How to handle aggressive patients
Knowing how to keep your cool when threatened with an aggressive patient while staying safe are invaluable skills, especially for sessional GPs in unfamiliar surroundings, writes Sarah Whitehouse
"What do you mean I can’t have any antibiotics?” shouted Mr T as he grabbed Dr S by the collar. “I’m sick of coming back and forth and getting nothing! You’re all the £&*%*$* same!” Mr T then spat as he threw Dr S towards the floor.
Thirty-year-old Mr T presented with a sore throat and cold-like symptoms. He had a history of violent behaviour – this was documented in his notes – but locum GP Dr S did not have time to read Mr T’s notes before calling him.
Mr T’s aggressive reaction may be a shocking example, but cases such as these are not uncommon in general practice.
During 2008-09, NHS trusts in England had one physical assault for every 61 primary care staff – 3,472 in total.
To avoid becoming another statistic, it is important to understand why patients may show aggression and learn how to manage them – before things get out of hand.
What makes a patient aggressive?
Patients often have very high expectations of a doctor’s power to treat them; when these demands are not met or are delayed, they become frustrated, anxious about their health and, sometimes, threatening or aggressive. Aggression can often mask poor communication or interpersonal skills.
Assaults on healthcare workers can be triggered by delays in treatment, restrictions, mistakes, a lack of privacy, and environmental factors, such as heating, noise or ventilation. Often, the angry patient may have personal problems, or a history of violence or drug or alcohol abuse.
Forewarned is forearmed
Violence can occur randomly, but in most cases there will be some advance warning during the consultation. Look out for agitation, an angry tone of voice, clenched fists and finger pointing or abrupt movements. Take action to remove yourself from the situation if any of these warning signs occur.
Sometimes, practices may have a “front-desk system” where alerts are recorded next to a patient’s name, eg, “Patient verbally aggressive towards receptionist”. It is important that a practice communicates these warnings with you, as a lack of communication can affect the quality of care that you can deliver and, ultimately, can threaten the safety of your consultation room. If a patient has a serious conviction, eg, for GBH, and this is in the public domain, it would not be a breach of confidentiality for the practice to alert staff to this fact, including sessional GPs.
Actions speak louder than words
Locum GPs often only have one chance to make a good first impression – and poor communication skills could result in an aggressive reaction from an agitated patient. Remember:
- 80% of communication is non-verbal
- stay calm, speak slowly and politely
- keep your voice at a conversational level
- maintain eye contact
- empathy can help. Show that you can understand the root of the patient’s anger, eg, “I know you feel angry about your long wait, but I’d like to try and help you with your chest pain.”
- it is possible to regain control of a potentially volatile situation by asking the patient a few questions, eg, who, what, why – to elicit their side of the story. By identifying the cause of the aggression, you might be able to deal with it
- maintain your distance from the patient
- never turn your back on a potentially aggressive patient, and always sit nearest to the door, in case you have to make a quick escape
- document all conversations and patient concerns carefully.
Patricia Jobson, practice manager at Deneside Medical Centre in County Durham, says: “Face-to-face confrontation doesn’t work. We make a rule of never saying “no” to a violent patient. For example, if we don’t have the drugs they need, we say we will look into it, or speak to the hospital consultant. Always offer alternatives.”
Aggressive behaviour is not necessarily a physical attack. Examples of unacceptable behaviour can include:
- physical violence
- verbal or physical abuse, threats or gestures
- discriminatory abuse
- intentional damage to practice premises
- sexual or racial harassment
- inappropriate emotional attachment to a doctor.
[Source: RCGP, Removal of Patients from GPs’ Lists: Revised Guidance for College Members, p3 (2004)]
Stay late, stay safe
Often, extended opening hours can leave doctors working alone. You should ensure that the work you do in extended hours is done safely.
MPS Educational Services conducted more than 100 Clinical Risk Self Assessments (CRSAs) at GP practices in 2009. Seventy nine per cent of practices experienced problems with security and personal safety for staff. Your practice has a duty, so far as is reasonably practicable, to protect your health, safety and welfare (Health and Safety at Work Act 1974).
Each practice should have their own policy for tackling violence, and follow local PCT guidelines. Simple measures can be taken, such as the installation of an entry buzzer system for use during extended hours.
You should know where to locate panic alarms, and what to do should one go off. MPS CRSAs found that 44% of practices experienced problems with panic alarms. For home visits, attack alarms can be of use to "stun” an aggressive patient for a few seconds, but cannot be a guarantee of assistance.
Removing patients from the practice list
In Good Medical Practice, the GMC states that: “In rare circumstances, the trust between you and a patient may break down, and you may find it necessary to end the professional relationship. For example, this may occur if a patient has been violent to you or a colleague, has stolen from the premises, or has persistently acted inconsiderately or unreasonably.”
If patients have been violent to any members of the practice staff or have threatened staff safety, the incident must be reported to the police straightaway. In these circumstances, the practice can notify the PCT and request immediate removal.
Even in these circumstances, the practice should inform the patient of the reasons leading to removal from the practice list, unless one or more of the following apply:
- it would be harmful to the mental or physical health of the patient
- it would put practice staff or patients at risk
- it would not be reasonably practicable to do so.
The practice is required to record this in the patient’s records and set out the circumstances leading to removal. Family members should not be struck off GP lists, unless there is a threat to the practice from the ex-patient as a result of keeping these patients on.
The RCGP states that: “Where violence has been an issue, the PCO has responsibility for ensuring that all patients can receive primary care services, if necessary within a more secure setting.” These are often known as violent patient services (VPS).
Recognising the signs
First impressions count. Sometimes, however, a patient will be angry no matter how you behave. If you put safety procedures in place, and treat all patients calmly and with respect, the occasions when heated discussions threaten to spill over into aggressive behaviour can be spotted, and stopped in their tracks.
Case study: Deneside Medical Centre
Deneside Medical Centre provides a violent patient service for practices in County Durham and Darlington. Practice manager Patricia Jobson says: “Our staff are trained in self-defence and counselling. Everyone knows where they have to be based when a violent patient is in the building.”
Violent patients are brought in at the end of the day so as not to put other patients at risk. They are treated the same as other patients – with respect. To ensure continuity they are treated by the practice partners. Locums and local out-of-hours providers are supplied with an updated list of Deneside’s violent patients to keep them informed.
Panic buttons at the surgery are linked directly to the police. Mrs Jobson says she usually tries to calm down a patient herself before the police come into the surgery, as this can further agitate violent patients.
At Deneside, a notice in reception stresses the practice’s zero-tolerance policy for verbal abuse. Mrs Jobson adds: “One of my ways of calming down an aggressive patient is by reminding them that the person they are shouting at is someone’s mother. I then ask them to consider how they would feel if someone shouted at their mother. That tends to make them stop and think. I always tell them to not blame the staff, but to blame the system.”
Mrs Jobson stresses: “We are a patient’s last resort – if we refuse to treat them, they have nowhere else to turn, except perhaps A&E. We can’t remove them from the practice list, as they would only be referred back to us. If we treat violent patients with respect, we expect the utmost respect in return.”
- NHS Security Management Services, National Violence Against NHS Staff Statistics 2008/2009
- NHS Security Management Services, Not Alone: A Good Practice Guide for the Better Protection of Lone Workers in the NHS, p19 (2005)
- GMC, Good Medical Practice, p21 (2006)
- RCGP, Removal of Patients from GPs’ Lists: Revised Guidance for College Members, p6, (2004)