This article, the last in our six-part series on communication skills, discusses how to respond to and de-escalate difficult situations
The final article in our six-part series on communication skills looks at how to approach people who are aggressive, angry, abusive, hostile or confrontational. It discusses various communications techniques and approaches that can help when managing challenging situations.
Citation: Ali M (2018) Communication skills 6: difficult and challenging conversations. Nursing Times; 114: 4, 51-53.
Author: Moi Ali is a communications consultant; a board member of the Scottish Ambulance Service and of the Professional Standards Authority for Health and Care; and former vice-president of the Nursing and Midwifery Council.
No nurse should be subjected to violence, assault or obscenities. Regrettably, however, verbal abuse and threatening behaviour sometimes go with the terrain, particularly for nurses working in mental health, general practice and accident and emergency departments. In healthcare, dealing with people who are aggressive, angry, abusive, hostile or confrontational can be a daily occurrence – and it often goes unreported (Harwood, 2017; Sato et al, 2013; Rahim and Shah, 2010).
Why difficult situations arise
Difficult situations may have a number of precipitating causes and the more factors at play, the greater the challenge will be. Your own circumstances (for example, whether you are tired or stressed) will also play a part. If you are tired, your patient is angry and in pain, and there are staff shortages on your shift, the encounter will be more difficult than if just one of those factors were present. Nurses are taught to be non-judgmental. Labelling a patient as unpleasant can be unhelpful: rather, think of the interaction as difficult.
Many healthcare encounters are emotionally charged, involving fear and worry, pain and distress – for friends and relatives, as well as patients; this can create a volatile situation. Communication techniques can help de-escalate aggression and can even prevent it from arising in the first place (Webb, 2011).
Good communication can help prevent challenging situations from developing. Accident and emergency departments are environments where circumstances conspire to create difficult conditions – long waiting times; people under the influence of alcohol or drugs; individuals in pain and distress – that can combine to create a ‘perfect storm’. However, research has shown that good communication can have a beneficial impact in these challenging environments (Neades, 2013).
After patients are triaged, updates on likely waiting times can offer reassurance. For example, “I’m so sorry you have had to wait so long, Mr Jones. Friday is a busy night in here and your wait is likely to be another two hours, although I will keep you updated as it could change depending on who else is brought in. You have been assessed and I’d like to reassure you that…” Keeping information channels open and friendly may stop problems escalating.
On wards, try to ‘connect’ with patients you find challenging by identifying common ground. Get to know them by asking a few questions about their family, work or interests; learn about their views and preferences; and acknowledge them as an individual (National Institute for Health and Care Excellence, 2012). By chatting, you may uncover an underlying concern, while a friendly and reassuring conversation may prevent an angry person from becoming an aggressive one.
Use observing and listening skills (Ali, 2018) to identify, at an early stage, situations that may escalate. Warning signs of irritated or agitated behaviour could include:
- Raised voices;
- Uncharacteristic silence;
- Sarcastic remarks;
- Negative body language: staring, invading personal space; posture such as clenched fists, a jutting chin or puffed out chest; threatening gestures such as finger pointing or foot stamping; pacing back and forth;
- Aggressive behaviour: kicking furniture or hitting themselves.
If patients are already known to you – inpatients on a psychiatric ward, for example – learn which triggers can result in violence and aggression for individuals, then work to avoid these.
For more information on defusing difficult situations in mental health, see the NICE (2015) guideline, Violence and Aggression: Short-term Management in Mental Health, Health and Community Settings.
Sometimes simple environmental factors can help avert aggression. Entertaining distractions such as music, a television or radio, books and magazines, crosswords and puzzles can relieve tension in places such as waiting rooms. Comfortable seating, and enough seats, so that no one has to stand, also helps keep people calm.
A water fountain, coffee machine or vending machine for drinks and snacks during long waits will at least remove hunger and thirst as sources of complaint. Calming colour schemes and non-institutional décor also help.
