2.  An increasing number of health care staff are physically attacked or verbally abused by patients.  During 2008-09, NHS trusts in England had one physical assault for every 61 primary care staff – 3,472 in total.  42% had experienced violence. A third thought the incidence of violence was increasing.  A BMA survey of 400 GPs. 2006

3.  Physical violence  Verbal or physical abuse, threats or gestures  Discriminatory abuse  Intentional damage to practice premises  Sexual or racial harassment  Stalking  Inappropriate emotional attachment to a doctor.

5.  Not met or delayed, Patients expectations;  Aggression can often mask poor communication or interpersonal skills;  Delays in treatment, restrictions, mistakes, & lack of privacy;

6.  Environmental factors, such as heating, noise or ventilation;  Personal problems, a history of violence, drug or alcohol abuse.

7. Triggering events escalation crisis resolution. Be warned!  Conciliatory or diffusing actions only work during the triggering and escalation phases.  During the crisis phase your safety is paramount – get out!

8.  Problems or perceived problems:  At home – financial, social, psychological, relationships etc.  With the surgery – no available appointments, unable to gain an appointment with the desired GP, mistakes by the surgery (perceived or real), no privacy at reception, poor communication etc.  Medical – psychiatric illness, intoxication, alcohol misuse, drug misuse, anxiety or fear.  Poor consultation skills e.g. missed cues, ignoring ICE, dismissive attitude etc.

9.  The upset patient may escalate to violence (crisis).  Indications of escalation are;  Symptoms – shouting, swearing, repeating themselves, threat etc.  Signs – clenched fists, wringing hands, pointing, pacing about, sweating, loss of eye contact or intimidating aggressive posture.

11.  Poor communication with the patient - especially lack of explanation (by staff or GP).  Ignoring the patient (often happens at reception)  Failing to try and resolve the issue.  Confrontational or an aggressive response.  Failing to apologise when appropriate.  Poor consultation skills.

12.  Stay calm and remember their anger may not be directed at you personally.  Take a conciliatory approach – give them space and privacy and time to ventilate.  Express empathy, concern and support.  Apologise for their upset.  Listen to the patient’s distress and explore what has upset them and the contributory reasons for their anger.

13.  Then discuss how you can help - present the patient with realistic, achievable options and  Come to a shared agreed plan.  Check their understanding of what you have agreed.  Ensure you deliver your side of the deal.  Remember to address your emotional housekeeping.

14.  e.g. of a reflection: 'You are upset because you think I do not really believe you are suffering.‘  Then;legitimise the patient's anger. E.g. 'I can understand why you are upset. You came to me to find some physical cause for your pain. I cannot find any problem and now I am sending you to a psychiatrist. I might be upset also, if I were in your position.‘ - This expression of understanding and legitimising your patient's emotion is reassuring to them. It usually prevents any further problems and is a powerful method for establishing trust and rapport between the doctor and the patient.

16.  Always ensure the arrangement of furniture in your consulting room does not block your exit.  Know where your panic alarm is and use it!  Ensure you and your staffs are trained as to how to respond to a panic alarm.  Consider attending ‘breakaway techniques’ courses.  Have a policy for seeking immediate police help.

17. Advance warning during the consultation:  Look out for agitation,  An angry tone of voice,  Clenched fists and  Finger pointing or abrupt movements

18.  Speech ( becoming louder & quicker);  Facial expression (changing, flushed, loss of eye contact);  Manner (impatience or non-compliance)  Body language (closing in, sudden or expansive movements).

20.  Take action to remove yourself from the situation if any of these warning signs occur.  “front-desk system” where alerts are recorded next to a patient’s name,

21.  80% of communication is non-verbal  Stay calm, speak slowly and politely  keep your voice at a conversational level  Maintain eye contact  Empathy can help. “I know you feel angry about your long wait, but I’d like to try and help you with your chest pain.”

22.  Is the Pt. agitated, restless or ready to explode? What does Pt. behaviour communicate to you?  Show willingness to talk & listen, acknowledge the Pt. anger or annoyance.  Keep a safe distance; neither too close, nor too far away.  Do not interrupt the patient’s outburst.  Ask open rather than closed Qs. Encourage the Pt. to talk.

23.  Do not make agreements or promises that cannot be kept; be reasonable & honest.  Help the patient to feel he has choices.  Do not talk to the Pt. from behind; also do not attempt to touch the Pt.  Do not block the Patient’s path; ensure the Pt. has an escape route.  If security staff are summoned, try to supervised their actions.

24.  Try to identify the cause of the aggression, you might be able to deal with it.  Maintain your distance from the patient  Never turn your back on a potentially aggressive patient, and always sit nearest to the door, in case you have to make a quick escape  Document all conversations and patient concerns carefully.