Violence at work: the experience of UK doctors

Transcription

1 Violence at work: the experience of UK doctors Health Policy and Economic Research Unit British Medical Association

2 Contents Summary...2 Introduction...4 Background...4 Method...5 Survey results...6 Discussion...18 Recommendations...20 References...23 Copies of this report can be obtained from the Health Policy and Economic Research Unit, British Medical Association, Tavistock Square, London WC1H9JP Tel: Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 1

3 Summary Aim The aim of the study was to explore the incidence of violence against doctors in an attempt to understand better the extent of such incidences and the impact such violence has on the lives of doctors. Method A national postal survey of 3,000 doctors was undertaken. Doctors were asked about their personal experience of workplace violence, in addition to their views and perceptions of violence in the workplace more generally. Findings Violence is a problem in the workplace for almost half of respondents and this is consistent for both GPs and hospital doctors. Differences do exist according to specialty of hospital doctor, with those working in A&E and psychiatry more likely to report violence as a problem in their workplace. More than a third of respondents have experienced some form of violence in the workplace in the last year. This is the case for both hospital doctors and GPs. Amongst hospital doctors, those working in A&E, psychiatry and obstetrics & gynaecology are more likely to report experience of patient violence. For the majority of respondents, the violence experienced was from patients or patients families/relatives. Around half of respondents knew the perpetrator before the incident took place. GPs are more likely to know the perpetrator or their family prior to the incident, compared with hospital doctors. Almost all those respondents who report experience of violence had been the victim of some form of verbal abuse in the past year, a third had experienced threats and a fifth physical assaults. The incidence of verbal abuse is by far the most frequent, with a quarter of respondents experiencing this form of abuse more than 5 times in the last year. The majority of violent incidents took place in the doctors office or hospital ward. Amongst GPs, the majority of incidents took place in their office or waiting room, whilst for hospital doctors, the most frequently cited location was the hospital ward. The most frequently stated reason for violence is that the perpetrator has health related/personal problems, followed by dissatisfaction with service provided, a history of violence/abuse or intoxication with drugs/alcohol. In a third of violence cases, no action was taken following the incident. A third of incidents were reported and in other cases the perpetrator had been removed from their patient list or the police had been called. Some form of support was received by less than two-thirds of respondents following a violent incident and more than half stated that the incident had not affected their work. More than a third of respondents had considered withholding treatment from a patient due to the threat of violence. 2 Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

4 The majority of respondents have not received any training on how to deal with violence from patients, although a third of doctors are worried about potential violence from patients. More than half of respondents have taken precautions against potential violence. The majority of respondents reported that they had witnessed violence from patients directed at others in their workplace in the last year. This was largely directed at nursing staff and receptionist/administrators and was in the form of verbal abuse or threats. A third of respondents were of the opinion that, as doctors, it was not possible to adopt a zero tolerance to violence. Reasons given for this opinion include the difficulties involved in both implementing and enforcing such a policy, the obligation of doctors to treat all patients, no matter what their condition, and the inherent problems of an over-stretched and under-funded healthcare system. Recommendations Measures to reduce violence need to be based on sound risk assessment and risk management underpinned by effective strategies and locally developed policies. A standard definition of violence must also be adopted to avoid confusion and misinterpretation. Under-reporting of violent incidents is a widespread problem amongst health professionals, particularly doctors. Recording of violent incidents should be encouraged and formal protocols should exist for documentation of violent episodes. Trusts and practices should provide a no blame environment, where staff do not feel guilty if they are the subject of violence and also know how to deal with it when it does occur. Reporting of incidents must be followed with appropriate action if the system is to be effective. De-briefing or counselling facilities should be offered, where appropriate. Tackling violence against doctors and other healthcare staff requires partnership working between local police, the relevant agencies and the media. Raising awareness of patients responsibilities and accepted behaviour will also contribute to a reduction in violence against doctors. A central priority should be the provision of training for doctors on the management of potentially violent situations. Training should be in place for all health care staff and should cover such issues as methods of restraint, communication, managing aggression and personal safety. Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 3

