Handling Difficult People in the Family Practice Setting

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Handling Difficult People in the Family Practice
Setting

• Anne Grant, LL.B, LL.M (ADR) C. Med
• MEDIATED SOLUTIONS www.mediatedsolutions.ca

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Today well talk about

• Why people engage in difficult behaviours
• How to plan for difficult conversations
• Responding to the angry patient
• Reacting to escalating levels of anger
• How you can make a difference in your Family
  Practice setting

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Difficult People

• People use aggressive behaviour in an attempt to
  take control
• Fear and loss is the motivating factor.
• Loss of control
• Loss of self-esteem
• Risk of substantive losses

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Difficult People

• At best
• Indulge in unpleasant behaviour that is
  unnecessary and unproductive
• Create uncalled emotional distress in others
• Impede productive effort
• Make situations more complicated then they have
  to be

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Difficult People

• At worst
• Use aggressive behaviour to instigate unwelcome
  and unnecessary conflict
• Pose a threat to the health and safety of others

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Defining the Problem IS the Problem

• ? Difficult Person
• ? Difficult Personality
• ? Difficult Behaviour

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Why do People Engage in Difficult Behaviour?

• Feelings of loss of control
• Feelings of vulnerability and/or persecution
• Reaction to criticism they feel is unfair
• Fear of discovery of an action of which they are
  ashamed
• Avoid a topic they cant discuss directly

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Why do People Engage in Difficult Behaviour?

• Unmet needs for recognition and respect
• Resistance to change
• Repressed anger over past injustices
• Feeling that no one likes them therefore they
  reject others before others can reject them
• Psychiatric disorders

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Behaviour Style Inventory

• Circle the numbers beside the phrases that sound
  like you

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What Style Do These Behaviours Suggest?

• I avoid conflicts (arguments, confrontations)
• I value my relationships with my peers
• I usually ask permission
• I do not say when I am angry (I may even smile)
• I say I should, Im sorry, but a lot
• I feel I must be nice
• I seldom talk in a group
• I have trouble accepting compliments

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What Style Do These Behaviours Suggest?

• I often slam doors
• I frown or squint my eyes critically
• I walk fast
• I subscribe to the Donalds style in The
  Apprentice
• I talk fast
• I use forceful language to make my intentions
  clear
• I value logic over the emotional needs of others
• I must let others hear my opinions, as I am
  usually right

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What Style Do These Behaviours Suggest?

• I listen attentively
• I can say no firmly
• I look at other peoples eyes when talking or
  listening
• I make decisions easily to deal with my problems
• I forgive others for their mistakes
• I am responsible for my own actions
• I trust others and myself
• I am usually confident and enthusiastic

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• What is a difficult conversation?

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Ask yourself these questions?

• What is my purpose in having this conversation?
• Do I need to have it now?
• How would I prefer to approach this?
• Are the right people present and engaged?
• Am I emotionally involved?

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Ask yourself these questions?

• Is there another way to achieve my purpose?
• Where should I have this conversation?
• What is the context and/or history between the
  parties?
• What will happen if I dont have this
  conversation?

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Communication is

• 55 verbal intonation and cadence
• 38 non-verbal
• 7 words

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Dimensions Of Non-verbal Communication

• Kinaesthetic
• Gestures, facial expressions, gaze
• Proxemics
• Territoriality and personal space
• Distance
• Paralinguistics
• Intensity, pitch height, extent

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Dimensions Of Non-verbal Communication

• Touch
• Gender, sociocultural factors, type location,
  nature of participants relationship
• Physical and environmental factors
• Formality, warmth, privacy, constraint, distance,
  familiarity, sound, furniture arrangement
  structural design

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Bullying Behaviours

• Openly or indirectly threatening others
• Aggressive
• Preventing others from expressing themselves
• Belittling
• Discrediting

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Bullying Behaviours

• Isolating
• Silent treatment
• Embarrassing, demeaning words or gestures
• Instigating rumours or malicious gossip

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Handling Bullying Behaviours

• Dont suffer in silence
• Tell the person to stop the behaviour
• Dont ignore it
• Advise them that if this continues you will raise
  it with next level - Management/ Human Resources/
  Union
• Be aware of Organizational policies and
  procedures

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Handling an Angry Patient

• 1. Turn the heat down
• Listen patiently
• Model calmness yourself
• 2. Validate the emotion
• Name the emotion
• I can see you're really angry

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Handling an Angry Patient

• 3. Be empathetic not apologetic
• Show you are listening to their concern, but
  dont take the blame for it
• 4. Wait a minute - literally
• If your patient is on an angry roll - let them
  vent for a full minute with no interruptions
• Exception - profane or other offensive language

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Handling an Angry Patient

• 5. Turn the rant into a conversation
• Anger is a secondary emotion
• Ask probing questions
• you seem adamant about the test why is this so
  important to you?
• 6. Disarm the patient
• It's hard to stay angry with someone who accepts
  your anger
• Use statements like I see your point, I
  understand

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Handling an Angry Patient

• 7.Stay curious
• Tell me more about whats upsetting you
• How has this condition affected you?
• 8. Summarize the Complaint
• Opportunity to show the patient you really are
  listening and for patient to correct any
  misperceptions

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Handling an Angry Patient

• 9. Stand your ground
• Accepting blame needlessly or giving in to
  bullying can actually erode a patients trust and
  respect
• It wasnt my intent to make you feel
  unsupported, - now how can we move forward?

