Assaults on Medical, Nursing and Paramedical Staff.

There has been recently yet another account of a physical assault by a patient towards a doctor 1 . The scenario is a familiar one, a drunken male in the emergency department with a minor injury. A tirade of verbal abuse and racist slurs was followed by physical violence against the doctor. The account highlights a problem that we have lived with for a long time. One of the most difficult situations faced by doctors is being threatened, abused, or physically harmed by one of their patients. Young doctors who are still in training and on the front line are most at risk of injury. The definition of medical workplace violence is behavior by a patient that is intended to physically or psychologically harm the healthcare worker. It includes physical injury, spitting, verbal abuse and threats. Unfortunately doctors and nurses worldwide are experiencing high levels of confrontation and aggression. The UK data for 2014 reports that 60 per 1000 healthcare staff were subjected to serious abuse. A previous 2008 staff report carried out for the UK Healthcare Commission found that 12% of staff across all trusts reported being physically assaulted over the previous year. The clinical areas most at risk are psychiatry, emergency departments, and general practice. Employers have a duty ‘so far as is reasonably possible’ to protect the safety and well-being of their staff. There have been prosecutions of the NHS for situations where staff were left unprotected. In one case a hospital trust in South London was fined £28,000 after a nurse was killed by a patient 2 . Earlier this year on 20 th January, Dr Michael Davidson, cardiac surgeon at the Brigham and Women’s hospital Boston, was shot dead in his office by a patient’s disgruntled son. The patient had survived the surgery but the son blamed Davidson for some post-operative pulmonary complications. A hospital spokesman stated that it represented the worse nightmare for doctors who have to undertake high-risk operations. There is very real fear and when this happens the fear becomes more real. A shocked Boston medical community was at a loss on how to respond. Comments included ‘we are all so vulnerable, there is nothing to protect us’. Between 2000 and 2011 there have been 154 hospital related shootings in the US. In the previous era 1980 – 1989, 22 doctors were killed while at work. Lisa Rosenbaum 3 tried to provide balance making the point that there has long been an implicit understanding between the profession and the public. She accepts that the public’s trust in doctors appears to have slipped. Renewed efforts need to be made to convince patients that we are all on the same side. In 1998 Jenkins et al 4 surveyed violence and verbal abuse against staff in 310 emergency departments in the UK and Ireland. Among 233 replies, staff reported 10 fractures, 42 lacerations, and 505 soft tissue injuries. There were 298 arrests, 101 court appearances, and 76 convictions. This equates to an arrest rate of 1:50 and a conviction rate of 1:200. Many departments stated that verbal abuse occurred daily. Nurses were most commonly the recipients of verbal abuse, followed by receptionists and doctors in descending order of frequency. The commonest perpetrators of the violence were the patients themselves, followed by their friends and family. A primary care study 5 has found that 78% had been verbally abused, 44% had been threatened, 13% had been physically abused, and 9% were sexually harassed in the preceding 12 months. Females were more likely to be verbally confronted, while males were at greater risk of physical abuse. Background factors included drug abuse and mental illness. A survey of 634 Irish GPs found that 21% had experienced violence or aggression 6 . Physical injury was sustained in 7% of doctors. Alcohol and drugs were important precipitating factors. Workplace violence has long-term consequences for staff. It causes anxiety, anger and psychological burn-out among caregivers. Hospitals with high rates of abuse experience loss of working days, poor staff performance, low staff morale, and reduced trust with management. There can be no excuse for physical or verbal abuse of healthcare workers. The risk factors for aggressive behavior among patients and their families are the role of drink and drugs, impatience during long waiting times, frustration with the lack of services, anxiety regarding their underlying medical condition, and resentment due their adverse personal circumstances. The waiting area should have distractions including patient education magazines, sufficient space, and wifi facilities if possible. The ways in which hospitals can ameliorate or prevent violent interactions with patients are the visible presence of security guards, surveillance cameras, panic buttons, written guidelines on how to deal with abusive patients, and a policy to vigorously pursue and where appropriate prosecute offenders. The layout of facilities, such as clinics, should allow for the expulsion of aggressive patients and their families. The doctor should always remain between the door and a potentially violent patient. Healthcare workers need more education and teaching on how to deal with aggression and violence among patients. Sudden, expected attacks are rare. Most assaults are preceded by mounting tension, and escalating threats 7 . One of the concerns expressed by many studies is that episodes of violent behavior against staff are significantly under reported. It is important that all Units accurately document each event so that the patterns and year on year rates can be analysed. As a rule of thumb one’s suspicion’s should be raised when a patient makes one feel uneasy or frightened. Assaults on Medical, Nursing and Paramedical Staff 1 The Medical Council’s Guide states ‘if you are asked to examine or treat a patient who presents a risk of violence, you should make reasonable efforts to assess any possible underlying clinical causes of the violent behaviour. However, you are not obliged to put yourself or other healthcare staff at risk of undue harm in the course of such assessment or treatment’. There needs to be continued vigilance and accurate monitoring of violence and abuse against care-workers. Staff need to know that management will uphold a zero tolerance when any member of staff is injured, threatened, or verbally abused.