At the sharp end: handling patient violence

by Seren Boyd

Three doctors give their personal experiences of patient aggression and violence. While they seek to understand the causes of hostility, they argue it should never be ‘part of the job’ – and support from colleagues is vital

Location: UK
Published: Friday 20 August 2021
42257 patient aggression

Having been attacked in his surgery by a patient, GP Nazrul Hossain took legal action. He thinks the complaints process is weighted unfairly

Nazrul hossain HOSSAIN: ‘People can’t abuse NHS staff like this’

‘In our LMC [local medical committee] in London, we’re getting alerts three or four times a week of physically aggressive behaviour towards colleagues at the moment. It is bad now but I had previously raised it with my local MP in 2019.

‘Three years ago, a patient hit me on the head with a hard, wooden baton. He had come in effing and swearing twice before, and I hadn’t told him off, so he had become emboldened. I called the staff in as witnesses and we called the police.

'My head was painful for four or five days: there was some bone thickening of the forehead. But there is an advantage to having a thick skull in this job.

‘The police gave him a warning, but I wasn’t satisfied. Two MPs I mentioned it to agreed it was not acceptable behaviour. So, I sent a letter to the patient threatening legal action for common assault.

‘I got £700 from him about a month later, after he sought legal advice. The patient was more than 80 years old, so I didn’t want to be too harsh. But I think it’s important to send a clear message.

We’re in a very weak position as doctors

Dr Hossain

‘I do view this as a racist attack. How many white doctors has he hit on the head? In my last practice, where this happened, some of the Asian doctors and the black doctors were getting complaints, but none of the white doctors.

‘Sadly, we’re in a very weak position as doctors: the complaints system, for example, is very much weighed in favour of patients. There is absolutely nothing about staff protection, staff morale or staff emotional welfare in the complaints’ guidelines and protocols.

'If I have made a clinical mistake, then I’m quite happy to pay a fine. But if I am found not guilty of that complaint, I want an apology from the patient, and I want them to pay investigation costs.

scales illo

'And I may prosecute them for harassment in the small claims court.

‘I’m reasonably robust, but some of my colleagues get very upset, understandably, when there’s a complaint or physical threat. This is one reason why some doctors go back to India or Australia, and why there’s a workforce crisis: they’re annoyed with this country’s system.

‘It helps when there’s media coverage when people are prosecuted for assaulting NHS staff: that sets a legal precedent. I hope my experience does, too. I’m pleased they’ve put video cameras on ambulance staff, and I’ve suggested we should use video cameras in our consultation rooms, too. The message needs to get out that people can’t abuse NHS staff like this.’

 

Shaan Sahota is a foundation year 2 working in cardio-geriatrics at a London hospital, having spent part of her FY1 working in critical care with COVID patients

shaan sahota SAHOTA: ‘You’re there for the patient but we do need to support one another too’

‘I had a patient once who was slightly delirious and probably dying, and she told me, “Get away, get me a white doctor!” Because she was so unwell, I found it easier to think, “OK, you’re the person who’s hurt right now.” But I’d understand if someone else couldn’t see it that way.

‘In the last few months, I’ve seen two nurses attacked: one had something thrown at her, the other one was punched.

‘There’s so much frustration at the moment from families not being allowed in hospital and about what’s happened to non-COVID healthcare. Families are dumping their anger on whoever they can get on the phone. You need to do a lot of deep breathing.

‘This week, we’ve had quite a racist patient and I’ve heard a few people say, “I can’t treat that patient any more. She said the ‘N’ word.” That’s devastating to hear. But we can’t all respond like that, so you decide you’d better go and treat them. You’re not going to punish or judge them but I probably enjoy caring for them a bit less.

It’s really important that someone acknowledges what’s happened

Dr Sahota

‘I don’t think we were prepared for this in training. So much of it focused on caring for patients, making them feel heard.

'There was no practice for actually asserting a boundary with a patient who’s being completely out of order, and caring for your colleague.

‘When the nurse who had something thrown at her told us what had happened, the senior doctor said, “Oh, no, is he OK?” All his training has been geared towards what the patient needs. Of course you’re there for the patient, but we do need to support one another too. And we’re not doing that.

are you ok pic

‘It’s really important that someone acknowledges what’s happened, that there is some measure of justice. What I’ve found really hard is when people try to brush over it.

'It’s quite embarrassing when patients are rude to you. You think, “Did I do something wrong?” It can make you feel inadequate and angry and confused.

‘So, it’s really cathartic when someone helps you process it, and draws it into the collective, and says, “Hey, I saw that and it wasn’t right. Are you OK?” It’s the response of the people around me that makes me feel either protected or really alone.’

 

Anna Christina Morawski is a core trainee 2 in general psychiatry in London

Anna Christina Morawski MORAWSKI: ‘Do my non-medical friends have to deal with things like this?’

‘I’ve been held by patients in violent ways, or I’ve witnessed them throwing tea at someone’s face or pulling lanyards. People touching my hair.

'I’ve had swearing and threats to the point of desensitisation. Sometimes these are psychiatric presentations: sometimes it’s just antisocial behaviour, or frustration.

‘COVID has definitely added stress because people weren’t allowed to receive visitors, and our patients are admitted for months sometimes.

'And they weren’t allowed to go on home leave or to smoke either. All their support groups in the community had to stop during COVID too.

‘Our patients definitely tend to be a bit more agitated but that’s because within psychiatry, we have the legal power to temporarily strip them of their freedom to prevent them from causing harm to themselves or others.

'So they’re in defensive mode and they might say or do things they don’t mean. Many times I’ve had to remind myself they’re unwell.

‘During my first CT job in psychiatry, I had a lady who basically told me to “eff off” every single day for about five months because I had to take her bloods. Then, at the end of the five months, we did a review where I asked her again, “Is it OK, if I take your blood?” And for the first time, she said, “Yes, doctor, that’s fine.”

'Sometimes if you just stick with it, and you give people time, they’ll stop.

Patients are in defensive mode and they might say or do things that they don’t mean

Dr Morawski

‘When I was in medicine, I got kicked in the head by an elderly patient, on purpose. It was the middle of the night, so we just moved on.

'But I remember sitting at home later and thinking, “I’m on my third night shift, I just got kicked and I’m expected to act like nothing happened. Do my non-medical friends have to deal with things like this?”

‘In most scenarios people just put their feelings to the side and get the job done. But I wouldn’t be human if I said that it doesn’t have an effect on the energy and the disposition and the focus that you can provide, not only to your patients, but also to colleagues, friends and family.

‘I definitely feel a lot safer in psychiatry in the sense that whenever somebody is physically aggressive, they’re restrained, de-escalated and, if necessary, offered oral medication to help them calm down.

coffee spill

‘At worst, they might be injected and moved to seclusion. Having worked in A&E, I know that if somebody is being aggressive, you just have to cry for help and hope that security comes on time.

‘We need security checks and safety alarms (which we do carry in psychiatry), and we need training in communication skills – acknowledging how the patient is feeling is key. We also need to develop cultural competencies.

'Telling someone to “calm down” is quite disrespectful in some cultures. Also, in other cultures, people engage by touching each other, but some people might see that as aggressive.

‘More than anything, we need that feeling of teamwork, not just between doctors, but also including the occupational therapist, physios, nurses, everyone. Psychiatry has been unique for me in the sense that every single time I’ve had an issue with a patient, my consultant has stepped in: there’s always that feeling somebody has your back, rather than you feeling abandoned.’ 

The story so far