This study suggests that professional-patient interactions which include unmet needs, involuntary assessment and unsolicited touch may trigger aggression. Encounters between health personnel and patients are intrinsically asymmetrical, with uneven distribution of power. The health personnel are the key to something the patient needs, and they therefore hold power in the interaction. Thus, the main responsibility for a decent interaction lies with the health professional. Recognizing interactions with increased risk of aggression might help the health personnel prevent aggressive incidents.
Aggression as struggle for recognition
In the theory Struggle for Recognition, Honneth describes how non- and misrecognition can become a potential motivator for interpersonal conflicts . He claims that within a social interaction, each individual needs to be recognized by the other(s) to preserve their self-esteem. Aggression can thus be perceived as a demand for rights (legal relations) and a demand for recognition as a unique person. This understanding adds to the comprehension of our main findings, and we will therefore discuss the findings in light of Honneth’s theory and existing literature.
Honneth describes several types of disdain which might affect the individual’s self-esteem. Firstly, an exclusion from what the individual considers to be his or her right, can be perceived as a humiliation, and therefore inflict damage to the person’s self-respect . When an experienced need is not met, this could be perceived as social contempt, disrespect or unjust, which would then be accompanied by anger . Several studies have identified unmet needs as a trigger of conflicts [17–19]. However, the perception of injustice does not necessarily arise from a refusal in itself, but when the patient’s perspectives and understanding of the problem are not emphasised at all . In line with this, studies have reported that positive encounters with aggressive clients were characterized by a mutual recognition between caregiver and client , and that patients might react more to the way rules are communicated and enforced, than to the actual rules . Furthermore, feeling ignored, misunderstood or misinterpreted seems to be particularly provoking . In emergency primary care aggressive incidents might therefore be reduced by paying more attention to the expectations and needs of patients , and by improving the health personnel’s ability to acknowledge these needs in situations where the needs cannot be met.
Secondly, Honneth claims that being deprived the right to decide over your own body is the strongest and most fundamental form of personal debasement . He also claims that “what is called ‘human dignity’ may simply be the recognizable capacity to assert claims” . In involuntarily assessments, the patients are deprived the right to decide over their own bodies. Furthermore, the patient may be expected to supress the otherwise normal response of trying to defend oneself if physically attacked or restrained . This makes the patient subordinate and extremely vulnerable. A study in a hospital found that enforced personal care and medical treatment on apparently reluctant recipients were related to aggressive incidents . It might therefore be that the aggression can be modulated by health professional overtly recognising injustice to the patient and trying to help them restore their dignity in the situation.
In a similar manner to involuntary assessment, unsolicited touch can be understood as an abuse or violation against physical integrity. A previous study found that physical contact initiated by health personnel was a stimulus which sometimes preceded assaults . Health personnel should therefore be made aware that although touching is an established way of conveying care, it could also be experienced as an invasion or a strong reminder of previous trauma. They should therefore be attentive when they approach a patient physically.
Study strength and limitations
We received several stories from different parts of Norway, describing various situations of threats or violence at work in emergency primary care. We consider the material to represent a broad range of experiences among emergency primary care personnel. A limitation to our study is that all authors are females, which might have influenced the observations and interpretations. Another limitation is that the focus group study included only health personnel, and that all narratives are told from their perspective. It has been shown that staff and patients have different perceptions of aggressive incidents and causes of aggression, and that some interpersonal factors important to patients were not mentioned by staff [25, 26]. Hence, we may lack relevant aspects of the patient-professional interaction . In addition, health professionals’ interaction with patients and their communication skills are potential sensitive and emotive topics. The stories and versions told by health professionals in our study may therefore be influenced by the need for showing themselves in a favourable light. Furthermore, our study was originally designed to explore health personnel’s experiences, focusing on organisational factors . Although the richness of the existing data on interpersonal interactions was one of our main reasons for pursuing this topic, the study’s original focus might have affected the findings.