It’s almost a fact of life when you work on the frontline of medicine; a disruptive person will eventually be in your care at the hospital.

It’s a common problem that’s getting worse, according to Jennifer Goebel, DO, an emergency department physician with Huntington Hospital, a member of Northwell Health, in Huntington, New York.

“Workplace violence is a hot topic these days,” she said. Recent government statistics explain why: Healthcare workers are five times more likely to experience violence on the job than people in other industries.

All disruptive patients don’t turn violent. But picking up on some signs early can help you defuse a situation before anyone gets hurt.

What Is Disruptive Behavior?

It’s behavior that can pose a threat to the health and safety of patients or staff. It may be:

• Intimidating
• Threatening
• Dangerous

Examples of behavior that could signal a patient may become disruptive include:

• Raising their voice
• Interrupting
• Ignoring the rules — like having too many visitors
• Clenching fists or jaw or crossing arms
• Rolling eyes
• Seemingly ignoring medical personnel
• Wanting to leave against your medical advice

This kind of behavior can slow hospital operations and affect care for that patient and others.

Who Is More Likely to Become Disruptive?

Any patient can turn disruptive, but some are more likely to do so, said Andrew Dunn, MD, professor of medicine and chief of the Division of Hospital Medicine at the Icahn School of Medicine at Mount Sinai in New York City.

This includes people with:

• Psychiatric problems
• Delirium due to health conditions, like hepatic encephalopathy
• Dementia
• Drug or alcohol problems or withdrawal from such substances

“Very often, a person has an immediate concern,” said Dunn, who is also a member of board of directors of Society of Hospital Medicine. “In most cases, we can address it and keep things on track, but in a disruptive patient, things can go off the rails.”

Some of the things that can set people off include:

Frustration: This can be as a result of their diagnosis or symptoms, said Dunn. “They feel they aren’t getting an answer quickly enough or not feeling better quickly enough. This can make them angry or lash out at staff or their doctor,” he said.

Unrealistic expectations: Patients “come in with information from the internet, a friend, or someone who knows someone who knows someone. Sometimes, I feel like patients come in with an agenda for better or worse,” said Goebel. There are certain things they expect, and situations can escalate if those expectations are not met, she said.

Medical mistrust: Since COVID, there’s a lot of skepticism with the medical field and a lack of trust in the system, Goebel said. During the pandemic, “patients came in and their loved ones were not allowed to be with them, and I think that has created a culture of mistrust in the health system,” she said.

Focusing on the past: Often patients have concerns about how they were treated in the past, Dunn said. “We address those: We explain what happened, why it happened, and how we are going to work together,” he said. It can be difficult to help them move on and talk about the current plan to help them feel better now. “That, to me, is a flag that it’s going to be hard to work with this patient and they could become disruptive,” said Dunn.

How to Defuse Emotionally Charged Situations

The name of the game is de-escalation, said Dunn. The best way to do that is by actively listening to the patient. Try to get to the root of why they are angry. Perhaps their pain isn’t controlled, or they feel like no one has told them what’s happening and they’ve been in the hospital for a long time.

Doctors may feel like they are working hard to educate their patients, but that’s not the patient’sperception. Address the concerns and reassure them that doctors and staff are working with them to help them feel better, Dunn said.

Goebel agreed and added: “We should avoid arguing with patients, taking comments personally, or rushing to judgment. Instead, we need to approach them with respect, take the time to listen, and try to understand what is upsetting them.”

If you set realistic expectations for patients, Goebel finds she can head off misunderstandings that can lead to disruptive behavior.

“If it’s busy or I just know that tests will take a long time, I tell them. For instance, labs take about 1-1.5 hours; CAT scans take a couple of hours,” Goebel said. When patients have somewhat of a timeline and they aren’t left guessing, it can calm them down.

If Things Go Off the Rails

You soothe, you calm, you de-escalate, you listen and try to address complaints and concerns, but still have gotten nowhere.

“The priority here is safety,” said Dunn. That includes for the patient themselves. “Sometimes they’re so wild they can pull out an IV [intravenous line],” he said. But safety of other patients, nurses, and yourself needs to be a priority, too.

Keep yourself in check: Try to remain professional and keep the patient as your compass. “It’s not easy because a lot of times, you’re also getting emotionally charged — whether you’re getting anxious or scared,” Dunn said.

Don’t go in alone: “I find it helpful not to be there by yourself,” said Goebel. You don’t know what’s going to happen. It’s not to “gang up” on the patient, but there is safety in numbers for everyone involved.

Ask a charge nurse, supervisor, or someone else to go with you.

“It helps to show we are united, we are a team, we all work together, and we’re here to help you,” she said.

Have security close: If the patient doesn’t want to engage or listen, the next step is to get security involved. Make sure there’s a presence on the floor in case things get physical, advised Dunn. “Fortunately, it’s not so common, but it does happen,” he said.

Use medication: That is a very challenging situation, said Goebel. If the patient wants to leave, for instance, “you have to decide if they have the capacity to do so safely. If we feel like the patient has an emergent medical condition that warrants them staying, we use intramuscular medication to sedate or alleviate their anxiety or pain,” she said.

Make sure to document in the chart that the patient got disruptive or worse. Pass along what strategies seemed to work or didn’t.

Final Thoughts

Keep in mind that patients come to the hospital filled with emotion, Goebel said. They didn’t wake up in the morning thinking they’d have to go to the emergency room or even be admitted to the hospital. Having chest pain, falling, or cutting themselves while prepping Thanksgiving dinner wasn’t on their bingo card.

“Take a step back and give them some grace,” she said.