Dr Vasumathy Sivarajasingam provides 11 top tips for preventing and managing violence and aggression in general practice
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Primary care staff have always been committed to delivering high-quality care, and have been at the forefront of healthcare throughout the COVID-19 pandemic, showing resilience in the workplace despite escalating demands, a lack of resources, and a diminishing workforce. Before the pandemic, the NHS faced significant pressure to ensure the safe and timely delivery of services; the pandemic has intensified these pressures, and the number of people on NHS waiting lists in England continues to rise.1
As waiting times increase and the care backlog remains unresolved, some people’s attitudes towards the NHS are changing—from supporting initiatives such as Clap for Carers to increasing dissatisfaction.1,2 GPs and practice staff have faced mounting aggression, abuse, and violent behaviour from patients.3–5 Furthermore, the adoption of new ways of working, such as telephone and video consultations, has opened new avenues for abuse.
In a 2019 report, the Health and Safety Executive (HSE) identified that healthcare professionals face a higher risk of violence at work than most people—in 2017–2018, healthcare roles carried more than three times the average risk across all occupations.6 This is borne out by the findings of the 2021 NHS Staff Survey, in which 14.3% of nearly 600,000 participants said that they had experienced at least one incident of physical violence at the hands of a member of the public in the preceding 12 months.7 In addition, a survey of GPs conducted in 2022 by the British Medical Association (BMA) found that almost 85% of respondents had witnessed verbal abuse directed at staff, and over 65% had experienced it themselves.8 This is despite the fact that incidents of abuse are often under-reported by healthcare staff.9 Indeed, many GPs and practice managers overlook threats and violence, although relatively common in primary care, until they or their staff are assaulted.9
In legal terms, public order offences contrary to the Public Order Act 1986 concern threatening, abusive, or insulting words or behaviour, or the display of visible representations, which:10–12
- are likely to cause fear of, or to provoke, immediate violence
- intentionally cause harassment, alarm, or distress
- are likely to cause harassment, alarm, or distress.
Those who use violence and aggression are punishable under criminal law relating to public order offences.11
In the primary care setting, work-related violence has been defined as ‘any incident where a GP or his or her staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, wellbeing or health’.13 Violent and abusive incidents are often associated with discontent with the service, alcohol or drug use, health-related or personal problems, and mental illness.9,14
In healthcare environments, it may be nearly impossible to completely eradicate abuse; nevertheless, employers and practice staff have a duty to assess, and take measures to minimise, the risk of harm.14,15 This article provides 11 top tips on reducing the risk of abuse and violence in general practice, and signposts useful resources to guide the implementation of preventive measures.
1. Understand the Consequences of Abuse
Workplace violence can have a significant and prolonged impact on an individual’s health and wellbeing,7,9 and can cause pain, distress, burnout, and depression.15–17 Reactions to violence can vary9 —from reduced confidence and increased anxiety to excess alcohol consumption and post-traumatic stress disorder.14 In severe cases, violence can even cause disability or death.16 Inevitably, incidents of violence and abuse lead to decreased job satisfaction, morale, and commitment to work.15,16 According to the 2021 NHS Staff Survey, violent attacks contributed to 46.8% of staff feeling unwell with work-related stress, and caused 31.1% to consider leaving the NHS.7
For employers, violence and abuse in the workplace can lead to a negative organisational image, resulting in recruitment and retention issues.16 The resulting absenteeism, raised insurance premiums, and compensation payments can generate significant costs,16 at a time when the NHS is already experiencing unprecedented staffing and funding pressures.
