Most consultations in primary care start and end well, with both doctor and patient satisfied that there has been a meeting of minds, and that the patient’s expectations have been met. This is similarly true of interactions between patients and other staff – practice nurses or receptionists, for example.
Unfortunately, in a minority of cases some consultations or interactions can escalate to aggression, or even violence. In 2015/16, for example, there were over 200 assaults on doctors, nurses and other NHS staff in England every day. While it is thankfully unusual to experience an aggressive or abusive patient or relative, these interactions are memorable and distressing.
Causes of aggression
Patients can become aggressive or violent for a number of reasons. Challenging behaviour can, in some cases, be explained by an underlying medical problem. Patients with an acute physical or mental illness may behave in a way which is not in keeping with their character when they are well. Patients who are unwell, afraid or in pain may react in an unpredictable way.
This can be a particular challenge. A patient whose behaviour has never previously given cause for concern can suddenly become aggressive if they feel that their request to be seen urgently is not being given sufficient priority by a receptionist, or if a clinician does not appear to be acknowledging their distress.
Other factors which may contribute to aggression include communication or language 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 troublesome 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, if possible, help may sooth a patient who otherwise could become aggressive.
Showing a willingness to listen, asking open ended questions and avoiding encroaching on the person’s personal space can also help to reduce tension. 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 in spite of 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 treated. This should be readily available, for example a notice in the patients’ waiting room, or on the practice website.
If it is necessary to warn a patient about their behaviour, then any warning should be dealt with separately from other issues – for example a response to a compliant. 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 helpful to be able to show 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.
Aggression or violence on practice premises are difficult to deal with, but the risks can be mitigated by having good staff training, as well as giving careful thought to the layout of consulting rooms, or the use of panic alarms.
An additional challenge is when patients become aggressive during the course of a home visit. The setting will be less familiar to the GP, and help may be less readily available. Trying to defuse the situation is an option, but it is also acceptable to end a consultation and leave, particularly if there seems to be an imminent risk of physical aggression.
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 there, to agree what behaviour will be acceptable, and to get a general feel for the patient’s mood may also be helpful.
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.
- Dr Farnan is an MDU medico-legal adviser