When those we care for don’t care for us: managing challenging behaviour

Catherine Deans and Peter Le Cren

Patients come in all different shapes, sizes and moods. Most are cooperative, polite and grateful for treatment. But there are also those who are rude and abusive. Some are sexually suggestive, demanding or attention-seeking. And there are those individuals who are just outright dangerous.

Unfortunately, these patients can disrupt the provision of health services and cause significant mental, emotional and even physical harm to workers, other patients and visitors.

So what can be done about this challenging behaviour?

The good news is that only rarely will a patient be completely unmanageable.  Most can be coached towards a sunnier disposition and we’re going to give you some tips about how to go about this below.

But first, it’s important to understand the relevant rights and obligations to keep in mind when managing difficult behaviour:

  • All workers (employees, contractors, volunteers etc.) have a right to a safe and healthy work environment. A failure to take reasonable steps to address and lessen harm caused by difficult behaviour from patients may result in a breach of the Health and Safety at Work Act 2015 (HSWA).
  • All patients have rights within the healthcare system (although there is no absolute right to access healthcare in New Zealand). A failure to provide healthcare in circumstances where treatment is clinically indicated may amount to a breach of patient rights.

So the challenge for employers is to keep workers and others safe but also ensure that the needs of patients are met.  This is not always an easy task and in extreme cases it may well seem impossible. But employers do need to take steps to meet the challenge.

Ok, let’s have a look at those tips….

The starting point:

  • First, employers should develop and implement a policy about how to identify and manage difficult behaviour;
  • Second, workers should receive appropriate training on how to put the policy into practice.

The policy should cover, and workers should be trained on, the following:

Identifying difficult behaviour – encourage workers to be vigilant about warning signs pointing towards a challenging patient – e.g. agitation, increasing and/or unreasonable demands, raised voices and swearing etc.

Diagnosing any underlying causes – there may be many different reasons why a patient is behaving badly – a clinical cause such as delirium or poorly managed pain; frustration with a lack of attention; fear and confusion; drug dependency etc. Staff should be encouraged to look past the behaviour to identify underlying drivers.  Think about what can be done to help to calm the patient and restore trust and confidence in the therapeutic relationship.

Management plans – in some cases it may be useful to put in place formal structures around when and how treatment will be provided. A management plan will set out clear expectations and rules about the patient’s behaviour when accepting treatment – including that unsafe behaviour in any form will not be tolerated.  For some patients the plan may identify a single point of contact or a pre-determined treatment path. The plan may also employ other mechanisms, such as the involvement of family or the use of legal tools. Where possible it should be developed in consultation with the patient.

When it might be appropriate to recommend a referral – in some cases the relationship between the patient and health practitioner(s) and/or healthcare provider may have completely broken down, and the patient would be better served by being referred to another provider/practitioner.

Protecting yourself and others – actual or threatened violence should never be tolerated. Workers must be confident to know when to remove themselves and others from dangerous situations and call for help (including hospital security or the police) if they feel threatened. Workers may also experience significant mental or emotional stress, especially when dealing with overly demanding, abusive or bullying patients. Workers should be advised to notify management of high stress levels.

Document everything – we repeat, document everything! This ensures there is a detailed factual record of the patient’s behaviour, which can help to track any deterioration that may point towards an underlying cause for the poor conduct (e.g. mental health issues). It will also protect health professionals and providers if the patient complains, as well as help to justify any decision to withhold or withdraw treatment.

Is it ever appropriate to withdraw or withhold treatment?

In extreme cases, treatment may be withheld or withdrawn from a very challenging patient. It is important that there is a clear process of assessment and escalation.  In some cases, a lack of cooperation may amount to an effective refusal of consent.  In other cases, it may simply no longer be safe to offer services. All other options to manage and defuse the patient’s harmful conduct should be explored before a decision is made to withhold or withdraw; and careful consideration should be given to any obligation to continue caring for a dependent patient.  Withdrawing or withholding treatment from a harmful patient, in the absence of alternative options, is consistent with employers’ obligations under the HSWA.

What is the take home message?

Dealing with challenging individuals is sometimes part of providing treatment, but the harm they can cause to workers and others must not be tolerated.

For additional guidance see the Good Practice Guide from Worksafe on Managing the Risk of Workplace Violence to Healthcare and Community Service Providers.

For further information contact one of the authors – Catherine Deans or Peter Le Cren.

Catherine Deans
DDI: 03 550 0453
Email:  catherine.deans@clarolaw.co.nz

Peter Le Cren
DDI:  09 557 0357
Email:  peter.lecren@clarolaw.co.nz

This article is intended to provide a summary of the subject covered only and is necessarily general and brief. It is not intended as legal advice and nothing in the article should be relied upon without getting specific professional advice.