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Handling an Angry Patient

• 10. Dont fight back
• Remaining calm and comforting in the face of an
  angry patient is a clinical skill and can be a
  defining moment in the relationship

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When Anger Escalates

• Documentation - Be especially diligent in your
  record keeping when dealing with unusually angry
  patients
• Transfer care - If the patient no longer respects
  your opinion and the relationship seems to be
  damaged beyond repair its prudent to pass it
  over to another HCP

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When Anger Escalates

• Safety Measures - If you feel the encounter is
  becoming dangerous, take precautions to ensure
  your safety
• Maintain physical distance
• Dont turn your back
• Plan a safe exit

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RESPONDING TO ESCALATING LEVELS OF ANGER

• LEVEL I Inappropriate Behaviour
• LEVEL II Escalating Disruption
• LEVEL III Physical Agitation
• LEVEL IV Threat of Violence
• http//www.workplaceviolence911.com

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LEVELS OF ANGER

• LEVEL I
• Individual upset, behaviour different than normal
  baseline
• Sensitive to criticism
• Irritable, frustration
• Facial effect frowns, staring, grimacing, signs
• RESPONSE
• Intervene as appropriate

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LEVELS OF ANGER

• LEVEL II
• Behavioural symptoms/escalating and discernable
• Angry remarks, criticism of others, company, etc
• More emotional, less rational
• Tight, fast, jerky body movements
• RESPONSE
• Active intervention
• May document and report up chain of command

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LEVELS OF ANGER

• LEVEL III
• Escalating physical, emotional and psychological
  arousal.
• Combative, aggressive
• Physical agitation - pacing the floor
• Extensive self-talk - profane and vulgar language
• RESPONSE
• Actively address
• Involve others - Organizational Process, call
  security
• Report up Chain of Command - continued
  documentation

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LEVELS OF ANGER

• LEVEL IV
• Assaultive behaviour - destruction of property
• Threats that are specific and means available
• Not rational, high level of physical, emotional
  and psychological agitation
• RESPONSE
• Emergency action
• Safety first
• Critical incident reporting

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LEVELS OF ANGER

• LEVEL IV
• Assaultive behaviour - destruction of property
• Threats that are specific and means available
• Not rational, high level of physical, emotional
  and psychological agitation
• RESPONSE
• Emergency action
• Safety first
• Critical incident reporting

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Be Aware Of Escalating Behaviours

• Irritating
• Annoying
• Disruptive
• Intimidating
• Bullying
• Verbal Aggression
• Physical Aggression
• Violence

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STRATEGIES, ATTITUDES TECHNIQUES

• Strive for integrity and be consistent
• Make your intentions clear
• Aggressive people hate surprises, they perceive
  them as threats.
• Get ground rules right from the beginning.
• Rigorously respect personal boundaries and
  differences (including your own)
• Give them options, but within the boundaries of
  the ground rules.

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STRATEGIES, ATTITUDES TECHNIQUES

• Monitor for Red Flags
• Take responsibility for your false expectations
• Consult share experiences with your colleagues
• Report situations that are out of the ordinary
• Be consistently respectful, courteous and
  acknowledging

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Plan your conversation

• Is this about
• A recent or past event?
• Different interpretation of the facts?
• Peoples feelings?
• Individuals roles?

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When planning for a difficult conversation
consider

• Personal style
• Purpose
• Parties
• Timing
• Emotions

• Approach
• Alternatives
• History
• Venue
• Follow up

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Make sure those involved have an opportunity to

• Air their differences
• Clarify issues and interests
• Brainstorm options

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Reflective Practice

• Learn from your own and the experiences of others

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How can You Make a Difference in your Family
Practice Setting?

• Identify situations early and encourage
  resolution at the lowest level
• Encourage colleagues to air their differences
  privately, appropriately, in a timely manner
• Coach colleagues to resolve their own conflict
• Ensure co-workers understand workplace
  expectations
• Harassment and bullying
• Codes of behaviour

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How can You Make a Difference in your Family
Practice Setting?

• Seek assistance as necessary
• Model desired behaviour
• Monitor situations and track trends
• Debrief difficult situations as a group and share
  experiences and techniques
• Advocate for clear processes

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Remember

• Remaining calm and comforting in the face of an
  angry patient is a clinical skill
• Dr. Wendy Levinson, Chair
• Department of Medicine
• University of Toronto

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• Unlike fine wine, disputes do not improve with
  age.
• Mr. Justice Willard Estey

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Anne Grant LLB LL.M, C. Medauthor ofA Nurses
Practical Guide to the Law, Dispute Resolution
in the Insurance Industry

• MEDIATED SOLUTIONS
• [phone] ext. 223
• 1-866-800-0020
• anne.grant_at_mediatedsolutions.ca