Abstract

Objectives. Our aim was to investigate the extended primary care team’s experience of aggression and violence from patients, in order to promote the formulation of multiprofessional team procedures for critical incident management and organizational development.

Methods. A qualitative study based on in-depth interviews and focus groups with primary health care teams and community staff was carried out in one inner London and one outer London health authority area. Key issues and themes were derived from transcripts of 30 individual interviews and five focus group discussions.

Results. Key issues identified during interviews informed focus group discussions. The focus groups identified existing and proposed responses to the problem of aggressive encounters. No practice had a protocol for dealing with incidents, and few kept records, but the incidence of violence and aggression was perceived to be increasing. Receptionists were most at risk, and relied on experience to cope with incidents. Due to being usually excluded from team meetings, they were not able to benefit from peer support and advice. Negative management tactics, such as patient appeasement or exclusion, were the norm. Recommendations include formal record keeping, communication skills training and team responsibility for incident management and for the development of practice protocols to ensure the consistency of response. Improvements to the working environment need to balance staff security with patient-friendliness, and constitute only one aspect of a measured response to the problem.

Conclusions. The success of the focus group format in this context suggests that entire primary care teams could be led in workshops to review their experiences and formulate responses on an inclusive, multidisciplinary basis. These findings fit in with the concept of systems analysis in risk management protocols. We recommend that the team collectively formulate protocols for managing threatening encounters, with agreed mechanisms and thresholds for recording and reporting. Together with improved support systems within the extended teams and post-incident analysis of adverse events, this would allow a formal approach to identifying systematic weaknesses and solutions that benefit the staff involved.

Naish J, Carter YH, Gray RW, Stevens T, Tissier JM and Gantley MM. Brief encounters of aggression and violence in primary care: a team approach to coping strategies. Family Practice 2002; 19: 504–510.

Introduction

It is difficult to determine the true extent of the problem of aggression and violence perpetrated by patients against primary care workers, because much of what has been written has been anecdotal or based on relatively small samples. However, the limited data available over the past decade from the published literature1,2 and a survey reported by a local GP forum3 show that the fear of violence has increased. For example, Myerson2 reported a study of 120 GPs in 1991, and 87% of these believed that levels of violence were increasing. Myerson called for urgent recognition of the problem, but there is still no central register of incidents, and little progress appears to have been made. In a 1998 study4 of >400 practices in England, ‘patient abuse/aggression’ remained one of the three causes of stress most cited by GPs and practice managers, and it was found that practices tended to have policies on monitoring various risks and hazards but failed to develop and apply solutions. Also, a 1999 survey5 of sources of stress among 83 inner-city GPs listed fear of complaint second and fear of violence fourth. Third was ‘out-of-hours stress’. Out-of-hours visiting has been reported elsewhere to be the worst time for clinicians’ fear of assault,6–9 a fear which is borne out by Hobbs’ 1991 survey1 of >1600 aggressive incidents suffered by 1093 GPs; although only 144 of these incidents involved assault or injury, 90 occurred during home visits, and 22 out of the 41 documented cases of injury occurred when visiting at night.

Some doctors feel that violence is an inherent part of their job, contributing to low levels of morale within the profession and a consequent negative impact on recruitment and retention of staff,1 particularly in inner-city areas, where the problem is perceived to be more pervasive.8 While persistent abuse may be assumed to have a detrimental effect on doctors and their staff, it is difficult to quantify the emotional distress caused by intimidation.8 Consistent under-reporting of the occurrence of violent or aggressive incidents is attributed to the absence of formal channels designed to record these data, lack of time, reluctance to fill in forms, fear of being blamed, embarrassment and an acceptance of violence as part of the job.9–13 In addition, a report by the Department of Health and Social Security in 1988 stated that 90% of attacks on Asian doctors were not reported due to fear of racial attacks against their families.9

Carter et al.14 found that some primary health care staff believe that violent or aggressive incidents arise through patients presenting urgent demands which simply cannot be met. They also pointed to the development of a ‘siege mentality’, resulting in negative stereotyping by both patient and professional. The staff interviewed for this study said that aggressive incidents were to be avoided, but gave no direct suggestions as to how this should be done. In an earlier review, Hobbs7 stated that potentially aggressive situations can be defused if patients are given at least some opportunity to express their feelings, if they are encouraged to interact with the staff and if staff are conciliatory and avoid pressuring patients or displaying fear to them.

