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Violent protest: squaring up to the unacceptable face of healthcare

29 August 2008

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Mark Greener

Freelance medical writer,
journalist and editor

Mark, a former research pharmacologist, is now an award-winning medical writer and journalist. He has also published numerous medical economic papers in peer-review journals and is the author of 10 books on health-related issues

A man banging on the reception desk demanding attention is, unfortunately, nothing unusual in primary care. However, what followed in a Bristol practice during 2004 is, perhaps, unique. When the receptionist turned away, a patient saw the man “pull pills out of his pocket and, with a smug expression, drop a number of tablets into her cup of coffee”. The pills contained diazepam. He told police that he had spiked the receptionist’s coffee because she “looked miserable”.(1)

Spiking the receptionist’s coffee is thankfully unusual. However, assaults, violence and threats are an occupational hazard in primary care.

In one case, a man punched a trainee GP in the face. He then locked the consulting room door and continued the assault. The panic alarm was out of the doctor’s reach. But the doctor’s screams alerted other practice members, who unlocked the door and pulled the man away. The trainee sustained numerous injuries – including a badly bruised jaw and cheek, and lacerations to the forehead – that required seven weeks off work.(2)

The scale of the problem
Despite their benevolent intent, many healthcare professionals face aggression from patients or their relatives. In a national British Medical Association (BMA) survey, 97% of doctors reported experiencing verbal abuse, while 56% and 31% experienced threatening behaviour and physical assault respectively.(3) A quarter reported encountering verbal abuse more than five times a year. Thirty-five percent of doctors who experienced physical violence or abuse received minor injuries, while 5% sustained serious harm.(3)

According to the Department of Health (DH), NHS staff endured 60,385 physical assaults from patients and relatives in 2005 – roughly one for every 22 NHS staff members. The risk of physical assault was, broadly, the same in primary care and hospitals: one assault for every 65 and 68 staff respectively.(4) Violence is not just an occupational hazard for GPs: 92% of GPs reported witnessing abuse of receptionists, administrators or both.(3)

Perhaps not surprisingly, GPs in innercity and urban estates are more likely to experience violence than those practising in rural areas.(5) Moreover, professionals working in certain community settings – particularly mental health, geriatric care, and nursing homes – are especially likely to encounter aggression and violence.(6) However, violence can occur at any time, in any setting, from any one.

Patients are the most likely perpetrators, according to 94% of GPs surveyed by the BMA. However, 29% and 8% of GPs reported that patients’ families, friends or companions had perpetrated violence.(3)

The effects of violence
Apart from cuts, bruises and broken bones, aggression and abuse leave many victims mentally traumatised. Some, for example, develop post-traumatic stress disorder (PTSD), anxiety and sleep disturbances. Encountering aggression also potentially undermines performance and productivity, and increases absenteeism, security costs, the risk of litigation and staff turnover.(6)

In one study, after being victims of violence, GPs reported difficulties concentrating and listening to patients, as well as rumination and intrusive thoughts when in an enclosed space during consultations. The problems were especially marked during consultations with aggressive patients, their families or coworkers, and similar patients. Such symptoms are hallmarks of PTSD.(7)

Violence may also leave staff unwilling to face professional responsibilities. After an attack, some GPs admitted avoiding places where the violence occurred, such as house calls, hospitals, nursing homes and consulting rooms in which they felt “enclosed”.(7) In some cases, this reluctance might represent a breach of contract and could undermine patient care. Therefore after each assault the practice manager and professional concerned should agree strategies (such as making the consulting room less enclosed or chaperoning on calls) that allows that professional to discharge their responsibilities and rebuild their confidence.

Violence also imposes a considerable economic toll on the NHS. The National Audit Office (NAO) estimated that the direct costs imposed by workplace violence in the NHS reach at least £69m annually.(8) This “crude estimate” excludes the human costs – physical pain, psychological distress, stress and so on, as well as costs associated with reduced staff confidence and retention.

Causes of violence
Understanding the causes of violence often helps prevent aggression or defuses a situation before it escalates into a physical assault.(9) Unfortunately, aggression arises from numerous causes. It may be a symptom of a psychiatric or
neurological illness.

Some people use violence to promote personal interests or defend their values. Some may use violence to compensate for feelings of shame. Others may use violence to re-exert influence because they feel they are not in control of the decisions that affect them.(10)

Obviously, few life events potentially threaten a person’s interests as intensively as illness – a potentially fatal disease, such as heart disease or cancer, is the ultimate threat. Several diseases and medical interventions can engender feelings of shame (think of a sexually transmitted disease, erectile dysfunction, a cervical smear or digital rectal examination). Many people may feel they lack control over the decisions that influence their health.

