Dealing with Unreasonable, Violent and Abusive Patients Policy
Version: 1
Review date: 1/11/22
Edited by: D. Lewis
Approved by: Dr M Singh
Comments: N/A
The purpose of this document is to provide guidance to staff at this organisation on how to manage unreasonable, violent and abusive patients in the workplace in line with extant legislation.
At Carrfield Medical Centre, the directive is that at no time will any violent, threatening or abusive behaviour be tolerated towards staff, patients or visitors.
Whilst violence and threatening behaviour is often easy to label, abuse may take on many forms. For the purpose of this policy, abuse can be towards any service user, visitor or staff member and includes (but is not limited to) sexism, racism homophobia, biphobia, transphobia and ageism, or harassment or abuse on the basis of disability, marriage or civil partnership, pregnancy or maternity, religion or belief.
In addition, unreasonable behaviour is also unacceptable and, as such, needs to be managed appropriately and consistently. This organisation has a zero tolerance towards poor behaviour and is committed to reducing the risk to staff and other patients.
This document will illustrate the organisation’s commitment to the safety of staff, contractors and patients whilst explaining the requirement for staff to undertake training and report incidents effectively to ensure that appropriate action is taken against offenders. It is policy for Carrfield Medical Centre to press charges against any person who damages or steals organisation property or assaults any member of staff, visitor or patient.
This document will be updated as and when changes to legislation occur. Staff should refer to the legislative documents to always ensure relevance.
It is the responsibility of all staff to ensure they recognise, respond to and take the necessary action when dealing with any patient who is behaving in a violent, threatening or abusive manner towards colleagues, contractors or patients.
The following legislation supports this policy:
Specifically, the legislation states that an employing organisation has a legal duty to:
In the document entitled ‘work-related violence’, the HSE establishes the employers’ responsibilities in relation to preventing and managing violence in the workplace. Employers have a duty of care to protect staff from threats and violence at work.
The organisation aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have regarding the individual protected characteristics of those to whom it applies.
This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment.
Any incident in which an employee is abused, threatened or assaulted in circumstances relating to their work
The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort
The use of inappropriate or discriminatory words or behaviour causing distress and/or constituting harassment
Behaviour that is hostile, destructive and/or violent
Discrimination is the unfair or prejudicial treatment of people and groups based on protected characteristics.
The fear or dislike of someone, based on prejudice or negative attitudes, beliefs or views about lesbian, gay or bi people. This can also include denying somebody’s lesbian, gay or bi identity or refusing to accept it. Homophobia may be targeted at people who are, or who are perceived to be, lesbian, gay or bi.
The fear or dislike of someone who identifies as bi based on prejudice or negative attitudes, beliefs or views about bi people. This can also include denying somebody’s bi identity or refusing to accept it. Biphobia may be targeted at people who are, or who are perceived to be, bi.
The fear or dislike of someone based on the fact they are trans, including denying their gender identity or refusing to accept it. Transphobia may be targeted at people who are, or who are perceived to be, trans.
Further information can be found on homophobic, biphobic and transphobic behaviour can be found at Stonewall.org.uk.
There are many reasons why a patient’s behaviour may become unreasonable, including:
All staff at Carrfield Medical Centre may experience patients who are:
There are several factors associated with difficult and challenging interactions with patients, such as a lack of resources, waiting times and interruptions during consultations. For these reasons, the ‘demanding’ or ‘difficult’ patient can potentially consume a large amount of the clinician’s and manager’s time.
Inappropriate behaviour is defined as being unacceptable if:
Inappropriate behaviour does not have to be face-to-face and may take other forms including written, telephone or e-mail communications or through social media. This is covered in the Patient Social Media and Acceptable Use Policy.
Some examples of inappropriate behaviour include, but are not limited to the following:
What constitutes inappropriate or unreasonable behaviour could be viewed as a subjective matter. Therefore, to ensure objectivity and prior to any further actions being taken, incidents of inappropriate behaviour will be discussed with a member of the senior management team.
