Keeping your team safe: How to de-escalate encounters with aggressive patients

During her 25 years of practice as a periodontist, Ann Blue, D.D.S., has encountered fearful and upset patients, but she and her staff are trained to de-escalate these situations to resolve them in a calm manner.

“Managing these patients and keeping my team and other patients in the practice safe is definitely an important skill to develop,” said Dr. Blue, a member of the ADA Council on Communications.

Recent violence against dentists, including the fatal shooting of a California dentist by a former patient in February, underscores the dangers dentists may face in their workplace.

Survey data from the 2024 ADA Council on Communications Trend Report found more than half of responding ADA member dentists sometimes or often encounter aggressive patients.

The survey was conducted this spring and included responses from about 560 member dentists who are part of the Advisory Circle research panel. Generally representative of overall ADA membership, the panel is made up of members who participate in surveys typically focused on practice-related topics. The report will be published this fall.

Encounters with aggressive patients were more common among dentists younger than 35 and dentists working at federally qualified health centers and dental school clinics, according to the survey. About 30% of respondents reported they have felt their safety threatened by a patient. These instances were more common among female dentists, dentists working at FQHCs and dentists working as employees or associates at dental support organizations.

While health care workers make up 10% of the workforce, they experience 48% of nonfatal injuries caused by workplace violence, according to 2023 data from the Bureau of Labor Statistics. The most common perpetrators of this violence against health care workers are patients, patients’ family members, visitors, colleagues and supervisors, according to the National Institute for Occupational Safety and Health. Health care workers may also experience violence from someone they know personally, such as an intimate partner or family member.

The Occupational Safety and Health Act’s General Duty Clause requires employers to provide their workers with a workplace free from recognized hazards that are causing or likely to cause death or serious physical harm. OSHA also requires employers to establish an emergency action plan for workplace emergencies such as workplace violence, natural disasters, fires and more.

For employers with more than 10 employees, the plan must be in writing, kept in the workplace and available to employees for review. An employer with 10 or fewer employees may communicate the plan orally to employees. The plan must include emergency escape procedures and route assignments, such as floor plans, workplace maps and refuge areas.

OSHA’s Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers call upon employers to establish a workplace violence prevention program as part of their overall safety and health program. The violence prevention program should have clear goals and objectives for preventing workplace violence, be suitable for the size and complexity of operations, and be adaptable to specific situations and facilities, according to the guidelines.

The guidelines encourage employers to conduct surveys to determine if employees feel threatened, solicit employee input to reduce the threat of violence, make structural and procedural changes that protect employees from enraged clients or customers, and provide training and education in the early warnings and prevention of workplace violence as part of their violence prevention program.

OSHA is considering establishing a standard for the prevention of workplace violence in the health care and social assistance sector that would include requirements rather than guidelines for employers. A May 2023 report on the proposed standard by the Small Business Advocacy Review Panel — which includes representatives from OSHA and other federal agencies — identified dentists and dental hygienists as direct care occupations that are at risk of workplace violence.

“Sadly, our reality as dental professionals is that what should be a safe place at our office is no longer the case,” said Kami Dornfeld, D.D.S., chair of the ADA Council on Dental Practice’s Dental Team Wellness Advisory Committee. “We must pivot and provide our teams with de-escalation techniques to safely manage aggressive or upset patients and prevent workplace violence. Training on these techniques could keep the entire dental team prepared to defuse aggressive behavior through proven communication methods or other safety and security measures.”

At her practice, Dr. Blue and her team regularly practice patient management skills, including communication and conflict resolution. She offers the following advice for dealing with upset patients:

1. De-escalation: Employ active listening, maintain a calm demeanor, use nonconfrontational language and acknowledge the patient's feelings. It is important to maintain empathy and avoid reacting defensively when a patient may be accusatory.

2. Maintain communication: As a team, attempt to explain diagnoses, treatment recommendations, alternative options and potential negative outcomes as clearly as possible in layman’s terms. A well-informed patient who understands what is being recommended and the possible side effects of treatment will be less likely to be upset when a negative outcome does occur.

3. Be observant for signs of patient agitation: Dentists and their teams need to be able to recognize the early signs of agitation or aggression in patients. These signs may include frustrated facial expressions and demeanor, snide comments, raised voice volume, clenched fists, pacing, or threatening body language. By identifying these signs early, dental teams can attempt to intervene before the situation escalates.

4. Establishment of boundaries: It is important for dental practices to have clear policies for proper professional behavior. Teams should show respect for patients and their concerns while also establishing boundaries for patients and encouraging them to maintain acceptable behavior and avoid offensive remarks.

5. Team collaboration: Team members need to work together to solve problems to avoid escalation. If a situation escalates, a colleague should be nearby to help, including by contacting on-site security or law enforcement if needed. Role-playing potential conflicts can help to develop team members’ confidence in dealing with patient concerns and disruptive behavior and avoid escalation to violence.

6. Ability to seek assistance: Ensure team members know it is always acceptable to ask for help if they feel overwhelmed or unsafe. Calling law enforcement may be necessary if they believe they are in danger.

“Following these steps and continuously refining your communication and conflict resolution skills will help you manage upset or aggressive patients in your practice and keep you, your team and your patients safe,” Dr. Blue said.