Most studies of aggression and violence in primary care have focused on the perspective of doctors to the exclusion of other members of the primary care team, and many responses to encounters of violence and aggression were designed to deflect the aggressive patient rather than actively to prevent or manage such incidents. No previous study has investigated the possibility of developing a team approach to the management of violence and aggression in primary health care. Hence, the present study was given a wider remit, shifting the focus from individual professions to a more team- and community-based approach, within the context of clinical risk management using a systems approach.15 The objectives of the study were:

  1. To promote a better understanding of the needs of primary care workers who have experienced aggression and/or violence in the course of their work.

  2. To encourage teams to formulate effective strategies in preventing and coping with aggression and violence.

  3. To explore collaborative initiatives between primary care service providers that respond more effectively to the needs identified by workers.

  4. To develop models of support within primary care teams.

Previous studies have used varying definitions of the terms aggression and violence. The Health and Safety Executive has defined violence as “any incident in which an employee is threatened or assaulted by a member of the public in circumstances arising out of the course of his/her employment”.16 Aggression has been defined as “any episode at work involving verbal or physical abuse or injury, which causes a person to feel intimidated or fearful”. For the purposes of the present study, we have taken the definition of violence and aggression as “episodes of either threatened or actual, verbal or physical abuse or injury, causing the person to feel intimidated or fearful, and occurring in the course of the working day”.

Methods

The study was conducted in two phases, in one inner London and one outer London health authority area. In the first, in-depth interviews were held with representative members of the extended primary care team. Key issues identified at interview then served as the basis for a series of focus groups. Ethical approval was granted by the respective research ethics committees. The names and addresses of all the practices were obtained from the health authorities.

Sample

Information for potential participants and a formal invitation to take part were sent to practice managers at all practices in the study area (n = 222), followed by one reminder 2 weeks later. Agreement to take part included informed consent to be interviewed or to join a focus group. Thirty-three practices replied with a declaration of interest (response rate 15%), nominating 71 individuals. Three of these (two receptionists from different sites, and a district nurse) were recruited for pilot interviews, resulting in minor modifications to the interview schedule. For example, it was suggested that when enquiring about the meaning of violence and aggression, the respondent should be encouraged to think about situations in their own discipline.

In phase one, a study sample was drawn purposively for maximum representation of extended primary care teams. Selection criteria included practice size/partners, location, individual role and the actual experience of one or more aggressive incidents. Seven practices were selected, and 30 team members interviewed (Table 1).

For phase two, the remaining 38 nominated individuals were invited to join local focus groups. Colleagues in their teams were also invited to attend. To encourage attendance, focus group meetings were arranged at convenient venues for each locality and were held over the lunch time period. A total of 44 people took part in five groups (Table 2).

Procedure

In common with an earlier, large-scale study of aggression and violence, it was decided to collect data relating to the preceding 12 months.1 We devised an individual interview schedule,17 drawing from previous research instruments from published1,18 and unpublished3 sources. The schedule fell into four parts, as outlined in Box 1. The interviews lasted between 15 and 40 min each. Six were conducted by telephone, and 24 face-to-face; research indicates little difference in answers to questions between these methods.18 All were conducted by an experienced interviewer (TS) with a social science background and no affiliation to any of the primary care disciplines.

Box 1
Section headings for individual interviews

Meanings (perceptions of aggression and violence).

Experiences (incidents and fears).

Beliefs (e.g. stereotyping of patients; vulnerability of staff).

Strategies (changes to date, or proposals for change).

In phase two, each focus group was led by a skilled moderator, assisted by a facilitator who monitored both group verbal and non-verbal interactions in order to improve the validity of results. Participants were issued with a page of scenarios; each illustrated by direct quotations from the phase one interview data (Table 3). These formed starting points for group discussions. The moderator also had a broad topic guide17 to ensure that these discussions covered all issues, and could be focused on key issues when required. Each meeting lasted ~1 h.