Any person, be they staff, visitor or service user, who encounters unreasonable behaviour will be fully supported by senior management.
It is acknowledged that a small minority of patients may become abusive or violent towards staff at Carrfield Medical Centre], making it difficult for the healthcare team to provide services. This organisation has a zero tolerance towards such behaviour and is committed to reducing the risk to staff and other patients resulting from such behaviour.
NHS England classifies violent or abusive behaviour as:
Classifications for assault are as follows:
A patient’s values, beliefs and circumstances all influence their expectations of their needs for, and their use of, services. Staff at Carrfield Medical Centre recognise that external factors that may influence a patient’s behaviour.
NICE Clinical Guidance 138 recommends that an individualised approach to providing care is required to improve the patient’s experience and to reduce the risk of the doctor/patient relationship breaking down.
Where interactions become challenging, staff are advised to discuss these more difficult consultations/conversations with their peer groups, seeking guidance where applicable and assurance that they have handled the situation in the most appropriate manner.
At Carrfield Medical Centre], clinicians must ensure that patients are aware that they may request a second opinion from another clinician, advising the patient how they can arrange this.
The following stepped approach to managing challenging behaviour will be followed:
To support any decisions made on behalf of the organisation, members of staff who experience patients who are challenging and make unreasonable demands must record the events as accurately as possible. Any record should be strictly factual.
In the first instance, and to maintain an effective relationship with the patient, it is recommended that the patient be spoken to by the clinician who is treating them. The clinician can provide reassurance to the patient about their condition and address any concerns.
A recommended approach to help in such scenarios is to verbalise the difficulty, such as:
“We both have very different views about how your symptoms should be investigated and that is causing some difficulty between us. Do you agree?”
Verbalising such difficulties may enhance the level of trust between the clinician and the patient, enabling feasible options for care and treatment to be discussed.
Clinicians will not be forced into giving a diagnosis or treatment if they are uncertain. This should be explained to the patient whilst also explaining that it is in his or her interest that the most appropriate solution be found and that it can take time to confirm a diagnosis.
Should the patient’s behaviour remain unreasonable despite the above actions having been taken, the matter will be referred to the practice manager who will then write to the patient using the template at Annex A.
The correspondence will, where indicated, also include links to relevant, evidenced literature or approved websites to enable the patient to carry out their own research.
Should the patient not be cooperating, or it is judged that their behaviour is not acceptable, then a further letter at Annex B may be more appropriate.
If a patient continues to act in an unreasonable manner despite being issued a letter about their behaviour, Carrfield Medical Centre may establish a ‘behaviour agreement’ that allows boundaries to be detailed and agreed to.
This agreement should be retained in the patient’s healthcare record and reference will be made to the agreement should the patients deteriorate once again.
A sample behaviour agreement can be found at Annex C.
Should the patient be non-compliant as per the behaviour agreement in a manner that contravenes the agreement then consideration should be given to removing the patient from the organisation list.
This final stage should never be taken lightly and will be agreed by the management team. The patient will be advised that the doctor/patient relationship has deteriorated to such a degree that there is no longer any trust between the parties and the relationship is not viable.
The patient will be asked to register at another organisation as detailed in the Removal of Patients Policy. Further guidance can be sought within the GMC’s ethical guidance for doctors on ending the professional relationship with a patient.
A sample letter can be found at Annex D.
Should any patient behave in an unacceptable manner, this should be reported to a member of the management team who will determine an appropriate course of action to deal with the issue.
As part of this process, the practice manager will investigate the incident and either:
Since 2020, all NHS-funded services under the NHS Standard Contract must declare twice a year that they meet the violence prevention and reduction standards.
Whilst aimed at our colleagues in secondary care, Carrfield Medical Centre considers these standards to be best practice and will aim to implement recommendations, where practicable, to support a safe and secure working environment for employees.
