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Safety for general practitioners and their practice teams

The RACGP recognises the real willingness of general practitioners (GPs) and their practice teams to continue to care for people who may have a propensity for violence, but it also recognises the right of GPs and their teams to feel, and be, safe.

The extent of violence in Australian general practice

A recent study1 found that the most common forms of violence were “low level” violence. The percentage of GPs who reported at least one incident of violence in the previous year follows – verbal abuse (42.1%), property damage/theft (28.6%) and threats (23.1%). A smaller proportion of GPs had experienced “high level” violence, such as sexual harassment (9.3%) and physical abuse (2.7%).

This study also found a significant association between high-level violence and lower socioeconomic status area, being female, having practice populations with more drug-related problems, and providing home visits during business hours. More experienced GPs encountered less violence for every additional 5 years of practice.

This suggests that the area in which the practice is situated, the gender of its GPs and staff, the experience of the GPs and staff, and the characteristics of the population served by the practice, are relevant considerations when considering the safeguards needed for the practice.

The practice ‘culture’ is important

Underpinning the establishment of safeguards for the safety of general practitioners and their practice teams needs to be a culture in the practice that allows the GPs and their team to express their anxieties and feelings. This allows for the early recognition of concerns amongst the team. GPs and their practice teams need to ‘have their wits about them’ and to trust their instincts about people the entire time they are at work. Sometimes that can mean recognising and expressing feelings about a person, even if staff cannot easily define those feelings.

Maintaining our focus on the many aspects of general practice can be difficult, as we are all human, and, for example, get tired at the end of a long day of consulting and attending to the needs of our families. It is important for practices to put in place mechanisms that allow GPs and their teams to have adequate breaks, and to attend to their physical needs (have lunch etc), so that the ability to notice and respond to threatening behaviour is not compromised. It is also important that GPs and their practice teams be able to express the fact that they are tired or distracted (for example), as this assists in allowing other members of the practice team to be vigilant.

The practice culture is also important to dealing with the aftermath of any violence – for encouraging de-briefing, for example.

Recommended precautions

In common with dealing with other risks, it is important to have a number of precautions in place.

1. Consider undertaking a safety audit

Practices may want to undertake an audit of the safety of their general practitioners and practice teams, using the material outlined in this information sheet as a basis.

Some police who have assisted with this information sheet have suggested that practices may want to ask their local community liaison officers to undertake a safety audit of the practice.

If you take this path, be mindful of the risks that would result from identifying a problem with safety and not addressing it. Be ready to prioritise the issues identified and to make meaningful changes.

2. Physical security

Consider having:

• counters that are wide enough to prevent a patient reaching across them easily
• adequate lighting, especially at the entrance and where cars are parked
• effective storage of s.8 drugs (or alternatively, coordinate your opening hours with a local pharmacy which stocks s.8 drugs and do not store them on your premises)
• a speaker phone and a single dial to reception (allowing you to press one button and have the activity in the consultation room heard in reception)
• the room furniture set up so that the GP is closest to an exit
• hard-wiring security, including panic alarms
• a safe place for staff to store their personal belongings (e.g. bags).

Especially if you are building the practice from scratch, consider:

• ensuring that consulting rooms have two exits
• designing the layout of consulting rooms and treatment rooms to allow the GP or their practice staff members to be closest to a door
• hard-wiring security
• designing a place for staff to secure their personal belongings (e.g. bags)
• the strength of external doors and windows.

Consider the access to the premises, including access through ‘back doors’ that are not visible.

If you have a security system installed, ensure that you have a routine for checking the battery back-up.

If the area warrants it, consider installing CCTV in the waiting room (only), and a monitor in every consulting room. It need not be expensive, the wireless ones that takes 2 minutes to DIY costing about $150 - 200. It is very effective that one can actually see who is coming into the waiting room rather than guessing. (Put a notice in the waiting room to warn people that CCTV monitoring is in progress)

