Coping with disruptive patients: Perspectives of primary care employees

Abstract

BACKGROUND:

The impact of patient aggression on primary health care employees is underexplored, yet imperative to address, given high rates of burnout.

OBJECTIVE:

We qualitatively explore perceptions of patient aggression among staff in women’s health primary care at the Veterans Health Administration (VA). Our objective is to identify coping strategies that staf devised in response to aggressive behavior.

METHODS:

We conducted semi-structured interviews with 60 VA women’s health primary care employees in 2021 and 2022. Informed by the Job Demands-Resources theoretical model, we used rapid qualitative analysis to identify themes related to patient aggression and employee coping strategies.

RESULTS:

Disruptive behaviors reported by participants included verbal and physical aggression. Staff cited disruptive patient behavior as emotionally draining and perceived a lack of consequences for low-level aggression. Respondents used coping strategies in response to patient aggression at three time points: before, during, and after a negative interaction. At each point, support from team members emerged as a dominant coping mechanism, as well as rapport-building with patients.

CONCLUSION:

Patient aggression can negatively impact the work experiences of primary care employees. At VA, women’s health primary care staff 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 has important implications for employee well-being and retention. Retention of women’s health employees in VA is critical given the need for a highly specialized workforce to address the complex health needs of women veterans.

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

2.1 Project setting

Data were collected as part of an ongoing system-wide improvement effort at VA to meet the needs of women veterans, who represent the fastest-growing group of VA patient users [19]. Efforts to better adapt VA services for women’s specific health issues include offering women veterans both primary care (e.g., care for acute and chronic conditions) and gender-specific care (e.g., pap smears, breast examinations, contraceptive counseling) from a WH-PCP within a single visit [17, 20].

2.2 Data source

From June to August 2021 and May to August 2022, our team conducted semi-structured virtual interviews with 60 women’s health primary care employees from clinics that had experienced turnover in the WH-PCP role in the previous two years. During the first wave of data collection, we interviewed 24 employees with established tenure in their roles (more than three years). During the second wave of data collection, we interviewed 36 employees who were newer to their role (within two years of starting their positions). Clinics were identified using the Designated Women’s Health Provider Assessment of Workforce Capacity (DAWC) survey, which captures WH-PCP attrition. Each interview ranged from between 45 to 60 minutes. Aims were to explore factors associated with workforce stability and employee retention in women’s health PACTs (WH-PACT) and to identify retention strategies used by individual employees that may be scaled up to improve WH-PACT retention more broadly.

The interview guide was informed by the Job Demands-Resources model, which provides a framework for understanding and addressing risk factors associated with job stress across occupational settings [21]. The model posits that a person’s risk for job strain and burnout is based on the demands of a job relative to available resources, which can act as buffers against the impact of demands. Demands refer to physical, psychological, social, or organizational aspects of a job that require sustained physical or psychological effort or skills, such as emotionally demanding interactions with patients, whereas resources include factors such as social support and job autonomy/controllability of stressors (ibid.). In line with this framework, interview questions explored five main topics, including: 1) employee background and training; 2) job resources and intention to stay in the role; 3) job demands and supports; 4) ability to job craft– employee optimization of the work environment by adjusting work tasks, processes, and relationships; and 5) pathways to retention. Our interviewing team consisted of three qualitative methodologists with doctoral training, and each interview had at least two team members present. The primary interviewer led the interview, while the secondary interviewer took notes on a structured template based on the interview guide. The secondary interviewer also asked follow-up questions when needed to probe further on emergent lines of inquiry. All participants gave verbal consent to be interviewed and recorded. We obtained a determination of non-research from VA’s Office of Women’s Health.

2.3 Data analysis

Rapid qualitative analysis methods guided our initial review of the data [22, 23]. Interview guide domains were used to create a structured summary template that was used by our team to summarize interview data from each interview. The team next created “summary of summaries” matrices that collated and summarized findings from each role. These summaries provided a synopsis of employee responses ahead of formal coding of verbatim transcripts. A three-person coding team reviewed these structured summaries and used domains drawn from the Job Demands-Resources model [21] to generate an initial list of codes. We used ATLAS.ti to organize our coding, guided by content analysis principles [24, 25]. The code list was iteratively refined and discrepancies in coding were resolved through consensus [26]. After coding, the team identified and refined general themes, including the theme of disruptive patient behavior experiences that emerged in interviews with 35 out of 60 respondents in response to the interview questions: “What are the most challenging aspects of your work?” and “What would you say helps you get past those challenging moments? What helps you cope?” The lead author identified and compiled themes and sub-themes related to patient aggression and coping strategies, as well as associated quotes from transcripts. Resulting themes and quotes were reviewed and validated by two members of the project team.