5 Introduction This report presents the findings from a national survey of 3,000 doctors on the incidence and impact of violence in the workplace. The aim of the study was to explore the incidence of violence against doctors in an attempt to understand better the extent of such incidences and the impact such violence has on the lives of doctors. This study is set against the background of increasing incidence of violence against the UK healthcare workforce in recent years. Background It has long been recognised that the health care workforce is at risk of violence in their working environment. According to the British Crime Survey 1, doctors and nurses are most at risk of threats and assaults in the workplace. In parallel with the increasing prevalence of violence in society, research suggests that doctors also perceive aggression towards them as increasing 2. Nevertheless, the true incidence of violence and aggression against doctors is difficult to determine from the literature. Recognising the danger facing many NHS staff on a daily basis, the government established a national target for reducing violence directed against its staff -a 20% cut by 2001 leading to a 30% fall by April In October 1999 the government launched a cross departmental campaign, the NHS Zero Tolerance Campaign, to reinforce the message that aggression, violence and threatening behaviour would no longer be tolerated by professionals and staff working in the health service. The two aims of the campaign were to (a) tell the public that violence against staff working in the NHS is unacceptable and that the government is determined to stamp it out and (b) to get the message over to all staff that violence and intimidation towards them are unacceptable and are being tackled. The definition of violence as used in the Zero Tolerance campaign 3 is as follows: Any incident where staff are abused, threatened or assaulted in circumstances relating to their work, involving an explicit or implicit challenge to their safety, well being or health. This definition includes verbal aggression or abuse, threat or harassment, as well as physical violence. Violence and abuse of staff in the NHS are both civil and criminal wrong. Violent or abusive behaviour infringes the rights that staff expect will be respected while they go about their daily work. In the United Kingdom, medical sites have been found to have the greatest risk of all workplaces for verbal abuse and threats to staff. Clinical areas most associated with violence are accident and emergency departments, psychiatry and general practice. A study of GPs in the West Midlands 4 found that two-thirds of respondent GPs had experienced abuse or violence and that 3 per cent had sustained minor injuries from assaults by patients in the previous year. In hospital settings, a recent study 5 found that a fifth of respondents reported having been assaulted in the previous year and the victims were predominantly nurses and staff working in medical wards. Mental health was found to be significantly worse among staff exposed to threats, and violence was found to be common in Accident and Emergency (A&E) departments 6. A survey of consultants in charge of A&E departments 7 attempted to quantify the incidence of violence and verbal abuse against A&E staff. The responses strongly suggest that these problems are extremely widespread and that anecdotal reports in the press only represent the tip of the iceberg. It is acknowledged 4 Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

6 that the degree of violence against doctors is difficult to quantify. Besides the rates among doctors, the measures must also include both the type and the frequency of violent incidents. This study aims to begin to bridge this gap in the evidence base. Method A postal questionnaire was sent to a total sample of 3,000 doctors. This was a stratified random sample of doctors from across the United Kingdom and included representation from all crafts. The questionnaire received a response from 30 per cent of the sample (890/3,000). Whilst the respondent sample is representative according to craft and specialty, it is slightly overrepresentative of females. In terms of ethnicity, the respondent sample is over-representative of doctors from White backgrounds and under-representative of those from Asian and Black ethnic backgrounds. Doctors were asked a series of questions about their personal experience of workplace violence, in addition to their views and perceptions of violence in the workplace more generally. For the purposes of this study, the definition of violence follows that used in the Government s Zero Tolerance campaign and is been defined as: any incident where doctors or staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health. Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 5

7 Survey Results Characteristics of Respondents Table 1 shows that respondents are fairly evenly divided by gender (56% males/44% females). Whilst the majority of respondents are of White ethnic origin (85%), 12 per cent are of Asian or Black ethnic origin. As mentioned above, the respondent sample is under-representative of non-white ethnic backgrounds. The age of respondents is wide ranging from 23 years to 77 years (average age 44 years). Table 1. Ethnicity of survey respondents (%) Male Female Total White Black Asian Other Total Table 2 shows that 57 per cent of respondents are hospital doctors, predominantly consultants (250/506) and 43 per cent report working in general practice, mainly as GP principals (326/379). The majority of GP respondents work in multiple partner practices. Table 3 shows the main specialties of those respondents who report working as hospital doctors. Table 2. Occupation of respondents (%) Frequency % Senior house officer Specialist registrar Consultant General practitioner* GP principal Other** Total No reply 5 * includes non-princpals, locums, registrars, assistants and salaried GPs; ** includes Associate Specialists 6 Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

