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I’m queuing up in eye casualty, waiting to request an urgent ophthalmology review for one of my inpatients. There’s a bright yellow sign at the reception desk. In capital letters, it warns me that threatening and abusive language will not be tolerated, and the trust has a zero-tolerance policy towards violence against staff.
You can’t really argue with that. No-one in their right mind would want to encourage yelling at nurses, or to turn a blind eye to people who spit at receptionists. The sign is management’s way of warning off patients who might otherwise get carried away. Surely it’s a good idea to remind the potentially aggressive punters to watch their Ps and Qs?
But what impact do these signs really have? The vast majority of people wouldn’t dream of being rude or threatening to hospital staff, while a small minority – the socially dysregulated, disinhibited or just plain unpleasant – will kick up a fuss regardless. The evidence that anyone will be deterred by a sign is non-existent.
Meanwhile, the effect such signs have on people’s interactions, and on the atmosphere of the clinic, is not necessarily benign. They implicitly suggest that violence is near and only constant vigilance keeps it at bay. Of course, you oughtn’t to be abusive to staff – but that really shouldn’t need pointing out. We don’t have signs reminding people not to urinate on the floor.
Old-fashioned council estates are often immediately identifiable, even where their architecture isn’t too obviously cheap and brutalist. One of the key giveaways is the proliferation of shouty signs: NO BALL GAMES. NO DUMPING. CCTV OPERATES IN THIS AREA. The rules themselves are perfectly reasonable, but the signs seem to suggest that the people living there are feral and need to be kept in order. In the haunts of the well-off, even if exactly the same rules apply, the prohibitions are far less prominent.
Nudge theory, a fashionable branch of behavioural science, suggests that the best way to get people to behave well is to make it clear that you assume they probably will. A sign that warns you against unacceptable behaviour does the opposite. If aggression has to be explicitly forbidden, then clearly it’s a possibility.
There are lots of ways we could cut down hostile patient interactions. Shorter and more predictable waiting times would help, as would waiting areas that don’t look as though they belong in a medium-security prison. Those things, of course, cost money, but putting up signs deploring the anticipated awfulness of the people we serve only contributes to a general feeling of threat, animosity and unwelcome. By all means have a zero-tolerance policy for the worst behaviour, but let’s start by expecting the best.
This is the first piece by our new Secret Doctor. Read more of the blog and follow @TheSecretDr on Twitter and on Facebook.
The Secret Doctor obviously doesn't live in the real world. The amount of verbal abuse, shouting and bad language that receptionists have to put up with every day, nothing to do with wait times or appointment availability, is unacceptable. Even as a locum GP, I often am in the position of comforting crying receptionists and having to step in to remind patients that bad language is unacceptable. Unfortunately we are in an area where we cannot do anything about it as our local council have allowed 20,000 new homes without any increase in GP facility.
Hypothetical scenario where there are no signs: Patient starts yelling abuse. Staff give warning. Patient continues. Staff refuse to treat patient based on a perceived risk to their personal safety. Patient becomes even more agitated because “you never said you wouldn’t treat me for a little argument”.
Staff abuse is all too common and it helps for patients to know their role when they have demands. It helps them set their own behavioural limits and allows distinction between pushy and harmful.
Another of the problems is the so-called 'zero tolerance' policy which is nothing of the kind. If patients are rude to our receptionists we have to write to them to tell them that their behaviour is unacceptable and only if the behaviour is repeated may we sanction them with removal from the practice list. This is clearly not zero tolerance.
All the fault of the liberals. Ban abusive patients. Simple Uber can do it why can’t the NHS.
What we need is evidence. A trial of no sign, shouty sign and nudge sign might resolve the debate?
Last contributor is completely missing the point. This blog, which I enjoyed, is not saying that abuse, verbal aggression etc does not exist. He/she is saying that putting up 'shouty signs' does nothing to prevent such behaviour , and may have the opposite effect. Correct!!
Yes, I agree with all of this. My Trust has, to my horror, just put up a sign saying that carrying weapons on Trust sites will not be tolerated. What message does that give to the 99.9% of our patients who don't carry weapons - 'There are people round you who may be or wish to carry weapons, and our defence of you is a sign'. I'm not saying we should tolerate abuse, threats or violence (although as a psychiatric intensive care unit consultant, I have to tolerate these every day), but I agree that such signs likely do nothing to help the problem and foster a generally negative environment. Some people are hostile and abusive - but some of them are in pain, anxious, confused by the labyrinthine NHS systems, waiting for hours, or even months for treatments, and sometimes, I'm afraid receive surly, uncaring or even rude 'care' from some professionals. I think they deserve some understanding and attempts to rectify what is causing their outbursts (if there is anything), as well as threats of being excluded from care.
