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Keeping the peace: dealing with difficult patients at work

Emma Cuzner
Medico-legal Adviser
Medical Defence Union

In 2007/08 there were 55,993 reported physical assaults against NHS staff in England.1 As nurses spend their working lives in close contact with people who may be at their most vulnerable, it is sadly not unusual for them to be on the receiving end of violence or abuse.

Fortunately, the NHS has a zero tolerance approach and nurses should feel confident in taking action if a patient is violent or abusive towards them.

The violent patient
A practice nurse saw a patient for a dressing change while he was recovering from an injury. The patient's nephew also attended the appointment. During the consultation, the nurse was called out of the room by a colleague. When she returned to the room, the nurse noticed that the nephew was rifling through her desk. When she challenged him, the man became abusive, produced a knife and threatened her before running out of the surgery, closely followed by the patient.  

The nurse rang the police who arrested the man and later prosecuted him. The surgery reviewed its security arrangements and made clear to the patient that the nephew, who was not a patient, would not be allowed back on surgery premises. The patient subsequently apologised for his nephew's behaviour.

MDU advice
Zero tolerance
The NHS has a zero tolerance policy regarding violence and abuse towards staff and you should feel confident to report a violent incident such as this to the police or your primary care trust (PCT). The PCT should have local policies on dealing with repeatedly violent or abusive patients; for example, by providing a secure environment where they can be seen. Your surgery should also have a protocol for seeing patients with a history of violence - perhaps stipulating that a second member of staff needs to be present at every consultation and, in extreme cases, a police officer.

Personal safety
Inform practice staff if you are about to take a patient with a history of violence into your room. Try to keep calm in tense situations, acknowledging grievances or problems; but if things escalate, it may be simpler to leave the room. Panic buttons and alarms should be considered in consultation rooms.

The aftermath
Violent incidents should be documented in the patient's record and relevant colleagues alerted. The practice might want to press charges or consider removing a patient from the practice list. If reporting an incident to the police, however, it is important that minimal details about the patient are disclosed, such as their name and address.

It is only in exceptional circumstances that clinical details should be disclosed; for example, when withholding information might place the patient or others at risk of serious harm or death. The Nursing and Midwifery Council (NMC) has guidance on disclosing information in the public interest (see Resource at the end of this article).

The rude patient
An elderly man with a number of chronic health problems was often rude to reception staff and nurses and had a reputation for being a difficult patient. Matters came to a head when the man saw the practice nurse for a medication review. The patient angrily explained that he was only attending because the GP had insisted he do so before she would issue any more repeat prescriptions. The patient accused the practice of trying to save money at his expense. He suggested to the nurse that she was incompetent. He later made a complaint to the practice manager and threatened to contact the local newspaper.

The nurse discussed the matter with the GP who felt that the practice's professional relationship with the patient was irretrievably damaged and wrote to him to say she was removing him from the practice list. Two days later, the PCT received a written complaint from the patient who now accused the practice of heartless disregard for his health problems. He said it would be impossible for him to register elsewhere because his mobility problems meant the other practices were too far away.

After discussing the case with the PCT and the MDU, the practice admitted their decision to remove the patient was prompted by his complaint. The practice agreed to hold a meeting to discuss the matter with the patient in the presence of a conciliator to see if the situation could be resolved.

MDU advice
Last resort
Nurses should only consider ending a professional relationship with a patient in exceptional circumstances, when the nurse-patient relationship has irretrievably broken down. The General Medical Council (GMC) in its advice to doctors (Good Medical Practice, 2006), advises against removing a patient solely because of a complaint.2

Issue a warning
In cases where a patient's behaviour is disruptive, it is advisable to discuss the problem with the patient, explain why their behaviour is inappropriate and find out what may lie behind it. If such a discussion is unproductive, the patient should generally be warned in writing that if they do not change their behaviour, they risk removal from the practice list.

Record your decision
Before you end a professional relationship with a patient you must be satisfied that your decision is fair and not influenced by your personal views. It is important to keep a clear and detailed note of any incidents that have led to the removal and any steps that have been taken to resolve the situation.

Amorous patient
A practice nurse saw a young male patient who requested travel vaccinations for a trip to East Africa. During the appointment the nurse commented that she had been on safari in Africa earlier that year and chatted to the patient about the trip. The patient rang later in the day and asked to speak to the nurse for further advice about avoiding mosquito bites during the trip. The man called again the following day to check the need for any further vaccinations and later that day sent flowers as a thank you. The following week the patient appeared at the surgery as the nurse was leaving and asked if she could give him a lift home. The nurse felt uncomfortable and politely declined.

She rang the MDU to ask what she should do and was advised to nip the situation in the bud. The nurse discussed the matter with colleagues in the practice and the practice manager wrote to the man asking him not to contact the nurse inappropriately, and suggesting that it would be advisable for him to consult with other nurses in the surgery in the future. The patient didn't contact the nurse again.

MDU advice
Appropriate relationships
The nurse-patient relationship is central to the trust between a nurse and patient, and health professionals have a duty to ensure that the appropriate balance is maintained at all times. While it may be heartening to know that a patient is grateful for your clinical management of their care, there are situations where it becomes apparent that a patient may have inappropriate intentions. These should be nipped in the bud and the patient reminded gently but firmly that your only role is a professional one.

Emergencies
In an emergency, it may be necessary for you to treat a patient who has shown amorous intentions to you. If this happens, you may want to suggest a chaperone is present during consultations, particularly for intimate examinations.

Get help
Every situation is different and you may wish to consider contacting your medical defence organisation or professional indemnity organisation as soon as you become aware of potential difficulties with a patient. Keeping a log of all calls, letters and gifts is advisable.

These scenarios are fictitious but based on cases from the MDU's files. Nurses with specific concerns are advised to get their own professional advice.

References
1. NHS Security Management Service, November 2008
© MDU; 2009.
2. General Medical Council (NMC). Good Medical Practice. London: GMC; 2006. Available from: www.gmc-uk.org/guidance/good_medical_practice/GMC_GMP.pdf

Resource
Nursing and Midwifery Council (NMC)
W: www.nmc-uk.org