Disruptive Patient Behavior: Case Studies and Best Practices

Disruptive patient behavior, particularly violence, is a growing problem that has been exacerbated by the COVID-19 pandemic.^1,2 Patient-physician conflict over COVID vaccines, treatments, and masking easily can become difficult to control.

Disruptive behavior can be defined broadly as patient behavior that has or could jeopardize the health and safety of others, or that impedes or disrupts the ability to provide healthcare. It can include threatening, profane, sexual, or offensive comments and gestures; violence; or aggression. Disruptive behavior poses an obvious risk to clinician and staff well-being. But disruptive patients also can undermine their own health by impacting the medical decision-making process, and may be more likely to pursue malpractice lawsuits.

Even mildly disruptive patient behavior can interfere with clinical decision-making, which can result in diagnostic error. Research indicates that emotional reactions to disruptive behavior can deplete a clinician’s cognitive resources.^3,4 Further complicating matters, clinicians are often unaware of the effects of emotion on diagnostic reasoning. This can make it difficult to mitigate the effects that disruptive behavior may have on patient safety. During disruptive patient encounters, obtaining assistance from a person with expertise in managing patient behavior (e.g., a social worker), can allow clinicians to better focus on the patient’s medical issues.

Different kinds of disruptive patient behaviors require different de-escalation and continuity of care strategies. For example, a patient who is verbally abusive because of a perceived service failure might be successfully calmed to a degree that the basis for their anger can be discovered and remedied. In that case, the appropriate next step might be a behavior warning or a patient behavior agreement.

On the other hand, de-escalation strategies may be too dangerous if the patient has a weapon. In those cases, the police/security should be called, and immediate termination of treatment would be appropriate. Managing a situation involving a disruptive patient often requires balancing patient rights against the well-being of the healthcare team. Sometimes, disruptive patient behaviors destroy the therapeutic relationship. In that case, termination of treatment with proper notice may be appropriate.

By identifying and understanding patterns and triggers of disruptive behavior, clinicians and staff can reduce the risks of disruptive behavior and help disruptive patients achieve behavior that allows for collaborative treatment. Policies, protocols, and staff and clinician training on how to effectively mitigate and manage disruptive behavior is a crucial aspect of ensuring staff and patient safety and well-being.

The linked case studies are based on closed claims and Risk Management Department calls from insureds. These scenarios provide the basis for strategies that can be used to identify catalysts to patient agitation and violence, de-escalate disruptive behavior, and appropriately follow up disruptive patient encounters. Ideally, by using these strategies clinicians and staff can recognize risk factors for disruptive behavior and mitigate or prevent an incident so no one gets hurt and patients receive the healthcare they need and reasonably expect.

Disruptive patient encounters are inevitable. They are risky from a workplace safety, patient safety, and professional liability standpoint. Successful management of an incident depends on developing the skills necessary to recognize risks and keep everyone safe. Successful disruptive patient management also requires follow-up policies and protocols that minimize liability risk and protect clinician and staff well-being following an incident.

Many disruptive patients are simply responding to unmet needs or expectations. It is incumbent upon clinicians and staff to adjust problematic patient expectations, discover what has triggered the patient’s unacceptable behavior, solve the problem when possible, or offer alternatives when appropriate. Although termination of the relationship with a non-violent disruptive patient may be the easiest way to respond to an incident, if the behavior is the result of dissatisfaction, in many cases the better strategy is to understand the patient’s complaint, empathize, apologize, and then re-establish behavioral expectations for moving forward in the physician-patient relationship.

References

1. The Joint Commission. Workplace Violence Prevention Standards. R3 Report. Issue 30. June 18, 2021. [PDF]

2. Howard Larkin. “Navigating Attacks Against Health Care Workers in the COVID-19 Era.” JAMA. 2021; 325(18): 1822–1824. DOI: 10.1001/jama.2021.2701.

3. H G Schmidt, et al. “Do Patients’ Disruptive Behaviors Influence the Accuracy of a Doctor’s Diagnosis? A Randomised Experiment.” BMJ Quality & Safety. 2017; 26(1): 19–23. DOI: 10.1136/bmjqs-2015-004109.

4. Sílvia Mamede, et al. “Why Patients’ Disruptive Behaviors Impair Diagnostic Reasoning: A Randomised Experiment.” BMJ Quality & Safety. 2017; 26(1): 13-18. DOI: 10.1136/bmjqs-2015-005065.