Dealing with Angry Patients and Relatives

Learning how to deal with angry patients and/or relatives is a valuable skill we can develop to support us in clinical practice. Given the nature of the healthcare environment, you will almost definitely encounter these situations in placements or when you start work. It is also a common station in OSCEs.

In this guide, we will talk through some strategies you can use to assist in these interactions, hopefully resulting in a more positive outcome for both you and the patient or relative.

Examples of reasons why patients/relatives become angry:

• They have been left to wait a long time before being seen in clinic or A&E
• An error has been made by the medical/surgical team
• There has been a delay in diagnosis or treatment
• They have just received bad news
• The patient/relative expectations are not being met

These issues can be exacerbated by drug or alcohol use, underlying mental health problems, a history of anger management issues and or violence/aggression.

Recognise that the patient is angry

It is very important that we first identify that the person we are talking to is angry.

The skill of identifying emotions is very useful when communicating with patients and relatives. Once the emotion is identified we can then start to respond accordingly with empathy, reassurance or an apology, depending on what the patient is feeling and what events have occurred.

People will vary on how they behave when they are angry. Sometimes it is very obvious. The patient may even state that they are angry.

You might note the following behaviours when a patient is angry:

• Loud speech or shouting
• Swearing/verbal abuse
• Oversensitivity to what is being said
• Aggressive posturing, not wanting to sit down
• Walking/threatening to walk away
• Pacing up and down
• A rise in the pitch of voice
• Shaking/fist-clenching
• Change in eye contact (e.g. suddenly looking down)
• Frowning

Other patients may display anger subtly (e.g. quiet and seething), however, you may still notice a sudden change in their demeanour, or how they are communicating with you. They may go quiet or start to give one-word answers. It can be useful to notice the subtle signs that patients are angry so we can address the emotion before it escalates.

Adjusting your style of communication when a patient is angry

Once we recognise our patient is angry, we can adjust our style of communication to try and defuse their anger or at least prevent them from becoming angrier.

Voice

Adjust the tone, speed and volume of your voice:

• Try to keep a calm tone and remain composed (this can be difficult when you are being shouted at)
• Speak slowly and clearly
• Do not raise the volume of your voice if the patient is shouting

Body language

Adopt a professional yet relaxed posture:

• An example, if seated, might be uncrossing your arms and legs with both feet on the floor.
• Sitting back in the chair can help slightly (though taking care not to appear like you don’t care) to avoid appearing confrontational.

Acknowledge the patient’s anger

At this stage, pointing out to the patient that they appear upset/angry can be helpful:

• An example might be: ‘You’re looking very upset by all of this’
• Sometimes hearing this back can enable the patient or relative to recognise their emotion and start to process it.

The patient might respond in two ways:

• They may correct you: ‘No, I’m actually just frustrated’ (you can then adapt to deal with the other emotion).
• They may agree ‘absolutely’ or ‘of course I am!’ (you have then confirmed the emotion).

Try to understand why they are angry

Often there are other emotions behind the anger for example frustration, or more commonly fear.

Ask open questions to identify the focus of why they are angry:

• ‘Tell me more?’
• ‘Why are you feeling this way?’
• ‘Is there anything else that happened that is making you angry?’

Listen to the explanation as to why they are angry:

• Demonstrate active listening skills such as eye contact, nodding, verbal responses (e.g. ‘mmm’).
• Allow the patient to vent at you completely if needed – they may need to get some things off their chest. Give them plenty of space to speak.
• Avoid interrupting the patient * (see the note on interruption below).

Respond to the anger

Once you have gathered information about the patient’s anger, and you feel they have said what they needed to say, start to respond to their anger and the situation they have described alongside answering any questions they may have.

Empathy

At this stage, it can be useful to demonstrate empathy towards the patient. Essentially this is the acknowledgement and appreciation of someone else’s emotions.

Empathic phrases you could use are:

• ‘Given everything you’ve told me, it’s understandable you feel that way’
• ‘It sounds like you have a lot going on at the moment, and it’s natural that you’re feeling angry’

When you demonstrate empathy, it can help make patients feel cared about and listened to. This helps build a rapport between you and the patient – potentially diffusing their anger and creating a safe environment for patients/relatives to talk openly.

Apologise if an error has occurred

If the patient is legitimately angry as a result of a medical error– apologise.

A phrase like the following could be used: ‘I’m so sorry this mistake has occurred and caused you/your relative harm’,

Acknowledge the seriousness of the mistake made and legitimize the patients’ anger.

In the scenario of a serious medical error, it is often useful to explain to the patient or relative that when medical errors do unfortunately occur they are taken very seriously and reports are filed to ensure things like this do not happen again.

If you or the medical team is not at fault, however, be careful about how you apologise. Do not enable the patient to blame when you have not done anything wrong. You should still apologise that the unfortunate event has occurred e.g. ‘Im sorry that you are feeling so angry about what has happened’, whilst being careful not to assume responsibility if you or the healthcare team were not at fault. This may affect the patients’ expectations in the future.

Thank the patient

Sometimes it can be appropriate to thank the patient (e.g. ‘Thank you for sharing how you feel with me, it’s important I understand how you feel so we can work together to help you’).

