The purpose of this document is to provide guidance to staff at this organisation about how to manage unreasonable, violent and abusive patients in the workplace in line with extant legislation. This organisation has a zero-tolerance policy towards violent, threatening or abusive behaviour towards staff, patients or visitors.

The Health and Safety Executive (HSE) advises that healthcare workers are four times more likely to experience violence at work than those in other vocations and provides guidance in its webpage titled Violence in health and social care. 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.

It is the responsibility of all staff to ensure that 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. It remains a management responsibility to ensure that all staff have undertaken the necessary training to be able to respond appropriately.

Legislation to support this subject and further reading can be sought from Annex A.

This document should be read in conjunction with the Health, Safety and Risk Management Handbook.

Dealing with Violent and Abusive Patients, Conflict Resolution, Accident and Incident Reporting, Risk Assessments including COSHH and Significant Events & Safety Incidents – An overview eLearning are all available in the HUB.

1.2 Status

In accordance with the Equality Act 2010, we have considered how provisions within this policy might impact on different groups and individuals. This document and any procedures contained within it are non-contractual, which means they may be modified or withdrawn at any time. They apply to all employees and contractors working for the organisation.

2 Identifying challenging behaviour

2.1 Unreasonable behaviour

There are many reasons why a patient’s behaviour may become unreasonable, including substance misuse, should they be scared, anxious or distressed, or if they are frustrated, unwell or in pain. As a result of this, staff may experience patients who are either demanding, unwilling to listen and/or uncooperative.

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.

It should be noted that unreasonable behaviour may be directed at patients and visitors in addition to staff. A standardised approach is to be adopted to manage any episode of poor behaviour.

2.2 Inappropriate behaviour

Inappropriate behaviour is defined as being unacceptable if:

· It is unwanted by the recipient

· It has the purpose or effect of violating the recipient’s dignity and/or creating an intimidating, hostile, degrading, humiliating or offensive environment

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.

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 with a standardised approach being taken.

2.3 Violent or abusive behaviour

This organisation has zero tolerance towards such behaviour and is committed to reducing the risk to staff and other patients resulting from such behaviour. The HSE provides a definition of violence in the workplace in its guidance titled How employers can protect workers from violence and aggression at work.

While for staff, the Assaults on Emergency Workers (Offences) Act 2018 details the legalisation that supports those who work in general practice, Section 3 (1) (j) (ii) defines an emergency worker. Should violent or abusive behaviour be directed towards a patient or visitor, then ordinarily further action will be taken, including reporting the incident to the police as appropriate.

2.4 Classifications

Further details to support classifications of inappropriate, violent, abusive and assault can be found at Annex B.

3 Managing unreasonable and inappropriate behaviour

3.1 NICE guidance

All staff are to adhere to NICE Clinical Guidance 138 which explains that patients value healthcare professionals acknowledging their individuality and, by tailoring healthcare services for each patient, this can enhance continuity of care and build positive relationships, thereby reducing the risk of unreasonable and/or inappropriate behaviour.

3.2 Process to manage unreasonable and inappropriate behaviour

The stepped approach to managing challenging behaviour can be found at Annex C.

4 Managing violent, abusive or threatening behaviour

4.1 Prevention

NHS England’s Violence prevention and reduction standard (version 2) provides detailed guidance on actions that can be taken to support managing unreasonable and inappropriate behaviour. This organisation will aim to implement any recommendations to promote a safe and secure working environment for employees.

This organisation will also adhere to the guidance detailed in the BMA’s Preventing and reducing violence towards staff as well as the HSE’s workplace violence guidance.

Do’s and don’ts when confronted by violence:

DO NOT

Recognise your own feelings

Meet anger with anger

Use calming body language

Raise your voice, point or stare

Be prepared to apologise if necessary

Attempt or appear to lecture them

Assert yourself appropriately

Threaten any intervention unless you are prepared to act upon it

Allow people to explain themselves

Make people feel trapped or concerned

An aggression and violence preventative measures for staff poster is available.

4.2 Process to manage violent, abusive or threatening behaviour

The organisation does not expect any staff member, patient or visitor to tolerate any form of behaviour that could be considered violent, abusive or threatening or that becomes so frequent it makes it more difficult for the organisation to undertake its work. Action will be taken to manage this type of behaviour whenever it occurs, including inappropriate behaviour on social media.

Should the episode of behaviour be significant, warranting an immediate application to remove the patient from the practice list, the steps within the organisation’s Removal of Patients Policy are to be followed. The BMA document titled Removing patients from your practice list titled should also be consulted.

It should be noted that the same standards of zero tolerance also apply should patients demonstrate violence towards other patients or visitors.

Should an incident merit a warning, then the process at Annex C is to be followed. Furthermore, sample letters can be sought within the annexes to support any type of poor behaviour. These can be amended to suit any situation.

Guidance on the removal of a patient process is at Annex D.

