Difficulties in Managing Aggression and Conflict in Healthcare
Published on the 01 August 2017
Published on the 01 August 2017
On my first ward placement, I found that when encountering patients with vascular dementia, the most minimal expression of disdain used to colour me a deep shade of crimson and reduce me to blinking back tears.
Throughout my childhood and teenage years, I never considered myself as someone who could be disliked. Suddenly, I was confronted with this recurring situation.
Although I understood that many of these patients were confused and their aggression was not personal, I still believed I had the capacity to change their mind.
While attempting to convince confused patients that I wanted to promote their best interests, I sometimes ended up scratched and bruised. Building up the capacity to make sense of these situations was not an easy task. When you’re used to a tension-free interactions, being confronted with these situations becomes an emotional burden.
In my first year of qualifying, I worked on a Neuro unit. Frequently, patients with traumatic injuries were unpredictable and agitated. Getting accustomed to their behaviour was a steep learning curve.
It didn’t take long to realise that rationalisation was not always an effective approach.
On one occasion, my colleagues and I were attempting to convince an agitated, unsteady patient to return to bed. His mobility was restricted and he required assistance and supervision to walk. A tall stature presented an obstacle for the provision of support. He also had a few invasive lines in situ, making walking independently a greater falls risk.
As the patient trailed his catheter along the corridor of the ward, we pleaded with him to return to his room. After an unsuccessful attempt, my colleagues and I tried to assist him with walking. While trying to hold the patient’s catheter, he shoved me forcefully to the side, where I stood, stunned. After failing to plead with the patient, haloperidol was administered.
After a year and a half of ward work, I moved to another hospital setting. During this time, I experienced frequent exposure to managing substance abuse.
In one shift when receiving a patient who had been found having consumed an excessive amount of alcohol, I made an error in not assessing the risks of the situation. Upon admission, the patient was rousable but not fully conscious.
While performing my assessment, the patient suddenly perked up and began exclaiming how hungry he felt. As I tried to respond to his request for food, he began to raise his voice. I remained in the cubicle and calmly explained that I would be happy to get him something in a minute but that I had one final assessment to do. Upon hearing this, he started progressively raising his voice and moving closer towards me.
My first instinct was to use reason. While in the middle of attempting to plea, one of the senior nurses walked over to my cubicle and told me to make an exit. Security was promptly called and the patient was removed from the department.
Working in the hospital with easy access to assistance lulled me into a false sense of security. In the community, managing aggression or escalation of conflict, can be dangerous as the primary contact for help is the police. Since conflicts don’t occur as frequently as in hospital, it’s hard to consider the possibility until it arises.
After a year and a half of working in a community setting, I experienced my first encounter. One afternoon, after finishing a consultation, I was sat writing in a set of notes when I overheard someone raising their voice at reception. Upon leaving my room, I walked behind the front desk to find out whether the receptionist was safe.
A patient’s partner was leaning over the desk, raising his voice and swearing at my colleague over appointment availability. Her body language indicated that she was afraid so I stayed beside her and politely asked what the matter was. Upon intervening, the partner became more agitated and directed his aggression towards me.
After showing no signs of retreating, I calmly asked him to leave the clinic while the receptionist phoned our manager. At this point, another colleague appeared and asked the partner to remove himself from the premises. He became threatening towards the three of us as the patient pleaded with him to stop.
When the patient finally escorted him out the building, I realised exactly how terrified I was. My legs were shaking uncontrollably and I was on the verge of tears.
It wasn’t until I reflected afterwards that I considered how the situation could have transpired if it were to escalate further. Was I aware of our security implementations in the clinic? Without truly understanding this, I had unintentionally put myself at risk. I considered it a warning and immediately enquired into the protocol.
Over the years, as I have increased my confidence in practice, I have continued to develop my understanding of other aspects in nursing, like the management of conflict and aggression. Fortunately, I have been lucky enough to escape situations relatively unscathed with minor scratches and bruises.
Despite these experiences, I continue to find it difficult to suppress instinct and emotion. The desire to possess the capacity to diffuse a situation and maximise care is often strong. Perhaps this can result in a clouding of judgement and, consequently, an unnecessary exposure to danger.
Another factor to consider in the outcome is that situations have the potential to be unpredictable. When something escalates past the point of civil management and verbal abuse gives way to the possibility of physical, there becomes a stark realisation of vulnerability. This can be avoided if it is possible to pre-empt how a confrontation may progress.
For self-preservation purposes, it becomes important to identify the right moment to step away from a situation and realise that it may not be resolved. As methods to control a situation are not always effective, the ability to comprehend when this point may be is vital to personal safety.
Florence Bull BSc (Hons) is a registered adult nurse. She has a background in neurosciences and emergency medicine. Currently she is working as a nurse practitioner in sexual and reproductive health and is an accredited sonographer in early pregnancy. Her work has been published by the Guardian and she writes her own blog, Subcutaneous. Florence has an interest in global health which was sparked by an elective placement in Tanzania during her studies. She aims to pursue a Master’s degree in this field in upcoming years.