Coping with disruptive patients: Perspectives of primary care employees

1 Introduction

Patient aggression toward healthcare workers is a prevalent, widespread problem that has negative implications for employees and health systems [1–3]. Covering a spectrum of disruptive behaviors ranging from verbal violence (i.e., hostility, verbal threats, harassment) to physical assault, patient aggression can impact the mental and physical health of healthcare workers, leading to physical injury, anxiety, fear, helplessness, anger, depression, and symptoms of post-traumatic stress disorder (PTSD) [4–6]. At the organizational level, it has been tied to lower quality of healthcare delivery and increased employee burnout, higher absenteeism, reduced job commitment, job dissatisfaction, and staff turnover [3] which in turn have been linked to adverse patient outcomes such as lower patient satisfaction and compromised continuity of care [7, 8]. In addition, patient aggression has financial implications. One study estimated that replacing a nurse due to injuries and stress can cost between $27,000 to $103,000 when accounting for separation, recruiting, hiring, orientation, and training [9].

In many countries including the United States, verbal violence is more common than physical assault, with one meta-analysis revealing that 42.5% of all healthcare workers had experienced non-physical violence such as verbal abuse, threats, and sexual harassment in the past year, while 24.4% had endured physical violence [7]. In the United States, healthcare workers report more than four times the rate of serious workplace violence incidents than employees in manufacturing, retail, and construction [9]. Moreover, rates are likely higher due to significant underreporting, even at facilities with formal reporting systems in place [9, 10]. Not reporting incidents may stem from lack of policy, perceptions that organizations will fail to respond, and fears of retaliation. Underreporting is particularly prevalent in situations involving bullying and other forms of verbal aggression [9].

Previous work on patient-perpetrated aggression in healthcare settings has largely focused on quantifying its type, prevalence, and causes in hospitals and psychiatric departments [1, 3]. Few qualitative studies have explored this issue in outpatient primary care clinics which is important to address given high rates of primary care burnout, especially during the current pandemic [11]. Primary care clinician burnout, particularly among primary care providers (PCPs), has been widely examined. Underexplored are the perspectives of non-clinician employees. We fill this gap in the literature by exploring experiences of patient aggression among providers and staff in women’s health primary care at the Veterans Health Administration (VA), the United States’ largest national integrated healthcare system. Recent work reveals that women’s health PCPs (WH-PCPs) experience more burnout and intent to leave when compared to general PCPs at the VA [12], which could compromise access and continuity of care for women veterans. WH-PCPs experience a 20% annual turnover rate [13], akin to turnover in the private healthcare sector, but significantly higher than the VA’s overall 9% turnover rate for its entire workforce [14]. This suggests a need for understanding WH-PCP work preferences and decision-making to support retention and to help enhance workforce stability. Retention of women’s health employees on patient aligned care teams (PACTs), VA’s patient-centered medical home model [15, 16], is critical given the need for a highly specialized workforce who can skillfully address the complex health needs of women veterans [17, 18]. Notably, researchers have concluded that turnover could be amenable to clinic- and system-level improvements [12].

By focusing on patient aggression in women’s health primary care, we move the literature beyond broad questions of prevalence and causality to focus on how healthcare employees experience and cope with this ubiquitous issue. We draw attention to how patient aggression impacts employees across a range of roles (from clinicians to clerical/administrative workers) with established tenure in their positions, and the coping strategies that they have devised throughout their careers. While recognizing how coping can help protect employees during times of stress, we ultimately question why coping becomes necessary in instances of workplace aggression, arguing instead for organizational solutions that tackle aggressive behavior itself, such as organizational prevention interventions. Given pervasive burnout and high staff turnover throughout the healthcare industry and its link to patient aggression [3], our findings have implications for employee retention and well-being.

2 Methods

3 Results

4 Discussion

Primary care employees described patient aggression as a challenging, stressful aspect of their jobs further exacerbated by the demands of providing care during the COVID-19 pandemic. To cope, respondents across roles utilized a variety of strategies before, during, and after stressful incidents. To attenuate or prevent potential negative interactions with patients, respondents described huddling with team members to plan for upcoming visits, building relationships with patients, and engaging in self-care practices. During stressful encounters, employees elicited help from knowledgeable colleagues or actively collaborated with patients to find solutions. After an incident, coping strategies included debriefing with colleagues or reflecting on root causes of patient aggression to “let go” of stress. We did not detect differences in coping behaviors between clinicians and non-clinicians.