5 Raising the alarm

5.1 Use and activation of an alarm

Panic alarms are used to inform staff that assistance is required in situations of aggressive behaviour. During induction, all staff are given an overview of the panic alarms available at this organisation and how they work.

Furthermore, staff will be advised during their induction of the alarm(s) to be used for a clinical emergency and actions taken should they feel threatened by a situation involving:

Verbal or physical disruption
Verbal aggression
Physical aggression or the threat of physical violence or mental distress
Physical violence
The receipt of a bomb threat or coming across a suspicious package.

· Any consideration of terrorist activity

· Planning for staff who work during periods of low manning should be considered

Further guidance can be found in the Health, Safety and Risk Management Handbook and as detailed further within this chapter.

5.2 Response procedure

Upon activation of the alarm or upon seeing the clinical system generated alarm then:

· All available staff should respond immediately

· Two members of staff will go to the incident location, proceeding with caution

· The first member of staff is to knock and then enter the room

· The second is to remain in the doorway, ready to summon additional support if necessary

The specific nature of the incident will determine if:

Additional staff are required for support
The police are required to attend and take any subsequent action
The situation can be resolved by the clinician with support from a staff member

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, then a nominated member of staff should be asked to attend, and an overview of the situation should be calmly detailed, preferably within hearing of the perpetrator. Should the person be acting in an unlawful manner, causing damage or assaulting another person, 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.

5.3 Police assistance

The police should be called in instances when physical assault is likely or when weapons or drugs have been identified.

The Practice Manager is required to notify the CQC of any incident that is reported to or investigated by the police as detailed within CQC’s GP mythbuster 21: Statutory notifications to CQC.

5.4 Bomb threats and suspicious packages

In the event of a bomb threat or a suspected package, the procedures detailed at Annex C and Annex T respectively within the organisation’s Health, Safety and Risk Management Handbook are to be followed.

5.5 Dynamic lockdown procedure

Should there be an immediate threat to the building and its occupants, staff are to adhere to the Stay Safe principles as detailed within Annex F to the organisation’s Health, Safety and Risk Management Handbook

5.6 Lone working

When considering staff who may be lone working, or those who work during periods when there is minimal manning, then actions within the lone working guidance at Annex L to the organisation’s Health, Safety and Risk Management Handbook are to be followed.

5.7 Deactivation instructions

All staff at this organisation are given training during induction and periodic refresher training on how to deactivate panic alarms and intruder alarms. Should staff be uncertain, they are to liaise with their line manager in the first instance.

6 Removal of the patient

6.1 Guidance

It is acknowledged that organisations are permitted to remove patients in appropriate circumstances as detailed within the GMC’s Ending your professional relationship with a patient and the BMA’s Removing patients from your practice list guidance.

However, removal should never be based on the grounds of race, gender, social class, age, religion, sexual orientation, appearance, disability or medical conditions.

Actions available to the organisation can be found at Annex D. A sample letter can be found at Annex H.

7 Reporting of incidents

7.1 Internal reporting

All incidents are to be reported to the Practice Manager at the earliest opportunity. They will ensure that any subsequent reporting action is taken while supporting staff in the completion of the significant event report and as detailed within the organisation’s Significant Event and Incident Reporting Policy.

7.2 Clinical record

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. Further information can be found at Annex C.

8 Risk assessment

8.1 Requirement

The organisation’s Health, Safety and Risk Management Handbook provides comprehensive guidance on managing specific risks and should be read in conjunction with the HSE guidance titled How employers can protect workers from violence and aggression at work.

A template for conducting a risk assessment can be found at Annex I.

9 Effects on staff and patients

9.1 Supporting the team

Any staff member who has been subjected to inappropriate behaviour will be supported. Staff who experience incidents of violence, aggression or assault may experience subsequent after-effects that may require support from the team or external resources.

A respect our staff poster detailing that violent, threatening or abusive behaviour will not be tolerated is available.

9.2 Debriefing the team

Clinical debriefing refers to learning conversations that occur soon after an event and involve those who took part. This is also known simply as ‘debriefing’ or could also be ‘hot debriefing’ or ‘proximal debriefing’.

The aims of debriefing are to:

· Discuss how, why and what occurred

· Promote learning and reflection for individuals and teams

· Identify opportunities for improvements in workflows, processes and systems

· Identify any key points and lessons learnt

· Ensure that the health and wellbeing of staff members are not adversely affected

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.

9.3 Supporting patients

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 debriefing about the incident although in many cases the police would need to be involved.

External support may also be required.

Annex A – Legislation and further reading

The following legislation supports this policy:

· Health and Safety at Work Act 1974

· Management of Health and Safety at Work Regulations 1999

· Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)

· Assaults on Emergency Workers (Offences) Act 2018

· Safety Representatives and Safety Committees Regulations 1977

· Health and Safety (Consultation with Employees ) Regulations 1996