Origins of interpersonal difficulties with patients

Staff members described separate categories for conflicts, either stemming from a misunderstanding of the organisation of EDs, emanating from the behaviour of patients labelled as deviant, or explained by societal changes deemed regrettable (incivility).

Patients’ lack of understanding of how EDs function

Some types of relationship-building practices on the part of medical staff are not feasible because of the intensity of their work. However, these practices involve transmitting information that concerns not only the patient but also the environment in which the patient is located. Staff members are put in a difficult position: they try to inform patients and field their questions, but they may not have all the answers.

Sometimes it’s also difficult because they want their turn to come right away, it’s complicated to handle, we try our best to explain how the department works, the specific functioning of the emergency department, but it’s not always easy. (Female administrative officer)

These explanations help to alleviate potential tensions, based on the idea that a patient informed about the way an ED is run is a patient who will be better able to accept this functioning, along with the constraints and waiting time that go with it. When this explanation is not provided, the patient’s behaviour may become violent.

It’s more often people who get upset because they're tired of waiting or because ‘I don't want to go back to Building X again’, where you can bring in patients for particular types of hand injuries. We emergency doctors don’t actually do much; it’s the surgeons, except in an emergency department you have to wait for the surgeon to be available, to finish an operation, to come and see you; people will sometimes wait four, five, six hour for someone to tell them, ‘Well, there’s no room today so you can come back tomorrow, we’ll admit you tomorrow’. And things heat up and they get angry. (Male doctor)

Even when an effort is made to inform patients, this still does not mean that they have a full understanding of how the department functions. Staff do not have the time to properly manage these misunderstandings, which can be the sources of many conflicts and acts of violence.

Deviant behaviour

Deviant behaviour from people with identifiable social and/or medical characteristics (alcoholism, psychiatric illness, drug use) is less complicated to deal with because communication is already impaired due to the condition of the patient.35 36 These types of patients do not try to make staff members enter into a relationship with them, they may even actively avoid such contact. Several protection strategies are available: limited contact, the presence of other trained professionals for this type of patient (psychiatric nurses) or restraint if the patient is agitated.

Often, when that happens, it is either because of purely psychiatric pathologies or what are called psychopaths in the medical field, that is, people who are not labelled with psychiatric conditions but who are very unstable in terms of their emotions and personalities, and with them it takes practically nothing for the situation to turn explosive (…). (Male doctor)

It might be expected that handling such patients would be especially difficult. However, situations like these often elicit a collective reaction that contrasts with the usual work of informing patients, in which cases the staff member is often alone in managing the situation. In the following account, we may note the presence of a hospital porter, security guards and a nurse.

A patient showed up in the emergency department, visibly drunk. I started hearing some aggravated tones at the reception desk. I was already nearby so I headed over there. He was in an argument with a porter at the time, insulting him. So he started to get angry, the porter started to get angry, but hey, he hadn’t started it. The guards were already there, he had already insulted everyone in the reception area, and suddenly I arrived, I started talking to him, he started to say to me, ‘Shut up, don’t talk to me, who are you anyway? I'm going to bust your legs.’ So I told him that he was going to have to listen to me and then I reminded him that in order for us to take care of him, he’d have to calm down, that he couldn’t talk like that to the caregivers. (…) He started [verbally] attacking me and saying, ‘If that’s how it is I'm getting out of here, I'm going to leave anyway.’ He insulted the security guards twice more and eventually calmed down. I told him that if the care we were trying to provide did not suit him, if he didn’t like it, he could actually leave, and he left, he went out, I didn’t hold him back. (Male nurse)

These deviant behaviours are not the most disturbing to deal with because staff are rarely isolated in these situations. They have resources available to help manage them. The responsibility in such situations shifts from individual to collective. In addition, communicating with an alcoholic patient or one under the influence of drugs is no simple matter, the staff member cannot be held responsible for deteriorating the relationships in such a case.

Incivility, individualism, selfishness

According to staff members, some behaviours that are considered as problematic might reflect an unfortunate change in the attitudes of individuals in social contexts, namely a lack of civic values and of courtesy. This is why the most frequent theme brought up by the health professionals during the interviews was incivility.

(…) Then again, I don't know, I don't have a problem with people - the only issue that comes up is rudeness. (…) Sometimes there are people whom I find poorly behaved, perhaps (…). (Female nurse)

According to the staff members, these incivilities can be explained by a wider trend—which they attribute to the modern society—of increasingly individualistic or selfish behaviour. They did not associate these acts with the suffering or anxiety of the patients or of those accompanying them. The staff considered that patients and/or their friends and family were at fault, lacking the basic manners needed for interacting with others, which explains why some suggested that a nationwide educational campaign should be carried out:

Or maybe it’s a problem with people’s upbringing from an early age, we need to re-educate the French population rather than adapt to the French population. Perhaps we should get them to understand that, actually, — no, that’s a whole other debate but, well… (Female nurse)

Rudeness was also perceived in solicitations that were deemed inappropriate or repetitive. While not violent in the strict sense of the word, these solicitations have an impact on the work of hospital staff.