Whilst appreciating your comments on ‘ zero tolerance ‘ signs ‘ I am afraid I for one do not agree fully with your observations that shorter waiting times and general decor of the reception area would decrease situations of abusive and insulting language of a minority of our clients.
Constant changes in the NHS increasing bureaucracy , advising on buying OTC medications - waiting list of hospital outpatient appointments , directive from NHSE which frustrate patients and this turns into unacceptable behaviour.
On a recent incident a patient not only shouted and insulted my staff members using unacceptable language witnessed by other patients who offered ‘ witness statements to confirm this incident’.
We have asked the patient to apologies to staff members to restore practice patient relationship .
This takes you away from your clinical work to ....
Problem is simple. People do not respect what they get for free. Make people pay.
About six months ago I was working late into the evening in my ED. I was aware of one of our security guards patiently trying to calm one of these abusive, aggressive patients you refer to. I took a wee bit more interest that usual in what is a common occurrence, because our guard had already had a chunk bitten out of his forearm earlier in the shift by a different patient. Without warning, patient number two delivered an uppercut to the guard, leaving him sprawled across an empty trolley while still being attacked. I ended up fighting in the ED with this man. I incapacitated him until the security guard and his colleague took over. Ten minutes earlier I had been wondering what antibiotic to prescribe for a septic patient and ten minutes later I was reducing a shoulder dislocation.
The police were informed, but neither attack resulted in a prosecution and shortly afterwards the guard resigned. The police are interested but are hamstrung by the system and hospital management are not interested al all, even though of course they say they are.
I read your story and was left thinking, 'who cares?' What is important is what abuse happens every day in out hospitals and surgeries, not whether someone's sensibilities are affected if they read a meaningless sign. What bollocks!
That attack sounds awful and as an A&E consultant I’ve faced similar. I’m very sorry it happened to you. But it doesn’t mean that nothing else is important, or we can’t have a civilised conversation about the way hospitals are designed or present themselves, or you dismiss a colleague’s views like that.
I think the Hospital environment is quite patronising in general, any effort to make it less so is welcome. I agree, shouty signs do not help.
I think the signs do help prevent some aggressive behaviour (clearly not all). Some people who for instance are worked up about having waited for hours in very delayed clinics becoming progressively more enraged may read them and be reminded to calm down when it comes to taking out their (reasonable) frustrations on staff. Staff who are being poorly treated can point out the signs as a non-threatening third party way of trying to calm patients down. I've actually not seen a shouty sign in the NHS, where I've worked they're mostly printed in a calming shade of blue with quite bland statements on. This seems a very non-issue in any case as I can't say I agree they make people feel threatened or unwelcome. The only people they should make feel threatened or unwelcome are those who think they can take their anger out on staff, and frankly that behaviour should be labelled as unwelcome.
I'm vaguely interested in those who support those signs: do they think they actually persuade people who think "I'm frustrated so I'm going to thump the next person I see" to suddenly behave in a more civilised manner? I'm guessing it's not going to happen. But for the rest of us who are sitting there trying to patiently pass the time, we look around and everywhere, in every direction, there's notices telling us that unless we pay heed, we're horrible people and we need to be chastised. This is no place for hope or pleasantries; expect no optimism or cheer in this waiting room. Abandon hope, and all that. Obviously I can't speak for everyone, but it makes me feel worse that I'm basically viewed as a potentially hostile and unwanted foreign entity by an organisation that has already couched itself as foreign and hostile.
I hasten to add that usually my experiences of the actual staff is absolutely the total opposite and that they're lovely and welcoming. But this doesn't create the ideal environment for either "them" nor "us", because it shouldn't be "them or us".
I'm not sure whether or not to add that I have on occasion experienced the wrong side of the security guards. Those times were due to autistic meltdowns, and whilst the cause and failure to diagnose in a timely manner are debates for elsewhere, the obviously (to me) hostile environment didn't exactly help. It would be very easy to blame me: don't be autistic, don't have meltdowns etc which is curiously enough my general aim because nobody wants an overly interesting life, at least not that sort of interesting. But when there's reason to be stressed sometimes it's difficult. And again, experiences are mixed. Generally the response has been appropriate (though ideally it wouldn't have been necessary, and calmer, more relaxed surroundings without eleventy billion distressed typewriter font notices saying "you are the enemy and we are watching you" may have helped) but there have been multiple occasions when those security guards have deliberately and repeatedly inflicted pain on the basis of "who's going to believe the nutter?" And in remarkable contrast to the zero-tolerance approach to assaults on staff, assaults on patients are indeed swept under the carpet even when escalated to a high level. So I guess the ALLCAPS notices everywhere you look are at least in keeping as far as the managers are concerned, but they malign and alienate patients and clinicians alike.