All individual interviews and focus group meetings were tape-recorded and fully transcribed. Analysis followed the SCPR Framework approach19 involving a systematic process of sifting, charting and sorting material according to key issues and emerging themes. A theoretical framework or index of these issues and themes was constructed and applied to the transcripts, so that the responses relevant to each theme could be lifted from the transcripts until the complete data set had been interpreted and mapped.

Results

Themes and quotations from the interviews and focus groups were recorded at length in the project report.17 We present here the main results and outcomes of the project, as summarized in Tables 4–6 and the Discussion. Table 4 sets out a summary of the themes emerging from the phase one interviews. According to the interviewees, not only was the incidence of aggression and violence increasing, but the problem itself was becoming more accepted as a part of the normal working day. This desensitization was contributing to under-reporting, as were self-blame, staff isolation and the shortage of recording mechanisms or agreed recording thresholds. In addition, agreed protocols for dealing with aggressive patients did not exist anywhere, and little relevant training was being made available. Status in the team hierarchy was regarded as the main determinant of the ability to manage adverse incidents. Physical security measures are always likely to be a mixed blessing, since an open and welcoming surgery environment was thought to have a significant calming effect on both the incidence and severity of adverse events.

Key issues identified from the phase one interviews were developed into scenarios used as topics for discussion in the focus groups during phase two (Table 3). From these focus groups, Tables 5 and 6 show a series of strategies that were formulated for shorter term incident management and longer term organizational development, respectively (defined in Box 2).

Discussion

Although the actual incidence of aggression and violence against primary care workers is difficult to determine reliably, our results agree with those of other studies that have reported a perceived increase in such problems. Social and economic deprivation, consumerism and unrealistic patient expectations in an overstretched National Health Service may all be contributing factors. However, all employers have a duty to protect the health and safety of their employees, and general practice is no exception. This study has demonstrated that, although the security and general environment of premises are important considerations, structural measures alone are not enough. Good teamwork is essential, both to reduce the incidence of difficult patient encounters and to support the victims of aggression and violence.

Our participants reported the negative effects of experiencing aggression and violence at work, including negative management tactics such as patient exclusion and minimum service provision. They also identified a need to develop positive tactics by learning about communication skills and the impact of chronic disease conditions. Good communications with patients and within the team will be vital to any new strategy, requiring the joint development of protocols and recording systems.

The implementation of policies in the ‘new’ National Health Service and Primary Care Groups and Trusts20 requires more collaborative working practices and closer relationships at all levels in primary care. Our findings could provide the basis for training and team building within an extended primary care team. Workshops and seminars focusing on incidents, responses and outcomes would provide excellent opportunities for multidisciplinary learning and team development. We recommend that a protocol for managing threatening encounters should be formulated by the team, with all disciplines sharing in the process and agreeing on mechanisms and thresholds for recording and reporting. Training for implementation of the protocol is recommended for it to be fully effective. Together with improvements in support systems within the extended primary care team, an adverse or critical incident analysis using the protocol allows a formal approach to identifying systematic weaknesses and solutions that benefit the staff involved. These opportunities could serve as the backdrop for systems analysis to reduce the risk of violent or aggressive incidents.15 It is not envisaged that the implementation of any of the recommendations arising from this study need incur exceptional costs.

Table 1

Participants in phase one interviews

Receptionists 
Practice managers 
District nurses 
GPs 
Community psychiatric nurses 
Practice nurses 
Community midwife 
Community pharmacist 
Occupational therapist 
School nurse 
Total 30 
Receptionists 
Practice managers 
District nurses 
GPs 
Community psychiatric nurses 
Practice nurses 
Community midwife 
Community pharmacist 
Occupational therapist 
School nurse 
Total 30 
Table 2

Participants in phase two focus groups

Practice managers 17 
Receptionists 12 
GPs 10 
Practice nurses 
GP co-operative co-ordinator 
Health promotion nurse 
Total 
Practice managers 17 
Receptionists 12 
GPs 10 
Practice nurses 
GP co-operative co-ordinator 
Health promotion nurse 
Total 
Table 3