Because, well, these are not necessarily conflict situations but for example when patients keep showing up at the reception desk every five min to pester us, to say, ‘Yes, I would like to get some news about so-and-so, what’s going on, why isn't anything happening?’ It’s not really aggressiveness or anything, it’s more disruptive, but in these cases it’s simply a question of manners, you know? (Female administrative officer)

This type of judgement against patients was the most pronounced among those professionals who are the furthest removed from the work of providing medical care for patients in the ED, such as administrative officers, who can only build relationships with them based on administrative issues, and also among doctors.

Strategies for handling interpersonal difficulties and violence

The staff members expressed that they have a harder time knowing how to deal with cases of aggressive, individualised relationships involving minor violent behaviours (rudeness, verbal violence, insults and others) compared with violent physical conflicts (beatings, death threats, armed violence and others). Thus, they develop and adopt strategies that they present as personal, even if they may be similar from one professional to another, namely avoidance, a style of communication aimed at gaining a reciprocal understanding of the situation or confrontation.

Avoidance and escape strategies

These are ways for hospital employees to escape from a situation that is getting out of hand, when they feel that a patient is exerting a form of domination through violent behaviours or threats.

And sometimes, I have to admit, we escape precisely because we don’t have the right techniques, I think. (Female nursing assistant)

Another nursing assistant cited avoidance as a way to keep from coming into overly direct contact with patients.

Sometimes we dodge a certain corridor so we won't have to come across the same people again, and have to listen to: ‘Are things moving forward? What’s going on?’ ‘Well, I already explained it to you, sir.’ ‘I’d like to see the doctor’, and sometimes it drains you (…) And that’s the main area where there can be conflicts. (Male nursing assistant)

Staff members admitted to experiencing such situations during the interviews but using this strategy was considered as akin to a failure in their relationship with the patient or with the person(s) accompanying the patient, even if doing so protects the hospital agent.

Communication strategies

This strategy brings together behaviours aimed at communicating effectively with patients and/or those accompanying them, that is, bringing about a reciprocal understanding of the situation. It involves an appeal to reason, along with rational explanations, seduction and empathy.

How do I go about it? Well, I let them talk. When they’re done saying whatever is on their minds, I try to give them answers by telling them how things work here, why they’re waiting, what’s going on. And if they don't understand, well, what can I say? I keep letting them talk and then at some point they stop and then sometimes they leave by slamming the door. So I try to let them speak so that they can let it all out, and then after a while they calm down, once they’ve got it off their chests. (Female nurse)

In the above example, it sounds as if providing an explanation leads the patient to a fuller understanding (and therefore a better acceptance) of his/her situation, provided, however, that the situation itself also enters into rational logic. However, this is not always the case, as confirmed by this nurse.

Well, sometimes they go along with it, sometimes they don't. Sometimes they scream even more loudly. In the end it’s… (sigh). We try to explain but at some point it doesn't work all the time. (Female nurse)

Medical professionals also use seduction techniques to keep the interaction pleasant and to avoid clashes. The goal is to involve the patient in the cause of the caregiver.

So I always try smiling, charming them first of all. Well, if it doesn't work, I can toughen up, but often it works very, very well. See, when you start to smile, the other person actually smiles as well… (Female nurse)

In general, smiling and trying to keep the interaction congenial can help these employees place the relationship under good auspices. This voluntary attitude does not merely reflect a sensitive intention. It also has a very pragmatic aim: to foster a peaceful and easy relationship.

I do a lot of moderating all the time, and I do it with a smile. And it’s true that it calms things down, when someone shows up – I often deal with aggressive people, and, well, when I – with a smile: ‘I'll look after you, sir, explain the problem to me, let’s calm down’, and it’s true that it cools things down right away, when we take the tension out of the situation, actually. (Female administrative staff)

Finally, some medical professionals choose to develop an empathetic relationship.

So a lot, a lot of empathy. It does tend to bring them back from the edge when they feel that we’re really putting ourselves in their shoes and that we understand what they are going through. So I think listening, empathy, is paramount in a situation of conflict… (Male nurse)

Other staff members made statements that were full of empathy, though less explicitly so, about the situations faced by patients, particularly about the issue of long wait times. For example, a nurse referred to her own experience involving queues at a large supermarket to explain how she was able to understand what a patient was going through.

Confrontation strategies

Another strategy involves the confrontation and the use of forms of aggression by the staff member, in response to the aggressiveness he or she perceives from patients or their accompanying family members. The staff member then uses personal resources that tend to establish the contentious nature of the interaction all the more firmly, therefore setting up a vertical relationship, or even one of domination, with the patient.

So I'm not that good at it! (laughs) I get carried away pretty quickly. (…) Honestly, I can’t just let it go when I am verbally assaulted. I have a hard time keeping my cool. I tend to raise my voice, I remain polite, but I do raise my voice. (Female nurse)

‘Raising one’s voice’ can be a double-edged sword. It may make the situation worse or it may effectively put an end to the aggression. Staff members who use this strategy do so individually but also collectively, especially during heated arguments. Finally, this strategy can also be concretised by calling for security guards, who represent the use of physical force, even if they do not implement it very often.

Since we, I mean the two people at the reception desk, are on the front line, and since the doctors are often behind us back there in the office, they hear what’s going on, there is always someone who overhears, someone who warns the security department and then they come, they intervene. (Female administrative staff)