Encourage questions/solutions

You might like to ask the patient or relative if there is anything you can do for them. This shows again that you care enough about the situation that you wish to help rectify it (e.g. ‘What can I do to help you?’).

Sometimes when people are angry they have difficulty thinking of solutions and therefore they may welcome your attempt at suggesting one.

Closing the interview

Conclude the consultation by thanking the patient/relative for their time.

Suggesting a plan going forward can help make sure a patient/relative does not feel abandoned soon after being very angry. Formulating some action points going forward also helps to acknowledge the patient’s anger.

Some examples might include:

• Organising a meeting with the clinical nurse specialist if the patient is dealing with a difficult diagnosis.
• Advise that you are going to pass on the information to a senior if an error has occurred.
• Organize a follow-up meeting with the patient or relative if they wish to discuss the situation further, and suggest they perhaps note down any questions they think of so you can be sure to address their concerns.

Things to avoid when speaking to angry patients

Suggesting a quick fix

Often patients want/need to explore the emotion they are feeling rather than finding a quick solution. Obviously, this will depend on the scenario but think carefully before coming up with a rapid solution that may not even serve you well.

Getting angry yourself

Try to be mindful and aware of how the interaction with the patient is making you feel. You, in turn, might feel angered by how the patient is speaking/the things they are saying. Try to keep control of your emotions and remain professional. You may feel entitled to being angry but demonstrating this to an already angry patient is likely to upset them even more. Perhaps talking to a colleague about the situation afterwards would be more helpful, should you feel the need to do so.

Being defensive

Becoming defensive might feel like the natural thing to do, particularly if you are feeling like someone is being angry at you for no legitimate reason. Try to avoid the temptation of responding defensively as it can escalate the patient’s anger.

Difficult situations

During consultations, you may encounter a number of tricky situations. Some examples are listed below.

The patient/relative is angry and does not want to sit down 

If initially, despite offering the patient a seat while you are both standing the patient refuses to sit down – it is important that you do not fixate on the fact they need to sit down. It might be that they are full of anger or another intense emotion and thus feel more comfortable standing up. If you repeatedly ask them to sit down in quick succession they may feel more irritated by this.

Sitting down from standing while the patient or relative is standing up, however, can feel awkward, and perhaps even threatening if they are particularly angry or aggressive.

If they are not seeming like they are going to sit down anytime soon, sometimes remaining standing and talking to the patient at this same level can be helpful. So long as you are not aggressive in your posture, this is ok. As you communicate with the patient further they may start to relax  – you can then offer the patient a seat slightly further into the consultation.

If you are both seated to start and the patient then becomes angry and stands up, sometimes it is appropriate to remain seated in this situation, so as to not appear confrontational.

If you feel threatened by an angry patient or relative

Some patients or relatives can become very aggressive when they are angry. They may have issues controlling their emotions and behaviours.

Occasionally when communicating with patients we may feel there is a possible threat of violence. If this is the case you should remove yourself from the situation and prioritise your own safety. Positioning yourself between the door and the patient can be helpful in this sort of scenario (making sure you’re not blocking the exit for the patient).

Avoid any sort of physical confrontation with the patient/relative. If you can see the conversation escalating, or witness the patient or relative become angrier or start to lose control, act before it’s too late. Make an excuse and leave if you have to.

Your colleague is to blame

You may encounter a situation where your colleague(s) have made an error and the patient/relative wishes to blame them. They may even start to speak about them badly in front of you.

In this situation, try not to get too defensive about your colleague. The patient may be legitimately angry. Use neutral phrases so as not to share your personal opinion about your colleague’s performance. Try not to encourage the patient to be abusive.

Phrases such as ‘I’m so sorry this happened’ may be useful in these scenarios.

Ideally, the colleague who made the mistake should be apologizing to the patient directly, so any anger or questions can be dealt with in a conversation directly between the two of them.

The patient/relative is still very angry despite your best efforts

Sometimes despite our best efforts and excellent communication skills, patients may remain very angry. It may even be unreasonable to expect to diffuse someone’s anger in one conversation, depending on the situation. Anger and other intense emotions take time to dissipate.

The patient/relative wishes to file a complaint

First, explore why the patient or relative wishes to file a complaint. This can be helpful as the issue can perhaps be dealt with on the spot. However sometimes regardless of the conversations, patients and/or relatives may wish (and are entitled to), file a complaint.

It is your duty to ensure that any patient or relative that wishes to file a complaint is given the information to do so (e.g. providing them with the contact details for the Patient Advice and Liaison Service (PALS)).

You are allowing the patient/relative to ‘vent’ and they are making themselves angrier (interruption can be helpful)

Sometimes we can see the patient is winding themselves up as they are venting at you – becoming angrier and angrier, with their emotions spiralling out of control. If this is the case, a gentle interruption can be helpful. Ensure the interruption includes an apology and/or empathy. You might use a phrase like ‘I’m so sorry to interrupt you – I can see that this has made you very upset. I’m so sorry this has happened. Is there anything I can do to help?’.

Don’t ignore how you feel

Remember dealing with conflict can be difficult and can contribute significantly to our own stress levels. Be mindful of how the interaction made you feel and take the necessary steps you need to relax. This might include talking to a colleague or taking a short break from the clinical environment.