People who work within healthcare professions assist, support and comfort patients and family members from a wide spectrum of the general public because of this they can be exposed to conflict and aggressive behaviour. The Health and Safety Executive (HSE, 2010) states that workers within the healthcare sector can be up to four times more likely to experience work-related violence and aggression than other workers, and reports that in 2009/2010 there were 56,718 physical assaults reported from NHS organisations in England. In 1999 the Department of Health (DH 1999) launched the NHS zero tolerance zone campaign with the support of the Home Secretary, the aims of the Government campaign were:
1. to get over to the public that violence against staff working in the NHS is unacceptable and the Government (and the NHS) is determined to stamp it out;
2. to get over to all staff that violence and intimidation is unacceptable and is being tackled.
The Department of Health (1999) defines violence and aggression as, ‘any incident where staff are abused, threatened or assaulted in circumstances relating to their work, involving explicit or implicit challenge to their safety, well-being or health’. Violence is not just limited to acts of aggression that actually result in physical harm it can include aggressive behaviour, with the use of gestures and language, that may cause the other person to feel threatened, frightened and abused. Garnham (2001) states that aggression is an act that intends to bring about harm to a person either through pain or loss that can be an active or passive act and further defines aggression into three forms:
1. Physical – kicks, punches, slaps bites.
2. Verbal – insults, threats, rumours.
3. Non-verbal – gestures, hate mail.
However what causes a person to become aggressive depends on the individual and their own state of health, mind and previous experiences, each individual person will also react differently to another. There are numerous indicators and signs of potential aggressive behaviour, many common behaviours can be found in the list below though this list is not a definitive list as each person is different:
1. Facial expressions tense and angry
2. Increased volume of speech
1. Prolonged eye contact
2. Discontentment, withdrawal, irritation
3. Verbal threats or gestures
4. Increased restlessness, body tension, pacing
6. Extreme anxiety
7. Invasion of personal space
8. Blocking escape routes
9. Staring, ’eye balling’
12. Refusal of eye contact
13. Clenched fists
14. Excessive swearing
15. Exaggerated gestures
16. Puffing chest
17. Refusal to speak/ listen
18. Defensive posture
19. Banging furniture
20. Inviting violence
21. Excessive sarcasm
22. Inappropriate laughter
Communication is vital when dealing with service user or family aggression and an awareness of the escalation of aggression is essential for staff, once the signs of potential aggression have been recognised preventative action can be taken which can increase the prospect of a satisfactory outcome and de-escalate the situation. Avoiding the situation because it is uncomfortable, or because the staff member doesn’t feel confident in dealing with the situation, is likely to increase the prospect of escalation of the situation and be detrimental to the final outcome.
As Alzheimer’s Society (2010) state on their website prevention is the best solution for aggressive behaviour. It is hard to foresee how someone will react or respond when confronted with the threat of aggression or violence, but if the staff or target of the aggression reacts to the situation with their own aggressive verbal or non-verbal behaviour this can escalate the person’s violent behaviour and distress them further, Hamolia (2004) maintains that the immediate response to someone escalating towards violence is to try to stabilise their emotional state and restore calm.
In my capacity as a student nurse I would follow the correct procedures to try and de-escalate the situation within my abilities but also notify either my mentor or the nurse in charge of the situation, if a situation cannot be resolved then there are forums within the hospital for service users or family members to make complaints, but if the situation became unsafe for myself, other staff members, patients or members of the public then security or police intervention may be required to remove the instigator.
Leadbetter & Paterson (1995) identified some core interpersonal skills in communicating with a person in an aggressive situation; empathise with the other person’s viewpoint and convey an understanding of their situation, respect the person’s individuality, be genuine and respond to them openly and personally avoiding stereotypes or an overly professional response, be concrete and deal with the other person’s issues and feelings in specific terms avoiding being vague and also maintain your integrity with awareness of your own competence and responsibility and look at the situation from different perspectives.
Reassuring the person that you want to understand, help and are concerned conveys to the person your involvement and can aid in ascertaining where the anger is coming from. By behaving calmly, maintaining a calm tone and communicating clearly increases the chances of them listening and engaging and this calming behaviour can be enough to de-escalate an aggressive situation with positive outcomes for both parties.