The BMA document, Preventing and reducing violence towards staff, suggests actions that employers may consider taking to reduce the risk of violence and protect their staff. Carrfield Medical Centre] will commit to the following:
An example infographic summarising violence prevention measures titled How staff can deal with aggression and/or violent behaviour can be found in the zero tolerance file
Whilst the above BMA link details the actions needed for staff members, consideration will also be given for visitors and service users and the support needed following any act of violence.
We do not expect our staff to tolerate any form of behaviour that could be considered abusive, offensive or threatening, or that becomes so frequent it makes it more difficult for us to undertake our work or help other people.
Therefore, management will follow the process at Section 4.1 and additionally support those staff members who are exposed to poor behaviour and act accordingly.
As for violence, offensive or threatening behaviour against staff members, the same standards of zero tolerance also apply should patients demonstrate unreasonable behaviour towards other patients.
Sample letters can be sought within the annexes to support any type of poor behaviour. These can be amended to suit any situation.
The organisation has adopted various panic alarms amongst its staff and within its premises, recognising the risks to the health and safety of staff that could arise from incidences of aggressive behaviour and this procedure enables staff to respond should a panic alarm be sounded by a member of staff.
There are several differing alarm types now in use within the organisation, including :
The existence of such alarms enables a member of staff to initiate a supportive response from within the organisation when they perceive themselves to be under threat or are experiencing aggressive behaviour.
Panic alarms are used to inform staff that assistance is required in situations of aggressive behaviour. Panic alarms are not to be used for emergency clinical situations as telephones are to be used for all non-aggression events.
All staff at Carrfield Medical Centre are given an overview of the panic alarms and how they work during the induction process.
This organisation uses EMIS which is equipped with a button on the top right-hand side of the screen. Activation of this alarm will send an alert to all users within the organisation, producing an instant message on each user’s computer screen.
A panic alarm should be used when an employee feels threatened by a situation involving:
All staff who work during periods of low manning within the building could wear a belt alarm, especially after the closure of normal clinics, i.e., extended hours and dependent upon the Lone Working Policy and/or risk assessment.
Should staff at any point feel threatened or sense that the situation may lead to an incident, they are to activate the alarm.
Upon seeing the alert from EMIS generated alarm then:
The specific nature of the incident will determine if:
Staff should always try to minimise the risk of harm to themselves and others.
In the first instance, a member of the staff should ask the perpetrator to stop behaving in an unacceptable way. Sometimes a calm and quiet approach will be all that is required.
Staff should not, in any circumstances, escalate or mirror the patient’s behaviour.
Should the person not stop their behaviour, or they cause damage or strikes another then the police should be called immediately.
Should it prove necessary to remove the person from the organisation then the police should be asked to attend. Staff should never attempt to manhandle the person from the premises.
The police should be called in instances where physical assault is likely or where weapons or drugs have been identified. It is the responsibility of the police to deal with patients who act in such a manner.
The organisation manager is required to notify the CQC of an incident that is reported to or investigated by the police as detailed within CQC GP Mythbuster 21: Statutory notifications to CQC.
In the event of a bomb threat or a suspected package and the information relates to a patient area, then the message is to be calmly discussed and subsequent evacuation procedures are to be commenced
Refer to the Bomb Threat and Suspicious Packages Policy.
A lockdown is a procedure used when there is an immediate threat to the building and its occupants.
Should there be any hint or if a credible warning or evidence of any ongoing terrorist activity, then staff must comply with the Stay Safe principles as detailed within the dynamic lock down procedure.
Stay Safe principles are:
Run
Hide
Tell
| Alarm types | Descriptions/locations | Deactivation instructions |
|---|---|---|
| Static – intruder system | Reception desk Office door Back door |
Turn deactivation key and ring control centre on [insert number], quoting password [insert password] |
| Portable | Units charging adjacent to desk 1 Sounders in corridors 2 and 4 |
Deactivation code on sounders is [insert code] |
| Computer screen software (button) | All screens when logged on | Administrator to reset |
Whilst it is acknowledged that organisations are permitted to remove patients in appropriate circumstances, the GMC’s Good Medical Practice states:
“You should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient.”
