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Saturday 22 October 2016
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Violence in the surgery – managing the risks

Quality Matters


Independent Consultant in Practice Management

Fiona is an experienced primary care trainer and facilitator. She is the national RCGP QPA Adviser and has advised on both the original and the review of the Quality and Outcomes Framework of the 2004 GP contract

All managers in general practice are aware that team members, including themselves, run the risk of violence at work. "But surely that's extremely rare!" we say, "There's sometimes a bit of shouting and desk thumping, but nobody's actually hurt."

The NHS Zero Tolerance campaign started in 1999, and in June 2002 the Department of Health (DH) published the results of a survey of reported violent or abusive incidents in English NHS trusts or health authorities. This study identified 84,273 reported violent or abusive incidents in 2000/01.(1)

This was a significant increase from the previous study in 1998, although part of the reason for the increase may have been previous under-reporting, along with the new definition of violence to include verbal abuse. In October 2002, Sir Nigel Crisp, then the chief executive of the DH, wrote to primary care organisations asking them to ensure that the risk of violence to GPs and their staff be properly assessed and that local plans be put in place for tackling violence. It is possible that, since this date, supporting practices with the Zero Tolerance campaign has gone onto a back burner.

The Health and Safety Executive (HSE) defines work-related violence as "any incident in which a person is abused, threatened or assaulted in circumstances relating to their work". This means that whenever a member of staff is abused, has personal comments directed at them, or is subject to offensive behaviour, this could be defined as "violence".(2)

Clearly, we need to protect staff from physical violence. We are also aware that unwanted personal comments and abusive or offensive behaviour constitute bullying and harassment.  However, although we may be extremely sensitive to workplace bullying of co-workers by co-workers, we may accept similar behaviour from patients towards staff as "just part of the job".

Staff tend to accept it too. This behaviour from patients is unfortunately extremely common – possibly becoming more so. While the effects of physical violence are obvious, the effects of numerous abusive calls can also be very real – the most common being anxiety and stress.

What should we be aware of?
In general practice, team members are often subjected to aggressive behaviour at the front desk and on the phones ("phone rage"), and additionally some may be lone workers.

The Health and Safety at Work Act 1974 (HSW Act) defines the legal duty of an employer to ensure the health, safety and welfare of their employees as far as reasonably practical. The Management of Health and Safety at Work Regulations 1999 clarify the duty to consider the risk of reasonably foreseeable violence, measure the risk, put in control measures and establish a management plan to achieve these measures.

What action should we take?
Consider the impact on your staff

  • Who might be affected by violent or aggressive behaviour?
  • What are the effects?
  • Is there a risk of physical injury?
  • Are staff experiencing work-related stress as a result of this behaviour?
  • Do staff tell you that they feel frightened or anxious?

Discuss these issues with your staff and record what you find.

Undertake a risk assessment
1. What are the hazards?
This means thinking about what it is that might cause harm. Again, you should discuss this with your staff. The main hazards may well include some or all of the following and your own staff may have others:

  • Handling patients who are ill, upset and stressed, on medication, or under the influence of substances such as alcohol or drugs.
  • Handling patients who cannot get what they feel they need at the time they want it.
  • Patients with unrealistic expectations.
  • Lone working.
  • Long shifts on the telephone.
  • Verbal abuse from patients.

We are in the position of having to find ways of dealing with all these hazards, as they are part of our working life in general practice.

2. Who might be harmed by these hazards?
Remember to consider that new staff and lone workers may be at a greater risk of harm than others. New team members who have joined the staff without much experience of dealing with the public may well feel anxiety and stress in dealing with difficult situations. Temporary workers may have less experience and have received less training than permanent staff.

Practices who directly employ nurses and doctors who visit patients in their homes should consider the particular hazards experienced by these team members. They may frequently be working in situations that harbour several potential hazards, mainly arising from patient behaviour but also from that of upset, frustrated or stressed family members.

Younger members of staff may also be at a greater risk of harm because their life experience is more limited. They have not had time to learn how to recognise warning signals and may have had less training. Young members of staff are sometimes more susceptible to being seen as an "easy target" by patients who have a great deal of anger or resentment, which they may express through aggressive behaviour.

There might be particular circumstances or times of day that generate particular high-risk situations for staff, depending on your systems. For example, you might run an open surgery where you limit the number of patients seen, and staff may frequently have difficult encounters with patients who have come to the surgery expecting to be seen and are then informed that they cannot, at least at the time they had expected.

