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Policy Discussions Archive

Conflicts in the Healthcare Setting

Discussion Ended on 03/02/2024

An emerging concern within the Board’s licensee population is the potential for confrontations leading to physical violence and/or verbal abuse between healthcare providers, their patients, and/or third parties, such as patient families or caregivers.  This position statement is intended to provide strategies to assist in de-escalating potentially volatile situations and prudent practices in the aftermath of such situations.

Strategies for De-escalation
When faced with a potential conflict in the health care setting, the following strategies may help to de-escalate the situation and/or foster a common understanding.

• Actively listening to the speaker and attempting to understand the nature of the speaker’s concerns.  Active listening entails remaining calm, encouraging the speaker’s expression of concerns, asking follow-up questions for clarification, resisting interruptions unless necessary, being respectful towards the speaker, and/or employing attentive body language.
• If possible, it may be helpful to attempt to identify those areas where there could be common ground and potential solutions that are acceptable to all parties.
• Demonstrating empathy for the speaker and acknowledging their perspective.  Empathizing with the speaker includes being open to the possibility that the speaker’s concern is valid, and/or a mistake or error may have occurred.
• When appropriate, it may be helpful to apologize to, or accept an apology from, the speaker.
• If there is an agreeable resolution, working with the speaker to identify potential next steps and to clarify responsibilities.

Licensees faced with an emotional and/or physical confrontation with a patient should also consider whether the challenging behavior results from a medical condition and, if so, whether it is possible to treat the patient without putting oneself at risk of harm.

An Act or Threat of Violence
In instances where violence is threatened and/or occurs, the top priority of the licensee is to ensure the safety of patients, medical staff, and the licensee themself.  If licensees find themselves in an unsafe situation, they should, if possible, immediately leave the physical area and call for help from security and/or law enforcement.  Any threat of violence, regardless of believed de-escalation, should be documented and reported to the appropriate channels.  

The Aftermath
The Board is aware that there will be times when a licensee’s efforts to de-escalate a conflict will be unsuccessful.  In some instances, the confrontation may make it untenable to continue a licensee-patient relationship.  If the licensee intends to terminate the licensee-patient relationship, they should do so consistent with the Board’s expectations outlined in the position statement “Licensee-Patient Relationship.”
Conflicts that take place in the context of providing medical care should be documented appropriately.  Such documentation should include all factual details of confrontations or abusive situations, including, but not limited to, the following:

• Names of those involved;
• Location;
• Date and time;
• Nature of the situation;
• Steps taken in response to the situation; and
• The identity of any witnesses present.

The Board encourages licensees who experience a conflict within the healthcare setting to reflect on the event, and when appropriate, debrief with any other medical staff involved.  Doing so may help manage and reduce stress responses after an event, defuse and express emotions, make sense of what happened, and identify areas for improvement.



Please address whether practice dismissal for threat of violence still requires 30 days of emergency treatment. Thank you.

By Michelle Scullock on Feb 29th, 2024 at 9:42am

A good way to de-escalate and create empathy and cooperation is to have the clinician repeat the complainant’s complaint verbally. This shows understanding, the complainant feels heard, and usually calms down.

By Steven Landau MD on Feb 28th, 2024 at 10:18pm

I greatly appreciate the approach of this document. Thank you for addressing this important issue.

By Susan Bane on Feb 28th, 2024 at 4:31pm

I think the Board should be aware that patients and family members can be terrifying.  I have spent a career in Emergency Medicine, much of it in North Carolina.  Increasingly, and that is why I am no longer in the ER, a Friday night in the ER felt more dangerous than my deployments to the Iraq war zone.
I suggest the Board be prepared to give the benefit of the doubt to the licensee in every situation.  I am 62 inches tall, and have frequently been in volatile situations with very large individuals in the ER.  I am a human being.  I have been terrified at times.  If someone with gang facial tattoos is screaming and spitting in my face, I’m not staying with them until help arrives.  I am going to get help and get away.  Hospital security individuals are not the law, and the law is under extreme duress these days.  De-escalating is not possible with people who do not speak English, are intoxicated, who are psychotic with a criminal history.  And they are not even the patient most of the time.  I’ve been pushed from behind, called names, threatened.  I have never had anyone pull a gun on me, but then, I left the ER.  That is only going to happen at the mall or the movies.

By Celia B Entwistle MD on Feb 28th, 2024 at 4:18pm

” If licensees find themselves in an unsafe situation, they should, if possible, immediately leave the physical area ...”
It’s all reasonable, but it does not acknowledge circumstances that occur in psychiatric wards, for instance, in which patients may act violently. Yes, the physician should leave, but he may need to physically engage the patient to get out - or perhaps grab a patient to prevent him from hurting others or himself.
Most commonly, this is done by a group of hospital ward staff. If unable to verbally calm a patient outburst, the staff will first present a “show of force” (usually 4-5 staff loosely surrounding a violent patient) to gain compliance without physical force. If still met with confrontation, the group will generally lift the patient off the ground and carry him to an area where sedation can be administered or isolation or restraints applied.

By David Naftolowitz MD on Feb 28th, 2024 at 3:50pm

This is very good and sadly necessary.  My only suggestion is to revise the sentence that begins, “Any threat of violence, regardless of believed de-escalation, should be documented and reported . . . .” The words “believed de-escalation” are not instantly clear and bury the lead, which is to urge documentation and reporting in every case.  I’d suggest something like this: “Every threat of violence should be documented and reported through appropriate channels, even if efforts to de-escalate the situation have been, or appear to have been, successful.”

By Steven M Shaber on Feb 5th, 2024 at 1:34pm