3 Results

3.1 Participants

Participants included clinicians and non-clinicians at VA medical centers and community-based outpatient clinics in women’s health. Our analytic sample (n = 35) consisted of 7 primary care providers (PCPs), 10 registered nurses (RNs), 8 licensed practical nurses (LPNs), and 10 medical support assistants (MSAs)/front desk personnel. Of these, 16 respondents participated in the first wave of data collection and had been in their roles for an average of 6.9 years. An additional 19 respondents were part of wave two of data collection and had been in their roles for 1.1 years on average.

3.2 Overview of findings

Clinicians and non-clinicians with various levels of experience in their roles cited disruptive patient behavior as an emotionally draining challenge of providing care. Disruptive behaviors included verbal and physical aggression. Respondents identified coping strategies that are employed at three time points to manage stress: before, during, and after a negative interaction. At each of these three points, support from team members emerged as a dominant coping mechanism, as well as rapport-building and communication with patients.

3.3 Experiences of aggressive patient behavior

Employees identified interactions with aggressive patients as one of the most challenging aspects of their work. Although frequency of occurrences varied, respondents described aggressive incidents as emotionally taxing and the mark of a bad workday. For example, one participant explained:

“[The most challenging aspects of work are] difficult patients. I would say people who become angry or [who are] hard to talk down. Luckily, that is not the majority, but those are my hardest days, is when, you know, a bad interaction with a patient.” (RN)

According to several respondents, the novel coronavirus of 2019 (COVID-19) had exacerbated patient anger:

“Anger …  sometimes can get exhausting. Especially this year, especially with COVID. I find that can be really challenging.” (PCP)

“Well, lately it’s been COVID. Veterans are getting upset a lot easier. So, I guess veterans’ moods really make or break the day sometimes.” (LPN)

Respondents described enduring verbal patient aggression, consisting of yelling, swearing, criticism, or threats. One respondent also described physical aggression in the form of slamming doors and kicking walls. According to employees, these behaviors stemmed from dissatisfaction with VA care, policy, or communication:

“Like I got yelled at the other day because it took over a week for him to get a letter. Well, I don’t control the mail so I can’t really, there’s nothing I can do to fix that.” (MSA)

“[Veterans will] say that the VA is not taking care of this, or they’re going too slow …   getting chewed out for lack of a better term would probably be the hardest thing. Most of the time it is stuff that is out of any of our control.” (LPN)

In several cases, employees perceived themselves as the unfair targets of patient anger for which there were few repercussions from the healthcare organization:

“They might come in and be rude and disrespectful to the whole staff, but they’re not, like it’s not like they won’t be able to come back tomorrow if they need to. They’re not required to apologize.” (MSA)

3.4 Coping: Pre-emptive actions

Respondents described using coping methods such as team collaboration to pre-emptively reduce negative encounters with patients. In cases that involve patients with known histories of disruptive behaviors, strategies included huddling with team members to plan for an upcoming visit. For example, plans may include having social workers or VA police on hand. Several respondents also described strategically choosing specific team members to interact with certain patients based on successful past interactions:

“ …  if there is somebody that really does not like me or just does not get along with me for whatever reason, [my colleague] a lot of times will call them …  If there is somebody who has had difficult interactions …  I will call them for [my colleague].” (LPN)

Additional pre-emptive coping included shaping patient interactions through rapport-building with patients and personal practices, such as taking time off from work. For example, respondents stated:

“I treat every patient the same with respect, regardless if they are being rude or disrespectful or acting out of the norm, and just being consistent with that, so they know what to expect from me when they come in and in turn they show me their appreciation by telling me, they’re nice to me, they share information with me, they talk about their families …  ” (MSA)

“We try to encourage each other that if you need a mental health day, take a mental health day. It is better to do that than to come in and not be able to be the nonjudgmental trauma-informed nurse and that starts with taking care of yourself.” (RN)

Employees also observed how their colleagues handled difficult interactions, which helped them assess their own experiences and coping behaviors. For example, a nurse said:

“I know when [my coworker] is talking to somebody challenging and just the care and the concern and the compassion that I can hear …   it can be the second or third time in a day that she’s dealing with the same veteran who is really, really struggling right now and I know how hard it is for her to dig deep and find that compassion for that person and to see what a beautiful job she does in those difficult situations just kind of tells me suck it up buttercup, you can handle what you’ve got on your plate.” (RN)