8 Table 3. Hospital doctors by specialty Frequency % General medicine (& medical oncology) Psychiatry Surgery Paediatrics Anaesthetics Radiology (& clinical oncology) A&E Obstetrics & gynaecology Pathology Geriatrics Other Total No reply 40 Doctors perceptions of workplace violence Respondents were asked whether they thought there is a problem regarding the level of violence from patients in their current workplace. Whilst half of respondents (50%) stated that violence is very much or somewhat of a problem in their current workplace, a further 36 per cent state that it is not really a problem and 14 per cent state that it is not a problem at all. Table 4 shows that this perception is consistent according to type of doctor, with around 50 per cent of both GPs and hospital doctors reporting violence to be at least somewhat of a problem in their current workplace. Nevertheless, substantial differences exist according to specialty of hospital doctors, with 90 per cent of A&E doctors and 70 per cent of doctors working in psychiatry reporting violence as a problem in their workplace, compared with only around 20 per cent of doctors working in geriatrics and pathology (Table 5) Table 4. Extent of violence as a problem in workplace by type of doctor (%) General Practitioner Hospital Doctor Total Very much a problem Somewhat of a problem Not really a problem Not a problem at all Total Respondents were also asked whether they thought that violence from patients has increased over the past year in their workplace. Whilst the majority of respondents (61%) state that it has not changed, a quarter report that it has increased in the past year. Table 6 shows that GPs are more likely to report increased violence from patients in the past year compared with hospital doctors. Among hospital doctors, those working in A&E, obstetrics & gynaecology, surgery, psychiatry and general medicine are more likely to report increased violence in the workplace (Table 7). Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 7

9 Table 5. Extent of violence as a problem in workplace by hospital specialty (%) Very much Somewhat Not really Not a problem a problem of a problem a problem at all Surgery General medicine (& medical oncology) Psychiatry Obstetrics & gynaecology Paediatrics Anaesthetics Radiology (& clinical oncology) Pathology Geriatrics A&E Table 6. Whether violence has increased in workplace by type of doctor (%) General Practitioner Hospital Doctor Total Increased Decreased No change Not applicable Total Table 7. Whether violence has increased in workplace by hospital specialty (%) Increased Decreased No change Not applicable Surgery General medicine (& medical oncology) Psychiatry Obstetrics & gynaecology Paediatrics Anaesthetics Radiology (& clinical oncology) Pathology Geriatrics A&E Other Total Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

10 Doctors experience of violence More than a third of respondents (350/890) report that they have experienced some form of violence in the workplace in the last year. Respondents who have experienced violence are fairly evenly divided between hospital doctors (55%) and GPs (45%). Table 8 shows that a greater proportion of hospital doctors working in A&E, psychiatry and obstetrics & gynaecology report experiencing violence in the workplace in the last year. A higher proportion of Black and Asian respondents (46%) reported experience of violence, compared with respondents from White backgrounds (38%). The experience of violence reported is fairly consistent according to gender (males-38%/females-41%). For around half (51%) of respondents, the violence experienced was from patients and 34 per cent experienced violence from patients families/relatives. Other respondents report experiencing violence from patients friends or companions (14%) or from others (2%). Others included staff such as PCT managers, nurses and medical directors and colleagues (Figure 1). Table 8. Whether experienced violence in the workplace by hospital specialty (%) Yes No A&E Psychiatry Obstetrics and gynaecology General medicine (& medical oncology) Surgery Paediatrics Anaesthetics Radiology (& clinical oncology) Pathology Geriatrics Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 9

11 Figure 1. Perpetrators of violence against doctors (%) other 2% patients friend/companion 14% patient(s) 50% patients family/relatives 34% Respondents were asked about the number of times in the past year that they had experienced some form of violence or abuse. Almost all those respondents (95%) who report some experience of violence, had been the victim of verbal abuse in the past year, 44 per cent had experienced threats and 22 per cent physical assaults. The incidence of verbal abuse was by far the most frequent, with 25 per cent of respondents experiencing this form of abuse more than 5 times in the last year. This was followed by threats and physical assaults (Figure 2). The main forms of verbal abuse reported are swearing/abusive language (32%) and shouting (27%). A further 18 per cent of doctors reported verbal threats, 14 per cent reported personal intimidation and 5 per cent racial comments. Other forms of verbal abuse include spitting, sexual harassment and threatening behaviour such as hate mail and s. 10 Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