How to de-escalate
It is a normal human reaction to take hostility personally, so it is important to remember that it may not be directed at you personally. Patients and relatives can be facing stresses and pressures that may not bring out the best in them. Try to identify any underlying cause creating the challenging situation. Put yourself in their shoes, show care, compassion and empathy, and you may be able to win people round or gain their cooperation. It can be difficult to react warmly to people who are aggressive when you try to help them, but staying in control of your own emotions – and body language – is vital.
If you encounter difficult situations routinely, ensure your employer provides training in techniques to help avert and manage likely scenarios – including dealing with aggression and violence. The advice offered here relates to communication, but dealing with violence may involve using restraint, which is beyond the remit of this article. When in a threatening situation, consider your own safety, that of colleagues and other patients and relatives, and also the aggressor. Assess the risks and deal with the situation yourself only if it is safe to do so. Follow workplace protocols and keep risks under review in a dynamic situation.
Difficult encounters can be de-escalated by employing communications strategies, yet good communication is often one of the first things to be abandoned in a challenging situation. We tend to stop listening to people we find challenging; our interruption rate increases; our body language can become closed and even hostile; we may be defensive; or become argumentative or difficult ourselves. The result is that the patient becomes even more hostile and a downward spiral begins. Direct confrontation is likely to make an already difficult situation much worse, while good communication skills can defuse the situation.
When you see things going wrong, try to stabilise the situation by taking control and helping the angry or upset person to regain their composure. Someone who is backed into a corner will lash out, so offer choices and a way out if possible. Give the person time to think. You may feel angry or personally affronted, but do not be provocative: it will only make the situation worse.
Do not speak while someone is shouting: it is futile and may exacerbate matters. Remain calm, listen attentively and show that you are listening. Wait until the person stops and never shout back in response. It is easy to shout at someone who is yelling at you but it is much harder to continue bellowing at someone who is calm and respectful. Eventually the patient or relative will run out of steam, allowing you an opportunity to intervene positively.
Acknowledge when a patient/relative is angry or upset: “I can see that you’re really unhappy about this.” Using open questions, ask them to explain why they feel upset: “Could you tell me what’s caused you to feel this way, please?” Listen actively and respectfully to the response, without interruption and without being defensive – even if they make sarcastic, untrue or unhelpful remarks. Failure to challenge them at this point does not mean that you accept or agree with what they say.
Try articulating any disagreement: “We seem to have rather different ideas as to the next steps.” This can be a useful technique to bring the area of disagreement into the open without assigning blame or criticism. A neutral statement of fact can help you both to focus on how to move towards a solution or mutually acceptable outcome. It also offers an opportunity for a patient to correct you if you have misunderstood. Consider asking what can be done to resolve the situation (Lowry, 2016), or offering options: “Would you like me to get a manager for you to speak to about your concerns?”. “Would it help if I got you a cup of tea?”.
Show positive, open body language such as appropriate smiling, nodding and eye contact. Take care to get the eye contact right: too prolonged could be interpreted as aggressive staring. It is also important to respect personal space: standing too close could be seen as a threatening act, and it may also be safer for you to maintain a physical distance.
Consider using the person’s name, if you know it. This can sometimes help to defuse a situation. However, use your judgement according to the circumstances: what to some may be seen as a friendly gesture, could appear insincere or patronising to others. You may make matters worse if you address women as Ms or Mrs without checking their preference; if you use full first names such as Ronald instead of preferred diminutives such as Ron; or if you address people by their first name when they expect a more formal Ms, Mr or Mrs.
Keep calm, remain composed, and do not take anger or insults personally. Unless you or others are in physical danger, avoid threatening to call security or the police, or to have the aggressor removed from the premises. At the very least, this should help to prevent the situation from degenerating. You might even turn it around and create a positive encounter (Box 1).
Box 1. Managing difficult situations
Janet Smith storms in, extremely angry, and goes to the nursing station demanding to know “What the hell have you done to my mother?” Her elderly mother, Gladys Parker, who is sleeping, has a large wound on her head following a slip on the ward. The nurse on duty, Kate Jones, is immediately defensive, which shows in her attitude – both body language and tone of voice. She is tired and wants to go home after a long, stressful shift and has been taking good care of Mrs Parker following her fall. She feels that Mrs Smith is extremely rude and the two women clash. Mrs Smith makes a complaint about her mother’s fall and about the nurse’s attitude.