Therefore to tackle violence, managers need to address environmental and personal factors. For example, in the BMA’s national survey, 55% of GPs believed that the violence arose from the perpetrator’s dissatisfaction with services. Furthermore, 49% and 31% of GPs believed that health-related or personal problems, and intoxication with alcohol, drugs or both, contributed to the violence.(3)

Responding to violence
Under the Health and Safety at Work Act 1974, practices should provide a safe environment and suitable staff training.(11) The NHS Counter Fraud and Security Management Service (CFSMS), BMA, Royal College of Nursing and UNISON have jointly developed a syllabus for conflict resolution training “to tackle violence in the NHS” and complement reactive measures implemented after an incident (see Resources). Staff should take refresher training every three years.

Managers need to consider the practice’s training needs. The NAO found “little evidence” that risk assessment had helped set training needs.(8) It also highlighted “wide variations” in the level and types of training, and the numbers and types of staff trained. In Northern Ireland, only 53% of GPs had received any training about dealing with violence from patients.(12) There is also a dearth of evidence-based information on which approaches to training are successful.(8)

To provide a safe environment, managers also need to address factors that potentially contribute to workplace violence such as lack of professional supervision, understaffing and high workload.(6) Insights into the causes of aggression can help managers develop programmes that address the underlying conflicts (such as threats to personal interests or values, shame and influence) that sow the seeds of violence.

For example, managers could consider developing “a comprehensive orientation package” for mentally ill patients. The pack would inform patients, relatives and partners about the team’s role in treatment. As McKinnon and Cross remark: “Communicating adequately with patients and their significant others is needed to clarify expectations and to avoid frustration and angry outbursts.”(13)

Such packs may help reassure patients and carers that the team will promote their personal interests and defend their values. It might also be worth considering whether other patient or demographic groups could benefit from similar packs.

Managers should communicate the zero-tolerance policy to patients in newsletters, posters and so on. However, they should also consider highlighting options for conflict resolution and arbitration to emphasise that there’s an alternative to physical violence.

Managers need to perform a robust, comprehensive risk assessment to reduce the likelihood of violence. A local policy should clearly articulate the strategies and tactics that the practice will employ to protect staff based on the
risk assessment.

Many practices have a policy; however, managers need to determine whether it’s fit for purpose. In its 2003 report, the NAO found that approximately 90% of trusts had violence policies.(8) In Northern Ireland, 70% of primary care practices had a “clear policy” about violence.(12)

Unfortunately, quantity is not always analogous to quality. The policies examined by the NAO included more than 20 definitions of violence.(8) In many cases, staff and other relevant parties did not contribute to the policy’s development and the documents had not undergone legal review.

The assessment should cover all of the surgery and the parts of the community where professionals deliver care. Knowing when and where attacks occurred is, obviously, critical to devising preventive strategies. In Northern Ireland, 42% of violent incidents occurred in the office, 26% in the waiting room and 12% in patients’ homes. Most GPs (77%) reported that incidents occurred during the working day. However, 12% reported incidents during out-of-hours care, and the same proportion reported abuse both during the working day and out-of-hours.(12)

One GP, following a violent attack, drew up three main suggestions:(2)

  • First, a “turn-bolt” lock on the consultation room door prolonged the attack; other staff needed to obtain a key from reception before they could intervene. The GP argues that if the consultation room has curtains, locks are not essential for privacy.
  • Second, placing the patient’s chair between the healthcare professional and the door gives the patient control of the room. The room layout should allow an escape route.
  • Finally, managers could consider punch locks to doors leading from waiting rooms to secure staff from public areas.

Indeed, there are numerous potential responses to the threat of violence in primary care (see Table 1), some of which are more appropriate than others. Managers could also consider panic buttons, attack alarms for community visits and even CCTV. They many also want to suggest chaperoning professionals when visiting local areas known for violence or that have a reputation for being unsafe.(9)


Nevertheless, managers need to be careful that some coping strategies that seem sensible are not counterproductive. For example, some practices consider installing protective screens, but removing barriers may reduce the number of violent incidents. And striking off aggressive patients can transfer the problem to another practice.(11)

Finally, managers should take advantage of the DH’s commitment to improving professional safety. In September 2007, the DH announced that NHS trusts in England would share £97m to help tackle violence and abuse against NHS staff. The DH plans to spend £29m on 30,000 safety alarms for lone workers that will help locate the user and link to a trained individual who can summon help.(14)

Other strategies include training in personal safety, conflict resolution and dealing with verbal abuse for all NHS staff who need it. At the time of the announcement, 250,000 staff had received conflict resolution training.

