It doesn’t “come with the job”: violence against doctors at work must stop

Which incidents do we report?

Patients in the emergency department who are in pain may behave uncharacteristically badly, and health workers have particular difficulty deciding which incidents of abuse to report, if any.

A good definition of workplace violence in healthcare settings might be: “Behaviour by an individual or individuals within or outside an organisation that is intended to physically or psychologically harm a worker or workers and occurs in a work related context.”1 This covers physical assault, such as spitting, and non-physical assault, such as verbal abuse and threats.

Doctors and nurses worldwide experience high levels of such aggression.2 3 Most Spanish healthcare workers reported having experienced insults at work, and similar levels have been reported in Ireland and the United States.4 5

In the latest NHS survey of more than 600 000 staff who responded, 28% reported bullying, harassment, or abuse from patients or relatives, of which 15% (68 683) identified the abuse as physical. Almost half of the staff who had experienced workplace aggression said that they had not reported it.6

Staff in psychiatric departments, emergency departments, and general practice are most at risk. Of the 68 683 assaults against NHS staff in 2013-14, 47 184 (69%) took place in mental healthcare settings, and the rest were in acute, ambulance, or primary care settings.2 3 6

Health workers may perceive that violence from patients stems from mental illness or from the influence of drugs, including alcohol.7 Other factors associated with workplace violence that are particularly relevant to emergency departments include long waiting times, stress, anxiety, and impatience.7 Workload pressures and inadequate staffing increase the risk of workplace violence.2 6 7

The NHS has a “zero tolerance” policy towards such violence, introduced in 1999. In 2013-14, the 68 683 reported assaults led to 1649 (2.4%) successful prosecutions.2 6 But the results of the NHS staff survey may represent only the tip of the iceberg6 7; a common reason given for under-reporting is a perception that violence from patients is something that comes with the job.7

The consequences of workplace violence for victims are multiple and go beyond the physical and mental injury inflicted: they can include ongoing anger and anxiety, substance misuse, and psychological burn-out.8 9 10 These are associated with loss of working days, poor staff performance, increased stress, erosion of morale, and reduced trust between staff and management,6 7 emphasising a need for aftercare.

The NHS has proposed several initiatives to reduce violence against healthcare workers. For example, better staffing levels reduce waiting times; the layout of clinics should allow for the expulsion of aggressive patients or relatives; and waiting areas should be as comfortable as possible, with regular updates of waiting times.6 Also, healthcare providers should install panic buttons, security cameras, and security staff.

Medical education should include lessons on how to deal with aggression and violence among patients.11 Learning about conflict resolution and self defence should be mandatory for all healthcare workers. Perhaps most importantly, staff should know that they have the support of their trusts and that assailants will face appropriate consequences, including prosecution.7

A protective barrier

After I was attacked but before the security staff and police arrived, other vulnerable patients in the waiting room held my assailant against the wall to protect me. More patients stood in front of me as a protective barrier. Several times my attacker broke free and launched himself at me but was again restrained by the patients, who were themselves unwell. They were hit and spat on, but they didn’t let a single blow land on me again.

The police were called, and my assailant was successfully prosecuted and jailed. He was also barred from entering the hospital grounds after it emerged that he had an ongoing history of frivolous emergency department visits while drunk. Although I didn’t make use of it, the BMA has a dedicated service that offers the opportunity to speak to a fellow doctor in confidence.

However difficult the profession of medicine becomes, and whatever challenges and obstacles our NHS faces, I am no longer disillusioned or burdened by these pressures. Workplace violence in healthcare settings can never be eliminated—but all healthcare workers deserve respect and the chance to work in a safe and civilised environment.