3. Practice processes and systems

• Ensure that the security arrangements are covered in the induction of all new GPs and practice staff
• Consider the role of e-commerce, and the use of a practice debit/credit card to reduce the volume of cash at the practice (but be mindful of the risk of fraud); and consider where (and how securely) cash is stored
• Consider using rooms close to Reception when there are fewer GPs working (e.g. after hours or weekends). It might mean ‘hot-desking’ for these periods.
• Ask the practice staff to notify the GPs promptly if patients arrive under the influence of alcohol or other drugs, just as they would notify the GPs of other risk factors such as chest pain or difficulty breathing.
• Have systems so that your practice can organise to see patients who are becoming anxious or threatening quickly – prioritise them so the patient’s issue can be addressed and patient can leave the practice
• Consider ways in which patients can be distracted while waiting. One practice has established a place for people to knit. It is possible to alter the perception of time spent waiting, reducing anxiety and frustration.
• Ensure staff are confident to raise waiting times, or other issues that may increase concern or agitation amongst patients, so that these issues can be managed proactively
• Consider the role of clinical meetings and case conferences to discuss a practice-wide approach to patients who are complex to manage (e.g. where there is a history of inappropriate behaviour)
• Consider routinely asking patients to take off their sunglasses and hats. Police indicate that this helps staff read non-verbal cues in a patient (e.g. helps staff know if the patient is agitated); and can assist staff to give an accurate description on the occasion that is needed
• Have a system that allows GPs and staff the option of not going to a consulting room with someone they have concerns about, and that allows them to unobtrusively indicate this to other personnel in the practice
• Consider telling reception staff to call the police if ever they feel they need to. By the time they are considering this action, it may be important for them to act.
• If GPs and staff ever feel threatened by a patient, especially someone who is affected by drugs and seeking a prescription or needles, consider giving the patient what they want and getting them out of the consulting room or practice as quickly as possible. Then consider calling the police. Don’t confront them.
• Consider the availability of de-briefing for members of the practice team who have been the subject of violence. At a professional level, consider reviewing what went well, in addition to what could be improved. Don’t forget that personal issues might arise, as well as professional ones.
• As a reflection of concerns expressed by the profession in relation to the safety of general practice staff outside the normal opening hours of their practices, the aspects of the RACGP Standards for General Practices 3 rd edition concerning care provided outside the normal opening hours of a general practice have a focus on what is safe and reasonable for a GP to provide, given all the circumstances.
• The safety of GPs and their team members is also one of the reasons why the RACGP’s Standards include the requirement to have at least one staff member in addition to the GP(s) present when the practice is open for routine consulting.
• A useful overall approach within the practice is – Document (the incident/issues), Discuss (the incident/issues), Relay (the incident/issues) to others who need to know.

4. GP and staff training in the recognition and management of ‘difficult’ patients

• GPs and members of their practice teams need to be well-trained in ‘people management’ or ‘customer service’, allowing them to
  • Spell out their expectations of behaviour within the practice (establish ground rules) early and clearly
  • Recognise and attempt to assist ‘difficult’ patients; and
  • Prevent, control and ‘de-escalate’ violent situations within their role in the practice.
• GPs and other members of the practice team need to be encouraged to recognise their instincts. If the instinct of GPs or staff start to ‘tingle’, it is important that they take notice. It could mean drawing the consultation to a close earlier than planned, or devising a pretext to get someone else into the consultation room or treatment setting, e.g. calling the receptionist to do something for you. This may assist in defusing a tense situation and bringing the consultation to a close. GPs and their practice staff can sometimes put their sense of professional obligation above concerns for their own safety. People working in general practice need to carefully consider the implications of doing this.
• Alert other staff members if you feel uncomfortable about a patient – arrange another staff member to interrupt the consultation after a prearranged time.
• Make sure that everyone is confident to disclose uncomfortable feelings or episodes that concern them. Unless this occurs, a perception can arise that inappropriate behaviour is ‘one-off’, when, in fact, it has happened to other people in the practice who have not felt confident to raise the issue with their colleagues
• Consider the propensity for violence amongst individuals (especially those with a history of perpetrating violence and when individuals are under pressure), or amongst groups within the practice population, and consider ways, as a whole practice, to address this risk. Ensure that staff are educated about the risks and involved in planning. For example, a practice may decide not to hold s8 drugs on its premises, or have specific precautions for patients with a history of violence.

5. Security when GPs and staff are moving around

As a reflection of concerns expressed by the profession in relation to the safety of general practice staff making home and other visits, the aspects of the RACGP Standards for General Practices 3 rd edition concerning home and other visits have a focus on what is safe and reasonable for a GP to provide, given all the circumstances.

It can be helpful to discuss ‘trouble spots’ or ‘no go’ zones within the practice, if the GPs or staff have experienced past violence; and it can be useful to share these experiences with nearby practices, to ensure that everyone takes appropriate safeguards. In particular circumstances it may be appropriate to make an alternative arrangement to a home visit.

The following actions have been proposed by the National Medical Deputising Services Australia as means of enhancing the safety of after-hours medical practitioners and have been adopted into the RACGP’s explanatory notes for its Standards for general practices:

• Patients must have a phone number on which the after hours care service can call back
• The after hours care service needs to be aware of the location of its duty medical practitioners at all times
• A medical practitioner is not sent to a patient/caller requesting pain relief for a chronic pain syndrome unless a pain management plan is in place
• Police are requested to attend patients threatening suicide, or who appear to be violent or abusive
• Callers are asked to restrain dogs, to turn on an outside light at night and provide guidance on identifying the residence (for example, nearest intersection)
• Patients are asked to provide their date of birth, and the name of their regular general practitioner / general practice. Where these details or a contact phone number are not provided, consideration is given to referring the patient to hospital or calling an ambulance (as appropriate)
• Services are mindful of situations where a medical practitioner has attended a patient for a longer period than seems necessary and details of each medical practitioner’s vehicle type and registration number should be available to inform police if contact with the medical practitioner is lost.

