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Violence in the workplace

• Violence is a problem in the workplace for almost half of the doctors who responded and more than a quarter were of the opinion that the level of violence had increased in their workplace over the last year.
• Doctors in the SHO hospital grade were more likely to report experience of violence in the workplace, followed by GPs. Comparison with a study of workplace violence against GPs in Northern Ireland undertaken in 2003, shows that the reported incidence of workplace violence has not improved in the last 3 years.
• Most respondents experienced violence from patients or from patients’ families/relatives. The incidence of verbal abuse was the most prevalent form of violence or abuse in the workplace, followed by threats and physical assaults.
• More than a quarter of doctors who reported experience of workplace violence, experienced physical violence or abuse. Among those doctors, a third stated that they received minor injuries as a result of the incident and 3 per cent reported serious injuries.
• The majority of violent incidents took place in the hospital ward or doctors’ office. In two-thirds of cases, respondents reported that the incident took place during working hours, whilst a fifth took place during out-of-hours.
• The most frequently stated reason for a violent incident against a doctor was dissatisfaction with service provided, followed by intoxication with alcohol/drugs, health related/personal problems or a history of violence/abuse.
• Some form of action was taken following the violent incident in less than half of cases. Three quarters of the doctors reported the incident to a line manager or senior colleague and a third reported the incident to the police.
• Following the violent incident, support was received by less than two-thirds of doctors. Around a third stated that their experience of violence had affected their work, either psychologically or physically.
• The majority of respondents had not received any training on how to deal with violence from patients and training of this nature is particularly poor amongst hospital doctors.
• Around half of the doctors were worried about potential violence from patients and GPs were more likely to express concern about patient violence. Two in five respondents had taken precautions against potential violence, particularly among GPs.
• Less than 10 per cent of respondents reported having access to a secure facility in which to treat violent patients. The majority agreed that there should be a register of violent patients set up in each Health Board area.
• More than half of the doctors reported that they had witnessed violence from patients directed at others in their workplace in the last year. Violence towards nursing staff and other doctors is more likely to occur in a hospital setting, whilst the incidence of violence against receptionists/administrators is more likely in general practice.
• Only half of respondents reported the presence of a clear policy on zero tolerance to violence in their workplace. Less than half were of the opinion that, as doctors, it was possible to adopt a zero tolerance to violence.

Respondents who had experienced violence were fairly evenly divided between hospital doctors (41%) and GPs (43%). Comparison with a study of workplace violence against GPs in Northern Ireland undertaken in 2003 Health policy and economic research unit 2003 Violence at work: the experience of GPs in Northern Ireland. BMA: London., shows that the reported incidence of workplace violence has not improved in the last 3 years: 44% of GPs in 2003 compared with 43% of GPs in 2006.

Figure 2 shows that doctors in the SHO hospital grade (63%) were more likely to report experience of violence in the workplace, followed by GPs (43%), whilst only one in five academic doctors reported workplace violence (table 8).

Four in five (79%) doctors experienced violence from patients and 52 per cent experienced violence from patients’ families/relatives. Other respondents reported experiencing violence from patients’ friends or companions (14%) or from ‘others’ (3%). ‘Others’ included nurses and colleagues (Figure 3).


Figure 2 - Reported experience of workplace violence according to current position (%)

Table 8 - Reported experience of workplace violence according to current position

	% reported experience of violence	Total respondents (n)
Foundation year trainee	36.4	11
SHO	63.0	109
Specialist registrar	34.2	114
Staff grade and associate specialist	36.8	68
GP (incl. principals, non-principals and locums)	42.5	407
Consultant	37.1	225
Clinical academic	20.	0 5
Other	30.	0 20

Figure 3 - Perpetrators of violence against doctors (%)

The majority of doctors who reported experience of violence in the workplace, experienced some form of verbal abuse (96%), followed by almost half (46%) who experienced some form of threat and 10 per cent who had experienced some form of physical assault.