12 Figure 2. Frequency of experience by type of violence (%) 100% 80% Once only 2-4 times 60% 5-6 times 7-10 times 40% More than 10 times 20% 0% Verbal abuse Threats Physical assult Almost a quarter of respondents (22%) who reported violent incidents, experienced physical violence or abuse. These incidents range from being pushed and shoved, hit and punched to being threatened with a knife, broken glass, a chair and a computer screen. Among those doctors who had experienced physical violence or abuse, a third (32%) state that they received minor injuries as a result of the incident and 6 per cent reported serious injuries. It is often suggested that racial or political motivation lie behind violent incidents. However, only 5 per cent of respondents state that the incident of violence against them was racially motivated and 3 per cent stated that the incident was politically motivated. Table 9 shows that for the majority of respondents, the violent incident took place in the doctors office (28%) or hospital ward (23%). Among GPs, the majority of incidents took place either in their office or waiting room, whilst for hospital doctors, the most frequently cited location was the hospital ward or A&E. Other reported locations include out-patients clinic, car park, OP clinic, treatment room and health centre. Respondents also report verbal abuse over the telephone. For the majority of doctors, the violent incident took place during working hours (83%). Respondents were asked why they thought the violent incident against them had occurred. Table 10 shows that the most frequently stated reason is that the perpetrator has health related/personal problems (27%), followed by dissatisfation with service provided (26%), a history of violence/abuse (22%) or intoxication with drugs/alcohol (15%). Dissatisfaction with the service provided includes such reasons as patients high expectations of the NHS and of doctors to fix anything, refusal to prescribe, refusal to home visit or to operate unnecessarily and dissatisfaction with diagnosis received. Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 11

13 Table 9. Location where violent incident took place by type of doctor (%) General Practitioner Hospital doctor Total Hospital-A&E Hospital-ward Hospital-public area Your office GP waiting room Patient s home Other Total Table 10. Reasons for violent incident Frequency % Perpetrator has health related/personal problems Perpetrator was dissatisfied with service provided Perpetrator has a history of violence/abuse Perpetrator was intoxicated with alcohol/drugs Perpetrator received bad news Perpetrator was provoked Don t Know Other Total Note: more than one response may apply Around half of respondents (49%) knew the perpetrator before the violent incident took place, whilst 47 per cent state that they did not know the perpetrator. This differs somewhat by type of doctor, with around two-thirds (64%) of GPs reporting that they knew either the perpetrator or the perpetrator s family prior to the incident, compared with less than half (43%) of hospital doctors. Table 11 shows that in a third of cases (34%), no action was taken following a violent incident. Several reasons were given for the lack of action and include guilt and self-blame and acceptance of violence as part of the medical profession. The following comments summarise these reasons: Considered part of practice life, especially with drug addicts Culture does not encourage reporting, but says that we should put up with violence-partly so that we don t upset the relatives Did not want to go through the emotional upset any furthertried to forget about the incident 12 Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

14 I blamed myself for not being able to quell her anger and did not think to report the incident Not reported to police for fear of consequences Incident was not of sufficient severity or dangerousness-just a common occurrence Table 11. Type of action taken following violent incident Frequency % No action Incident reported Perpetrator removed from doctor s list Police called Other Total Note: more than one response may apply Nevertheless, a third (36%) of respondents did report the incident, usually to another member of staff such as GP partner, senior consultant, ward sister or practice manager. Many incidents were reported using an incident form or report. 14 per cent of respondents state that the perpetrator had been removed from their patient list. A further 16 per cent of respondents state that they had called the police or taken other action including calling security or direct attempts to resolve the incident with the patient or their family via letter or telephone. Following the violent incident, support was received by less than two-thirds of respondents (58%). This was largely in the form of peer support (40%). Managerial support (8%), counselling service (0.3%), and de-briefing (2.2%) were received by few respondents. Respondents were asked whether the violent incident had affected their work. More than half of respondents (56%) state that it had not. Nevertheless, a third (34%) of respondents state that their experience of violence had affected their work. In many cases the reported impact was both psychological and physical and includes increased stress, becoming wary of particular patients, such as those addicted to drugs/alcohol or with mental health problems, greater awareness of personal safety and a secure environment, disillusionment, increased anxiety, loss of confidence and enthusiasm for treating patients. All respondents, regardless of whether they themselves had experienced violence, were asked whether they had ever considered withholding treatment from a patient due to the threat of abuse or violence. More than a third (39%) of respondents had considered withholding treatment and this is consistent for both GPs (41%) and hospital doctors (38%). The government has called for training of NHS staff to deal with violence from patients, however the majority of respondents (70%) have not received any such training. Figure 3 shows that almost a third of doctors (29%) are very or fairly worried about potential violence from patients, whilst only 15 per cent are not worried at all. Respondents working in general practice Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 13