The DH also plans to employ extra local security management specialists in health bodies. Trained and accredited by the NHS CFSMS, these specialists take a local lead on security management. A centralised reporting system will allow the NHS CFSMS to identify poor performing trusts, analyse security weaknesses, and recommend targeted preventive measures.(14)

Why do we still ignore violence?
Nevertheless, the initiatives and the growing awareness have not yet translated into marked reduction in the risk of violence. The national BMA survey found results consistent with those reported five years previously, leading to the suggestion that “there has been little improvement in the situation of workplace violence among the medical profession”.(3)

Furthermore, in more than half of cases, the assault or abuse is simply ignored. The survey found that in 52% of cases, GPs or practices took no further action. Of those that took the issue further, 60% reported the incident, a third called the police and 22% removed the perpetrator from the practice list.(3)

Further action followed in 68% of cases in which the practice called the police. The DH notes that the number of prosecutions for violence against NHS staff rose from 51 in 2002/03 to 850 in 2005/06. However, the DH believes that “numbers are still too low compared to the number of assaults that are reported”.(4)

Several factors contribute to the under-reporting and lack of follow-up. Some healthcare professionals may worry that management may view the incident as a reflection of their incompetence. You may need to reassure healthcare professionals that this is not the case. Some healthcare professionals do not want the attention. Some need to complete complicated or inappropriate forms.(8) Managers need to deal with such concerns sensitively, and ensure that paperwork does not impose an unnecessarily high barrier.

Some professionals feel that the trust will either take no action or offer only inadequate support. However, in many cases, management does not feed back the actions they have taken to deal with, reduce, and prevent violence in the wake of an incident to the clinical staff. This lack of communication may further discourage reporting.(8)

Managers need to build trust, emphasise that the practice takes all events seriously and feed back to all staff members what action is planned and the outcome. Indeed, 65% of GPs reported receiving peer support after a violent incident in the BMA survey. Just 20% reported support from managers.(3) While prone to recollection bias, this may suggest that managers need to do more, and be seen to do more, to support healthcare professionals that face abuse.

In other cases, the trust or professional culture may accept a certain amount of aggression, abuse and violence as part of caring for distressed or mentally ill patients. It’s difficult to see, for example, the value of prosecuting a demented, aggressive patient after an assault.

However, while such motives are laudable, managers need to reinforce that under-reporting could be counterproductive, and stress they cannot take appropriate action unless they know the extent and the circumstances of each violent or aggressive incident.(15) Even if the professional does not wish the matter to go further, the incident needs review to determine if any preventive strategies or tactics could help prevent abuse in the future.

Despite the DH’s “zero tolerance”, aggression and violence remain an occupational hazard in primary healthcare. Indeed, despite a high profile, there seems to be relatively little reduction in the number of incidents. Managing aggression in the NHS, as with society more generally, requires a coordinated, multi-faceted response from managers and policymakers. Therefore, without an even more determined effort from managers, violence against professionals will remain the unacceptable face of healthcare.

1. Guy E. Standing up to violence against members of practice teams. Management in Practice 2006;4:7-8.
2. Langmead J. Safety of doctors at work: lessons learnt from personal experience. Br J Gen Pract 2008;58:439.
3. British Medical Association. Violence in the workplace – the experience of doctors in Great Britain. London: BMA; 2008. Available from:$FILE/Violence.pdf
4. Department of Health. Press release 10 June 2006. Available from:
5. Magin P, Adams J, Ireland M, et al. The response of general practitioners to the threat of violence in their practices: results from a qualitative study. Fam Pract 2006;23:273-8.
6. Camerino D, Estryn-Behar M, Conway PM, et al. Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study. Int J Nurs Stud 2008;45:35-50.
7. Coles J, Koritsas S, Boyle M, et al. GPs, violence and work performance – “just part of the job?”. Aust Fam Physician 2007;36:189-91.
8. National Audit Office. A Safer Place to Work: protecting NHS hospital and ambulance staff from violence and aggression. London: NAO; 2003.
9. Greener M. Violence in the workplace: don’t turn the other cheek. Nursing in Practice 2008;42:60-4.
10. Steffgen G, Gollwitzer M. Emotions and aggressive behaviour. Goettingen: Hogrefe & Huber; 2007.
11. Hobbs FDR. General practitioners’ changes to practice due to aggression at work. Fam Pract 1994;11:75-9.
12. British Medical Association. Violence in the workplace: the experience of doctors in Northern Ireland. November 2006. Available from:
13. McKinnon B, Cross W. Occupational violence and assault in mental health nursing: a scoping project for a Victorian Mental Health Service. Int J Ment Health Nurs 2008;17:9-17.
14. Department of Health. Press release 25 September 2007. Available from:…
15. Maguire J, Ryan D. Aggression and violence in mental health services: categorizing the experiences of Irish nurses. J Psychiatr Ment Health Nurs 2007;14:120-7.

NHS Counter Fraud and Security Management Service