regimen, or recovery process. Certain barriers may be at play, such as language or literacy, or different cultural norms.²
- STEP THREE: Look them in the eye.
When the patient is finished explaining their problem, look the patient in the eye and express sympathy and compassion for what they are going through.
- STEP FOUR: Offer assistance.
Ask the patient what you can do to help them and listen carefully to their answer, even if you already have an idea of what would solve their issue. The patient's response to this question will give you a much better understanding of what they need to help them feel calm and understood.
- STEP FIVE: Articulate next steps.
The next steps do not have to be the same ones expressed by the patient, but rather the best solution you can offer that is within your abilities as a medical professional.
- STEP SIX: End on the same page.
Once the problem has been resolved, take time to thank your patient for expressing their feelings with you. After moments of emotion, many people can feel anxious or embarrassed, so it is important to show empathy and respect by clarifying that you appreciate their vulnerability in sharing their story with you.3,4
Remember it is also important to educate patients on your office policies regarding both patient and provider expectations. Consider placing a poster regarding a Zero Tolerance policy for disrespectful, disruptive, and/or threatening language or behavior.
Once de-escalation techniques have been successfully implemented to re-establish the physician-patient relationship, document the incident factually without emotion as soon as possible in the medical record. Use quotation marks to denote the patient’s specific behaviors and verbal threats, or unacceptable language.
There may be situations where the patient might not respond positively to the de-escalation techniques or other interventions putting the provider, staff, or others at risk of harm. Depending on the circumstances, termination of the patient-physician relationship should be considered and may be the appropriate next step.
Dona Constantine, RN, BS, is a Senior Risk Management and Patient Safety Specialist. Questions or comments related to this article should be directed to DConstantine@CAPphysicians.com.
References
¹Wenske, Wayne. (2021). “De-Escalation of Angry or Disruptive Patients.” Texas Medical Liability Trust. The Reporter. https://cdn.prod.website-files.com/6790ae6ff3e4aa35f74b86d5/67bdc147d91…
²Beaulier, Jed. (2013). "Dealing with Disruptive Patients." https://ctafp.org/wp-content/uploads/2015/08/Session-2B-How-to-Deal-wit…
³Great Practice Design. (2022). “Soothe Stress With The Universal Upset Person Protocol.” https://greatpracticedesign.com/universal-upset-person-protocol-2/?v=0b…
4Drummond, Dike. “Doctor Patient Communication – The Universal Upset Patient Protocol VIDEO TRAINING.” thehappymd.com. https://www.thehappymd.com/blog/bid/290399/Doctor-Patient-Communication-The-Universal-Upset-Patient-Protocol