Patient Behavior Policy

THE WALL HOUSE SURGERY

PATIENT BEHAVIOUR POLICY

INTRODUCTION

1.1 Policy Statement

The purpose of this document is to provide guidance to staff at this organisation on how to manage unreasonable, violent and abusive patients in the workplace in line with extant legislation.

At TWHS, the directive is that at no time will any violent, threatening or abusive behaviour be tolerated towards staff, patients or visitors.

Whilst violence and threatening behaviour is often easy to label, abuse may take on many forms. For the purpose of this policy, abuse can be towards any service user, visitor or staff member and includes (but is not limited to) sexism, racism homophobia, biphobia, transphobia and ageism, or harassment or abuse on the basis of disability, marriage or civil partnership, pregnancy or maternity, religion or belief.

In addition, unreasonable behaviour is also unacceptable and, as such, needs to be managed appropriately and consistently. This organisation has a zero tolerance towards poor behaviour and is committed to reducing the risk to staff and other patients.

This document will illustrate the organisation’s commitment to the safety of staff, contractors and patients whilst explaining the requirement for staff to undertake training and report incidents effectively to ensure that appropriate action is taken against offenders. It is policy for TWHS to press charges against any person who damages or steals organisation property or assaults any member of staff, visitor or patient.

This document will be updated as and when changes to legislation occur. Staff should refer to the legislative documents to always ensure relevance.

It is the responsibility of all staff to ensure they recognise, respond to and take the necessary action when dealing with any patient who is behaving in a violent, threatening or abusive manner towards colleagues, contractors or patients.

The following legislation supports this policy:

· Health and Safety at Work Act 1974

· Management of Health and Safety at Work Regulations 1999

· Reporting of Injuries, Diseases and Dangerous Occurrences Regulations

2013 (RIDDOR)

· Safety Representatives and Safety Committees Regulations 1977

· Health and Safety (Consultation with Employees) Regulations 1996

Specifically, the legislation states that an employing organisation has a legal duty to:

· Ensure, so far as reasonable, the health, safety and welfare at work of their staff

· Identify risks to staff (including the potential risk of violence), decide how significant these risks are, decide what to do to prevent or control the risks and develop a clear plan to achieve this

· Notify their enforcing authority in the event of an accident at work involving any employee resulting in death, injury or incapacity for normal work for seven or more days. This includes any act of non-consensual physical violence done to a person at work

· Inform, and consult with, employees in good time on their health and safety

In the document entitled ‘work-related violence’, the HSE establishes the employers’ responsibilities in relation to preventing and managing violence in the workplace. Employers have a duty of care to protect staff from threats and violence at work.

1.2 Status

The organisation aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have regarding the individual protected characteristics of those to whom it applies.

This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment.

DEFINITION OF TERMS

2.1 Violence

Any incident in which an employee is abused, threatened or assaulted in circumstances relating to their work.

2.2 Physical Assault

The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort.

2.3 Non Physical Assault

The use of inappropriate or discriminatory words or behaviour causing distress and/or constituting harassment

2.4 Aggression

Behaviour that is hostile, destructive and/or violent

2.5 Discrimination

Discrimination is the unfair or prejudicial treatment of people and groups based on protected characteristics.

2.6 Homophobia, biphobia and transphobia

The fear or dislike of someone, based on prejudice or negative attitudes, beliefs or views about lesbian, gay or bi people. This can also include denying somebody’s lesbian, gay or bi identity or refusing to accept it. Homophobia may be targeted at people who are, or who are perceived to be, lesbian, gay or bi.

The fear or dislike of someone who identifies as bi based on prejudice or negative attitudes, beliefs or views about bi people. This can also include denying somebody’s bi identity or refusing to accept it. Biphobia may be targeted at people who are, or who are perceived to be, bi.

The fear or dislike of someone based on the fact they are trans, including denying their gender identity or refusing to accept it. Transphobia may be targeted at people who are, or who are perceived to be, trans.

Further information can be found on homophobic, biphobia and transphobic behaviour can be found at Stonewall.org.uk.

IDENTIFYING CHALLENGING BEHAVIOUR

3.1 Unreasonable behaviour

There are many reasons why a patient’s behaviour may become unreasonable, including:

· Substance misuse

· If they are scared, anxious or distressed

· If they are frustrated, unwell or in pain

All staff at TWHS may experience patients who are:

· Demanding

· Unwilling to listen

· Uncooperative

There are several factors associated with difficult and challenging interactions with patients, such as a lack of resources, waiting times and interruptions during consultations. For these reasons, the ‘demanding’ or ‘difficult’ patient can potentially consume a large amount of the clinician’s and manager’s time.