3.5 Coping: During an incident

When encountering an aggressive patient, respondents reported relying on team members, especially colleagues with expertise in behavioral health such as psychiatry nurses or social workers. Colleagues were enlisted to help respondents better understand patient needs or to help connect patients to resources. One RN explained:

“So, our team does meet difficult patients …  I have a provider who works very well with mentally ill patients who maybe have an agenda that is hard for us to understand. She is very good with those types of patients, so that helps. But, we definitely approach it from a team perspective.” (RN)

Others described employing various communication strategies to cope with difficult interactions, through collaboration with patients and recognition of their points of view. Specifically, an LPN described working with patients to find care solutions (e.g., brainstorming available pain therapies while waiting to get in to a specialist), and an MSA described the importance of acknowledging a patient’s frustration and explaining the purpose of VA policies (e.g. COVID-19 mask policies):

“ …  it’s trying to redirect that conversation and say what other things [can we do]? Would community care be a good option? If they are having severe pain …   would chiropractic care be something that is appropriate in the interim of getting into whatever specialty [service] they need to see. Kind of brainstorming some of that stuff.” (LPN)

“ …  veterans who are very angry, who won’t let us screen them because they say they’re vaccinated, [we change the script] and say, ‘Hey, I know you’ve probably been vaccinated but I still need to ask you these questions, do you mind’? And they’re more responsive than just throwing a bunch of questions. [Or I] just say, ‘Hey, can I explain to you why you need to [wear a mask], because this is a medical facility and people are very, very sick, you need to wear it’.” (MSA)

3.6 Coping: After an incident

Respondents cited informal debriefing as a coping strategy after a stressful patient encounter. Many sought emotional social support by talking about their negative experiences to work colleagues and family members, which sometimes involved trying to find humor in the situation or brainstorming solutions:

“I was really happy when I got another PACT team that I worked really well with. I had a couple of RNs that, we got along well and we could vent. Really kind of like finding your family at work, that’s a big thing.” (LPN)

“So, if we are having a particularly rough day, we [co-workers] go for walks or maybe go out for lunch, or, you know, de-escalate our own thinking and come up with ideas amongst ourselves or just laugh about them, and that really does help very much.” (RN)

“My husband is a veteran, a combat veteran, so that helps a lot with just kind of being like it was a rough day and I got chewed out for XYZ or called some choice names that weren’t so nice. So just kind of talking about it for myself, that helps a lot. It helps me try to let things go.” (LPN)

Finally, respondents engaged in cognitive coping by reflecting on situations to determine the root of a patient’s complaint and “letting go” of what is beyond the employee’s control. For example, respondents endorsed recognizing how some behaviors might be tied to traumatic histories or larger organizational or structural issues. Two respondents stated:

“Sometimes it [aggression] is a reflection of their own past experiences, their unrealistic expectations, whatever struggles they’re dealing with. Sometimes you have done everything that you can do, but it is a systems issue and we just do not have any appointments to bring them in to the clinic and that’s not your fault. We don’t have anything to do with that. You have to recognize that this is out of my control and figure out a way to let it go.” (PCP)

“Like there are things like that that are just, they’re asinine but, okay, if you feel that you need to yell at me for this, I guess go ahead.” (MSA)

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].

4.1 Limitations

This study has several limitations. First, participants were recruited from a limited number of VA healthcare sites and may not be representative of all women’s health primary care employees. However, findings were consistent across roles and sites suggesting robust themes. Second, the range of aggressive encounters may be underrepresented as we did not directly ask questions about these encounters. Rather, descriptions were emergent findings in response to challenges faced at work. And finally, our findings would benefit from triangulation with administrative data on patient aggression rates at sample sites which is not readily accessible for research purposes.

4.2 Future research directions

Future work should investigate how perceptions of and responses to aggression may vary among employees in primary care. Findings presented here uncovered experiences of patient aggression across primary care roles, but more work is needed to better understand how the complexities of intersectional identities may shape difficult patient encounters. Another area for future research is healthcare employees’ experiences of patient verbal aggression. This type of aggression is underreported, yet it has consequences for employee well-being. More research is needed to better understand how primary care employees in different roles manage this type of aggression and the accumulative impact of this aggression on employee well-being and retention, which may help organizations craft targeted interventions.

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.