How to deal with aggressive patients

GP partner and trainer Dr Pipin Singh offers advice on ways to recognise and handle aggressive behaviour in patients while maintaining the safety of staff and patients

Practices may be experiencing an increased amount of aggressive behaviour from patients due to the impact of the pandemic.

A survey by the Institute of General Practice Management found three-quarters of practice staff reported receiving abuse on a daily basis, while four in five had needed to remove a patient and over 60% had called the police because of abusive behaviour.

Aggression can present in a number of ways and may be verbal or physical. It is often a manifestation of underlying stress, which may be linked to the patient’s physical or mental health, or both.

The increased prevalence at present may be linked to frustration around delays to treatment from secondary care or increased waiting times for investigations within primary care, alongside anxiety as a direct result of the pandemic.

The change in consulting model due to the pandemic may also be promoting increased frustration for those patients trying to navigate a slightly more complex system, particularly if lacking in digital knowledge. Frail elderly patients and those with learning disability may find it particularly difficult to send pictures, or use video or online consultations.

It is important to undertake training in recognising and handling aggressive behaviour in your practice, to help all staff manage it and gain the best possible outcome for both patients and your team.

Here I cover some tips to managing aggression and how to possibly de-escalate situations, while prioritising your own and patient safety.

Being prepared for aggressive behaviour

Your reception team can warn GPs and other staff about a frustrated patient or potential for a complex consultation or discussion, so make sure you all speak to your receptionists regularly and that you are available for them to communicate any issues to you.

If a patient has already shown signs of impatience or more overt aggression prior to a consultation, either on the phone or face to face, it is worth doing a bit of extra preparation before seeing or speaking to them, such as:

• Check the last few consultations
• Read any recent hospital letters, OOH letters, casualty letters
• Check results of any recent blood work or imaging
• Also check for alerts warning about aggression or previous violent behaviour or risk of carrying weapons
• Are there mental health disorders that may increase the risk of aggression, for example antisocial personality disorder?

These checks may help you to pre-empt the patient’s concerns and create a positive direction to a consultation focused on their goals. If it is flagged that a consultation has the potential to be more problematic and the patient needs to be seen face to face, this can be done with another member of staff as chaperone – either waiting outside the room or, if you have serious concerns, you are within your rights to have a chaperone in the consultation room with you. 

In that case, advise the patient in advance that another clinician will be present during the consultation. If they want to know why, practices will have different approaches but I would be open and honest and explain there is an alert that the patient needs to be seen with two clinicians, due to the potential risk they pose or have posed in the past.

Recognising aggression on the telephone

Signs of aggression during a telephone consultation include:

• Tone of voice – basically do they sound angry or calm? Is the patient using foul language?
• Is the tone of voice changing throughout the consultation?
• Are there any prolonged silences which may signify frustration?
• Can you hear anyone in the background that may suggest anger, frustration or that the consultation may not be going well?

It is also worth considering the following:

• Is there a history of aggressive behaviour? Do the notes suggest anything? Are there any alerts?
• Are there any recent consultations? Has anything been documented in previous consultations to flag a potential problem?

Being attuned to the above can help you to take a pause or check during a consultation to potentially re-orient the discussion, help regain trust on both sides and prevent any frustration from escalating.

Recognising aggression during face-to-face consultation

Again being attuned to any initial signs of impatience or aggression is important, so you can be prepared and remain in control of the situation.

• Does the patient appear frustrated in their manner, for example clasping head?
• As above, gauge the tone of voice – is it changing or is the person speaking loudly?
• Do you perceive any potential physical threat, for example a loud knock on the door, exaggerated gesticulation or slamming of door or furniture?

The first thing to remember if you pick up any potential aggressive behaviour is to stay calm and not react defensively. There are ways to get the situation back on track and reach a positive outcome.

Defusing aggression

It is important to acknowledge any genuine frustration a patient may be feeling. Empathy and listening are key skills in this situation. Stay calm and focus on identifying the source of the frustration. Try to elicit the patient’s thoughts and feelings and what they were hoping for from either their consultation or the situation that currently may not be going well for them.

Once you’ve got the conversation back on track, you can prioritise according to the needs identified:

• Is there an obvious solution?
• If not, are there any alternative options that may not yet have been pursued?
• Is continuity a problem? Frustration for patients can often be down to having to deal with multiple clinicians and it may be worth scheduling repeat appointments.

Managing ongoing abusive or threatening behaviour

There will be times you are unable to de-escalate a situation, or you have no opportunity to intervene to calm a patient down. If, for example, they are shouting or swearing at you or a member of staff continually, then you should politely but firmly ask the patient to leave the premises.

In this situation you should have a protocol in place to ensure another member of staff attends and that you keep a barrier between the patient and your staff and other patients, where possible.

If a repeated request to leave is ineffective then explain calmly that you will call the police unless the patient leaves directly.

Make a record of the incident and send the patient a warning letter; if it is a second offence the surgery is within its rights to remove them from the list – see below.

Safety is paramount

While it is important to be mindful of the potential reasons behind patient aggression and ways that it can be defused, the safety of your team and other patients is absolutely paramount.

Staff should call the police if there is an ongoing situation with a patient refusing to leave, or if there is any immediate threat to the safety of the team and / or other patients such as a weapon being branded.

If you perceive any threat to safety during a consultation, try to leave the room as quickly as possible.

• Make sure you’re aware of your emergency messaging system
• Know where your panic button is.

Removal of patient from a list

The BMA suggests that removal of a patient from a list for any reason should be a rare event, but you can do so where there has been disagreement between the practice and patient and an irretrievable breakdown of the relationship.

Earlier this year, NHS England updated guidance to say practices can also now consider deregistering patients who have ‘unnecessarily persistent or unrealistic service demands that cause disruption’, in order to better protect GP practice staff and their mental health.

(Other reasons are where a patient has died, moved out of the area or chosen to move to another practice.)

Ultimately if you cannot find a way forward, there is a violent patient scheme that you can refer patients to – usually run by another practice in your area that manages these patients under an enhanced service.

Dr Pipin Singh is a GP partner and trainer in Wallsend, Tyne and Wear

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