Clinical psychologist Dr Craig Newman explains the importance of not normalising patient abuse and suggests solutions to help staff deal with the emotional harm it causes
In primary care, patient interaction is central to every area of care, from first contact through to discharge. And whether or not this is fully understood, healthy interaction is as much needed by staff as it is by the patients.
However, these exchanges are being threatened by an alarming trend – the increasing patient abuse levelled at NHS staff. The unfortunate truth is that this abuse has become so pervasive it is in danger of being normalised. Failing to address this issue appropriately can lead to disengaged, burned-out staff, which can compromise the quality of patient care.
This article aims to help practices prevent that happening by providing clarity on what abuse is, what it isn’t and solutions to help staff manage its emotional and psychological impact.
Is abuse being normalised?
With the rising frequency of hostile encounters, there is a concern that GPs and other practice staff may not even recognise these incidents as abuse, viewing them instead as a part of their daily work. A disturbing symptom of this normalisation is staff dismissing abusive behaviour as ‘part of the job’, which is a perception that needs urgently addressing. In my work with teams, I often hear examples of abuse at staff couched within phrases such as, ‘our receptionist, who’s only 19’ or ‘she was only two days on the job when a patient told her X. This both dramatises the significance of the experience but also carries a hidden message, that older staff who have served longer in the job are perhaps more able to tolerate, or are less shocked by or emotionally unphased by abuse – which is, of course, not true.
Currently, there is a lot of focus in the media on abuse in the celebrity world. But what do we mean by abuse in healthcare?
Let me give a few examples I’ve been told about from staff we have supported, with a warning that this could be triggering for staff who have been abused:
- A receptionist who could not provide a GP appointment rapidly being told, ‘I hope you and your children all get Covid and die’.
- A manager being threatened with violence for refusing to provide a GP after a complaint was escalated.
- A nurse being physically attacked.
- A GP being shouted at and insulted during the entire consultation.
- Regular experiences of the words, slag, bitch, slut and more.
- Racial abuse at an ethnic minority staff member.
- Relentless shouting during a practice call, with no opportunity to respond.
This happens, many times daily, across primary care. It may be difficult to read, it was difficult to write – and so we can be sure, it is difficult to endure. Abuse is behaviour that causes someone emotional or physical harm. It creates fear, guilt, shame, anger and other feelings that are tough to experience on repeat in a work role. These are damaging to patient care and patient relationships if not adequately supported.
Abuse requires an organisational response that supports a staff member’s position. Being able to agree what abuse is, as an organisation, is empowering for staff. Then a good process to follow is identifying it, asking staff to report it and responding to it. This includes keeping accurate records of incidents, training staff to recognise and respond effectively to various forms of abuse, and creating a supportive environment where staff feel safe to discuss and report such incidents.
But it all starts with defining abuse well and helping staff develop strong communication skills. This empowers staff and over time, educates patients too.
Abuse vs difficult conversations
It’s important to be able to understand the difference between abuse and difficult conversations. Staff need to be capable of managing difficult communications – it’s part of their job – and be equipped with the skills to spot someone experiencing emotional difficulties and then support them so they have a positive encounter with the service.
However, we sometimes hear staff talk about patients in generally negative ways; expecting bad behaviour from them as the norm. They can also perhaps be too quick to end calls or snap back at patients who are presenting with medical needs that create difficult conversations.
Communication can be difficult in primary care – patients often have high fear, poor sleep, pain, neurological conditions and more. And a low threshold, resentment, low patient expectations and potential burnout experienced by staff can sometimes lead to a loss of the skills and compassion needed to support good communication, which is a vital part of the care we should be providing.
Alongside that, however, it’s critical that staff recognise when a conversation should move from supporting a patient’s needs, to supporting their own need to avoid abuse. It’s essential to be able to understand when abuse is abuse and be aware of how the practice responds to this. Staff need to feel that they aren’t just expected to learn how to tolerate it but that there is a process for managing it and support available.
Safeguarding Mental Health
Let’s look at some key support approaches for staff who have experienced abuse from patients.
1. Developing staff resilience
The best response is a proactive one. Train staff well in managing difficult conversations and provide them with a clear policy on how to respond to abuse that also includes a precise definition of abuse. This should outline exactly what they should say to a patient who is being aggressive, remembering that managers / GPs will have to support that response if a complaint is later raised. In roles where abuse is regularly experienced, rotate staff as much as possible to vary the work and give them time away from patient communications so they can reflect and process. Support staff if they need time out immediately after an incident.
2. Recognising the need for external support
There are various warning signs that can indicate a staff member might require external help to deal with the stress of patient abuse. These include mood swings, increased anxiety, loss of motivation, changes in sleep or appetite, or frequent physical illnesses. These can manifest as talking negatively about patients, being quick to see abuse in difficult conversations, being abrupt when communicating with patients and calling in sick repeatedly.
External support can take many forms, such as counselling or psychological services, stress management programmes, or support groups for practice staff. Employee Assistance Programmes (EAPs), if available, can provide confidential mental health services to employees. Practice staff should also consider reaching out to professional bodies and unions for additional support and resources. All of these are valid, when we recognise ‘abuse’, and we don’t minimise its impact.
3. Helping each other
Creating a culture of support among colleagues is essential. This can involve regular whole team check-ins with one another, providing a listening ear during tough times, and collaborating to find solutions to ongoing issues. Offering validation and an empathetic to a colleague who has experienced abuse can also go a long way towards fostering a supportive environment.
There are some less conventional approaches that teams adopt that can also work well, such as ‘abuse bingo’. We’ve seen teams turn abuse into humour and create an ‘abuse encounter card’ where a staff member wins a prize or a work break if they get a line or a full house! Humour, compassion, empathy and shared experiences are powerful for staff members – even more so if GPs, managers and clinical staff also share their experiences with the wider team.
4. Offering support between practices
Sharing best practice, resources, and experiences between different practice sites (perhaps across PCNs also) can provide a network of mutual support. Collaboration could involve regular inter-practice meetings, collaborative training sessions, and sharing of support resources that seem to work. Make a space that is dedicated to ‘how we cope with abusive patient interactions’.
5. Bringing in services for post-attack support
In the aftermath of a physical or particularly emotionally charged attack, practices might consider implementing services such as immediate counselling, trauma debriefing, legal assistance, and additional time off work. A structured plan for post-incident support can help staff to feel more secure and looked after by their practice team.
6. Getting policy and procedure right
We often advise taking a multifaceted approach to tackling the issue of patient abuse. In addition to the measures mentioned above, practices should aim to develop zero-tolerance policies for abuse, ensure that staff are aware of their rights, and work towards creating a culture of respect and safety. This involves training staff, fostering a supportive environment, and ensuring that there are proper systems in place to report and manage incidents.
Staff need to be familiar with your policies on abuse and be aware what behaviours will trigger them.
One approach we have seen work incredibly effectively is to note when a patient has behaved in an abusive way and they be given a one strike warning (as part of a zero-tolerance policy) by a GP partner when next seen. It should be communicated to all staff that this needs to be the consistent response.
In conclusion, patient abuse of NHS staff by patients should never be normalised or minimised. Recognising and addressing this issue is crucial to protecting the mental health of practice staff and, in turn, maintaining the best care for our patients.
Dr Craig Newman is an award-winning clinical psychologist and team coach who specialises in developing NHS teams and leaders, particularly in primary care. He authored the book ‘Leading Primary Care: Resilience, Team Culture and Innovation’. He is also CEO of a team development service, Aim your team.