Every doctor has a right to a safe workplace

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The recent killing of New South Wales paramedic Steven Tougher and the brutal stabbing of a Tasmanian emergency department doctor were deeply triggering for us as we continue to live with our grief over the killing of Dr Khulod Maarouf Hassan by a patient 17 years ago. Khulod, a brilliant ophthalmologist and general practitioner, was a precious mother and a highly esteemed colleague and friend.

For nearly two decades, we have advocated for effective action on violence against health care workers to try to prevent another tragic death – and a traumatic loss that our words cannot express. We hope by sharing our experience and advice, as painful as that is, the medical profession will take greater leadership against patient violence in the future.

Every doctor must refuse to accept increasing patient violence as “part of the job”

During the coronavirus disease 2019 (COVID-19) pandemic there has been a global rise in assaults against health workers, and in Australia there has been an amendment to the Crimes Act and some government initiatives to address increasing violence against nurses, paramedics and other front line health workers. The NSW Australian Medical Association has recently advocated to government to extend the penalties in the amended Crimes Act to include assault against all medical practitioners. Otherwise, there seems to be a lack of action to address violence against doctors – in part because most assaults are not reported and, therefore, not included in national and state datasets.

Unfortunately, many verbal and physical assaults in health care continue to be dismissed as “part of the job”. This is unacceptable, not only because of the risk of serious mental workplace injury or trauma in victims, but because it is difficult to implement effective health system changes to prevent future violence against other health workers without accurate data and insights into trends and root causes.

Every doctor must follow appropriate procedures following a verbal or physical assault

Any assault must be responded to in order to immediately protect everyone’s safety and followed up to put systems in place to protect against future assaults. 

We recommend the following steps, which are based on our experience and WorkSafe guidelines:

1. Know the definition of assault

Workplace guidelines differ slightly from state to state, and in Victoria, assault is defined as “physical assault such as biting, spitting, scratching, pushing, shoving, tripping and grabbing, [and] extreme acts of violence and aggression such as hitting, punching, strangulation, kicking, personal threats, threats with weapons, sexual harassment and assault”. Other examples include “aggressive gestures or expressions such as eye rolling and sneering, verbal abuse such as yelling, swearing and name calling, and intimidating physical behaviour such as standing in a worker’s personal space or standing over them”. It is recognised that “being exposed to these incidents repetitively can have a cumulative and significant ongoing effect on wellbeing”.

In summary, assault is any act that intentionally or recklessly causes another person to fear or be subjected to physically or mentally harmful offensive contact.

2. Be clear that your first priority is to protect yourself from danger not to your duty of care to a violent patient

If an abusive or violent patient refuses to calm down or leave a health service, staff must first act to try to keep themselves and other patients safe until police or security arrive. If a violent patient is cognitively impaired for any reason, police or security can assist a clinical team to provide essential medical or psychiatric treatment safely.

In assessing the severity of violence, staff must try to immediately assess the likely intention behind the threat. This distinction is important because the management may be different. Intentional malicious incidents are criminal assaults, which should always be reported to the police urgently. What is not widely recognised is that malicious verbal assaults may also require urgent police intervention as they can be more damaging than physical assaults. For example, consider this scenario: a threat by a patient to rape, stalk a doctor or abduct a doctor’s children is likely to be more traumatic than unintended physical contact by a patient in extreme pain.

3. Request a clinical team meeting to discuss and debrief post assault

Any threat or incident of violence should be reviewed thoroughly at a timely clinical team meeting to check on the wellbeing of the victim and to prevent future assaults on other health workers. This review is the responsibility of the clinical team, not a distressed victim, and it is a workplace right, not an overreaction.

