Gulati et al (2021) cite evidence that between 2013 and 2014, there were 68 683 assaults reported against NHS staff in England, of which 25% involved primary care staff. In 2017, the Royal College of Nursing undertook a survey of its membership, reporting that ‘28% of all nursing respondents working in the NHS stated they had experienced physical abuse in the previous 12 months'; and in primary and community care 68.1% and 15.9% of respondents experienced verbal abuse and physical abuse, respectively (Royal College of Nursing, 2018).
Violent episodes
Professor Gautam Gulati is a consultant forensic psychiatrist and Adjunct Associate Clinical Professor at the University of Limerick. ‘The following violent scenario,’ Prof Gulati told Practice Nursing, ‘occurred in primary care: a GP registrar at a busy inner-city practice saw Mr A – a young man with a history of substance misuse – recently released from prison. Mr A sought a prescription of diazepam, but the registrar explained that he saw no justifiable clinical indication and advised alternative treatments. Mr A became angry, seized a chair, and threatened to throw it at the registrar, who raised the alarm and was joined by an experienced practice nurse. Together, they used de-escalation strategies and eventually, Mr A was escorted from the practice. Nobody was injured but several practice staff were visibly shaken. An incident debrief revealed that Mr A had a history of violence against healthcare professionals and whilst this was flagged on his records, the computerised record system was not functioning that day due to a cyber-attack.’
Major risk factors for violence are long waiting times; discrepancies between patients' expectations and the services provided; substance abuse by the patient; and psychiatric conditions.
Elston and Gabe (2016), in their survey of 1300 GPs in England, cite this encounter reported by a female GP: ‘He [drunk male] came in effing and blinding and giving aggro to the girls [receptionists] and I went out and said “Look, you will not be seen drunk”. This guy walks right round the building until he identified my room and then he stood there, unzipped himself and p****d on my window.’
Violence during the COVID-19 pandemic
The COVID-19 pandemic, however, has exacerbated already challenging working conditions. For example, the International Committee of the Red Cross (ICRC) recorded 611 incidents between Feb 1 and July 31 2020, with the ICRC suggesting that these figures were probably ‘the tip of the iceberg’ (Devi, 2020). Significantly, 67% of incidents were directed at healthcare workers, with more than 20% involving physical assaults (Devi, 2020).
Özkan Sat et al (2021) apply the term ‘mobbing’ to behaviours like psychological violence, emotional abuse, humiliation, exclusion, damaging the employee's self-confidence, breaking motivation, and restricting powers, and this behaviour is often seen in health institutions. Their Turkish study of 263 nurses from a variety of nursing disciplines ‘determined that the rate of nurses’ exposure to mobbing increased in the pandemic period’ Özkan Sat et al (2021).
More specifically, Prof Gulati and colleagues (Gulati et al, 2021) have addressed the rise of violence in general practice settings and considered possible mitigating measures. Prof Gulati told Practice Nursing that despite relatively few reports on absolute rates of violence in different practice settings, reports from the international medical community are concerning: ‘During the pandemic,’ he explained, ‘attacks on healthcare workers have included, for instance, throwing of faeces and sending of funeral wreaths to doctors in Latin America; funeral rites denied to a deceased doctor in India; a doctor stabbed in India; a mob in Russia attacking a healthcare worker; and gun-related violence in parts of Pakistan.’
What causes violence in primary care?
In a systematic review of 44 studies published between 2000 and 2018, Raveel and Schoenmakers (2019) found that major risk factors for violence are long waiting times; discrepancies between patients' expectations and the services provided; substance abuse by the patient; and psychiatric conditions. And Gulati et al (2021) note that in the context of UK primary care settings, a perception of reduced face-to-face consultation availability has been cited as a reason for frustration and abusive behaviour.
Violence mitigation measures
Primary prevention, suggests Prof Gulati, involves systemic and patient-specific approaches: ‘Systemically,’ he explains, ‘displaying zero-tolerance policies such as the NHS zero-tolerance posters might have a deterrent effect, although its efficacy remains to be determined, and specialised primary care centres for patients with a history of violence may help play a role. However, such facilities are not often available, and predicting violence is difficult.’
‘During consultations one should not underestimate the importance of techniques such as allowing the patient space to vent, reducing arousal by using empathy, and maintaining a calm tone of voice.’
Gulati et al (2021) acknowledge that violence prevention in respect of the pandemic is more complex but note that the ICRC and the World Health Organization have produced a checklist for managers of healthcare services that focusses on local risk assessment and accountability towards those receiving care (Devi, 2020).
The aim of secondary prevention is to escape or de-escalate an evolving violent situation (Gulati et al, 2021), and Raveel and Schoenmakers (2019) state: ‘During the event of violence or agitation, applying de-escalation techniques is a highly recommended component of violence prevention. Physical restraint should be considered as a last resort strategy.’ Prof Gulati suggests that in an acute situation where violence is imminent, a practitioner may need to exit the consultation for help: ‘Having an unobstructed exit route on the practitioner's side of the room is critical to these circumstances, and given the importance of summoning colleagues' help, especially out of hours, protocols are useful, with appropriate training for practice and support staff.’
Prof Gulati also explains that during consultations one should not underestimate the importance of techniques such as allowing the patient space to vent, reducing arousal by using empathy, and maintaining a calm tone of voice. Importantly, Gulati et al (2021) cite a study in two London settings which found a lack of protocols for dealing with violent incidents and where practice receptionists were at highest risk as they were excluded from team meetings and denied appropriate support and advice.
Finally
Given the uncertainty of how primary care might evolve in a post-pandemic world, preparedness is key, and Prof Gulati is clear: ‘More research is needed to evaluate not just the prevalence of incidents, but also what works in respect of systemic strategies aimed at reducing violence and aggression towards primary care staff.’