To activate the panic button…

• press CTRL+SHIFT+ENTER on Systm1 or
• alternatively select panic button from the SYSTM1 horizontal user menu

All clinical rooms at the surgery are kitted out with a panic button.   This alerts all members of staff that you are in difficulty – who will then run to your rescue (hopefully).   However, please consider how you use this button very carefully.

• You should try to calmly diffuse all situations down using your communication skills first rather than reach for the panic button. In fact, reaching for the panic button might alert the aggressor who may then panic even more and will then be able to throw a punch or even stab you by the time other staff get there.
• What sorts of things can you do before the panic button?
  • • If you are standing up, sit down.  Adopt a submissive position.
    • Ensure that the patient doesn’t come between you and the exit, in case the situation escalates and you need to leave quickly
    • Apologise to the patient for the upset (whether you are at fault or not).
    • Keep regular brief eye contact BUT do not stare.   Do not constantly stare at them too directly in the face (this is one instance where constant eye-contact can be seen as an act of aggression rather than a tool for building rapport).
    • Back down and aim to either get yourself out of the room or them.
    • Only reach for the panic button if physical assault is imminent and you can feel it coming and there is no way out. But remember -most situations can be diffused by speaking nicely in a nice tone, using helpful and positive words (including an apology).   Back off from becoming an alpha-male; and be the submissive and friendlier omega-male.

DO NOT BE CONFRONTATIONAL AND WITHDRAW IF NECESSARY

• Decide whether you feel you are able to cope with the situation, if not seek help from other colleagues, Assistant / Practice Manager.  If the behaviour continues, staff should inform the Practice Manager, Assistant Practice Manager or a Doctor.  The patient will be asked to leave the premises if the behaviour continues.
• If the abusive behaviour is taking place by telephone, inform the person that you are trying to help then, but if they continue to speak to you in this way you will put the telephone down.
• The SystmOne PC panic alarm should be used if the individual fears a situation may be becoming out of control or violent.
• Where urgent Police response is required for a violent situation, staff should ring ‘999’ informing the operator the nature of the call and use the code words “GP ASSIST”, giving the surgery and location details.
• Staff should not continue to deal with a person if they feel that their personal safety, or that of anyone else, is in jeopardy. The police should be called immediately using the ‘GP Assist’ process if they feel that this is the case.
• If an incident occurs, the critical incident procedure will be followed by the Practice Management. This involves the Practice recording the incident, reporting to the relevant authorities, PCT and possibly other local Practices to help avoid the situation in future. Therefore it is vital all incidents are reported. It will form part of the practice significant event reviews process.

Diffuse means to disperse or calm down.    So, this section is about how to calm down the angry situation.

1. Keep safe – don’t directly approach an overtly aggressive patient face-to-face without the protection of a barrier or being close to an safe exit point.
2. Change your attitude – see the patient in a more positive light – that aggression is simply a manifestation of someone not getting their needs met. If you are feeling worked up, take some deep breaths and calm yourself down.
3. Apologise for the upset – even if it is not your fault. ‘I’m sorry Mr X for upsetting you.’
4. Be positive – both with your mouth and your behaviour. ‘I’m sorry Mr X for upsetting you.   Shall we see if I can make things right?’
   1. 1. Your speech – use a steady, calm and clear voice, positive language.
      2. Eye contact – keep regular contact but do not stare
      3. Face – show attentiveness, use nods to signal interest and relax facial muscles
      4. Your behaviour and posture – should be non-aggressive, open and gentle. Sit down if you are standing.  Adopt a submissive position.
      5. Your attitude – should reflect a sincere ‘wanting to help’ the other person
      6. Acknowledge feelings in the other people and empathise.  ‘I can see why that would upset you’ or ‘I can see that you’re finding this very upsetting’
5. Encourage a good conversation between you and the other person to

• • • Help understand the difficulties
    • Help you understand what need is not being met
    • Help you appreciate each other’s feelings

Make sure that the person is aware that you are listening for their feelings, concerns and intentions.  Both of you need to see each other’s perspective.  In doing so, hopefully the other person will apologise for their behaviour too

When to back down: if these simple de-escalation techniques are not working after 5 minutes, it may be best to back off and ask another member of staff to intervene as it could be that the staff-patient relationship has broken down.

Any member of staff involved in an incident should have a discussion with the Assistant / Practice Manager as soon as possible after the incident has taken place.  The purpose of this is to:

• Discuss the incident in order to support the worker
• Discuss the need for further / expert counselling for the member of staff if necessary
• Evaluate the actions of staff involved to see if any system has failed
• To take any steps to ensure protective actions need to take place following an incident to staff or property.