2. Know Employers’ Legal Obligations
Everyone has a legal right to be safe at work.18 Box 1 details the most relevant health and safety law, which applies as much to risks from violence and abuse as it does to other work-related risks.17–19 As employers, members of practice management are legally obliged to ensure that they follow this legislation,14,18 even when facing unsustainable pressure in the workplace.20
|Box 1: Health and Safety Legislation Relevant to Work-related Abuse17,18,20|
3. Implement and Share a Zero-tolerance Policy
The DHSC launched the NHS Zero Tolerance Zone campaign in 1999 which emphasised that aggression, violence, and threatening behaviour would no longer be tolerated in the NHS.13 Further to this long-standing policy, NHS England published the Violence prevention and reduction standard in 2021, which provides a risk-based framework for creating and maintaining a safe and secure working environment for NHS staff.21 It is intended to complement existing health and safety legislation, and help employers to safeguard their staff against abuse, aggression, and violence.21
It should be made clear to the public that violence against NHS staff is unacceptable—for example, many practices and hospitals have organised No Excuse For Abuse campaigns, or added information in their waiting rooms and on their websites about their zero-tolerance policy.
Staff should also be reminded that violence and intimidation are not to be tolerated, and be reassured that steps will be taken to tackle them.13 A practice policy should be created on abuse and consequences such as distress or injury.15 It may also be useful to add ‘staff abuse’ as a recurring item on the staff meeting agenda, allowing staff members to share their concerns.
4. Provide Training for Staff on Recognising and Tackling Abuse
Staff training can play an essential role in reducing the risk and incidence of violence.15 It should be considered as part of any risk assessment, and be appropriate to the risks encountered—for example, personal safety training for staff who work alone.15,22,23
NICE guidance on the management of violence and aggression in primary care settings emphasises that ‘health and social care provider organisations … should consider training staff … in methods of avoiding violence, including anticipation, prevention, de-escalation and breakaway techniques, depending on the frequency of violence and aggression in each setting and the extent to which staff move between settings’.24
When violence and aggression are being managed, the safety and dignity of both service users and staff should be prioritised,24 as all patients and staff have rights and responsibilities as outlined in the NHS Constitution.25 Training should therefore emphasise that approaches to minimising violence and aggression must respect patients’ independence, choice, and human rights.24
The need for training is not limited to clinical staff—often, patients’ anger and annoyance is directed at receptionists or other members of staff, who are less likely to be offered the relevant training.9 The Violence prevention and reduction standard stresses that ‘suitable and sufficient training and support [should be] accessible and provided to all staff’,21 a sentiment reflected by the HSE.22
5. Reduce Potential Triggers for Violence
Employers must assess, and establish measures to diminish, the risk of violence towards their employees.14,18,19,26 The work environment must therefore be made as safe and secure as possible. Examples of measures that may reduce the risk of abuse in primary care, such as increasing security and reducing environmental stressors, are shown in Box 2.9,20,22
|Box 2: Improvements to the Working Environment9,19,22|
6. Consider Installing Physical Security Measures
It may be beneficial for a practice to use physical security measures in areas where there is patient contact, such as in consulting rooms or reception areas; examples include:9,16,22
- panic buttons
- video cameras and closed-circuit television
- alarm systems, both personal and organisational
- coded security locks on doors.
For lone workers in particular, personal communication devices (for example, mobile phones, automatic warning devices, radios, or emergency alarms) are likely to improve protection, as they will help the lone worker to alert other staff to any issues.22
7. Introduce a Lone-working Policy
Lone workers are individuals who work without a colleague nearby, in direct sight, or within earshot. This can include people working in a building with others, such as a practitioner in a consultation room.23 In situations where healthcare staff work alone, such as on home visits, there is an increased risk of abuse from patients or the public, as these staff do not have the immediate support of colleagues.23 Lone workers therefore need extra consideration and training.22,23,27
Risk assessments and up-to-date policies are imperative for ensuring the safety of lone workers.14,22,23 A lone-working policy usually guarantees that more than one staff member is present in the building at any one time, in case their coworker encounters a challenging interaction. Lone-working staff should be aware of any policies and arrangements that are in place to protect them.23 Lone workers can also take practical steps to protect their personal safety, including by attending relevant training, continually assessing any emerging risks to their safety, and being familiar with all relevant safety measures.23
8. De-escalate Situations Where Possible