Based on our experience, here are some simple questions to help the whole team debrief, learn from an incident, and tailor policies and procedures to prevent future incidents:

• What happened? Have we talked to all the victims and witnesses? What are the facts? Should the police or security be notified although the incident has passed?
• Are staff safe now? Do staff including doctors require debriefing or employee assistance to manage any physical or psychological trauma? The mental health consequences of workplace violence may emerge in the months following an incident. Who will follow up the victim to ensure they have not suffered these impacts?
• What factors may have triggered the violence? For example, keeping someone waiting while attending to other patients is of course never an acceptable excuse for abuse or assault. However, if waiting times are routinely excessive, it may help to improve workplace policies to manage workflow more efficiently or warn patients about waiting times in the future.
• Could the incident have been prevented? Are all staff aware of their responsibility to identify patients at risk of violence early? For example, any patients displaying problematic behaviours in waiting areas must not be allowed to enter a consulting room without support or security in place. Patient anger can usually be de-escalated and resolved through communication skills. In contrast, an aggressive patient should be asked to leave temporarily in order to calm down and to return only when they are able to comply with behavioural guidelines.
• Should staff flag the patient’s file to warn other practitioners about the future risk of violent behaviour? If a patient has displayed threats or unreasonable behaviours in a health service, the incidents should be documented in their clinical record to warn other staff at future consultations. Patients who are at greatest risk of perpetrating assault on other staff are those who have past histories of having done so before.
• After any incident, the patient must be followed up by telephone and formal letter to outline acceptable behaviours when visiting the health service again in the future. This follow-up may be undertaken by police, security, or the management of the health service in consultation with the medical defence provider, whatever is most appropriate to the particular situation.

4. Report the assault and clinical team meeting recommendations to the most senior level of the health service immediately

When a verbal or physical assault occurs, it must be immediately reported through an incident reporting system to the most senior levels of management. This information allows the governing body or employer to determine whether resources should be allocated to implement other safeguards or barriers to minimise the risk of recurrence in the future.

Threats and incidents of violence are serious occupational health and safety issues. Every employer should consider workplace safety as a priority, proactively implement systems to prevent assaults, and have a formal process in place for reporting and managing all incidents. There must be comprehensive orientation to new staff and ongoing training about all occupational health and safety issues, including policies and procedures on the prevention and management of patient violence, such as verbal de-escalation skills. Ongoing education and training for doctors of all levels to upskill in managing patient anger, aggression and violence is imperative.

There are personal financial and criminal penalties for governing bodies and employers if employees are seriously injured or killed due to work related violence, which vary from state to state. If management are not aware of their responsibilities, they can be referred to the Fairwork Ombudsman or the relevant Work Safe authority.

Every doctor must take responsibility for a safer health workplace

It is every doctor’s responsibility to take leadership to prevent and address violence in health care for the safety of patients, colleagues and ourselves. We can do this by following appropriate procedures (above) after a verbal or physical assault, creating a groundswell of action to expose the true extent of the problem and improving systems of health workplace safety for all health workers. If doctors continue to accept patient violence as “part of our job”, what message is the medical profession sending to our communities about the public health issues of escalating domestic and stranger violence in Australia?

Doctors of all specialties, in addition to psychiatrists, also have an important role in the early identification of patients with severe mental illness at risk of violence. Although people with severe mental illness are more likely to be the victims than the perpetrators of violence, they are overrepresented in the criminal justice system. This human rights issue is directly related to poor access to mental health care and requires strong, united advocacy by our medical organisations to governments. It is not a coincidence that the three cases of violence noted in this opinion piece were perpetrated by young men with acute severe and untreated mental illness – this is part of a national trend.

As we remember the legacy of our extraordinary mother and colleague, Dr Khulod Maarouf Hassan, on the 17th anniversary of her death, we send our love and support to the grieving families and traumatised colleagues of NSW paramedic Steven Tougher and the seriously injured emergency department doctor from the North West Regional Hospital in Tasmania. We know that there are no words to adequately express your loss.

Our healing will only come when every doctor takes greater leadership to prevent patient violence and another tragic death.

Dr Gifar Hassan is a hospital medical officer, having recently worked in metropolitan Melbourne at Austin Health and Peninsula Health, and the rural Murrindindi Shire. She also has a Master of Public Health and a Biomedical Science Degree. She is the medical co-editor of Every Doctor: healthier doctors = healthier patients.

Clinical Professor Leanne Rowe AM is a rural GP, co-author of Every Doctor: healthier doctors = healthier patients and past Chairman of the Royal Australian College of General Practitioners and Deputy Chancellor of Monash University.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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