The Manager or Assistant Manager with at least two doctors will decide on the required action to deter the patient from future similar behaviour. This will either be:

1. A warning (last chance) to the patient advising that they will b e removed from the list if the unacceptable behaviour continues.
2. Removal of the patient(s) from the Practice list. This would also include any other patients for who they are a guardian, carer or likely to have a future input for them. This is only used when it is felt that the warning is unlikely to stop the behaviour or the actual incident has undermined the doctor-patient relationship and a doctor is not then willing to treat the patient. The practice patient removals policy must then be followed. Even this action should serve as a warning for the patient not to behavior in an appropriate manner with a new practice.

The PCT has contracted with Shipley HC for them to provide GP services to patients removed from a practice list due to violent behaviour. Therefore the practice should be contacted.

If a patient remains on the practice list, the member of staff has the right to see the patient with another staff present.

Ashcroft Surgery has a zero tolerance for aggressive behaviour.  A person does not have to be physical to be aggressive.    The simple way to think of it is to remember that if someone is making you feel intimidated, then they are being aggressive.  So, people can be aggressive by their  behaviour OR simply by the way the words they use and how they say them.  If you feel that a patient may end up being very aggressive to you need to…

• Protect yourself. Get behind a protected screen counter, in a protected area (like reception area) or near a safe exit point.
• Call another member of staff to be with you (do not be on your own) or even to take over.
• Now politely and firmly tell the patient:
  • • (i) how they are making you feel,  (ii) ask them to stop and  (iii) that you want to help them but only if they calm down.
    • ‘Mr X, please would you lower your voice and calm down. You are making me feel very uncomfortable.  I really would like to help you but it is difficult when you’re shouting at me’. 
• If they continue… ask them to leave the premises.
  • • ‘Mr X, I’ve asked you politely to calm down but you’re still shouting at me. I’m sorry but I need you to leave the premises.’
• If they fail to leave, tell them that you will be calling the police if they don’t.
  • • ‘Mr X, I’ve asked you politely to leave the premises and you have not. You are leaving me with no choice but to call the police.  I don’t want to call the police but I will do if I have to.  Now, I will ask you politely one more time to leave the premises.  It’s up to you…’
• You may wish to involve the Practice Manager, the Assistant Practice Manager or a GP to help you.

In common law, assault is the act of creating apprehension of an imminent harmful or offensive contact with a person – in other words, a sense of threat of violence.  Put another way, assault is an “attempt, threat or offer to apply unlawful force sufficient to create fear that actual violence may ensue”.   If a person feels intimidated or fearful that something awful might have happened, then that is enough.  Therefore, assault may result in either criminal and/or civil liability. The term is often confused with battery.  Battery applies when physical contact is involved.

Being physical to another patient or person is simply unacceptable.  The physical act doesn’t necessarily need to be throwing a punch.  Even pulling someone’s glasses of their face can be a aggressive physical act – depending on the context and whether the recipient consented to that act.    If they didn’t consent, then the act could indicate an act of battery.  In these situations…

• Call another member of staff to be with you (do not be on your own).
• Make sure you are behind a protected screen, in a protected area or near a safe exit point.
• Call the aggressive person over to the screen and ask them to leave the premises.  Explain why you are asking them to leave and conclude by saying that their behaviour is not acceptable.
• If they refuse to leave, tell them that you will call the police if they don’t.
• Once they have left, go to the victim and ask them how they are and whether they wish to file an assault charge.
• If they do, call the police.
• Whether the patient makes an immediate assault charge or not, please make a written record of what went on. A person can make a claim of assault up to 6 months after the event!
• You may wish to involve the Practice Manager, the Assistant Practice Manager or a GP to help you.

• Yes, definitely!
• Please warn the doctor, nurse or any other member of staff who is due to see a patient that you either know to be aggressive or has been aggressive with you.   You have a duty to protect your colleagues.

Ensure that you have a personal system of safety:

• We would never recommend going alone to patients who are known to be aggressive – instead, take a colleague with you or better still, encourage them to come to the surgery.
• If you do visit (because you think the level of threat isn’t so high), make other staff members aware when you are on a visit to a potentially risky patient and when you are expected to come back. Therefore, if any incident happens, this is more likely to be spotted by colleagues by your absence and in a timely way.  When you are there, make sure you are near an exit point at all times.  Any slight worry – get out!