3.2 Inappropriate behavior

Inappropriate behaviour is defined as being unacceptable if:

· It is unwanted by the recipient

· It has the purpose or effect of violating the recipient’s dignity and/or creating an intimidating, hostile, degrading, humiliating or offensive environmen

Inappropriate behaviour does not have to be face-to-face and may take other forms including written, telephone or e-mail communications or through social media. This is covered in the Patient Social Media and Acceptable Use Policy.

Some examples of inappropriate behaviour include, but are not limited to the following:

· Aggressive or abusive behaviour, such as shouting or personal insults, in person or via social media

· Discrimination or harassment when related to a protected characteristic under the Equality Act 2010

· Unwanted physical contact

· Spreading malicious rumours or gossip or insulting someone

· Stalking

· Offensive comments/jokes or body language

· Persistent and unreasonable criticism

· Unreasonable demands and impossible requests

· Coercion, such as pressure to subscribe to a particular political or religious belief

What constitutes inappropriate or unreasonable behaviour could be viewed as a subjective matter. Therefore, to ensure objectivity and prior to any further actions being taken, incidents of inappropriate behaviour will be discussed with a member of the senior management team.

Any person, be they staff, visitor or service user, who encounters unreasonable behaviour will be fully supported by senior management.

3.3 Violent and abusive behavior

It is acknowledged that a small minority of patients may become abusive or violent towards staff at TWHS, making it difficult for the healthcare team to provide services. This organisation has a zero tolerance towards such behaviour and is committed to reducing the risk to staff and other patients resulting from such behaviour.

NHS England classifies violent or abusive behaviour as:

Any incident in which “an employee is abused, threatened or assaulted in circumstances relating to their work” (HSE 1996)
The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort
The use of inappropriate or discriminatory words or behaviour causing distress and/or constituting harassment
Behaviour that is hostile, destructive and/or violent

Classifications for assault are as follows:

· Physical assault is the intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort

· Non-physical assault is deemed to be the use of inappropriate or discriminatory words or behaviour causing distress and/or constituting harassment

MANAGING UNREASONABLE BEHAVIOUR

4.1 Process

A patient’s values, beliefs and circumstances all influence their expectations of their needs for, and their use of, services. Staff at TWHS recognise that external factors that may influence a patient’s behaviour.

NICE Clinical Guidance 138 recommends that an individualised approach to providing care is required to improve the patient’s experience and to reduce the risk of the doctor/patient relationship breaking down.

Where interactions become challenging, staff are advised to discuss these more difficult consultations/conversations with their peer groups, seeking guidance where applicable and assurance that they have handled the situation in the most appropriate manner.

At TWHS clinicians must ensure that patients are aware that they may request a second opinion from another clinician, advising the patient how they can arrange this.

The following stepped approach to managing challenging behaviour will be followed:

· Record keeping

To support any decisions made on behalf of the organisation, members of staff who experience patients who are challenging and make unreasonable demands must record the events as accurately as possible. Any record should be strictly factual.

· Speaking to the patient

In the first instance, and to maintain an effective relationship with the patient, it is recommended that the patient be spoken to by the clinician who is treating them. The clinician can provide reassurance to the patient about their condition and address any concerns.

A recommended approach to help in such scenarios is to verbalise the difficulty. Verbalising such difficulties may enhance the level of trust between the clinician and the patient, enabling feasible options for care and treatment to be discussed.

Clinicians will not be forced into giving a diagnosis or treatment if they are uncertain. This should be explained to the patient whilst also explaining that it is in his or her interest that the most appropriate solution be found and that it can take time to confirm a diagnosis.

· Writing to the patient

Should the patient’s behaviour remain unreasonable despite the above actions having been taken, the matter will be referred to the Practice Manager who will then write to the patient.

The correspondence will, where indicated, also include links to relevant, evidenced literature or approved websites to enable the patient to carry out their own research.

· Cooperation

Should the patient not be cooperating, or it is judged that their behaviour is not acceptable, then a further letter may be more appropriate.

· Behaviour agreement

If a patient continues to act in an unreasonable manner despite being issued a letter about their behaviour, TWHS may establish a ‘behaviour agreement’ that allows boundaries to be detailed and agreed to.

This agreement should be retained in the patient’s healthcare record and reference will be made to the agreement should the patients deteriorate once again.

All new patients registered since July 2023 will have this sent to them upon registration.

