How to handle aggressive patients

MDU medico-legal adviser Dr Ellie Mein offers some advice for GPs on how to deal with aggressive and violent behaviour in patients.

Most consultations in general practice start and end well with the patient feeling their expectations have been met. Unfortunately, in a minority of cases, some consultations or interactions can escalate to violence or aggression.

The recent strains on the health service caused by the pandemic have resulted in longer waits for treatment; different ways of accessing care; delays in blood tests and the incorrect impression that GPs are not open as usual. There is mounting evidence that aggression towards primary care staff has escalated as a result.

Incidents in primary care

In an MDU survey of 418 members in August 2021, 79% of GPs said levels of abuse from patients and their representatives had increased since the start of the pandemic with 44% having experienced bullying, abuse or harassment from patients or relatives.

Of the reasons identified for this, nearly half of doctors surveyed (49%) said waiting times for treatment and referral were the main cause. A third (32%) of GPs said the cause was appointment availability.

MDU members’ enquiries about inappropriate behaviour take a wide range of forms. As well as being on the receiving end of aggression and abuse, in extreme cases GPs, nurses or administration staff have been subject to rape or death threats, work or personal property has been damaged, or actual physical assaults occur either in the practice or on home visits.

Practices are at the forefront of dealing with patient frustration and it can be difficult to avoid confrontations given the backlogs currently being experienced. Abuse is not just experienced by GPs but by the whole practice team, causing understandable distress. However, being aware of common trigger factors and techniques for diffusing difficult situations can help in dealing with challenging behaviour.

Causes of aggression

Patients can become aggressive or violent for many reasons. Patients may have an underlying medical problem or an acute physical or mental illness which causes them to behave in a way which is not in keeping with their usual character, especially when faced with a stressor such as the current delays in treatment. People who are ill, scared or in discomfort or who feel their request isn’t being listened to or actioned appropriately can react in an unpredictable manner.

Other factors which may contribute to aggression include communication problems, frustration, previous poor experience and unrealistic expectations. Patients may have a history of difficult behaviour, even when there is no underlying problem to explain this. It can be possible in such cases to anticipate problematic behaviour.

Anticipating challenging behaviour

Being aware of the possibility of a situation escalating, even in patients with no history of challenging behaviour, is the first step. Observe a patient’s manner, what they say and how they say it. Acknowledging that a patient is unhappy or frustrated and indicating you wish to understand why and help, if possible, may help de-escalate the situation.

Showing a willingness to listen, asking open ended questions and avoiding encroaching on the person’s personal space may also help to calm the situation. Give careful thought to the layout of consulting rooms, or the use of panic alarms. NICE has published guidance on how to manage violence and aggression in a healthcare setting; this includes advice concerning staff training.

If a patent becomes aggressive or violent despite these steps, then it may be appropriate to consider what follow up action is required. Have a clear policy in place setting out how abusive and threatening behaviour from patients will be dealt with. This should be readily available, for example a notice in the waiting room, or on the practice website.

Set clear boundaries from the outset

It is important to be clear that unreasonable or unnecessary requests cannot be met. We have previously issued guidance on why it is not necessary for GPs to complete mask exemption certificates and are seeing queries about requests for vaccination exemptions letters also.

It can be helpful in managing expectations to notify patients, via the website and a waiting room notice, how to make requests and that certain requests cannot be processed.

In relation to requests for vaccine exemptions, Chapter 14 of the Public Health England (PHE) ‘green book’ provides up to date information about the various vaccine options. The contraindications and precautions are listed. Unless the patient meets the criteria outlined in PHE’s guidance for those who should not receive the vaccine, it is advisable not to confirm that a patient is exempt from receiving the vaccine.

COVID-19 vaccine queries

We have seen some patients challenging their GP inappropriately to provide a detailed scientific rationale for the coronavirus vaccine. In line with the GMC’s guidance on consent patients who request more information about the risks and benefits of COVID vaccination can be provided with clear, accurate and up to date information.

This should be based on the evidence about the potential benefits and risks of each option, including the option to take no action. The GMC adds: ‘It wouldn’t be reasonable to share every possible risk of harm, potential complication or side effect. Instead, you should tailor the discussion to each individual patient, guided by what matters to them, and share information in a way they can understand.’

Such discussions should include the risks of harm you believe the patient would want to know or consider significant, any risk of serious harm and common side effects, the GMC explains.

Provide patients with the standard patient information about COVID vaccination and answer reasonable questions, for example, about potential side effects. You are not obliged to provide a detailed analysis of all current medical studies. If a patient asks not to receive further vaccine reminders, their wish should be respected.

Warning patients

The possibility of a warning for unacceptable behaviour should be discussed within the practice, and the discussion noted. In the MDU’s experience, warnings about behaviour, or removal from a practice list can result in a complaint; it is therefore helpful to be able to demonstrate that the decision taken was reasonable and proportionate. Any warning should be dealt with separately from a complaint response.

The GMC, and the standard GP contract usually require a warning to have been issued before a patient is removed from a practice list. However, if there has been a threat of violence, or actual violence, it is appropriate to call the police and removal from the practice list without prior warning may then be possible.

Consider carefully how much confidential information might justifiably be released to the police and get advice from your medical defence organisation.

Home visits

Dealing with aggressive behaviour during a home visit can be particularly challenging given the unfamiliar setting and lack of backup support. Trying to defuse the situation is one option, but it is also acceptable to end a consultation and leave, particularly if there seems to be an imminent risk of physical aggression from the patient, relative or carer.

If a patient who has previously been aggressive requires a home visit, and is unable to come to the surgery, then a risk assessment may be necessary. It may be appropriate to visit with a colleague (staff numbers and workload permitting). Phoning in advance to find out who will be present, to outline what behaviour will be acceptable, and to get a general feel for the patient’s mood could help.

Challenging consultations with patients or relatives are upsetting for all concerned. It is worth reviewing your practice policy on this issue including security in the practice and on home visits and staff training to ensure you minimise the risk of patients becoming violent or aggressive.

This is an updated version of an article that was first published in February 2019.

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