Respondents were asked about the number of times in the past year that they had experienced some form of violence or abuse. The incidence of verbal abuse was the most frequent, with 25 per cent of respondents experiencing this form of abuse more than 5 times in the last year. This was followed by threats and physical assaults. The main forms of verbal abuse reported were swearing/abusive language, shouting, verbal threats and personal intimidation (Table 9).

Table 9 - Forms of verbal abuse experienced by respondents

	% reported experience of violence	Total respondents (n)
Swearing/abusive language	89.5	359
Shouting	73.1	293
Verbal threats	48.4	194
Personal intimidation	34.2	137
Spitting	9.5	38
Sectarianism	9.0	36
Racial comments	3.5	14
Other	3.5	14

More than a quarter (27%-108/401) of doctors who reported experience of workplace violence, experienced physical violence or abuse. These incidents ranged from being kicked, scratched, shoved, urinated upon, hit and punched, to knife assaults and being threatened with a chair, a drip stand and hot soup. Among those doctors who had experienced physical violence or abuse, a third (45%) stated that they received minor injuries as a result of the incident and 3 per cent reported serious injuries.

Table 10 shows that for the majority of respondents, the violent incident took place in the hospital ward (26.5%) or doctor’s office (23%). Among GPs, the majority of incidents took place either in their office or waiting room, whilst for hospital doctors, the most frequently cited location was the hospital ward or A&E. Other reported locations included out-of-hours clinics, community health centres or outpatients clinics. Several respondents also reported verbal abuse over the telephone. In two-thirds of cases (68%), respondents reported the incident taking place during working hours. However, a fifth (21%) of respondents reported the violent incident taking place during out-of-hours (table 11).

Table 10 - Location where violent incident took place by type of doctor (%)

	General Practitioner	Hospital doctor	Total respondents
Hospital-A&E	3.7	28.0	17.3
Hospital-ward	2.3	45.5	26.5
Hospital-public area	-	6.1	3.4
Your office	41.6	7.9	22.7
GP waiting room	26.0	0.7	11.8
Patient’s home	12.3	0.4	5.6
Other	14.2	11.5	12.7
Total	100.0	100.0	100.0

Table 11 - Timing of violent incident by type of doctor (%)

	General Practitioner	Hospital doctor	Total respondents
During working hours	76.8	60.2	67.5
Out-of-hours	11.6	28.9	21.3
Both	11.6	10.9	11.2
Total	100.0	100.0	100.0

It is often suggested that racial or political motivations lie behind violent incidents. However, only 1 respondent stated that the incident of violence against them was politically motivated. Instead key motivations included drugs, alcohol, mental illness and confusion. Respondents were asked why they thought the violent incident against them had occurred. Table 12 shows that the most frequently stated reason is that the perpetrator was dissatisfied with the service provided, followed by intoxication with alcohol/drugs, health related/personal problems or a history of violence/abuse. Dissatisfaction with the service provided includes patients’ high expectations of the NHS and frustration with long waiting times, refusal to prescribe or admit for treatment and dissatisfaction with diagnosis received.

Table 12 - Perceived reasons for violent incident

	Frequency	% of total respondents
Perpetrator was dissatisfied with service provided	210	52.4
Perpetrator was intoxicated with alcohol/drugs	167	41.6
Perpetrator has health related/personal problems	137	34.2
Perpetrator has a history of violence/abuse	133	33.2
Perpetrator received bad news	42	10.5
Perpetrator was provoked	1	0.2
Don’t Know	14	3.5
Other	41	10.2

Note: more than one response may apply

Two in five of doctors (41%) reported knowing the perpetrator or the perpetrator’s family before the violent incident took place, whilst 59 per cent stated that they did not know the perpetrator. This differs somewhat by type of doctor, with two-thirds (66%) of GPs reporting that they knew either the perpetrator or the perpetrator’s family prior to the incident, compared with less than a quarter (23%) of hospital doctors.

