Dealing with Violent or Aggressive Patients
- Introduction
Medicare Francais has zero tolerance policy of all violence and aggression. This policy is for the protection of all staff, but also for the protection of other patients, their families, visitors, etc. In order to ensure that this zero tolerance approach is adhered to, it is essential to have robust policies and procedures in place. In General Practice, this will need to cover a variety of situations in which incidents could occur. Generally speaking, the majority of patients behave in acceptable or manageable ways, however the incidence of excessively aggressive or violent attacks may occur.
Medicare Francais recognises that there can be contributory reasons for patients behaving in difficult, challenging or an overly friendly ways, however, where this tips over into aggression or violence, the practice will adopt a zero-tolerance approach.
Medicare Francais aims to provide high quality healthcare and we will treat all patients with respect and dignity. In return we expect all our staff to be treated with respect. We will not tolerate abusive language, threatening behaviour, discrimination explicit or implied against any member of staff. Such behaviour may result in the offender being denied access to the doctor and/or further measures as appropriate.
1.1 Communication
The practice will communicate this policy by a variety of communication mediums e.g. a clear policy on the web site, the practice newsletter, the policy (sign) clearly displayed in the waiting area near to the reception desk etc
2.0 Aims and Objectives
The aims and objectives of this policy are as follows:
• To ensure adequate processes are in place for the protection of staff and patients
• To ensure staff are fully aware of their responsibilities when dealing with violent or aggressive patients
• To ensure that staff are fully aware of their rights when they have to deal with such incidents
3.0 Aggressive Patient
What is an aggressive patient?
The Health & Safety Executive1 defines work-related violence as: ‘Any incident in which a person is abused, threatened or assaulted in circumstances relating to their work.’
This could be from a patient (carer/ relative/ friend) who exhibits one or more of the following patterns of behaviour:
• Verbally abusive, offensive or intimidating in their behaviour towards staff
• Threatening physical violence
• Making excessive demands and/or maintaining certain expectations and failing to accept that these are unreasonable (e.g. wanting an immediate appointment and becoming aggressive when this is not possible)
• insisting that a member of staff is dismissed
• insisting that treatment is carried out on demand
3.1 Risk assessment
The HSE2 recommends a proactive approach to the assessment of risk from aggressive or violent patients. This could involve the practice team “walking through” the logistics of the reception area, identifying an escape plan(s), panic button protocol, security personnel support etc. The practice may wish to undertake a generic risk assessment which should consider the overall needs of the organisation, for example:
• general risks to staff from patients, service users and their relatives or visitors
• risks associated with the design of the work environment, ie layout of rooms, lockable doors, escape routes, alarm systems, access to car parks at night
• risks associated with lone working, whether working in the community or alone in work premises
• identification and testing of appropriate instructions, information and training
• identification, agreement and testing of security support arrangements.
4.0 Dealing with an Aggressive Patient
Patients can become aggressive for a variety of reasons, and it is always advisable to try to calm down the situation as early as possible, as this may prevent an incident. Being observant of patients/relatives is often the first sign that a difficult/tense situation is imminent.
4.1 Recognising the signs of an impending aggressive incident
The use of appropriate inter-personal skills in potentially difficult situations is essential.
Observation of the patient/client can help in predicting when aggression may occur. The following are some of the signs to look for:
• Staring, unblinking, uncomfortable gaze.
• Muscles tensed; jawline tensed.
• Facial expression
• Person balanced to move quickly
• Fingers or eyelids twitching
• Pacing about, uncomfortable stance, alternate sitting/standing
• Withdrawn on approach
• Voice-change of pitch or tone, use of insults, obscenities or threats
• Sweating
• Increase in rate of breathing
• Tears (crying)
• Offensive weapon carried or visible
4.2 Proactively diffusing a recognised condition
Having recognised such signs and assessed the potential of violence occurring, staff may feel they are able to diffuse the situation by using some of the following behaviours:
• Adopt an empathic, understanding approach, and attempt to show some affinity with the other person’s position – “I can see why you are upset about that”
• Use active NLP (neuro linguistic programming) – saying a small portion of a sentence back to the patient in the patient’s own words
• Avoid confrontation, do not argue but do not agree to reward their bad behaviour
• Speak and stand calmly with an open posture, but always remain balanced and ready to move away
• Do not move closer to the patient, even if they are speaking in whispers
• Try to distract the person from the immediate cause of concern by changing the course of the conversation – buy time to think, to plan, to obtain assistance – if possible, ask the patient to have a seat “while I go to see what I can do to help you” – this buys time and allows you to think of your options.
• Speak clearly, evenly and slowly and do not necessarily stop talking because the other person does not answer
• Even if the other person is very loud, do not raise your voice
• Try to identify the source (nub of their problem) of concern, acknowledge this and offer to help if possible
• Do not disagree where it is not necessary
• Do not give orders or use status or authority as a threat, remember your body language
• Never make promises which cannot be kept
• Never reward aggressive behaviour
• Do not make threats
• Be alert and send for assistance where necessary
• Be prepared to leave the situation if necessary to avoid injury
4.3 If the incident escalates further
If the aggressor continues or becomes more verbally aggressive, then the following process should be followed:
• If they continue with their aggressive behaviour, the receptionist should be clear in telling them that they will not be dealt with until they calm down.
“I am sorry (use aggressor’s name here if it is known), we do not deal with people who are being aggressive or abusive. I will try to help you but must *stop shouting/ *stop swearing/*stop being aggressive, or I will not be able to deal with you.
