A patient with chronic pain presents to clinic requesting a refill of an opiate prescription. The internal medicine resident recommends anti-inflammatories. The patient becomes agitated and paces the room.
The mother of an infant, admitted for bronchiolitis, is frustrated because “no one is doing anything.” The pediatrics resident is paged to meet with her. The mother becomes increasingly upset, yells, and threatens to sue.
A patient presents to the emergency department, intoxicated and with multiple rib fractures, after a motor vehicle collision. The consulting surgery resident tries to examine him. The patient lashes out and strikes the resident.
These incidents are all examples of workplace violence, defined as any act or threat of physical violence, harassment, intimidation, or other disruptive behavior that occurs in a work context and may cause physical or emotional harm.1 Workplace violence is divided into 4 types (Table 1).2 This perspective focuses on Type II violence, which includes the actions of patients, as well as the actions of their family members and friends.
Workplace violence impacts physician well-being. Research has demonstrated negative consequences, including physical injury and mental health issues, which can impair work performance and strain personal relationships.3 Victims frequently report symptoms of depression, anxiety, fear, and altered mood. These symptoms result in higher rates of emotional fatigue and depersonalization, which may undermine career satisfaction and contribute to burnout.4,5
According to 2015 data from the US Department of Labor, the rate of injury secondary to workplace violence was higher in health care than in any other industry.6 High rates of violence have been reported in the nursing literature,7 and within specific health care specialties (eg, emergency medicine, psychiatry, geriatric medicine).8–10 In a survey study of emergency medicine physicians, more than 75% of respondents reported being verbally or physically threatened by a patient at least once in a 12-month period.11 There are very little data for many other specialties. Workplace violence, in general, is thought to be underreported in health care, making its true incidence unknown.12 In non–health care fields, younger and less experienced employees are more frequently victimized.13 We believe Type II workplace violence is an underrecognized problem in graduate medical education that impacts trainees from all specialties.
Conflict Management and De-Escalation Training
Education and training have been identified as “key elements of any workplace violence prevention program.”6 Conflict management refers to techniques and strategies designed to reduce the negative effects and enhance the positive effects of conflict for all parties involved.14 Within health care, conflict de-escalation builds on conflict management principles, and is specifically aimed at preventing the escalation of agitation and aggression to physical violence.15 This is different from conflict de-escalation in some other fields, which focuses on mitigating violence that is already occurring. We refer to these skills collectively as conflict management and de-escalation (CMD). Workplace violence is a multifaceted problem, influenced by environmental factors (eg, noise, lack of privacy), system-based factors (eg, delays of care), patient factors (eg, intoxication, cognitive impairment), and care team factors (eg, prior disagreements).13 Many of these factors are beyond the physician's control at the time of the conflict. Competency in CMD, however, can help individuals attain an optimal outcome for a given situation. Training has been shown to improve trainee confidence levels and performance in CMD, and may improve the safety and emotional well-being of the health professional.16,17
To our knowledge, there are no CMD training guidelines for resident physicians. There are general recommendations for remediating residents in patient-centered communication skills (eg, discuss patient interactions with faculty mentor), but the only recommendation specific to CMD requires outsourcing the training (eg, attending conflict resolution and communication courses).18 Simulation-based training is recommended, but specific curricula and training principles have not been reported. Furthermore, existing curricula in the health literature frequently target nursing and ancillary staff.19 In a study of workplace violence prevention programs in 167 hospitals, physicians were the employee group least likely to attend training.20 Survey data from emergency medicine and pediatrics suggest that resident physicians are not being reached in appreciable numbers when institutions use an “all staff” approach to training.11,21 We recommend that all resident physicians who engage in direct patient care receive CMD training.
A Conceptual Model to Guide Training
A robust body of literature related to CMD can help inform educators interested in developing curricula for residents. This includes several models for conflict analysis and mapping, all of which use a curve to represent escalating behavior.22–26 The literature suggests that aggression in health care settings follows a pattern that is affected by various factors, including the physician's response to aggression.27 A situation may escalate rapidly, in part due to previous interactions (eg, prior hospitalization).
We have developed an arc of conflict, which applies this curve to model CMD in health care (figure) and maps the risk (instead of the severity) of violence over time. The model is intended for individual-level, rather than group-level, conflict. It consists of a curve broken into 3 zones (disagreement, agitation and aggression, and physical violence) corresponding to the level of threat. The model serves as a scaffold for organizing CMD skills, with conflict de-escalation skills that build on conflict management skills. Effectively managing conflicts using the least traumatic intervention benefits the patient, the physician, and the health care team.30 This model can help educators create learning objectives related to specific CMD skills, that are appropriate for targeted workplace violence scenarios (ie, arc of conflict zones).
Conflict management is the foundation for approaching disagreement with any patient. Many physicians have a basic familiarity with pertinent interpersonal skills, including active listening,31 addressing the emotional aspects of the situation,32 building trust and empathy,33 discussing options,34 and establishing limits.35 Other concepts from the conflict management literature may be less familiar to physicians (Table 2); for example, separating interests from positions.28 The interest is the underlying goal or concern; the position is the statement or action. Recognizing this difference helps to establish common goals, identify unmet needs, and find creative solutions to problems. Another important skill is self-reflection to recognize internal biases, understand one's contribution to the conflict, and identify potentially incorrect assumptions about the situation.36 Differentiating between intention and impact can help physicians identify unanticipated negative impacts of their own actions on patients.29 This differentiation is also important when interpreting the actions of an agitated patient, and it can help a physician reframe an interaction that would otherwise be regarded as negative.
Conflict de-escalation adapts many of the conflict management principles to situations of increased threat (ie, agitation and aggression). The American Association for Emergency Psychiatry Project BETA De-escalation Workgroup Consensus Statement on Verbal De-escalation of the Agitated Patient serves as a valuable resource for this type of intervention.37 When the patient becomes more aggressive and less effective at communicating, the physician must be more verbally concise. Additional emphasis is placed on communicating nonverbally, assessing danger, and maintaining personal safety. The approach to physically violent patients, including physical and pharmacologic restraint, is addressed elsewhere.38–40
Conclusions
The incidence and impact of workplace violence in graduate medical education is not fully understood. We believe it is an underrecognized issue and that all resident physicians should receive CMD training. There is a robust body of literature pertaining to CMD, and our conceptual model will help to organize this information and inform training efforts.
References
Author notes
Funding: Funding and support for this project was provided by the State of Washington, Department of Labor and Industries, Safety and Health Investment Projects (Grant 2014XH00293 to MCV, RF). The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.