Phase one interview quotations used in phase two focus group discussions

Belief in targeted aggression 
    “Our receptionists have probably experienced more problems than us because they’re often having to resolve irreconcilable situations, patients wanting to be seen instantly or when they’re having to run a system that the practice has put in place which doesn’t always coincide with what the patient wants so I think they take more flak than we do. Patients who come in to see us are quite often meek and mild and quite polite having been quite angry at the receptionist.” 
Inadequate support systems 
    “We can bring up anything at the practice meeting, things that are worrying you, new ideas about how to improve the practice. Or if you have incidents such as this that have affected you, that’s when you get to talk to the whole team rather than just one person at a time. It really helps when all the team get together then you just bring it out into the open and you can take advice on how to cope with things like this in the future.” 
    “We don’t really get counselling for anything as receptionists at all. It’s a shame really because sometimes I think you could do with speaking to someone . . . We have a receptionists’ meeting usually every two weeks and a full meeting with the receptionists, doctors, nurses about every two or three months. We bring these issues up but don’t get much of a response, no.” 
Poor communication between disciplines 
    “Maybe what we do need to do as a team is just write to all the people who refer to us and just reinforce that if there is a risk of aggression, a risk of danger to the staff then that needs to be documented and we need to be told of that.” 
Surgery environment and security 
    “It is difficult to get this balance of making it not like Fort Knox which then makes the patients come in aggressive.” 
    “I think a very open reception area can actually reduce the incidence of aggression amongst patients, an open desk without any screens or anything, no barriers to patients. I think the receptionists feel the same way as we do, they don’t like feeling closed in inside the reception area with small windows and that’s one of the things we’re hoping to change in the future.” 
Perceptions of authority within the practice 
    “They [patients] come in here, start screaming and shouting at the desk but when they get in there [surgery] they don’t say anything. I just accept that. That’s the way it is.” 
    “Yes we try and sort it out between ourselves, if we don’t get any joy like that we often ask the practice manager to come in or a doctor, someone who’s got kind of a bit more authority.” 
Absence of a unifying protocol 
    “I think we’ve discussed it in a general chat sort of way but not formally, you know, what are we going to do about this?” 
Belief in targeted aggression 
    “Our receptionists have probably experienced more problems than us because they’re often having to resolve irreconcilable situations, patients wanting to be seen instantly or when they’re having to run a system that the practice has put in place which doesn’t always coincide with what the patient wants so I think they take more flak than we do. Patients who come in to see us are quite often meek and mild and quite polite having been quite angry at the receptionist.” 
Inadequate support systems 
    “We can bring up anything at the practice meeting, things that are worrying you, new ideas about how to improve the practice. Or if you have incidents such as this that have affected you, that’s when you get to talk to the whole team rather than just one person at a time. It really helps when all the team get together then you just bring it out into the open and you can take advice on how to cope with things like this in the future.” 
    “We don’t really get counselling for anything as receptionists at all. It’s a shame really because sometimes I think you could do with speaking to someone . . . We have a receptionists’ meeting usually every two weeks and a full meeting with the receptionists, doctors, nurses about every two or three months. We bring these issues up but don’t get much of a response, no.” 
Poor communication between disciplines 
    “Maybe what we do need to do as a team is just write to all the people who refer to us and just reinforce that if there is a risk of aggression, a risk of danger to the staff then that needs to be documented and we need to be told of that.” 
Surgery environment and security 
    “It is difficult to get this balance of making it not like Fort Knox which then makes the patients come in aggressive.” 
    “I think a very open reception area can actually reduce the incidence of aggression amongst patients, an open desk without any screens or anything, no barriers to patients. I think the receptionists feel the same way as we do, they don’t like feeling closed in inside the reception area with small windows and that’s one of the things we’re hoping to change in the future.” 
Perceptions of authority within the practice 
    “They [patients] come in here, start screaming and shouting at the desk but when they get in there [surgery] they don’t say anything. I just accept that. That’s the way it is.” 
    “Yes we try and sort it out between ourselves, if we don’t get any joy like that we often ask the practice manager to come in or a doctor, someone who’s got kind of a bit more authority.” 
Absence of a unifying protocol 
    “I think we’ve discussed it in a general chat sort of way but not formally, you know, what are we going to do about this?” 
Table 4