Other appointment-related arrangements can cause difficult behaviour from patients: eg, being told at the front desk to go back outside and phone in on your mobile. Repeat prescribing systems can also be a cause of stressful patient contact at peak times.

3. Identify the seriousness of the risks and decide what measures to put into place.
At this stage in your risk assessment, you need to analyse the risk in terms of the seriousness of the potential harm to staff exposed to the hazards. This might include the following:

Staff working on the phones may be identified as being at risk of harm from "phone rage" behaviour (characterised by shouting, swearing, abuse (racial/sexual), personal insults, threats or other kinds of intimidation).

You may well conclude that the risk of staff experiencing this is high – it is likely to occur on a fairly frequent basis. You will want to analyse the impact on staff. The behaviour may be low-level aggression but it may be persistent in nature and happen quite frequently, depending on circumstances such as systems in the practice, workload in the practice, patient behaviour, doctor behaviour and other variables.

You will then wish to consider, in consultation with your staff, how serious the impact of this is for them. Feelings may range from, "I feel tearful after it happens and I always feel apprehensive when I am on the phones" to, "Well, it does happen but I feel able to handle it and it doesn't bother me."

Frontline staff on the front desk may be identified as at risk from similar stressors as those above. Additionally, depending on circumstances in the practice and the practice's patient population, they may be exposed to risks resulting from the physical presence of patients.

It may be that your reception desk offers little protection to staff in terms of the height and depth of the desk itself. Your reception desk may not give the receptionist a clear view of the waiting area and you may consider that this potentially places patients at risk as well as staff. In a health-centre environment, multiple services may be offered to patients so that security is difficult to maintain and, depending on the services themselves, some patients in the building may display difficult or unpredictable behaviour.

Again, you will now consider along with your staff the impact of these hazards.

Now you will wish to consider control measures. This will involve asking the following questions of yourself and the staff:

  • What are we already doing to control these risks?
  • Are these control measures still working/working properly/is everyone aware of them?
  • Are we doing enough – are there other reasonable measures we could be taking?

Control measures may take the following forms, for example:

  • Changes to the work environment may include redesigning the front desk and the location of staff in relation to waiting areas.
  • Installation of CCTV.
  • Introducing new procedures for dealing with types of incidents.
  • Training in anticipating, defusing/preventing and dealing with difficult behaviour, violence and aggression.
  • Training in how to apply a zero-tolerance policy – staff may tend to soldier on in extremely difficult situations, and need to be given encouragement and "permission" to take measures such as warning a patient that an interaction will terminate if their behaviour does not change. Additionally,
  • staff benefit from knowing the point at which involving someone else or calling for the manager would help resolve a situation.
  • Implementation of a reporting, recording and debriefing procedure. This should include sensitive and immediate support for staff who are upset, including not blaming staff for causing the incident.

Staff will have lots of feedback and ideas to give at this stage. It is extremely tempting to assume that you are aware of all the issues of this kind affecting your staff, but this may not be the case. Staff who are consulted and involved in the solutions are much more likely to buy in to any control measures you put in place and will be motivated to make sure they work.

  • Encourage your staff to take part in developing and implementing procedures for handling difficult situations.
  • Involve your staff in discussions on how to access training.
  • Use opportunities for experienced staff to share techniques and knowledge with other team members.

4. Record your decisions and take action.
Keep a note of what you have decided to do, and identify who is to take the action and within what timescale.

It is good practice in any circumstances to record your risk assessment; this is actually a statutory requirement if you employ five or more people. If an incident was to happen and the HSE were to be involved, this could be an important document.

5. Review and update your risk assessment.
Of all the stages in a risk assessment, this is the most likely to be neglected. Delegate responsibility for this to someone in the team who has been very involved in the risk assessment and development of control measures, and ask them to report back to you within a certain timescale.

Involve your staff in the evaluation of how well the control measures you have put in place are working. Incidents should be discussed afterwards to identify any learning or changes necessary to the control measures.

Concentrating on this kind of behaviour should not detract either from the skills of our staff or from the fact that the vast majority of patients are courteous and appreciative of the services we deliver. However, as managers we have a responsibility to protect our staff by making sure that, if and when they do find themselves dealing with aggression and violence, they are equipped to handle it well and ensure the safety of themselves and others.

1. See
2. Health and Safety Executive. Work-related violence. Available from:


Healthy Working Lives
Support to help employers in Scotland create a healthier and more motivated workforce.

NHS Security Management Service
Organisation dedicated to the security of NHS staff and property in England.

Violence at Work
Key information about workplace-related violence and aggression, Health and Safety legislation and employment rights.