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Monday 24 October 2016
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Patients behaving badly

Dealing with disruptive and sometimes abusive patients is a challenge for all members of staff at a practice. But steps can be taken to manage difficult patients

In an ideal world, all patient interactions would be easy and we would get on well with everyone registered at our practice. However, this isn’t always the case and when practice staff encounter patients whose behaviour is particularly difficult to deal with, it can be tricky to know how to respond. In these situations, practice staff may wish to consider using an Acceptable Behaviour Agreement (ABA).
Practice staff interact with a large number of patients every day. The vast majority will be polite and courteous, but occasionally a particularly difficult patient will leave practice staff unsure of what to do. The Medical Defence Union (MDU) receives around 400 calls a year from members – most of them working in general practice – asking how best to manage difficult patients.

Why do patients become challenging?
There are a number of reasons why patients may become challenging, for example:

  • If they are unwell.
  • If they are in pain.
  • Due to drink or substance misuse.
  • If they are scared, anxious or distressed.
  • Frustration.
  • Guilt that they did not seek help sooner, especially if the challenging behaviour is coming from a friend or relative of a patient.  

What form can challenging behaviour take?
Practice staff may be faced with challenging behaviour in many forms. A patient may be:

  • Demanding or controlling.
  • Unwilling to listen.
  • Acting uncooperatively.
  • Verbal abusive or threatening.
  • Physically violent, either against people or property.

What action can be taken?
Although removing a challenging patient from the practice list may seem like a solution, it isn’t always warranted or a viable option. It is also important to remember that patients must not be denied necessary treatment, even if they are aggressive or violent. Treatment must be based upon clinical need, however demanding the patient is. Nevertheless, you should assess and minimise the risks to yourself, the patient and to others. In some cases it may be reasonable and necessary to consider alternative arrangements for treatment.
One strategy for dealing with a challenging patient is to make use of behaviour agreements. Sometimes called a doctor-patient contract or an acceptable behaviour contract, these aim to improve the relationship by:

  • Outlining to the patient what behaviour is unacceptable or inappropriate.
  • The impact their behaviour may have on others.
  • How this behaviour can interfere with the delivery of healthcare.
  • The potential outcomes if their behaviour does not change.

In 2012, NHS Protect published Unacceptable behaviour – guidance on warning letters and other written communications.1 This guidance describes the types of behaviour that may be seen as unacceptable and the various ways it can be appropriately addressed, including ABAs.
It is important that these agreements are viewed as a useful tool for rescuing a deteriorating professional relationship before it becomes unsalvageable, rather than as a punitive measure. The MDU advises using ABAs only in cases of persistent bad behaviour that would otherwise lead to a breakdown in the doctor-patient relationship and the patient’s removal from the practice list.
Behaviour agreements or contracts are more likely to be successful if the patient is involved in drafting them, as a sense of ownership may then translate to responsibility for implementing it. Patients may be more receptive to an ABA if it doesn’t focus just on what is expected of them, but also explains what they can expect from the service provider in return.
The use of positive language can also increase the likelihood of an ABA being successful. By stating what the patient should do, rather than what they shouldn’t. For example, “treat staff with respect” instead of, “do not swear, shout or insult staff”. The patient may be more open to the request. There will, however, be cases where it is necessary to be explicit about what behaviour will not be tolerated so that the patient understands what is required of them.
Although on the surface it may seem like a patient is simply being unreasonable, there are a number of factors to consider before making use of an ABA. Examples include:

  • Consider if the patient’s behaviour is related to an underlying medical condition that needs treating first.
  • Make sure the patient has the capacity to understand what they are agreeing to when asking them to co-sign an ABA.
  • Be aware that when signing an ABA, you need to be satisfied that its use will not prevent the provision of necessary healthcare to the patient.
  • Adhere to the General Medical Council’s Good Medical Practice (2013), paragraph 71,2 which requires you to be honest and trustworthy in signing documents and take reasonable steps to ensure what you are signing is correct.

Any member of practice staff who is considering placing a patient on an ABA may wish to consider contacting their defence organisation before doing so.

Dr Ellie Mein, medico-legal advisor, Medical Defence Union.

1 NHS Protect. Unacceptable behaviour - guidance on warning letters and other written communications. (accessed 21 September).
2 General Medical Counicl. Good Medical Practice. 2013. (accessed 21 September).