Furthermore, the GMC advises that organisations should consider the following as reasons for removal if the patient has:
The GPC advice relating to the breakdown a patient-doctor relationship recognises the complexity of the area. Specifically, it advises:
Removal should never be based on the grounds of race, gender, social class, age, religion, sexual orientation, appearance, disability or medical conditions.
Prior to seeking formal approval to remove a patient from the organisation list, the practice manager is to adhere to the following:
The letter template at Annex A is to be used and this advises that, should there be any further incidents of inappropriate behaviour, they will be removed and requested to register elsewhere
b. Removal
For instances where there is deemed to be a breakdown of doctor-patient relationship or should there be any repeat of the inappropriate behaviour within a 12-month period since the previous warning, then the patient can be removed.
The useful guidance from the BMA titled Removing patients from your practice list should be consulted coupled with the Removal of Patients Policy.
The process is further detailed at Section 7.5, Section 8.5 and Chapter 12.
Where removal has been found to be justified, the manager will:
NHS England will remove patients eight days after they receive the request. However, if patients require treatment at intervals of less than seven days, Carrfield Medical Centre is obliged to provide such treatments until the condition of the patient improves.
In such instances, removal will occur on the eighth day after treatment ceases or until the patient is accepted by another organisation.
In instances where patients are violent, abusive, threatening or have displayed signs of generally unacceptable behaviour, or where there are concerns for staff and other patients’ safety, the police are to be notified.
The organisation can have the patient immediately removed within 24 hours once they have notified PCSE by either telephone or email. Secondary or local commissioner approval is no longer necessary. However, the incident must have been reported to the police and the police incident number is to be supplied to PCSE either immediately or within seven days of the removal request (if not available when the request is submitted).
To request immediate removal of a patient, the practice manager is to refer to PCSE guidance and NHS England guidance.
The organisation must ensure that the reason(s) for removal is recorded in the patient’s healthcare record, along with any supporting documentation such as previous warnings or information leading up to the removal of the patient.
The responsibility for ensuring that the patient meets the criteria for immediate removal rests with Carrfield Medical Centre] as stated in the Primary Medical Care Policy and Guidance Manual – Section 7. The removal of a patient in these circumstances results in them being allocated to a provider of the Special Allocation Scheme (SAS).
All incidents are to be reported to the practice manager at the earliest opportunity. He/she will ensure that any subsequent reporting action is taken whilst supporting staff in the completion of the significant event report.
A factual entry is to be made in the patient’s healthcare record detailing exactly what occurred; the record should include timings, the build-up to the incident and details of staff members and witnesses present.
In addition to recording the information in the patient’s healthcare record, the staff member dealing with the patient is to complete a significant event report/form.
Further advice on significant events including understanding and acting on any lessons that should be learnt following any incident can be found in the Significant Event and Incident Policy.
Whilst it is acknowledged that a risk assessment alone will not reduce the occurrence of work-related violence, the subsequent actions following the assessment should do so. The findings of the risk assessment(s) will inform the procedures needed to enhance safety within the organisation.
The following constitute foreseeable risks to staff at Carrfield Medical Centre]:
HSE provide both Risk assessment for work-related violent document and a guidance document to support the management in dealing with violence within the workplace.
A template for conducting a risk assessment can be found at Annex E.
Effects on staff and patients
At Carrfield Medical Centre, it is understood that much of the abuse and episodes of violence are directed towards front of house colleagues. The senior management team will support any staff who are exposed to poor behaviour and act swiftly to manage the situation, including removing patients from the list where indicated.
Staff who experience incidents of violence, aggression or assault may experience subsequent after-effects which may require support from the team or external resources.
Debriefing refers to learning conversations that occur soon after an event and involve those who took part. This is also known as ‘hot debriefing’ or ‘proximal debriefing’.
The aims of debriefing are to:
The management team will support all staff members following any incident, no matter how minor it may seem. Both positive and negative points should be considered that can support organisation-level training in the support of any future events.
