Comment

---

Patient violence in general practice not ‘just part of the job’

---

The recent police killing of a patient after a confrontation at a Nowra general practice in NSW was deeply traumatic for those directly involved and triggering for all Australian GPs.
 
For more than 17 years, I have advocated for effective action on violence against healthcare workers since the killing of my friend, Dr Khulod Maarouf Hassan to try to prevent another tragic death.
 
More recently, despite all my experience and expertise on the topic, a patient threw a punch at my face in my consulting room two weeks after starting at a rural practice. When I removed myself from the room to let practice staff know, they said: ‘Get used to it – that’s what we put up with most days’.
 
I beg to differ…
 
GPs must refuse to accept increasing patient violence as ‘part of the job’
Assaults against health workers rose around the globe during the pandemic, which the Australian Government responded to with an amendment to the Crimes Act and some initiatives to address increasing violence against nurses, paramedics and other frontline health workers.
 
However, it did little to address violence against frontline GPs – in part because most assaults in general practice are not reported to the police, and therefore, not included in national and state datasets.
 
This lack of action in general practice is unacceptable.
 
GPs must follow appropriate procedures following an assault, including reporting physical assaults to the police when appropriate
Any assault must be responded to in order to immediately protect everyone’s safety and followed up to put practice systems in place to protect against future assaults. 
 
The following steps are based on WorkSafe guidelines:
 
1. Know the definition of assault
Guidelines differ slightly from state to state. In Victoria, assault is defined as ‘physical assault such as biting, spitting, scratching, pushing, shoving, tripping and grabbing, [and] extreme acts of violence and aggression such as hitting, punching, strangulation, kicking, personal threats, threats with weapons, sexual harassment and assault’.
 
Other examples include ‘aggressive gestures or expressions such as eye rolling and sneering, verbal abuse such as yelling, swearing and name calling, and intimidating physical behaviour such as standing in a worker’s personal space or standing over them’. It is recognised that ‘being exposed to these incidents repetitively can have a cumulative and significant ongoing effect on wellbeing’.
 
In summary, assault is any act that intentionally or recklessly causes another person to fear or be subjected to physically or mentally harmful offensive contact.
 
2. Be clear: your first priority is to protect yourself from danger, not your duty of care to a violent patient
If an abusive or violent patient refuses to calm down or leave a general practice, practice staff must first act to try to keep themselves and other patients safe until police or security arrive.
 
If a patient threatening violence is cognitively impaired and lacks insight, police must accompany that person to a secure facility where they will receive acute medical or psychiatric treatment safely.
 
What is not widely recognised is that malicious intentional verbal assaults may also require urgent police intervention as they can be more damaging than physical assaults. For example, consider this scenario: a threat by a patient to rape, stalk a doctor or abduct a doctor’s children is likely to be more traumatic than unintended physical contact by a patient in extreme pain.
 
3. Convene a timely practice team meeting to discuss and debrief post-assault
Any threat or incident of violence should be reviewed thoroughly at a timely practice team meeting to check on the wellbeing of the victim and to prevent future assaults on other practice staff or GPs.
 
This review is the responsibility of the practice team, not a distressed victim, and it is a workplace right, not an overreaction.
 
Here are some suggested questions to help the whole team debrief, learn from an incident, and tailor policies and procedures to prevent future incidents:

• What happened? Have we talked to all the victims and witnesses? What are the facts? Should the police or security be notified although the incident has passed?
• Are staff safe now? Do staff including GPs require debriefing or employee assistance to manage any physical or psychological trauma? The mental health consequences of workplace violence may emerge in the months following an incident. Who will follow up the victim to ensure they have not experienced these impacts?
• After any unacceptable incident, the patient must be followed up, if appropriate, by telephone and formal letter to outline acceptable behaviours when visiting the general practice again in the future. This follow up may be undertaken by police or the practice manager in consultation with a medical indemnity provider, whatever is most appropriate to the particular situation.
• Should staff flag the patient’s file to warn other GPs about the future risk of violent behaviour? If a patient has displayed threats or unreasonable behaviours in a general practice, the incidents should be documented in their clinical record to warn other staff at future consultations. Patients who are at greatest risk of perpetrating assault on other staff are those who have past histories of having done so before.
• What else has been learnt from the incident to prevent future assaults by other patients, for example, what factors may have triggered the violence? Could the incident have been prevented? Are all staff aware of their responsibility to identify patients displaying aggression in the waiting room early?

4. Recognise that threats and incidents of violence are serious occupational health and safety issues
When a verbal or physical assault occurs, it must also be immediately reported through an incident reporting system to the most senior levels of the general practice or the board of a group of general practices. This information allows the governing body or practice owner to determine whether more resources should be allocated to implement other safeguards or barriers to minimise the risk of recurrence in the future.
 
Every employer should consider workplace safety as a priority, proactively implement systems to prevent assaults, and have a formal process in place for reporting and managing all incidents.
 
New staff must receive comprehensive orientation and ongoing training about all occupational health and safety issues, including policies and procedures on the prevention and management of patient violence, such as  de-escalation skills.
 
Governing bodies and employers face financial and criminal penalties if employees are seriously injured or killed due to work related violence, which vary from state to state. If management are not aware of their responsibilities, they can be referred to the Fairwork Ombudsman or the relevant Work Safe authority.
 
Every GP must take responsibility for a safer health workplace
It is every GPs responsibility to show leadership and take steps to prevent and address violence in general practice for the safety of patients, colleagues and ourselves.
 
We can do this by following appropriate procedures (above) after a verbal or physical assault, creating a groundswell of action to expose the true extent of the problem and improving systems of practice safety for all staff.
 
GPs also have an important role in the early identification of patients with severe mental illness at risk of violence.
 
Although people with severe mental illness are more likely to be the victims than the perpetrators of violence, they are overrepresented in the criminal justice system. This human rights issue is directly related to poor access to mental health care and requires strong, united advocacy by our membership organisations to governments.
 
It is not a coincidence that violence is commonly perpetrated by young men with acute severe and untreated mental illness – this is part of a disturbing national trend.
 
I know that many GPs will be deeply saddened by the events at the Nowra general practice and all will be sending love and support to our traumatised colleagues and the grieving family of the deceased young patient.
 
It is my long experience in general practice that collective grief can be used as a constructive catalyst for change rather than another reason for anger and despair.
 
Let’s address rather than accept violence in general practice. It’s not ‘just’ part of our job. 
 
Further reading: Preventing and managing patient aggression and violence.
 
Log in below to join the conversation.

---

---

GP safety mental health patient violence workplace violence

---