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

While such incidents are rare, it is understandably distressing for the staff directly involved and also highlights the risks healthcare staff can be exposed to.

A 2017 report in the BMJ looking at crime figures obtained from UK police forces, showed a 9% rise in the overall number of recorded crimes committed on GP premises and health centres from 1,974 crimes in 2015-16 to 2,147 in 2016-17. The figures showed a rise in assaults, harassment and threatening behaviour, illustrating that physical attacks can just be the tip of the iceberg when it comes to dealing with challenging behaviour.

Incidents in primary care

Over a recent five-year period, the MDU supported members in primary care with a little under 300 case files involving threatening, abusive, or aggressive behaviour directed at GPs or their staff. We also receive many hundreds of calls a year from members on this difficult dilemma.

While it was reassuring to note from our figures that there did not appear to be an increase in incidents over the period, there was a disturbing level of aggression in many of the more recent events.

MDU members’ enquiries about inappropriate behaviour took a wide range of forms. Queries ranged from how to deal with patients who become verbally abusive often in response to their request for a particular treatment, prescription or sick note being declined because it wasn’t clinically appropriate.

At the other end of the spectrum were cases where GPs, nurses or administration staff were subjected to rape or death threats, work or personal property was damaged, or actual physical assaults occurred. Some members asked about being subject to abuse or threats on home visits.

In other instances threats were sent to home addresses, personal emails or personal mobile numbers of GPs, nurses or other practice team members. Occasionally these mentioned family members or details of the recipients’ personal life indicating that the person had carried out research into their background.

Causes of aggression

Patients can become aggressive or violent for many reasons. This can include an underlying medical problem or an acute physical or mental illness which causes a patient to behave in a way which is not in keeping with their usual character. Similarly, patients who are ill, scared or in discomfort or who feel their request isn’t being listened to 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.

Other patients have a history of difficult behaviour, even when there is no underlying problem to explain this. It can be possible with these patients 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. It is prudent to 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 patients’ waiting room, or on the practice website.

Warning patients

It can be difficult to know how to handle a complaint from a patient that you also want to warn about their behaviour. However, any warning should be dealt with separately from a complaint response.

The possibility of a warning 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.

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 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 giving 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 may also be helpful.

Protecting your privacy

With personal information being more easily accessible online, it is worth considering how to protect your privacy. Consider whether your home address, email address or connections with family members are accessible online including on business and company websites and in research papers you have published. 

Even if your social media security settings are high it is helpful to check what parts of your profile are publically visible – are you happy to have family members included in public profile pictures for example? Sometimes your social media profile is private but you can appear in lists of friends or tagged in photos on friends’ pages which are publically available.

Challenging consultations with patients or relatives are thankfully unusual but 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.

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