In less than half of cases (45%), some form of action was taken following the incident. Where action did follow a violent incident, three quarters of respondents reported the incident (124/166). This was often to a line manager, senior consultant, medical director, practice manager or other senior staff member in the workplace. In a third of cases (63/166), the incident was reported to the police and in the majority of these cases (69%), some action was taken by the police. Following the violent incident, support was received by less than two-thirds of respondents (58%). This was largely in the form of peer support (36%). Managerial support (8%), debriefing (4%) and counselling service (1%) were received by few respondents.

Doctors were asked whether the violent incident had affected their work. Around a third (31%) said that their experience of violence had affected their work and in many cases the reported impact was both psychological and physical. Impacts include greater awareness of personal safety, ensuring a secure environment, increased anxiety and stress, loss of confidence and professional disillusionment.

All respondents, regardless of whether they themselves had directly experienced violence, were asked whether they had ever considered withholding treatment from a patient due to the threat of abuse or violence. More than a third (38%) of doctors had considered withholding treatment. Almost half of GPs (45%) had considered withholding treatment due to the threat of patient violence, compared with a third of hospital doctors (33%).

The government has called for training of NHS staff to deal with violence from patients, however the majority of doctors (64%) had not received any such training. This does vary somewhat according to type of doctor, with more than half of GPs (53%) reporting receiving some form of training on how to deal with violence from patients, compared with less than a quarter (23%) of hospital doctors.

Figure 4 shows that more than half of respondents (57%) were very or fairly worried about potential violence from patients, whilst a quarter (25%) were not worried at all. Doctors working in general practice were more likely to be worried about patient violence (67%), compared with doctors working in hospitals (49%). Two in five respondents (41%) had taken precautions against potential violence. Again, this was more likely to be the case among GPs (62%), compared with hospital doctors (25%). Panic alarms/buttons were the most widely adopted precaution, but others included room layout, chaperoning and CCTV. Less than 10% of doctors reported having access to a secure facility in which to treat violent patients. Hospital doctors (11%) were more likely to have access to such a facility, compared with GPs (4%). The vast majority of doctors (90%) agreed that there should be a register of violent patients set up in each Health Board area.

Figure 4 - Concern about potential violence from patients (%)

Violence in the workplace
More than half (57%) of respondents reported that they had witnessed violence from patients directed at others in their workplace in the last year. This was largely directed at nursing staff (31%) and receptionist/administrators (32%) (Table 13) and was in the form of verbal abuse (54%), threats (19%) or assault (10%). According to Table 13, violence towards nursing staff and other doctors was more likely to occur in a hospital setting, whilst the incidence of violence against receptionists/administrators was more likely in general practice.

Table 13 - Work colleagues at which abuse is directed by type of doctor (%)

	General Practitioner	Hospital Doctor	Total respondents
Nursing staff	13.6	46.2	33.7
Receptionist/administrator	65.0	15.3	34.4
Other doctors	19.4	30.1	26.0
Porter/cleaner	0.9	2.7	2.0
Other	1.2	5.6	3.9
Total	100.0	100.0	100.0

Note: more than one response may apply

The government has launched a Zero Tolerance campaign to reinforce the message that violence against health service staff will not be tolerated. Doctors were asked whether there was a clear policy on zero tolerance to violence in their workplace. Only half of respondents (52%) reported the presence of such a policy. GPs (70%) were more likely to have such a clear policy in their workplace, compared with hospital doctors (36%). Respondents were also asked whether as doctors, they thought that it was possible to adopt a zero tolerance to violence. Less than half of respondents (48%) stated that it is possible, and a further third (33%) did not think that it is possible to adopt a zero tolerance to violence. GPs (61%) were more likely to be positive about adopting a policy of zero tolerance to violence compared with hospital doctors (38%). Respondents who agreed that it is possible to adopt a zero tolerance to violence were generally of the opinion that any form of abuse or violence is not acceptable and rules should be put in place to enforce this. Many also stressed that the zero tolerance policy must be made clear to all patients and members of the public if it is to be effective.