6. Effective complaints management

Difficulties can arise from unresolved issues for patients, relating to their treatment (both clinical and otherwise) in health care settings.

Keeping patients informed of any delay, for example, can assist to prevent frustration, anger or violence.

Effective complaints management can assist to ensure that such issues do not escalate, creating a trigger for violence.

7. Effective relationships with local services

There is a range of patients in general practice whose health needs are best met in conjunction with other local services.

It can assist general practices to have effective referral arrangements with local mental health, domestic violence, and alcohol and drug dependence services, for example. This can reduce the uncertainty and related anxiety for patients who need referral to these services.

8. Patient information sheet

It may be useful to include a statement in your practice information sheet that informs patients of the value of mutual respect between staff and patients.

This can assist in establishing an appropriate culture within the practice.

9. Patient behaviour contracts

For patients with ongoing behavioural issues, a behaviour contract may be useful in setting boundaries and consequences.

Discontinuing care where safety concerns exist

The RACGP recognises that it is appropriate for a GP to discontinue treating a patient, especially when the GP thinks they can no longer give the patient their best care.

1. When is it appropriate to discontinue care?

The RACGP recognises that most GPs consider discontinuing care, only when they are no longer confident that they can provide high quality care. There are no hard and fast rules about when it is appropriate to discontinue the care of a patient.

It is useful to ask oneself whether a group of one’s peers would understand and support the choice to discontinue care if they were in the same circumstances. If you believe they would, then this supports your decision.

2. How do I convey the decision to discontinue care to the patient?

Reflect on the patient’s situation, especially any short-term risks to the patient’s health that will occur by discontinuing care, and keep them in mind as you decide how to convey your decision, and what to convey.

In the ideal, it would be useful to have a discussion with the patient about the basis for your decision to discontinue care; and to reach a mutual agreement that the patient seeks a new general practitioner. It is important, if possible, that the patient understands that it is in their best interests that the GP is taking this difficult step, and that they do not feel abandoned by the doctor. 

If you decide to take this path, consider the way you tackle the discussion carefully (as you do when telling a patient that they have a life-threatening illness); and ensure that the practice is prepared for the discussion.

Some words that might be appropriate are:

"This is a very difficult situation. On the one hand, I want you to receive the best health care possible; on the other, I feel I cannot provide it to you while you are so angry."

"I understand why you are angry. I am unable to give you the care you require, as are the other doctors in this practice. What do you see as options for your future health care?"

"I am sorry that we cannot continue as doctor and patient. I need to be sure that you do receive the health care you need. When you have found a new GP, I will make sure that your medical records are transferred if you wish."

Such a discussion needs to be immediately followed up with a clearly worded letter that acknowledges the patient's situation while providing firm boundaries for future interactions with the practice.  Arrangements for alternative health care (preferably negotiated with the patient) need to be spelt out clearly.

In many circumstances, especially where violence has occurred, a discussion with the patient may not be appropriate.

In these cases it is useful and important to write the patient a brief letter advising them that you are discontinuing their care.

• Consider starting with common ground (e.g. your mutual interest in ensuring that they receive high quality care)
• Focus on the behaviour that led to your decision, not on assumptions or judgemental statements about it – be dispassionate
• Minimise use of emotive words which may trigger a reaction by the patient
• Be clear about the boundary you are setting (e.g. the patient is not to call the practice, or attend the practice) – a patient may continue to harass the practice by calling, though not attending
• Propose a realistic way for the patient to seek continuing general practice care if you can (this might involve looking for another practice in the phone book, but might be more complex in rural locations)
• Make an offer to transfer a copy of the patient’s health information to a new practice with the patient’s permission.

3. What else do I need to do?

• Keep a contemporaneous record of any discussions with the patient, and a copy of any letter sent to the patient
• If the result of the interaction is a quality of care less than you would normally provide, consider notifying your Medical Defence Organisation about the incident
• Agree on the practice’s response to a violation of the boundaries you have set (e.g. what the practice will do if the patient calls or attends)
• Be aware that you are legally and ethically bound only to treat a person in an emergency situation.

Additional resources

The AMA also has a policy on Personal Safety and Privacy for Doctors, 2005 (accessed June 2006).

Useful resources from the United Kingdom include:

A Handbook: Preventing Violence in General Practice (from the South Wales Police)

Exeter PCT's Zero tolerance policy (This has excellent practical ideas for ‘lone workers’ that may be of assistance for GPs who are undertaking home and other visits)

Policy on violence and aggression in general practice I.O.W Primary Care Trust 2003

Magin PJ , Adams J , Sibbritt DW , Joy E, Ireland MC. Experiences of occupational violence in Australian urban general practice: a cross-sectional study of GPs. MJA 2005; 183 (7) : 352-356.

Publication Date: 30 November 2006
Authorised By: GP Advocacy and support