Here’s how to manage challenging patients, advises MDU medico-legal adviser Dr Kathryn Leask
Fortunately, most consultations in general practice run smoothly and patients are grateful for the support and advice they receive from their clinician. However, there are a small number of cases where consultations don’t go according to plan and patients can become violent or aggressive. This may occur in the consulting room or in public areas like reception or the waiting room.
Incidents of verbal or physical abuse towards staff are obviously upsetting and expose staff and members of the public to risks of harm. The MDU receives a number of reports from its members each year where staff have been threatened or have been subject to aggressive behaviour.
Here, we suggest ways to manage these risks and to keep staff safe.
1.Anticipate challenging behaviour
There are some patients who have a history of challenging behaviour, which may be due to physical or mental health problems. It may be possible to put measures in place when you know these patients are due to attend the practice or to ensure that staff are alert to the need to deal with them quickly and sensitively should they attend the practice unannounced. There are other patients, however, who may have no history of challenging behaviour or who are new to the practice. It is easy to be taken by surprise when these patients become abusive or aggressive.
Where it is clear that a patient or their carer is unhappy or frustrated it is important to show a willingness to listen, asking open ended questions and giving them an opportunity to air their concerns. If possible, take them to a quiet area away from other patients but be aware of your own personal safety. This may include giving careful thought to the layout of consulting rooms that may be used to interact with patients, or the use of panic buttons.
The practice should also have a policy in place setting out how abusive and threatening behaviour from patients should be dealt with. This should be made available to staff and patients by posting notices on the waiting room notice board and on the practice website, for example.
2. Warn patients
Where a patient has behaved inappropriately, you may wish to consider issuing a warning. This should set out why their behaviour was inappropriate and should bring the practice’s policy to their attention. A warning gives a patient the opportunity to reflect on and amend their behaviour and consider the impact it may have had on the staff at the practice.
The possibility of a warning should be discussed within the practice, and the discussion noted. In the MDU’s experience, warnings about behaviour or removal from a practice list can result in a complaint. It is therefore helpful to be able to demonstrate that the decision taken was reasonable and proportionate.
The GMC and the standard GP contract usually require a warning to have been issued before a patient is removed from a practice list. However, if there has been a threat of violence, or actual violence, it is appropriate to call the police and removing the patient from the practice list without prior warning may be possible. Consider carefully how much confidential information might justifiably be released to the police and seek advice from your medical defence organisation.
3. Carefully consider home visits
If a patient who is known to have previously been aggressive requires a home visit, a risk assessment may be necessary. If possible, it is better to avoid one member of staff going to see the patient alone and to arrange the appointment at a time when staff numbers and workload enable more than one members of staff to attend.
Any previous poor behaviour from the patient or their carer should be addressed and a discussion of what the expectations of the patient or carer are should take place beforehand.
Where a patient becomes unexpectedly aggressive during a home visit, this can pose particular challenges due to the unfamiliar setting and lack of backup support. If the situation can’t be defused, it may be necessary to end the consultation and leave, particularly if there is an imminent risk of physical aggression.
4. Protect your privacy
As well as face-to-face and over the phone, aggression can also be displayed through other means such as email. It is important to make clear to patients how they can contact the practice and, if email is available, the appropriate address to use.
If a patient continues to use a member of staff’s personal work email address, it should be explained to them that this is not appropriate. They should be warned of this risk of correspondence going unchecked if that person is on leave and that continuation of this behaviour will result in their email address being blocked so no further emails will be received by the personal account.
Individual members of staff should also consider how to protect their own privacy, for example with social media sites like Facebook and Twitter. It is important to remember that even where privacy settings are high, it is not impossible for personal information to be seen or for information to become public.
5. Train up staff
Any member of staff can be subject to abusive behaviour and NICE has published guidance on how to manage violence and aggression in a healthcare setting.
One suggestion is for staff to have training so they know how to deal with difficult situations, particularly those that may escalate to aggression or violence. This could include, for example, conflict resolution training, which may assist staff in managing a difficult situation from the outset, preventing tensions from escalating further.
Where an incident does occur, it should be documented carefully but details should only be recorded in the patient’s medical records when a clinician feels that it is clinically relevant and important for the patient’s ongoing care.