Dealing with aggressive and challenging behaviour

David Lauder provides effective ways of responding to challenging patients

Most patients get on well with their dentist and the majority of dental appointments are uneventful. But, occasionally, the professional relationship can turn sour and, sadly, it is not unknown for patients to pose a threat to the wellbeing and safety of practice staff.

Challenging situations

Between 2014 and 2018, the Dental Defence Union (DDU) supported members in 118 cases involving harassment or threatening and aggressive behaviour directed at dental professionals or practice staff.

We also receive many more advice line calls each year from dental professionals who are worried about how to deal with challenging situations.

While the overall numbers remain low, there was a rising trend over the period – with 64 cases in the second two years compared with 54 in the first three years; a rise of 19%.

This may point to an increase in unacceptable behaviour, but it could also reflect a zero-tolerance approach by dental professionals who rightly want advice about how to protect practice staff and other patients.

The files show in at least nine cases the dental professional had contacted the police because of safety concerns or because a confrontation had become violent.

The majority of cases involved abusive or aggressive behaviour towards professionals and their colleagues, such as calling the practice repeatedly to harass staff, making vexatious complaints, using abusive and threatening language, and posting allegations on social media. A handful of cases involved a long history of threatening and aggressive behaviour.

Most DDU members were concerned about aggression from patients, but 15 incidents involved threats or abuse from a third party, usually a family member who was unhappy about the treatment their relative had received.

Understandably, members wanted to know whether they would be justified in ending their professional relationship with the patient in these circumstances.

Although every case has its distinctive features, it is possible to see a number of common themes:

Disputes over treatment – this featured in at least 39 cases and included patients who were unhappy about the outcome of a procedure, such as an extraction or root canal treatment that left them in discomfort. Other cases included patients who believed the dentist had failed to diagnose their condition, including periodontal disease, and those demanding a particular treatment against the advice of the dental professional

Health – at least 10 patients had an existing medical condition that was likely to be a factor in their behaviour, including mental health problems and addiction; although this could account for many more instances of aggression and violence

Fees – disputes over dental fees featured in at least seven cases, including demands for refunds by patients unhappy with the outcome of their treatment and those alleging the practice had not properly explained its charges

Appointments – several cases involved patients or relatives who were angry because of the wait for an appointment or were unable to book an one. A number of patients had a history of failing to attend appointments, which had contributed to a breakdown in their professional relationship with the practice.

In nearly half of the cases, dental professionals contacted the DDU to get advice about how to deal with a complaint from a patient who had behaved aggressively.

In six cases, there was a General Dental Council (GDC) investigation. This highlights the difficulties that dental professionals often face in responding to challenging behaviour, and why it is a good idea to speak to a dental defence organisation for advice at an early stage.

Responding to challenging behaviour

While aggression and violence from patients and relatives are thankfully rare, it is understandably distressing for the dental professionals involved. The following DDU advice may help practices manage challenging behaviour.

Have a zero-tolerance policy

The policy should set out how abusive and threatening behaviour from patients will be treated and should be readily available; for example, a notice at reception, in practice leaflets and on the practice website. Ensure patients and staff are familiar with the policy, and organise workplace training, if necessary.

Recognise and act on warning signs

It is not just what patients’ say – their body language can also reveal increasing frustration and anger.

If possible, try to reduce tension by asking open-ended questions, providing reassurance and not encroaching on the person’s personal space. This applies to all interactions, including those at reception not just interactions in the surgery. As with all patients, it is important to manage expectations, such as over waiting times and treatment prognosis.

Address challenging behaviour

It may not be possible, but if you believe an incident is isolated or out of character, give the patient the opportunity to change. Explain the problem, explore any difficulties they might be experiencing and follow up this conversation in writing. Doing so may also allow you to more easily justify ending the professional relationship, if you were to do so at a later stage.

Ensure individual staff members can alert the team

Some practices have a panic button in reception and consulting rooms. Some computerised records software also have an alert function. If using such a system, ensure all staff know what to do if the alert is deployed.

When removing a patient is justified

If you believe your professional relationship with a patient has irretrievably broken down and you have little choice but to stop treating them, it is important you are able to justify your decision, and observe your ethical and contractual obligations.

In particular, the GDC warns ‘you should not stop providing a service… solely because of a complaint the patient has made about you and your team’. You should not refuse to treat a patient’s family solely because of a patient’s behaviour, either. Seek advice from the DDU or your own dental defence organisation, if you aren’t sure.

Follow the correct procedure when removing a patient

Unless the patient has been violent, you should inform them in writing, explaining your reasons and take steps to ensure arrangements are made promptly for their continuing care; for example, explain how an NHS patient can obtain a list of NHS dental practices.

Depending on where you practise in the UK, you may also need to follow the relevant NHS regulations. If in doubt, contact your defence organisation for further advice.

To find out more about the DDU, visit www.theddu.com