15 are more likely to be worried about patient violence (35%), compared with doctors working in hospitals (24%). More than half (54%) of respondents have taken precautions against potential violence. Panic alarms/buttons are the most widely adopted precaution, but others include chaperones on home visits or consultations, attention to room layout, self defence training and CCTV. Figure 3. Concern about potential violence from patients (%) 60% 50% 40% 30% 20% 10% 0% Very worried Fairly worried Not very worried Not at all worried Violence in the workplace Almost two-thirds (61%) of respondents report that they had witnessed violence from patients directed at others in their workplace in the last year. This was largely directed at nursing staff (36%) and receptionist/administrators (33%) (Table 12) and was in the form of verbal abuse (69%) or threats (23%). According to Table 12, violence towards nursing staff is more likely to occur in a hospital setting, whilst the incidence of violence against receptionists/administrators is greater in general practice. 14 Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

16 Table 12. Work colleagues at which abuse is directed by type of doctor (%) General Practitioner Hospital Doctor Total Nursing staff Receptionist/administrator Other doctors Porter/cleaner Other Total Note: more than one response may apply The government has launched a Zero Tolerance campaign to reinforce the message that violence against health service staff will not be tolerated. Respondents were asked whether, as doctors, they thought that it was possible to adopt a zero tolerance to violence. Whilst more than half of respondents (52%) state that it is possible, a third state that it is not possible and a further 15 per cent were unsure. Respondents who agreed that it is possible to adopt a zero tolerance to violence were generally of the opinion that any form of abuse or violence is not acceptable and rules should be put in place to enforce this. Many also stressed that the Zero Tolerance policy must be made clear to all patients and members of the public if it is to be effective. The following comments illustrate the key themes: Zero tolerance is an attitude. It will not always work, but makes a statement Any form of abuse is unacceptable and strict rules are needed Enforce the message to patients that treatment is conditional on certain behaviour on their part If everyone takes firm decisive action against a violent situation and the perpetrators are disadvantaged in some way they will be less inclined to be violent Refusal to treat those who are abusive/violent is entirely appropriate Stop all violence, it is unacceptable. Clinically ill patients can be dealt with effectively if active support from security staff is present Ultimately we cannot withhold all treatment. However NEARLY zero tolerance should certainly be adopted On the other hand, a third of respondents are of the opinion that the Zero Tolerance campaign is not possible or effective and is only a political tool, which is difficult to both implement and enforce. Several respondents are of the opinion that as doctors, they are obliged to treat all Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 15

17 patients, no matter what their condition and hence adoption of zero tolerance is virtually impossible. Increasing patient expectations is seen to be a problem. Many respondents are of the opinion that violence is an inherent problem in an already over-stretched healthcare system and that it is the underlying issues such as long waiting lists and lack of staffing that need to be addressed. The key reasons against adoption of a zero tolerance policy are illustrated by the following comments: In A&E abuse is part of the job if you don t like the heat, get out of the kitchen Difficult to balance the health needs of individuals against risk of violence Difficult to justify refusing to treat someone in urgent need of medical help, who is violent. Doctors are to treat the sick not to practise self defence Government jargon-underlying causes must be addressed such as long waiting lists, mental illness, lack of information and support following incidents Have to treat patients no matter what their condition Life is not black and white- it [zero tolerance] is a simple approach to a complex issue Patients still have to be treated-by the very nature of their problems they are unpredictable Respondents were also asked to suggest what could be done to reduce the incidence of violence against NHS staff. A number of common themes emerged from the analysis of these responses. Many respondents suggest that the key to reducing patient violence is improved communication with both staff and patients and increasing public awareness that violence will not be tolerated. Educating patients and increasing public perception of the limits of the NHS and promoting realistic expectations is also seen to be crucial: Inform public that violence is not acceptable and patients will be removed from GP s lists if violent or threatened in any way Make patients aware of zero tolerance BEFORE attending doctors/hospital More education by the government on patient and relatives responsibilities and a more realistic explanation of what general practice/healthcare can provide 16 Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

