Strong emotions, including anger and frustration, are common in the clinical setting. Fear, feeling sick, loss of control, frustrating gaps in the health care system, and disrupted schedules & sleep can all contribute to a short fuse. Sometimes strong emotions can disrupt care and pose a threat to both the patient and to the provider.
It is important to pay attention to warning signs that something is wrong. There are many signs that patients may be angry: clenched fists, furrowed brow, hand wringing, pacing, raised voice, restricted breathing patterns, etc. Once these signs are recognized it is important to avoid being drawn into conflict. In these moments it is imperative that we take a pause and recognize our triggers and be careful not to respond with anger. Instead make sure to keep yourself safe, identify your boundaries and try to uncover the source of difficulty for the patient. De-escalation techniques are important such as using “I” statements to acknowledge their anger and working toward ways to resolve the situation. “I can understand why you are upset. Can we talk about ways to fix the situation?” Also remember that a sincere apology can go a long way to rectifying a relationship.
Using techniques to empathize with the patient may help to create a more constructive connection between you and the patient. Think back to the boiling pot analogy discussed in the chapter Delivering Serious News, the displayed behavior may be anger however the deeper emotion may be something else (fear, loss of control, etc.). Exploring and acknowledging the deeper emotion may help you and the patient align and work together to address the issue.
We must also look at the factors that we bring to the encounter. Time pressures, stress, sleep deprivation, burnout and many other issues may weigh heavy on us. Recognizing the personal baggage we bring into the room is important. Finding time for ourselves and loved ones and developing personal practices which may address these stressors are important to help foster a healthy environment for patients and ourselves. When these issues are impacting the encounter in the moment, take a pause and practice a brief moment of mindfulness before engaging with your patient. Consider HALTing and assessing your needs in the moment. Am I Hungry, Angry, Lonely, Tired? Can any of these issues be addressed right now or soon? Remember to STOP before continuing with the patient encounter.
Stop. Pause, just for a moment.
Take a breath. Center yourself and regroup.
Observe. What is happening? How might you respond more constructively?
Proceed
When strong emotion enters a clinical encounter, these strategies can help to de-escalate the situation and keep everyone safe.
Strategies to help with de-escalation
- Listen closely and actively. Reflect what you heard, request and accept corrections. Did I get that right?
- Identify and validate wants and feelings and try to accommodate reasonable requests
- Apologize if possible
- Be mindful of personal space – maintain two arms length between you and your patient and a clear path to the door for both of you.
- Be concise. Cognitive function is impaired when people are upset or angry – the prefrontal cortex shuts down and the ‘fight or flight’ amygdala takes over.
- Stay calm, in control, and measured. Our natural reaction is to reflect the emotion expressed to us – AVOID returning anger for anger.
- Offer choices and optimism
- Set limits but don’t order specific behavior
- Find common ground – agree or agree to disagree, while avoiding negative statements. This validates what the patient is saying and puts you on the same side.
- Debrief with your team or a colleague afterwards