Summary of themes from phase one interviews

Beliefs Responses Subsequent effects 
Incidence: Levels increasing Aggression is expected More common in larger practices Associated with unfulfilled patient expectations Targeted against certain staff roles Budget constraints compromising safety of community staff Recording: Need to define incident seriousness Few recording mechanisms Fear of casual negative stereotyping of patients with problems Training: Little training available Ought to focus on communication skills including language and negotiation Receptionists more inclined to rely on learning by experience 
Causes: General increase in antisocial behaviour “Just cause” Not racial or sexual harassment Support: Avoid self-blame Use higher status team member to defuse any incident Confidence in colleagues Incident exposure: Desensitization Improved management through experience of incidents 
Perpetrators: Poor communicators Demanding patients Patients failed by other agencies Stereotyping of patients based on cultural or physical characteristics, e.g. size, personal space offered Negative management: Patient exclusion Patient appeasement Avoid patient or deal with as quickly as possible Offer minimum level of service Post-incident analysis: Team meetings good, but receptionists often excluded from participation 
 Service delivery: Provide more information and explanations to patients Some staff have developed model responses Environment and security: Reception staff more in favour of a closed environment 
Beliefs Responses Subsequent effects 
Incidence: Levels increasing Aggression is expected More common in larger practices Associated with unfulfilled patient expectations Targeted against certain staff roles Budget constraints compromising safety of community staff Recording: Need to define incident seriousness Few recording mechanisms Fear of casual negative stereotyping of patients with problems Training: Little training available Ought to focus on communication skills including language and negotiation Receptionists more inclined to rely on learning by experience 
Causes: General increase in antisocial behaviour “Just cause” Not racial or sexual harassment Support: Avoid self-blame Use higher status team member to defuse any incident Confidence in colleagues Incident exposure: Desensitization Improved management through experience of incidents 
Perpetrators: Poor communicators Demanding patients Patients failed by other agencies Stereotyping of patients based on cultural or physical characteristics, e.g. size, personal space offered Negative management: Patient exclusion Patient appeasement Avoid patient or deal with as quickly as possible Offer minimum level of service Post-incident analysis: Team meetings good, but receptionists often excluded from participation 
 Service delivery: Provide more information and explanations to patients Some staff have developed model responses Environment and security: Reception staff more in favour of a closed environment 
Table 5

Incident management: summary of strategies from phase two focus groups

Main issue Aim Team strategy 
Recording and documentation Safeguard against future complaints Standardize recording procedures Improve management of future incidents Record all significant incidents Define recording threshold and format Encourage staff to use recorded information Pass information on to other team members 
Incident analysis Clarify frequency and severity Joint examination of impact on single-case basis 
Patient–staff relationship Improve patient–staff communication Training in ethnic minority languages Develop model responses Develop consistent approach 
 Develop flexibility in patient management Empathize with patient Team input to develop and interpret protocol More information to team about particular symptoms/patients 
 Maintain patient–staff relationship Talk issues through with patient 
Manage immediate incident Prevent incident escalation Move to private area Intervention/support of other staff 
 Ensure consistent response Improve management techniques Develop practice protocol Staff training: communication skills, role-playing 
Support systems Enhance staff confidence and morale ‘Time out’ for staff Encourage ‘no blame’ discussion of incidents Facilitate channels of support with a range of interventions Encourage staff not to condone or tolerate incidents 
 Reduce expectation of aggression  
 Avoid undermining staff Develop consistent responses using protocol 
Post-incident Avoid staff isolation; foster team-building Team response to incidents; mentoring Collective rather than individual responsibility 
 Depersonalize incident Take action as a team to reduce individual feelings of powerlessness Non-judgemental analysis to reduce self-blame Reduce avoidance mechanisms in future 
 Establish improved management practices Staff training: ‘critical incident review’ Review practice protocol 
Main issue Aim Team strategy 
Recording and documentation Safeguard against future complaints Standardize recording procedures Improve management of future incidents Record all significant incidents Define recording threshold and format Encourage staff to use recorded information Pass information on to other team members 
Incident analysis Clarify frequency and severity Joint examination of impact on single-case basis 
Patient–staff relationship Improve patient–staff communication Training in ethnic minority languages Develop model responses Develop consistent approach 
 Develop flexibility in patient management Empathize with patient Team input to develop and interpret protocol More information to team about particular symptoms/patients 
 Maintain patient–staff relationship Talk issues through with patient 
Manage immediate incident Prevent incident escalation Move to private area Intervention/support of other staff 
 Ensure consistent response Improve management techniques Develop practice protocol Staff training: communication skills, role-playing 
Support systems Enhance staff confidence and morale ‘Time out’ for staff Encourage ‘no blame’ discussion of incidents Facilitate channels of support with a range of interventions Encourage staff not to condone or tolerate incidents 
 Reduce expectation of aggression  
 Avoid undermining staff Develop consistent responses using protocol 
Post-incident Avoid staff isolation; foster team-building Team response to incidents; mentoring Collective rather than individual responsibility 
 Depersonalize incident Take action as a team to reduce individual feelings of powerlessness Non-judgemental analysis to reduce self-blame Reduce avoidance mechanisms in future 
 Establish improved management practices Staff training: ‘critical incident review’ Review practice protocol 
Table 6

