This site is intended for health professionals only
Sunday 21 July 2019
Share |

Managing patient hostility

As gatekeepers to the practice, receptionists are likely to encounter hostile patients. How can practice managers protect their staff from this behaviour?

Most patients are patient, accepting, courteous and agreeable. Most of the time, receptionists are

the same. But the wonderful mix of anxious patients and pressurised receptionists can prove a cocktail of explosive emotions, resulting in patients who behave in a hostile manner and receptionists who struggle to retain their composure. How can we help our staff retain their professional cool when an interaction with a patient turns sour?

Reception work is complex and challenging and many receptionists would earn the same if they were on the till in the local supermarket - and would certainly experience less stress. They remain in the job because the satisfaction they get from the work far outweighs the pressures. Their loyalty makes it all the more important that they are valued and supported in dealing with the challenges of the job. Dealing with patient hostility is one of these challenges.

Suppressing emotions

Why is this difficult? A report in Social Science and Medicine1 recognises that receptionists are constantly engaged in suppressing their own emotions as part of the process of delivering a service to patients. They undertake demanding work in which they are aware that the patient has a long-term, close relationship with the practice that needs to be preserved. They handle a constant flow of ‘people, tasks, regulations, procedures and relationships’.

To maintain a state of professional composure while trying to manage the emotional responses of the patient, they are engaged in ‘emotional labour’. What does this mean?

While projecting a constant external image of caring for the patient, they emotionally switch between two states: empathy or emotional neutrality. Maintaining emotional neutrality to persuade a patient to accept a situation demands energy and concentration. Calm patients can be cared for by the receptionist in ‘empathy mode’,

but hostile patients can only be effectively managed using emotional neutrality. Matching hostility with hostility usually ends badly (see below).

The work of maintaining the relationship and making the patient feel cared for is an emotionally demanding performance. It is rarely formally recognised and is usually associated with higher-status team members. Indeed, although GPs and nurses undertake emotional labour as well, switching modes to respond to the patient’s needs, they do not switch as often as receptionists are required to.

It is important that GPs as well as practice managers understand the hard work and, indeed, impossibility of maintaining this act all the time. It is also important that we work to recognise and minimise the triggers that make patients behave in a hostile manner.

Top 10 hostility triggers

The following is ten ways to tackle hostility triggers and this behaviour.

1. Signposting

Changes to the practice team, recruitment pressures, shortages of appointments and other good reasons have all resulted in the widespread introduction of receptionist signposting, where the receptionist has to seek information from the patient about their problem. Many react to this with hostility because it can look obstructive. They do not want to give clinical information to the receptionist and, anyway, they want to see the GP, so ‘what’s the problem’? They don’t want to be ‘fobbed off with a pharmacist’. Signposting in a practice is often introduced without much receptionist input. If your practice is having issues with this, consider a rethink to make things safer for both the receptionist and the patient. This may involve a more scripted conversation in which the receptionist uses agreed wording to explain her purpose and glean information.

2. Policies and procedures are inconsistently applied

‘Well’, the patient says, ‘I got X last time I called and it wasn’t a problem’. Sometimes, staff deviate from policy because a new way would be quicker, or new staff are shown different ways of doing things on induction. These inconsistencies lead to patient frustration. Sometimes long- established procedures should be reviewed. Delegate this to the people who use them and re-issue them with brief training to reinforce consistency. Inconsistency from GPs and nurses will often create chances for patients to pressurise receptionists – so training in procedures needs to include GPs and nurses as well.

3. There’s nowhere for the patient to go

Practices whose appointments are under extreme pressure will experience high levels of patient hostility – and, possibly, staff turnover. To relieve pressure on reception, it might be worth actively signposting to alternative services and health professionals, according to what is available locally.

4. Patients can’t get through on the phone

Before a conversation with the receptionist has even begun, the emotional stakes have been raised. Some practices have alleviated this problem by putting more staff on the phones at busy times or managing the number of lines available. But there is a balance between too few and too many lines. Call queuing helps, but on the other hand, the patient might become frustrated by having to follow messages and press buttons.

5. The language barrier

This is surely one of the most difficult (and increasing) challenges we face. Solutions are limited. The patient is concerned about their health and is anxious. Their ability to express their needs is limited by their command of English. Their frustration and lack of linguistic ability may make them come across as hostile. The receptionist is frustrated by an inability to grasp what the patient needs and feels that the hostility is unwarranted. This interaction will be challenging and receptionists may find it difficult to be empathetic when under time pressure. If you don’t have the luxury of staff who speak an array of languages, consider encouraging patients making face-to-face contact to use a translation app on their mobile.

