What's the best plan of attack for aggressive patients?


It's important to make sure all staff in the practice are safe.  Most GPs have seen or experienced aggression at work, so it’s important to develop a whole-of-practice response to challenging behaviour.

One afternoon, the receptionist asks the practice manager to speak to a patient who is upset and disturbing everyone else in the waiting room.

The practice manager invites the patient to come into her room to discuss his complaint. He follows her in and shuts the door. Then she realises he is standing, with arms crossed, between her and the exit.

Unfortunately, this situation is becoming more frequent, prompting the need to address aggression in the general practice workplace.

According to a 2018 RACGP report, four out of five Australian GPs say they have seen or experienced violence in their workplace.

Most incidents involve verbal or written aggression, but physical assault, destruction of property, sexual harassment and stalking have also been reported.

This behaviour can affect any or all members of the practice team. While half of GPs or GP registrars have experienced verbal or written aggression from patients, one-third of other practice staff have reported similar incidents during their career.

A safe environment for all staff

Employers are legally obliged to provide, as far as is reasonably practicable, a safe working environment for staff.

For practice owners and managers, this includes identifying risks and then eliminating or minimising them as much as possible.

This involves steps such as: consulting with all members of staff, including casual staff; ensuring adequate training and information is available; putting appropriate policies and procedures in place; and ensuring compliance with these policies.

Some questions to ask yourself include: If there is a system for calling for help, how will this be triggered and who will respond? Does the casual receptionist know what steps to take if an alarm is raised? Do all staff have training in how to identify an issue and avoid inflaming the situation?

A whole-of-practice response

When planning strategies for managing challenging patient behaviours, it is important to think through the impacts for everyone in the practice.

A good prevention strategy is to involve all staff in thinking about how the practice team responds to an incident.

Similarly, thinking and talking about ‘near misses’ — not just when something has actually gone wrong — can help avoid incidents.

You will develop a more coherent, prepared and efficient team if you can create an environment where everyone feels confident raising concerns or contributing to strategies.

Also, think about how you would support your staff following an incident, should one occur.

Upon reflection

The practice manager in the previous scenario managed to calm the patient, but said it made her realise how easily the situation could have turned out differently.

If she faced a similar scenario again, she would stand aside to let the patient go in first and leave the door open.

Other staff could have then monitored the situation and assisted or sought help if required.

Setting limits

Sometimes doctors’ professional obligations might lead them to put up with poor behaviour.

However, it is particularly important for the team leaders to demonstrate the importance of following practice policies about employee safety and standards of patient behaviour.

Practice owners and managers also need to ensure policies are reviewed and updated regularly as circumstances change or new issues arise.

Ending patient care

Doctors are not compelled to continue the care of a patient where they hold genuine concerns about their own safety or the safety of staff.

However, this consideration needs to be carefully balanced with any care required by the patient, in particular a doctor’s duty to provide care in an emergency.

It is important to be confident that actions taken by doctors and the practice are reasonable in the circumstances. It is particularly important to take into account the fact that the nature of the patient’s illness may be contributing to the behaviours.

It may be that in some cases issuing a formal warning or developing a behaviour agreement with the patient would be the more reasonable first step.

Before making moves to end the doctor-patient relationship, it can be useful to contact your medical defence organisation for advice.

More information:

This article was originally published in Aus.Doc.PLUS on 21 March, 2019.

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