18 Increased security, enforced sanctions against violent patients and taking legal action where appropriate are key measures suggested to reduce the incidence of violence against healthcare staff. Patients must be aware that violent behaviour will not be tolerated and may result in enforced removal from treatment: Better sanctions against patients, ie. the right to withhold treatment for verbal abuse- I am sick of this. Improve general security measures-make it clear to violent patients that they are not entitled to treatment Patients and the public in general need to be made aware that any type of abuse or violence will not be tolerated. This message needs regular enforcement Many respondents suggest that the inherent culture of the medical profession needs to change from one of blame and guilt, to one of support. All staff must feel confident that if a violent incident does arise, they will have the necessary support and back-up and their colleagues will take the incident seriously: It s a blame culture, many staff, especially nurses are too afraid to stand up in case patients complain about them. Trusts must encourage staff to refuse to treat rude patients and support their staff in cases of complaints made by patients General cultural change-i see no reason why patients who are verbally abusive should not be addressed in the language they chose to use-without exception Give staff more confidence, back up and support- I sometimes feel that my consultants do not take violence and abuse seriously Have a clear supported hospital position so that staff at the coalface feel supported and do not feel that they maybe left in the lurch or criticised for their actions Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 17

19 Discussion Doctors experience of violence The incidence of violence against doctors is widespread and increasing for a variety of reasons. The results of this study show that more than a third of respondents have experienced some form of violence during the last year. The incidence of violence reported here is not confined to either general practice or hospital medicine, but is evident in equal measure across the different areas of medicine. Whilst the majority of violent incidents take the form of verbal abuse, threats and physical abuse are also frequently experienced by many doctors. In the majority of cases, the perpetrator is known to the doctor and the incidents largely take place during office hours in either the doctors office or hospital ward. The literature on violence in the workplace suggests that perpetrators are disproportionately drawn from those with health-related personal troubles, such as substance misuse or some form of mental illness 8. Whilst intoxication and illness are frequently cited causes of violence 9, the results of this study show that dissatisfaction with the service provided is an important factor contributing to the incidence of patient violence. Respondents suggest that high, often unrealistic patient expectations of the health service is a key factor contributing to the increased incidence of patient violence. As one doctor comments: Patient s expectations have been unrealistically raised by the government. When these expectations are not met, it is almost inevitable that people will become upset and intolerant and direct their anger at their doctor Consequences of violence Of equal importance with the violence itself, are the consequences for the victim and the general level of intimidation among doctors. Despite policies designed to promote greater awareness and encourage the reporting of violent incidences, under-reporting of both physical and verbal incidents remains a problem. Whilst explanations vary and individuals have different perceptions as to what constitutes violent behaviour, doctors have reported coping with aggression as part of the job and some feel too guilty or embarrassed to report events 10. Evidence from this study suggests that acceptance of violence as being part of the job is a real problem, and as a result, the incidence of violence is potentially more widespread than published statistics suggest. A variety of factors may lead doctors to avoid discussing or reporting that they have suffered violence or abuse: it might be seen as an inevitable feature of the job, suffering regular abuse may be seen as a consequence of poor doctoring skills, anonymity is sometimes sought because victims fear retribution; there may be concern to avoid publicity in case this presents doctors as legitimate targets. All doctors have been encouraged to be zero tolerant, not to see violence as a normal risk of the job and to make greater use of patient removal and the criminal justice system as punitive and deterrent sanctions. Nevertheless, doctors accounts of perpetrators of violent incidents were often medicalised in the sense that a medical framework was generally used to describe the factors that lay behind individual deviants behaviour and to categorise many incidents 11. Many NHS trusts still believe that staff are less likely to report violence and aggression than any other health and safety incident 12. Under-reporting is seen as a problem and reasons include 18 Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