Should any patient be subjected to violent, abusive or aggressive behaviour then, as for staff members, they may need support and this may be from a clinical or non-clinical member of the team. It is likely that the minimum would be to have a debrief about the incident, although in many cases the police would need to be involved.
External support may also be required.
Should the police be called, or should a service user be injured following an incident then the CQC are to be notified and as detailed within Section 7.5 and CQC GP Mythbuster 21: Statutory notifications to CQC.
At this organisation, we use blue stream e-learning to support this process as part of our ongoing training commitment to providing a safe environment.
NICE have produced a document titled Safeguarding NHS staff from violent and aggressive patients and advises that by undertaking training, staff can ensure that they have the skills to defuse a potentially violent or aggressive situation. Staff training in de-escalation should enable staff to recognise the early signs of agitation, irritation, anger and aggression, use techniques for distraction and calming and ways to encourage relaxation.
It is widely accepted that at times patients may act unreasonably when attending or contacting the organisation. The effective management of such patients will give support to staff whilst also ensuring that the patient receives the appropriate level of care.
With violence or aggression, statistically, HSE advise that healthcare workers are four times more likely to experience this at work than in other vocations. Therefore, effective risk assessment and incident reporting is essential to support the organisation in the appropriate management of offenders, thereby reducing risk to staff, visitors and service users.
Further reading can be sought from:
NHS E
Violence prevention and safety
BMA
Preventing and reducing violence towards staff
At the sharp end: handling patient violence
On the receiving end: violence aimed at doctors
MDU
Dealing with challenging patients
[Address]
[Insert date]
Dear [insert name of patient]
This is to inform you that your [unreasonable/abusive/aggressive behaviour] on [date] at [place] is unacceptable to the practice. Please treat this letter as a formal warning that any such behaviour in the future will not be tolerated.
Any repetition of [unreasonable/abusive/aggressive behaviour] may result in you being removed from this practice’s patient list and you will be required to register elsewhere.
Yours sincerely,
[Signature]
[Name]
[Role]
For the partners
Dear [insert patient name],
As the [practice manager] of Carrfield Medical Centre, I am writing to you on behalf of the partners at the practice.
We value you as a patient and our aim is to always provide you with the best level of care. In order to do so, we need you to accept that it is not acceptable to [insert issue here, e.g., make repeated demands for information]. Members of the team have advised me that [insert information, e.g., “over the past [insert time frame] you have called the practice on [insert number] separate occasions to discuss your medical condition].
Your GP has informed me that they have advised you a number of times about managing your condition and that they have also written to you to clarify the advice given during your consultation.
If, during your consultation, you are unsure about anything your GP has said to you, please ask at the time. Your GP will happily explain everything to you to ensure that you are best placed to manage your condition.
Our doctors follow the guidance detailed in Good Medical Practice (2013):
Our receptionists are not permitted to give medical advice about your condition; the responsibility of your continued care rests with your named GP.
Should you seek a second opinion regarding your condition, please arrange an appointment requesting that the appointment takes place with a different GP and the reception team will facilitate this.
We have 1400 registered patients at Carrfield Medical Centre which generates a high volume of telephone calls throughout the day. It is essential that our resources are used appropriately if all of our patients are to receive the expected level of care.
Thank you in advance for your cooperation.
Yours sincerely,
[Signature]
[Name][Role]
For the partners
Dear [insert patient name],
As the practice manager of Carrfield Medical Centre], I am writing to you on behalf of the partners at the practice. We value you as a patient and want to continue to provide you with high-quality care and service you currently receive. To do so, we need to set boundaries and expectations that will foster an effective relationship.
It is hoped that this is agreeable and that we can improve upon our relationship to maintain the effective patient/doctor relationship that is required.
Please review and sign the agreement carefully. This agreement will be witnessed and retained within your healthcare record.
Agreement
This agreement is between [insert patient name] and Carrfield Medical Centre].