· Removal from the organisation

Should the patient be non-compliant as per the behaviour agreement in a manner that contravenes the agreement then consideration should be given to removing the patient from the organisation list.

This final stage should never be taken lightly and will be agreed by the senior leadership team. The patient will be advised that the doctor/patient relationship has deteriorated to such a degree that there is no longer any trust between the parties and the relationship is not viable.

4.2 TWHS Behavior Protocol

At the time of event;

1. Staff member to raise concern to Team Lead. Police alert if significant threat. Team Lead email PM (or APM in absence) documenting events and discussion. Document factually in Emis record if relevant to care/clinical interaction.

2. Team Lead to consider any immediate or short-term support for staff member.

3. PM (or APM in absence) to discuss with Duty GP if any on-the-day clinical intervention considered likely to be necessary.

Next 48 hours;

4. Discussion between PM (or APM in absence) /involved staff member and KC as safeguarding lead or named GP (dependent on availability). Review any previous issues for patient and current circumstances. Propose actions and feedback to Team if episode completed.

5. For Partner’s meeting agenda if warning letter/off listing proposed (PM (or APM in absence))

6. Complete actions (PM (or APM in absence))

7. Feedback to team at practice meeting and involved staff member personally

8. Feedback from staff if unhappy with plan

MANAGING VIOLENT BEHAVIOUR

5.1 Violence, offensive or threatening behavior

We do not expect our staff to tolerate any form of behaviour that could be considered abusive, offensive or threatening, or that becomes so frequent it makes it more difficult for us to undertake our work or help other people.

Therefore, management will follow the process at Section 4.1 and additionally support those staff members who are exposed to poor behaviour and act accordingly.

As for violence, offensive or threatening behaviour against staff members, the same standards of zero tolerance also apply should patients demonstrate unreasonable behaviour towards other patients.

5.2 Alarms

TWHS uses the Green Button which is available on all desktops and as a separate desk device in all clinical rooms. This has been deployed amongst all staff within the premises, recognizing the risks to the health and safety of staff that could arise from incidences of aggressive behavior. This procedure enables staff to respond should a panic alarm be sounded by a member of staff.

For further information please see the Green Button Policy and Lockdown Procedure

REMOVAL OF A PATIENT

6.1 GMC Guidence

Whilst it is acknowledged that organisations are permitted to remove patients in appropriate circumstances, the GMC’s Good Medical Practice states:

“You should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient.”

Furthermore, the GMC advises that organisations should consider the following as reasons for removal if the patient has:

Been violent, threatening or abusive to you or a colleague
Stolen from you or the premises
Persistently acted inconsiderately or unreasonably
Made a sexual advance to you

6.2 General Practitioners Committee (GPC) Guidence

The GPC advice relating to the breakdown a patient-doctor relationship recognises the complexity of the area. Specifically, it advises:

· Violence or threatening behaviour: this usually implies a total abrogation by the patient of any responsibility towards the doctor or other members of the organisation and will normally result in removal from the list. As well as having a right to protect themselves, GPs have a duty as employers to protect their staff and, as providers of a public service, those who have reason to be on their premises

Since 1994 it has been possible to request the immediate removal of any patient who has committed an act of violence or caused a doctor to fear for their safety
Clinicians must exercise their judgement in determining whether a patient’s violent behaviour is a result of their medical condition, be it acute or chronic. Where doubt exists, further guidance should be sought from the Local Medical Committee (LMC)

Removal should never be based on the grounds of race, gender, social class, age, religion, sexual orientation, appearance, disability or medical conditions.

6.3 Actions by the Practice

Prior to seeking formal approval to remove a patient from the list, the practice manager will if appropriate issue a yellow written warning. They will also adhere to the following:

· Consider discussing the problem with an independent party

· Records of all warning will be retained

· If a previous warning has been sent in the last 12 months, TWHS can request removal.

In all cases of removal, there must be a justifiable reason to seek this from PCSE.

For instances where there is deemed to be a breakdown of doctor-patient relationship or should there be any repeat of the inappropriate behaviour within a 12-month period since the previous warning, then the patient can be removed.

Should a patient be violent, e.g., when the police are involved, then in these cases the patient will be removed immediately. It should be noted that if the removal is on the grounds of violence or threatened violence, the police must always be informed. Determine the most appropriate arrangements for continuing the patient’s care and facilitate the timely transfer of the patient’s healthcare record

If it is for a clinical reason as to why the patient’s behaviour was deemed inappropriate, consider changing the patient’s GP internally.

