Working in healthcare will always be challenging, and doctors expect long hours and accept the reality of limited resources. What they don't expect - or deserve - is to be met with aggression and violence for simply doing their job.

And it is not just a British phenomenon. For example, the BMJ reported, in June 2019, that doctors in India were demanding a new, national law to address violence in hospitals. The BBC reported in December of that same year that China had launched a new law to protect doctors from violence. The World Health Organisation notes that health workers are at "high risk of violence" all over the world, and that it is unacceptable: its consequence is that the quality and the provision care is compromised, and that it leads to "immense financial loss" in the health sector.

The chances are, if you are reading this article, you will be lucky if you have never experienced violence in the workplace. The GP publication Pulse reported in January 2019 that three-quarters of doctors had been assaulted or threatened at work, while the NHS Staff Survey 2020 provides data on the incidence of violence at work - which has sadly remained fairly constant at around 15% of staff each year experiencing at least one incident of physical violence. For ambulance staff the figures are over twice as high: almost 35% experience at least one incident of violence each year.

The Health and Safety Executive (HSE) defines workplace violence as being, "any incident in which a person is abused, threatened or assaulted in circumstances relating to their work"…"This can include verbal abuse or threats as well as physical attacks".

The HSE definition is useful because it reminds us that workplace violence is not limited to physical assaults that lead to injury, although such incidents are plainly deplorable. It can also include tirades of verbal abuse, or threats of violence or intimidatory invasion of personal space.

MDU experiences

Despite the prevalence of violence towards healthcare staff, most do not relate to medico-legal issues and it is rare for members to seek MDU advice. Of those who do, approximately 25% were the victim of an assault in a healthcare setting, the remainder were witnesses to a colleague's assault.

In nearly 40% of cases the perpetrator of violence had either mental illness or dementia or a learning disability. In two cases, staff were assaulted by relatives of patients they were actively resuscitating.

The reason members sought MDU advice was mostly related to having a draft statement reviewed and to answer questions about what information could be disclosed - to the police, for example. Some doctors were concerned about possible conflicts of interest where they were providing factual evidence relating to an assault as well as an opinion on fitness to plead.

In primary care, advice was often sought about removing patients from the practice list after they had been violent in the healthcare setting.

The HSE has published a list of risk factors that increase the possibility that a healthcare worker might be assaulted, which can be broadly categorised into worker characteristics and individual (patient) characteristics.

Health policy

Despite the clear evidence of violence against healthcare staff, health policy in England has been inconsistent. In 1999 the NHS adopted a "zero tolerance" campaign towards violence, and in 2003 a new NHS body, the Counter Fraud and Security Management Service (later NHS Protect) was established to assist in bringing prosecutions against offenders.

But in 2017 NHS Protect was abolished and only its counter fraud arm function was retained. In 2018, the Secretary of State for Health announced that an NHS violence reduction strategy would be introduced and the zero tolerance principle reinstated.

The NHS violence reduction strategy comprises:

• collaboration with police and prosecutors to secure convictions
• scrutiny of reports of violence against staff by the CQC in its inspections of NHS bodies
• training for staff
• mental health support for affected staff.

However, there appears to have been no substantive progress on the strategy since 2018. This is despite the fact there is the budget to do something - the NHS Long Term Plan allocates £2 million a year from 2019/20 on programmes to reduce violence, bullying and harassment of NHS staff.

MDU advice and learning points

Based on MDU experience and national guidance, here are some learning points to help reduce the risk of being caught up in a violent situation at work.

• Be aware of some of the underlying causes of violence (e.g. mental illness, drug and alcohol intoxication, boredom, restriction of patient's liberty, etc) so you can better judge risk.
• Recognise the warning signs associated with progression to a violent state. This is often escalating behaviour: restlessness leading to agitation/irritability, which in turn progresses to verbal aggression, gestures and threats and potentially then moving on to damage to objects and physical assault.
• Consider whether you might benefit from further training on communication skills (including non-verbal skills). Be an active listener and avoid confrontational responses.
• Although challenging, remain calm and professional at all times.
• Finally, become skilled in appraising your environment and modify it where possible. For example, aim to position yourself between the patient and the exit and know how to raise the alarm in an emergency.

Some specialties, such as psychiatry and emergency medicine, will have staff who are trained and experienced in de-escalation and conflict resolution, but many doctors will have had no formal training.

There is a NICE guideline (NG10) on the short-term management of violence and aggression in mental health, health and community settings. The guidance emphasises the need to train staff where there is a reasonable anticipation of the risk of violence or aggression. This training could involve specialist de-escalation techniques or important skills to escape from a violent situation (breakaway techniques).

Involving the police

Despite a doctor's best endeavours, sadly there will still be instances of physical violence, or threats, that require police intervention.

The law has been strengthened in recent years, and the Assaults on Emergency Workers (Offences) Act 2018 created a specific offence with longer sentences where a healthcare (or other public sector worker) is assaulted at work.

There is evidence that the legislation is being utilised - in its first year 20,000 people were charged under the Act with a 90% conviction rate. But, perhaps unsurprisingly, 90% of assaults were against police officers.

Summary

If you are unsure about what to do after experiencing or witnessing violence at work - for example, if you have concerns about what to say to the police without breaching confidentiality - contact the MDU for further advice.

Also, don't forget to follow your organisation's reporting procedures to ensure that the incident is properly recorded, and to seek medical advice and assistance if necessary. Where you have suffered a physical injury, it may be necessary for you to be examined by a forensic physician to make sure the evidence considered by prosecutors will be of the highest quality.