How individuals cope with events perceived as stressful is a complex process tied to environmental factors (e.g., demands on time, organizational resources) and personality dispositions [27]. Researchers have identified a variety of coping strategies, ranging from problem solving to situation avoidance and social isolation [28]. Drawing on the Job Demands-Resources model [21], managing patient behavior can be understood as a healthcare job demand that requires psychological effort and has associated costs. Demands create stress when they exceed an employee’s adaptative capability and outstrip available job resources. When resources are limited, employees will job craft [21], in this case through coping, to improve fit with their environment [cf. 29].

Many respondents in this study engaged in problem solving approaches, such as strategically drawing on colleagues’ expertise to deescalate negative patient interactions. Other strategies included information-seeking (e.g., observing how colleagues deal with aggressive patients), support-seeking (e.g., getting emotional support from family members or colleagues), and comfort-seeking (e.g., venting with colleagues). Others engaged in cognitive restructuring, e.g., by attempting to change their stress response by attributing the root cause of a patient’s aggressive behavior to a patient’s trauma history. As Nau et al. [30] observe, external attribution can serve to exonerate individuals of personal culpability, in this case employees, thereby reducing employee stress. A form of “deep acting,” as discussed in the emotional labor literature, cognitive restructuring entails consciously modifying one’s feelings to express desired emotion in line with organizational goals, such as maintaining a compassionate demeanor during patient interactions [31]. Although frequently studied, findings related to the impact of deep acting on employee well-being have been inconsistent [32].

Stressors perceived as controllable often trigger problem solving coping strategies, while stressors deemed impossible to change trigger cognitive restructuring or other forms of accommodation [29]. Ameliorating the impact of patient aggression on healthcare employees requires organizations to facilitate conditions required for strong cohesive teams, supportive leadership, and training but also devising and acting on institutional policies that hold patients (and other employees) accountable for aggressive, disruptive behavior. At VA, workplace violence prevention has long been a focus with its development of the Prevention and Management of Disruptive Behavior Program in the 1970 s, which was subsequently updated in 2000 [33]. Most recently in 2015, VA implemented the Disruptive Behavior Reporting System enabling providers across all facilities to track and report patient-generated disruptive incidents that pose safety concerns. However, unlike other healthcare systems that often refuse care to threatening and violent patients, veterans by law are entitled to health benefits and cannot be denied care [34]. Purcell et al. [35] observe that this entitlement that veterans earn through their military service, combined with VA’s prioritization of patient needs, has created an organizational “culture of tolerance” when it comes to low-level patient aggression. This aligns with our finding that employees perceive a lack of organizational support in addressing verbal aggression. It may also explain why some employees utilize cognitive restructuring as a coping technique as opposed to problem solving, which requires a sense of control over organizational factors.

Our findings suggest that employees deploy coping strategies at different points in time throughout the course of an aggressive event. Coping research predominantly focuses on how people manage present or past events, but fewer studies look at how people cope in advance to prevent possible negative outcomes, such as respondents in our study who engaged in rapport building with patients. Similar to the concept of “emotional preparedness” [36, 37], these pre-emptive strategies can be understood as preparations that employees make to manage their own stress and that of patients to deliver more effective care. Kranke et al. (ibid.) maintain that anticipating stressful events can help health workers maintain their own emotional health and prevent emotional exhaustion.

Emotional exhaustion, a component of burnout, may result from exposure to aggressive behavior [3]. Further, burnout is associated with intention to leave a role [8]. Recruiting and retaining healthcare staff is the biggest workforce challenge faced by healthcare institutions, which researchers predict will worsen in coming decades [38, 39]. To attract professionals to the field and stem attrition, it is crucial that organizations address all forms of patient aggression against healthcare staff.

In women’s health primary care at VA, retaining specially trained healthcare staff is particularly important for ensuring healthcare equity among all veterans given women veterans’ high clinical complexity [17]. In line with other research, we maintain that creating a cohesive team environment may help retain staff in VA women’s health [40]. Having strong teams and supportive leadership, in addition to employee skills in patient rapport building and communication are organizational resources that may aid employees’ ability to cope with patient aggression and sustain their retention in their roles. In addition, having clear expectations for appropriate patient (and employee) behavior and meaningful repercussions for boundary-crossing may also bolster problem-solving capabilities among employees. Although burnout and turnover are tied to a host of factors that can be challenging to address, stemming workplace aggression is actionable, requiring a comprehensive violence prevention program that includes hazard prevention and control [9].

5 Conclusion

Patient aggression can negatively impact the work experiences of primary care employees across roles and role tenure. At VA, employees in women’s health primary care have devised multiple strategies to cope with these interactions. However, the ability to effectively prevent and manage patient aggression is limited by the lack of meaningful repercussions for aggression at the organizational level, which may impact employee well-being and retention.