Team organization: summary of strategies from phase two focus groups

Main issue Aim Team strategy 
Development of practice protocol Develop team working Establish communication links for feedback and dissemination Avoid undermining of staff 
 Define remit of practice Develop and disseminate clear rules of practice operations, e.g. registration, practice services, roles and responsibilities, removal of patient from list 
 Avoid negative management Foster patient education Develop knowledge of practice procedures 
 Improve quality of service Ensure realistic patient expectations Multidisciplinary staff training programmes Audit and review of incidents Regular team review of protocol 
Communication within team Improve formal and informal processes Team meetings for all members at convenient times Overlapping shift systems Procedures for information transfer within and across disciplines 
Location of incidents Reduce vulnerability, e.g. out-of-hours Modify working practices Record calls Improve communications between base and GPs 
Surgery design Create positive atmosphere Improve surgery security High standard of interior decoration Provision of activities for children Music/TV/reading material Community information/health promotion information Regular team review Achieve balance between ‘closed’ and ‘open’ environments 
Decision making Improve participation Facilitate team members’ input into process via team meetings, devolution and delegation of responsibilities Utilize resources of team to take more informed decisions Foster team decisions 
Main issue Aim Team strategy 
Development of practice protocol Develop team working Establish communication links for feedback and dissemination Avoid undermining of staff 
 Define remit of practice Develop and disseminate clear rules of practice operations, e.g. registration, practice services, roles and responsibilities, removal of patient from list 
 Avoid negative management Foster patient education Develop knowledge of practice procedures 
 Improve quality of service Ensure realistic patient expectations Multidisciplinary staff training programmes Audit and review of incidents Regular team review of protocol 
Communication within team Improve formal and informal processes Team meetings for all members at convenient times Overlapping shift systems Procedures for information transfer within and across disciplines 
Location of incidents Reduce vulnerability, e.g. out-of-hours Modify working practices Record calls Improve communications between base and GPs 
Surgery design Create positive atmosphere Improve surgery security High standard of interior decoration Provision of activities for children Music/TV/reading material Community information/health promotion information Regular team review Achieve balance between ‘closed’ and ‘open’ environments 
Decision making Improve participation Facilitate team members’ input into process via team meetings, devolution and delegation of responsibilities Utilize resources of team to take more informed decisions Foster team decisions 

We thank all those primary care workers who participated in this study for giving their time and telling us about their experiences. In addition to the contributors listed above, we acknowledge the contributions of the other members of the project steering group: Joanne Brown, Sue Collinson, Peter Elliott, Errol Lobo and Hilary Scott. The research was supported by a grant from the NHS Executive North Thames Inner City Health Research and Development Programme.

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