Managing difficult behaviour

Owing to high rates of adverse childhood events, complex trauma and PTSD, homeless patients may struggle to trust others, develop relationships, manage stressful or difficult situations and wait for treatment (18). This can often lead to patients in genuine need of medical care, escalating and being removed by security or discharging themselves (18).

Bear in mind that these patients have attended the ED due to a genuine need and try to show empathy. Try to understand why they are behaving in a particular way, provide information, develop trust and provide practical solutions (18). Common triggers for challenging behaviour are hunger (patients may not have money for food), shame about themselves (particularly if they are dirty or malodourous), perceived judgement or stigmatisation from hospital staff and drug or alcohol withdrawal. These patients frequently experience dismissal, disapproval and unfriendly behaviour throughout their life and are often primed to perceive interactions in a negative way. Often introducing yourself with a smile, and demonstrating that you see them as a person and recognise the challenges they are facing (e.g. by providing them with a cup of tea and sandwich) can go a long way in deescalating a patient and keeping them in ED for treatment. If their primary reason for wanting to leave is that they are entering withdrawal from alcohol and/or drugs, this should be managed appropriately as quickly as possible.