This practice will endeavour to:
In return, this practice will expect that you to undertake that you will do the following:
I also understand that failure to meet these expectations may result in the practice requesting that I register elsewhere at another GP practice.
I have read, understand and agree to the above listed expectations.
Patient signature
Date
Practice signature
Date
Witness signature
Date
Should you have any questions, can I ask that you please contact the main practice number and request a meeting with either myself or the lead GP
Yours sincerely,
[Signature]
[Name]
[Role]
For the partners
[Address]
[Insert date]
Dear [insert name of patient]
Further to my previous letter in [date], this is to inform you that your [unreasonable/abusive/aggressive] behaviour continues to be unacceptable to the organisation.
On [date] at [place] it was reported to me that you [insert incident] and today I have requested to NHS England that you be removed from Carrfield Medical Centre list.
Therefore, you will need to register at another organisation and…
[Delete as appropriate]
[this removal will take effect on the eighth day after the request is received by NHS England].
[or],
Should you need any assistance in finding another GP organisation, it is suggested that you visit the following website:
https://www.nhs.uk/service-search/find-a-gp
Yours sincerely,
[Signature]
[Name]
[Partner]
Risk Assessment and Control Form
Brief task description: [Interacting with violent or aggressive patients]
Organisation name: Carrfield Medical Centre Risk assessment reference:
Date completed: 01/11/22
| General risk description (Hazard/ consequence) |
Hazard rating | Likelihood (including relevant people, environmental and data factors as well as existing control measures) |
Likelihood rating | Risk rating | Additional control measures required | To be implemented By who? By when? |
Residual risk (Risk - after all additional controls are implemented) |
|---|---|---|---|---|---|---|---|
| Clinical and non-clinical staff interact with patients daily, were a person to be aggressive/ violent due to illness, mental health issues or a known history of violence and/or aggression, it may result in an assault, causing moderate harm to a staff member(s) or service user(s). |
3 | There are 1400 patients at Carrfield Medical Centre with a history of violence and aggression. Alerts are recorded on the clinical system for these patients For this patient cohort, chaperones are invited into the consultation When dealing with this patient cohort, clinicians ensure they have an escape route from the consulting room Panic alarms are fitted in each consulting room and all staff are trained to respond to said alarms The response to an alarm is detailed in the Dealing with Unreasonable, Violent and Abusive Patients Policy There have been no reported physical assaults on staff in the last 12 months There have been zero incidences of verbal abuse to staff in the last six months Staff are professional when dealing with the public/patients and are trained in de-escalation techniques |
3 | 9 | Add patient responsibilities to the organisation website Inform patients/public via posters on reasonable expectations and the potential outcomes that may result from abusive or aggressive behaviours Ensure a record of alarm tests is retained Ensure periodic training to staff is given regarding dealing with violent and abusive patients Debrief process established Posters are placed in public areas and on the organisation website advising that we have a zero-tolerance approach to abusive and violent behaviour Robust process in managing the different types of poor behaviour |
manager 01/01/23 manager 01/11/22 manager 01/08/23 N/A Manager future PLI 2023 manager [Date] manager 01/11/22 manager [Date] |
General Administration
| Risk assessor’s name: | Contribution to risk assessment by: | Manager approval |
|---|---|---|
| Dawn Lewis | ||
| Risk assessor’s job role: | Contributor’s job role: | Date of approval |
| Practice Manager |
This document was reviewed/updated by: D.Lewis
Job role: Practice Manager
On date: 01/11/22
Next planned review due: 01/11/23
| Risk Review Profile | Recommended risk assessment and risk controls review periodicity Guidance Note: The principle of review is that the more significant the risk level, the more often it must be reviewed. Always review if an incident has occurred: |
|---|---|
| If the risk is 15 – 25 (Very high) Review at least every 1 – 3 months | |
| If the risk is 8 – 12 (High) Review at least every 6 – 12 months | |
| If the risk is 4 – 6 (Moderate) Review at least every 12 – 18 months | |
| If the risk is 1 – 3 (Low) Review at least every 18 – 24 months |