• Remain calm and clear and keep repeating that the behaviour is unacceptable. Insist that you are trying to help but cannot do so until they calm down. For example, immediately giving the aggressor what they have asked for just to end the situation, or the Practitioner agreeing to see the patient just “to keep them quiet”. This just sets a precedent which will repeat in the future and sets a poor example to on-lookers. If the patient continues/ does not desist, in the interests of safety, it is best to have another member of staff come to you at the desk. Staff should never isolate themselves with a potentially violent patient. The second member of staff may ask other patients (in queue) to step back while the current patient is being dealt with.
• If it is deemed appropriate, get a more senior member of staff to speak to the patient, again keeping calm and stressing that you are trying to help. If possible, move the patient to a side of the desk whilst being mindful about not isolating the member of staff or allowing the patient access to the receptionist/ reception area.
• If the aggressor refuses to calm down or refuses to leave when requested to do so, the risk assessment at 3.1 should have identified the additional security arrangements which will come into place at this point.
4.4 Repeated Incidents
If there are repeated incidents from a particular patient, then the practice should write to the patient warning them that no other incidents will be tolerated, and the patient will be removed from the list if this happens again.
Note that it is important to carry out this action once it has been written down. If the patient continues with this behaviour, even after the written warning, then they should be removed from the list for the sake of staff and other patients.
5.0 Violent Patients
Dealing with a violent patient requires a much more immediate response. It is good practice to test these procedures on a regular basis. As soon as a patient turns violent, then immediate action must be taken, as follows:
• Step back from the desk.
• Lock the reception door (may consider this door is locked as a matter or course)
• If the aggressive behaviour continues employ the additional security measures as described in 3.1
• If the patient is in the consulting room with a clinician, then the correct procedure should implemented (see app 2)
• Phone the police. Once violence occurs, it becomes a crime.
• If there are other patients in the vicinity, then there is a duty to protect them. If possible remove/instruct other patients in the vicinity to move to another part of the waiting area or another room away from the situation. The logistics of this action should be tested in a “dummy” run and the policy updated.
5.1 Staff support following a violent incident
• Staff directly involved in the incident should talk through the incident on a one-to one basis with the manager/partners/nurse
• Staff not involved in the incident should be briefed about the incident
• If the person affected is not employed by the practice then inform their line manager immediately after the incident
• The policy should be reviewed in light of the incident to update it with any additional learning points/changes necessary
• Following an incident of violence, the practice should hold a significant event meeting to decide if the patient should be removed from the list.
• If the patient is to be removed from the list, then the practice should now follow the procedure for the removal of patients.
6. Following an Incident
Every incident of violence or aggression should be recorded in the patient’s notes and additionally in a log specifically used for this purpose. This log should contain the following information:
• Patient ID
• Time and date of incident
• Nature of incident – particularly the trigger point (eg not able to get appointment)
• Perspective of staff member dealing with the incident,
• Names and statement of any witnesses
• Record of any actions taken
7.0 Removal of Patient from 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
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 our 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). Unfortunately, VPS service is not offered at the Medical Francais.
When it becomes necessary to remove the patient from the practice list, for reasons of violent or aggressive behaviour, then a specific process should be followed.
8. Discrimination to include Prejudice
Discrimination exists in all aspects of life, including in Health and Social Care. Everywhere we look, we see differences and these differences can lead to prejudice; a pre-formed negative judgement or attitude towards someone who is different to ourselves.
Prejudice may lead people to view certain individuals or groups as inferior, or to treat people different to themselves unfairly or to be patronising or to not consider the feelings, the opinions or the needs of people different to themselves at all. This results in discrimination, which is defined as the unjust or prejudicial treatment of different categories of people.
Discrimination can be based on many different characteristics, however, it is only unlawful discrimination under the Equality Act 2010 if you are treated or treat someone unfairly because of any one or more of the so-called protected characteristics.
These characteristics are:
- Age.
- Disability.
- Gender reassignment.
- Pregnancy and maternity.
- Race/ Ethnicity
- Religion or belief.
- Sex.
- Sexual orientation.
This does not mean that discrimination is not also happening based on other categories, such as:
- Socio-economic.
- Education level.
- Nationality (which is different to Race).
- Regional or national accent.
- Appearance.
Although these are not protected characteristics under the Equality Act 2010, public authorities* have responsibilities not to discriminate under the Human Rights Act 1998. The Human Rights Act also protects people from discrimination, but only in connection with their human rights under the Act.
This means people must not be discriminated against in their enjoyment of their human rights; therefore, the protection against discrimination under the Human Rights Act is wider than under the Equality Act. Whilst the Human Rights Act includes the Equality Act’s protected characteristics, it also protects people from discrimination because of other characteristics.
These are:
- Language.
- Political opinion.
- National or social origin.
- Property.
- Birth.
- Association with a national minority.
- Other status.
An example of where the Human Rights Act 1998 has been applied successfully to combat discrimination in Health and Social Care, and where the Equality Act 2010 could not be applied, is when a council had a policy to pay lower allowances to foster carers who were family members, compared to carers who looked after children who were unrelated to them.
The hearing found there had been a disproportionate difference in treatment on grounds of ‘family status’, which the council had failed to justify. This meant that the policy fell foul of Article 8 and Article 14 of the Human Rights Act 1998.
A public authority is an organisation which provides public services. This can be a public sector organisation, for example the NHS or social services. Private organisations or charities which carry out public services or functions are also called public authorities and this includes private care homes funded by a local authority.
9 Governance Arrangements
This policy will be approved by the Practice Manager. The Practice Manager will be responsible for notifying all staff of the process, ensuring all staff has up to date copies of the document and that the staff are following the processes documented within.
This policy will be reviewed 2 years from the date of publication
Medicare Francais 19/10/21
Review date : 18/10/22