All removals will be discussed with the senior leadership team prior to a decision being made.

6.4 Actions by NHSE

In the case of unreasonable behavior NHS England will remove patients eight days after they receive the request. However, if patients require treatment at intervals of less than seven days, TWHS is obliged to provide such treatments until the condition of the patient improves.

In such instances, removal will occur on the eighth day after treatment ceases or until the patient is accepted by another organisation.

In instances where patients are violent, abusive, threatening or have displayed signs of generally unacceptable behaviour, or where there are concerns for staff and other patients’ safety, the police are to be notified.

The organisation can have the patient immediately removed within 24 hours once they have notified PCSE by either telephone or email. Secondary or local commissioner approval is no longer necessary. However, the incident must have been reported to the police and the police incident number is to be supplied to PCSE either immediately or within seven days of the removal request (if not available when the request is submitted).

To request immediate removal of a patient, the practice manager is to refer to PCSE guidance and NHS England guidance.

The organisation must ensure that the reason(s) for removal is recorded in the patient’s healthcare record, along with any supporting documentation such as previous warnings or information leading up to the removal of the patient.

The responsibility for ensuring that the patient meets the criteria for immediate removal rests with the senior leadership team as stated in the Primary Medical Care Policy and Guidance Manual – Section 7. The removal of a patient in these circumstances results in them being allocated to a provider of the Special Allocation Scheme (SAS).

REPORTING

7.1 Internal Reporting

All incidents are to be reported to the practice manager at the earliest opportunity. They will ensure that any subsequent reporting action is taken whilst supporting staff in the completion of the significant event report

7.2 Clinical Record

A factual entry is to be made in the patient’s healthcare record detailing exactly what occurred; the record should include timings, the build-up to the incident and details of staff members and witnesses present.

7.3 Significant events

In addition to recording the information in the patient’s healthcare record, the staff member dealing with the patient is to complete a significant event report/form.

Further advice on significant events including understanding and acting on any lessons that should be learnt following any incident can be found in the practice SEA Polic

RISK ASSESSMENT

8.1 Requirement

Whilst it is acknowledged that a risk assessment alone will not reduce the occurrence of work-related violence, the subsequent actions following the assessment should do so. The findings of the risk assessment(s) will inform the procedures needed to enhance safety within the organisation.

The following constitute foreseeable risks to staff at TWHS:

Known or suspected abusive, aggressive or violent patients
Patients suffering from stress and/or mental illnesses
Patients for who services may be withdrawn or withheld
Patients with a criminal history

Note: this list is not exhaustive

HSE provide both Risk assessment for work-related violent document and a guidance document to support the management in dealing with violence within the workplace.

EFFECTS ON STAFF AND PATIENTS

9.1 Supporting the team

At TWHS it is understood that much of the abuse and episodes of violence are directed towards front of house colleagues. The senior management team will support any staff who are exposed to poor behaviour and act swiftly to manage the situation, including removing patients from the list where indicated.

Staff who experience incidents of violence, aggression or assault may experience subsequent after-effects which may require support from the team or external resources.

9.2 Debriefing the team

Debriefing refers to learning conversations that occur soon after an event and involve those who took part. This is also known as ‘hot debriefing’ or ‘proximal debriefing’.

The aims of debriefing are to:

· Discuss how, why and what occurred.

· Promote learning and reflection for individuals and teams

· Identify opportunities for improvements in workflows, processes and systems

· Identify any key points and lessons learnt

· Ensure that the health and wellbeing of staff members are not adversely affected

The management team will support all staff members following any incident, no matter how minor it may seem. Both positive and negative points should be considered that can support organisation-level training in the support of any future events.

9.3 Supporting patients

Should any patient be subjected to violent, abusive or aggressive behaviour then, as for staff members, they may need support and this may be from a clinical or non-clinical member of the team. It is likely that the minimum would be to have a debrief about the incident, although in many cases the police would need to be involved.

External support may also be required. Should the police be called, or should a service user be injured following an incident then the CQC are to be notified and as detailed within Section 7.5 and CQC GP Mythbuster 21: Statutory notifications to CQC.

SUMMARY

It is widely accepted that at times patients may act unreasonably when attending or contacting the organisation. The effective management of such patients will give support to staff whilst also ensuring that the patient receives the appropriate level of care.

With violence or aggression, statistically, HSE advise that healthcare workers are four times more likely to experience this at work than in other vocations. Therefore, effective risk assessment and incident reporting is essential to support the organisation in the appropriate management of offenders, thereby reducing risk to staff, visitors and service users.