20 staff perceptions that they will be seen to have failed and/or mishandled the situation or that it could be regarded as professional incompetence. Research undertaken by UNISON 13 on violence to NHS staff, found that less than two thirds of staff were encouraged to report incidents, between 15 and 20 per cent were discouraged from doing so and a third of staff were unaware of the reporting procedures. The possible effects of aggression on an individual are varied and likely to depend on the severity and frequency of episodes and the perceived vulnerability to further episodes. The health implications of violent incidents can be considerable and research suggests that doctors can develop psychological sequelae such as post-traumatic stress disorder, insomnia, agoraphobia, depression and fearfulness. Results from this study support these findings. Experiencing aggression from patients can also lead to changes in behaviour such as increasing prescribing or referring patients for further specialised hospital care. A third of respondents in this study report that the violence they experienced had affected their work and many had altered their working patterns as a result. There is a need to look also at the fear of violence because it affects the ways in which professionals work and deal with situations where they may be at risk. Results from a recent study 14 of GPs suggests that 2 out of 3 GPs reported being afraid of becoming a victim of violence while undertaking their work. Results from this study show that a third of doctors, both GPs and hospital doctors, were worried about potential patient violence and have taken precautions against this and 40 per cent of respondents had considered withholding treatment from a patient due to the threat of violence. The perceived vulnerability to further violent episodes may also lead doctors to seek long-term sick leave, poor staff morale and higher than necessary staff turn-over. Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 19

21 Recommendations Measures to reduce violence must be based on sound risk assessment and risk management underpinned by effective strategies and locally developed policies. The National Audit Commission 15 found that although 90 percent of trusts have policies, the content varies considerably and staff and other relevant parties are often not consulted in designing them. There is also a need to adopt a standard definition of violence, such as that used in both this study and the Government s Zero Tolerance campaign, to avoid confusion and misinterpretation. Despite guidance recommending such a definition, the National Audit Commission reports more than 20 different interpretations were still in use. Reporting Incidents and Action Under-reporting of violent incidents is a widespread problem amongst health professionals, particularly doctors. Whether due to heavy workloads and the lack of time, the culture of the medical profession or the lack of official policies and procedures in place, all health professionals must be encouraged to report incidents of violence and abuse. The Royal College of Nursing 2002 survey 16 noted that although most cases of serious physical assault were reported, in nearly 80 per cent of cases, there was no outcome from the action. They concluded that unless appropriate action was taken through feedback to staff, then under-reporting would continue to be a problem. It is recommended that trusts and practices should be providing an environment where staff did not feel guilty if they are the subject of violence, but also know how to deal with it when it does occur. Recording of violent incidents should be encouraged and formal protocols should exist for documentation of violent episodes. Reporting of incidents must also be followed up with appropriate action if the system is to be effective. As one doctor states: Its frustrating that we get treated this way when a)we are trying to help and b) we are doing our jobs and c) little is done to prevent it or follow-up One of the ways suggested to minimise the psychological effects following a violent incident is to follow an early de-briefing model, employing counsellors with specialist skills. Counselling, either formal or informal, should be offered without fear of breaches of confidentiality and a formal aftercare and reporting procedure followed routinely 17. Interventions Clearly, there needs to be a balance between the amount of security that can be put in place, the operational requirements of trusts and general practices and creating a patient-friendly environment. In general practice in England, there is a requirement on primary care trusts to provide secure surroundings in which GPs can offer general medical services to patients known to be violent. A recent BMA GPC survey showed that many of the PCTs had not met this requirement. Ideally, practices and trusts should be planned in such a way so as to minimise the risk of violence and contingency plans should be established to manage incidents before they occur. However, this can be a complex process, because a range of emergencies may arise in most settings and there may be many ways in which a task can be performed safely. One suggestion is that on wards and similar units, different shifts could be approximately matched for experience. Evidence suggests that relatively inexperienced and unskilled staff tend to be at higher risk of violence and so competent and experienced staff are needed on all shifts. Staff need to know how to defuse potentially violent situations and how to disengage themselves if 20 Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors

22 they are actually assaulted. Planning and training in specific interventions can reduce the likelihood that violence will occur, or increase the chance that the incidence can be defused or contained safely. 18 Increasingly, there are various interventions available to trusts and practices to deter violent and abusive behaviour from patients. The Zero Tolerance campaign includes written warnings to patients (yellow cards) culminating in withholding treatment (red cards) from patients who are repeatedly violent or abusive. Nevertheless, this guidance exempts patients who are mentally ill and may be under the influence of drugs and/or alcohol, even though they are often the perpetrators of such incidents. Tackling violence against doctors and other healthcare staff requires partnership working between local police, agencies such as the Home Office, Crown Prosecution Service, Social Services and the media. The launch of the NHS Zero Tolerance campaign is an example of attempts to increase partnership working. Furthermore, widespread publicity of the issue, together with education and communication across all groups, including both patients and healthcare staff, is crucial. Raising awareness of patients responsibilities and acceptable behaviour will also contribute to a reduction in violence against doctors. Training A recent report of the National Audit Office called for improved training for doctors in how they cope with violent patients. The appeal comes as figures show increased incidence of violence against health professionals in secondary care. Evidence suggests that only half of all doctors have ever received any induction training and are least likely to attend specialist violence related training courses, compared with nurses for whom three quarters have received induction training 19. This is particularly so for junior doctors, who are often on rotation and face conflicting demands on their time, making it difficult to attend such courses. Local induction training for all staff is crucial, including support staff such as receptionists and porters. A central priority now must be the provision and training for doctors on the avoidance and management of potentially violent situations 20. Training should be in place for all healthcare staff and should cover such issues as methods of restraint, communication, managing aggression and personal safety. A clear message should be sent out that violence will not be tolerated Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 21

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24 References 1 Budd, T, 1999, Violence at Work: Findings from the British Crime Survey. London: Home Office. 2 Hobbs, 1994, F.D.R, Fear of aggression at work among general practitioners who have suffered a previous episode of aggression, British Journal of General Practice, 50: Department of Health, Campaign to stop violence against staff working in the NHS: NHS Zero Tolerance Zone, Health Service Circular 1999/266, London. 4 Hobbs, F.D.R, 1991, Violence in General Practice: a survey of general practitioners views, British Medical Journal, 302: Whittington, R, Shuttleworth, S and Hill, L, 1996, Violence to staff in a general hospital settings, Journal of Advanced Nursing, 24: Cembrowicz, S.P. and Shepherd, J.P, 1992, Violence in the Accident and Emergency Department. Medicine, Science and the Law, 32: Jenkins, M, Rocke, L, McNicholl, B and Hughes, D, 1998, Violence and verbal abuse against staff in accident and emergency departments: a survey of consultants in the UK and Republic of Ireland, Journal of Accident and Emergency Medicine, Vol 15 (4): Elston,M, Gabe,J, Denney, D, Lee R and O Beirne, M, 2002, Violence against doctors: a medical(ised) problem? The case of National Health Service general practitioners, Sociology of Health and Illness, 24 (5): Hobbs, F.D.R, 1991, Violence in general practice: a survey of general practitioners views, BMJ, 302: Cembrowicz, SP, and Shepherd, JS, 1992, Violence in the accident and emergency department, Med Sci Law, 32: Elston,M, Gabe,J, Denney, D, Lee R and O Beirne, M, 2002, Violence against doctors: a medical(ised) problem? The case of National Health Service general practitioners, Sociology of Health and Illness, 24 (5): National Audit Commission, 2003, A Safer Place to Work: Protecting NHS hospital and ambulance staff from violence and aggression, Report by the Comptroller and Auditor General HC527 Session , The Stationary Office: London. 13 Committee of Public Accounts Second Report, , Health and Safety in NHS Acute Hospital Trusts in England, House of Commons: London. 14 Gabe, J, Denney, D, Elston, M, Lee, R and O Beirne, M, 2002, Violence against professionals in the Community, ESRC Violence Research Program, Royal Holloway, University of London. 15 National Audit Commission, 2003, A Safer Place to Work: Protecting NHS hospital and ambulance staff from violence and aggression, Report by the Comptroller and Auditor General HC527 Session , The Stationary Office: London. 16 Royal College of Nursing, 2002, Working well: a call to employers. RCN: London. 17 Sarte, J, 1993, Violence against doctors, British Journal of Hospital Medicine, 50 (1): Cembrowicz, S, Ritter, S and Wright, S, 2001, Violence in Healthcare: Understanding Preventing and Surviving Violence: A Practical Guide for Health Professionals, Second Edition, Shepherd, J (ed), Oxford university Press: Oxford. 19 Hobbs, FDR and Keane, UM, 1996, Aggression against doctors: a review, Journal of the Royal Society of Medicine, 89: Zahid, M.A, Al-Sahlawi, K.S, Shahid, A.A, Awadh, J.A and Abu-shammah, H, 1999, Violence against doctors: 2. Effects of violence on doctors working in accident and emergency departments, European Journal of Emergency Medicine, 6: Health Policy and Economic Reseach Unit Violence at work: the experience of UK doctors 23

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