6. Frustrated staff feel that patients ‘play the system’

Although this behaviour may not be hostile, it still engenders an emotional response from receptionists. While acknowledging that patients will always work out ways to do this, you can reduce instances by applying procedures consistently.

7. Pressurised receptionists don’t help patients find suitable options

In an interesting piece of research on patient calls to the surgery,2 Elizabeth Stokoe and others found that some receptionists put the patient into the position of having to push for solutions to their problem or did not have confirmatory information volunteered to them. This made patients frustrated. For example, some receptionists would verbally push to end a call if an appointment or result was not available, instead of looking for other ways to help the patient get what they needed. Of course, the receptionist might be hampered by a lack of options, but this approach might be worth addressing through training.

8. Patient online services have not been maximised

Make sure you are using your IT systems to best advantage. Create opportunities for patients to access services at a time that is convenient to them. This really does work.

9. Patients perceive the receptionist as ‘parent’ and react as ‘child’ to get what they want or need

If you are not already aware of transactional analysis, this is worth a discussion. Briefly, transactional analysis is a method of understanding your own mental state, the mental state of others, and how they both impact on the interaction. This is described in the book I’m OK, You’re OK by Thomas A Harris and on line at http://www.businessballs.com/transact. htm. I find that a basic grasp of these principles really helps receptionists to manage difficult calls and patient hostility.

Harris describes three mental states: parent, adult and child. At any time when interacting with someone else, we will be in one of these states and choosing which mental state to use in response - or indeed allowing a mental state to take over. ‘Parent’ and ‘child’ are hard wired in us because we learned them in childhood and our brain may automatically respond in one of these states, especially when we are upset. Getting into a parent v child interaction or, indeed, a child v child interaction will rarely work out well

– because both parties have allowed their mental state to control their responses. A child response to a situation is easy to observe in others (or ourselves). It will be a freely emotional response, whether positive or negative. The kind of negative child responses a receptionist may hear might be ‘That’s not fair’ or ‘I could be dead if I have to wait until then’. A child response may be triggered by the patient hearing a parent trigger phrase from the receptionist – something authoritative, a generalisation, or an implication that the speaker ‘knows best’. For example: ‘House calls must be in by 10.30’ or ‘I’ll do it for you on this occasion’ or ‘You should have called earlier – you’ll have to wait until tomorrow’. A patient who is already feeling anxious (child) may respond to a parent phrase with more child behaviour, triggering more parent responses in the receptionist. The secret is for the receptionist to avoid either parent or child phrases and stick to adult. This will take the form of empathetic or neutral behaviour (see above) and removes the triggers for a hostile (or child) response. As mentioned above, this is hard work but the understanding of these mental states can help a receptionist grasp the crucial importance and impact of maintaining composure.

10. Lack of opportunity to meet with GPs, discuss patient access and reception techniques and get training

Of course, a symptom of the general pressure of workload in practice is that meeting, reflection and training time are limited. However, time spent on these activities will often help avoid several of the triggers to hostility and may prove to be a good investment.

An additional piece of interesting research into GP receptionists’ work and behaviour is Slaying the Dragon Myth.4 Again, the authors recognise the complexity and demands of the job and find that the problem is not receptionists’ individual lack of skills, but the circumstances in which they are working. Each of these pieces of research is worth a read and worth sharing with your staff. 

Fiona Dalziel MA (Hons) FRCGP (Hon) CIHM, has been involved in primary healthcare management for 25 years.

References

1. Ward J, McMurray R. The unspoken work of general practitioner receptionists: A re-examination of emotion management in primary care. Soc Sci Med 2011; 72(10): 1583-1587

2. Stokoe E, Sikveland R O and Symonds J. Calling the GP surgery: patient burden, patient satisfaction and implications for training. Br J Gen Pract 2016; DOI: 10.3399/bjgp16X686653

3. Harris, Thomas A. I’m OK, You’re OK. Pan Books, London, Sydney and Aukland, 1970

4. Hamond J, Gravenhorst K et al. Slaying the dragon myth: an ethnographic study of receptionists in UK general practice. Br J Gen Pract 2013; DOI: 10.3399/ bjgp13X664225