Staff should have knowledge of the skills and techniques required to anticipate and de-escalate behaviour that is likely to become violent or aggressive (whether for personal, mental, physical, environmental, social, or behavioural reasons).24 The ability to avert or defuse imminent violence and aggression when it arises, through techniques such as verbal de-escalation, is particularly useful.24
Most de-escalation models emphasise open communication between the aggressor and the de-escalator, and focus on conflict resolution.28 They tend to follow a three-step process of delimiting the situation (through ensuring the safety of everyone in the area), clarifying the patient’s concern, and resolving it.29 Box 3 offers some practical tips on de-escalation.28,30,31
|Box 3: Practical Tips on De-escalation28,30,31|
9. Learn What to do if a Member of Staff Receives Abuse
Report the Incident
It is important that all members of staff are encouraged, feel able, and know how to report any occurrences of abuse or violence. All incidents should then be investigated, and the original risk assessments reviewed, to see if further measures are necessary to reduce the risk of recurrence.15
Some members of staff may hesitate to report incidents of aggressive behaviour, or may even accept abuse as part of their job; they should be encouraged to report and record all incidents, including verbal abuse and threats, promptly and fully.16 Managers should inform staff that this is expected, and is for their benefit.16
In cases of physical assault, it is important to report the incident to the police immediately, even if the assault was carried out by a confused patient.19 Failure to report an incident may result in the refusal of a subsequent criminal injuries compensation claim.19 Verbal abuse can be as distressing as a physical assault, and should not be overlooked—threats to harm a member of staff should be taken seriously and reported to the police.19
Put a System in Place to Record All Threats or Acts of Violence
It is useful to keep a detailed record of all incidences of abuse in order to build a more complete picture of the problem, both locally and nationally.15,16 It may be helpful to use a critical incident book or database for this purpose.9
It may also be useful to keep a record of patients with a history of violence or with relevant conditions, so that staff can anticipate abuse more effectively. The HSE recommends that suitable systems should be in place for recording and exchanging information about service users who may be abusive.22
Decide What Measures to Take Going Forward
Each incident needs assessment. When abuse has taken place but a patient still requires care, it may be appropriate to discuss acceptable behaviour with patients and their families or carers.15 Policies for dealing with inappropriate behaviour should include a process for taking matters further and, in circumstances that continue to worsen and are not related to a physical or mental health issue, clinicians may have to withdraw all but emergency care.15 In the case of violence or threatened violence, particularly when the police are involved, abusive patients should be removed from the practice list immediately in line with BMA guidance.32
10. Conduct a Debrief for Victims of Abuse
Employers have a duty of care to provide timely and effective post-incident support for anyone who has experienced abuse or violence in the practice.14,15 After an incident, employers should:
- encourage staff members to discuss their experiences, and share information with the rest of the team16
- offer the person time off work—individuals’ reactions to an incident will vary, and they should be allowed to recover at their own pace16
- advise staff on how to access counselling services for emotional support16 —for example, members of the Royal College of Nursing (RCN) can access free, confidential support to help with emotional issues, both work-related and personal33
- provide information on legal support services in serious cases—some victims of abuse or violence may be entitled to compensation from the Criminal Injuries Compensation Authority if injured in England, Scotland, or Wales; the RCN offers longer-term support and advice regarding legal claims and NHS injury benefits15
- support other staff who may need guidance or training, especially regarding the care of any patient with a history of violence
- treat the incident as a collective learning experience—staff members can reflect on their own behaviour after each critical incident, regardless of their level of involvement; timely feedback can also be given to staff concerning any actions taken to prevent a recurrence.15
11. Utilise Available Resources
There are many useful resources that offer advice on the prevention and management of abusive incidents in primary care. Box 4 contains some examples.
|Box 4: Useful Resources|
HSE=Health and Safety Executive; BMA=British Medical Association; RCN=Royal College of Nursing; PDA=Pharmacists’ Defence Association
Abuse of healthcare staff is unacceptable, and should not be tolerated. Through careful planning, it is possible to mitigate some of the abuse experienced by staff, and hopefully avoid any violent situations.
It is essential to increase public awareness of the zero-tolerance policy towards abuse, and reiterate the importance of patients working together with healthcare professionals. When patients are better educated about the impacts of their actions, they will get the best from the service.
Dr Vasumathy Sivarajasingam
GP Partner, Hillview Surgery, West London