Although Kate Jones is tired, she puts herself in Mrs Smith’s position, understands her reaction, and does not take the anger personally. She remains calm, polite, respectful and professional; she invites Mrs Smith to sit down, acknowledges her understandable distress, and explains that she had telephoned several times to inform her of her mother’s fall but received no answer. She explains the circumstances that led to Mrs Parker’s fall and the treatment provided, then reassures Mrs Smith that her mother has been seen by the doctor and that there are no complications other than the cut to her head. Nurse Jones brings Mrs Smith a cup of tea and asks if she’d like to speak with the doctor; Mrs Smith leaves the ward regretting her initial hostile behaviour.
Consider whether you are the best person to deal with a particularly difficult situation (especially if you are newly qualified and inexperienced in managing challenging encounters). Never be afraid to ask for help when you need it. The more situations you deal with, and the more time you spend reflecting and learning from your own performance and that of colleagues, the more confident you will become in dealing with challenging situations (Boxes 2 and 3).
Box 2. Reflection
After observing or dealing with a challenging scenario, take time to reflect:
- Did the difficult situation appear to come from nowhere?
- Were there any warning signs?
- What have you learned?
- What could have been better?
- What might be done differently in the future?
- How did you feel?
- Was it a good outcome in the circumstances?
Observe difficult situations at work and outside the workplace and try to learn what helps turn a challenging encounter around – as well as what exacerbates an already bad situation. We can all learn from the mistakes of others
Box 3. Tips on managing difficult situations
- Recognise that it is human to have feelings and emotions
- Do not lose your temper; raise your voice; get angry, sarcastic or provocative; or attempt to humiliate the aggressor
- Take a deep breath, relax, and remain calm, neutral and respectful
- Do not react and start disagreeing: pause and think before acting
- Say “No” to unreasonable demands, but be prepared to manage any adverse reaction
- Do not tell the person that you know how they feel but do try to see the situation from their perspective
- Show warmth and empathy
- Do not let a bad experience with one person affect your whole day/shift or your family life – keep a sense of perspective and a professional attitude
- Hostile and aggressive behaviour may have a number of precipitating causes
- Many healthcare encounters are emotionally charged, involving fear and worry, pain and distress
- Observing and listening skills can identify, at an early stage, situations that may escalate
- Simple environmental factors can help avert aggression
- Nurses should never be afraid to ask for help when dealing with difficult situations
Also in this series
- Communication skills 1: benefits of effective communication for patients
- Communication skills 2: overcoming the barriers to effective communication
- Communication skills 3: non-verbal communication
- Communication 4: the influence of appearance and environment
- Communication 5: effective listening and observation skills
Ali M (2018) Communication 5: effective listening and observation skills. Nursing Times; 104: 4, 60-61
Harwood RH (2017) How to deal with violent and aggressive patients in acute medical settings. Journal of the Royal College of Physicians of Edinburgh; 47: 176-182.
Lowry M et al (2016) De-escalating anger: a new model for practice. Nursing Times; 112: 4, 4-7.
Neades B (2013) Aggression. In: Dolan B et al (eds) Accident and Emergency Theory into Practice. London: Bailliere Tindall.
National Institute for Health and Care Excellence (2015) Violence and Aggression: Short-Term Management in Mental Health, Health and Community Settings.
National Institute for Health and Care Excellence (2012) Patient Experience in Adult NHS Services: Improving the Experience of Care for People using Adult NHS Services.
Rahim H, Shah B (2010) Pharmacy students’ perceptions and emotional responses to aggressive incidents in pharmacy practice. American Journal of Pharmaceutical Education; 74: 4, 61
Sato K et al (2013) Factors associated with nurses’ reporting of patients’ aggressive behavior: A cross-sectional survey. International Journal of Nursing Studies; 50: 10, 1368-1376.
Webb L (2011) Facing challenges in healthcare communication. In: Webb L (ed) Nursing: Communications Skills in Practice. Oxford: Oxford University Press.