Violence Report 2006 final.pdf - BMA

Health Policy & Economic Research Unit
Violence in the workplace
The experience of doctors in Northern Ireland
November 2006
improving health
NORTHERN
IRELAND

Health Policy & Economic Research Unit
Summary
Aim
• The aim of the study was to explore the incidence of violence against doctors in an attempt to
understand better the extent of such incidences and the impact such violence has on the lives
of doctors.
Method
• A postal survey of 4,669 doctors in Northern Ireland was undertaken. Doctors were asked about
their personal experience of workplace violence, in addition to their views and perceptions of
violence in the workplace more generally.
Findings
• Violence is a problem in the workplace for almost half of the doctors who responded and more
than a quarter were of the opinion that the level of violence had increased in their workplace over
the last year.
• Doctors in the SHO hospital grade were more likely to report experience of violence in the
workplace, followed by GPs. Comparison with a study of workplace violence against GPs in
Northern Ireland undertaken in 2003, shows that the reported incidence of workplace violence has
not improved in the last 3 years.
• Most respondents experienced violence from patients or from patients’ families/relatives. The
incidence of verbal abuse was the most prevalent form of violence or abuse in the workplace,
followed by threats and physical assaults.
• More than a quarter of doctors who reported experience of workplace violence, experienced
physical violence or abuse. Among those doctors, a third stated that they received minor injuries as a
result of the incident and 3 per cent reported serious injuries.
• The majority of violent incidents took place in the hospital ward or doctors’ office. In two-thirds of
cases, respondents reported that the incident took place during working hours, whilst a fifth took
place during out-of-hours.
• The most frequently stated reason for a violent incident against a doctor was dissatisfaction with the
service provided, followed by intoxication with alcohol/drugs, health related/personal problems or a
history of violence/abuse.
• In less than half of cases, some form of action was taken following the violent incident. Three
quarters of the doctors reported the incident to a line manager or senior colleague and a third
reported the incident to the police.
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Health Policy & Economic Research Unit
• Following the violent incident, support was received by less than two-thirds of doctors. Around
a third stated that their experience of violence had affected their work, either psychologically
or physically.
• The majority of respondents had not received any training on how to deal with violence from
patients and training of this nature is particularly poor amongst hospital doctors.
• Around half of the doctors were worried about potential violence from patients and GPs were more
likely to express concern about patient violence. Two in five respondents had taken precautions
against potential violence, particularly among GPs.
• Less than 10 per cent of respondents reported having access to a secure facility in which to treat
violent patients. The majority agreed that there should be a register of violent patients set up in each
Health Board area.
• More than half of the doctors reported that they had witnessed violence from patients directed at
others in their workplace in the last year. Violence towards nursing staff and other doctors is more
likely to occur in a hospital setting, whilst the incidence of violence against
receptionists/administrators is more likely in general practice.
• Only half of respondents reported the presence of a clear policy on zero tolerance to violence in
their workplace. Less than half were of the opinion that, as doctors, it was possible to adopt a
zero tolerance to violence.
Violence in the workplace – The experience of doctors in Northern Ireland

Health Policy & Economic Research Unit
Introduction
The Northern Ireland Council of the BMA decided that a local campaign to highlight and tackle the
issue of workplace violence against doctors was required and commissioned the BMA’s Health Policy
and Economic Research Unit to undertake a study to help inform such a campaign. The aim of the
study was to explore the incidence of violence against doctors in an attempt to understand better the
extent of such incidences and the impact such violence has on the lives of doctors. This study is set
against the background of increasing incidence of violence against the Northern Ireland healthcare
workforce in recent years. This report presents the findings from a survey of doctors in Northern
Ireland on the incidence and impact of violence in the workplace.
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Health Policy & Economic Research Unit
Method
A postal questionnaire was sent to a total of 4,996 doctors, representing all doctors in Northern
Ireland. The questionnaire received a response from 19 per cent of the sample (969/4,996). Doctors
were asked a series of questions about their personal experience of workplace violence, in addition to
their views and perceptions of violence in the workplace more generally. For the purposes of this study,
the definition of violence follows that used in the Government’s Zero Tolerance campaign and is
defined as:
‘any incident where (doctors or staff) are abused, threatened or
assaulted in circumstances related to their work, involving an explicit
or implicit challenge to their safety, well-being or health’.
Violence in the workplace – The experience of doctors in Northern Ireland

Health Policy & Economic Research Unit
Survey Results
Characteristics of Respondents
Table 1 shows that respondents were fairly evenly divided by gender (54% males/46% females). Whilst
the majority of respondents were of white ethnic origin (95%), 4 per cent were of Asian or Black ethnic
origin. The age of respondents was wide ranging from 23 years to 85 years (average age 42 years).
Table 1 Ethnicity and gender of survey respondents (%)
White
Black
Asian
Other
Table 2 shows that 56 per cent of respondents were hospital doctors, predominantly consultants
(225/537) and 42 per cent were working in general practice, mainly as GP principals (303/407).
The majority of GP respondents worked in multiple partner practices. Table 3 shows the main
specialties of those respondents who reported working as hospital doctors.
Table 2 Current job title of respondents (%)
Male Female Total
50.9
0.2
2.3
0.6
* includes principals, non-principals, locums, registrars, assistants and salaried GPs;
** includes CMO, Portfolio, clinical assistant, retired, not working, CMP and medical director.
Violence in the workplace – The experience of doctors in Northern Ireland 5
43.8
0.3
1.5
0.4
94.8
0.4
3.8
1.0
Total 54.2 45.8 100.0
Foundation year trainee
Senior house officer
Specialist registrar
Consultant
General practitioner*
Staff and associate specialist
Clinical Academic
Other**
Total
No reply
Frequency Per cent
11
109
114
225
407
68
5
20
959
10
1.1
11.4
11.9
23.5
42.4
7.1
0.5
2.1
100.0

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Health Policy & Economic Research Unit
Table 3 Hospital doctors by specialty
General medicine (& medical oncology)
Psychiatry
Surgery
Paediatrics
Anaesthetics
Radiology (& clinical oncology)
A&E
Obstetrics & gynaecology
Pathology
Geriatrics
Other
Total
No reply
Doctors’ perceptions of workplace violence
Doctors were asked whether they thought there is a problem regarding the level of violence from
patients in their current workplace.
Almost half of respondents (43%) stated that violence is very much or somewhat of a problem in their
current workplace, whilst a further 43 per cent stated that it is not really a problem and 14 per cent
stated that it is not a problem at all.
Table 4 shows that this perception was consistent according to type of doctor, with at least 40 per cent of
both GPs and hospital doctors reporting violence to be at least somewhat of a problem in their current
workplace. Nevertheless, substantial differences exist according to specialty of hospital doctors, with 57
per cent of surgeons and 54 per cent of A&E doctors reporting violence as a problem in their workplace,
compared with less than a third of doctors working in general medicine and pathology (Table 5)
Table 4 Extent of violence as a problem in workplace by type of doctor (%)
Very much a problem
Somewhat of a problem
Not really a problem
Not a problem at all
Total
Violence in the workplace – The experience of doctors in Northern Ireland
Frequency Per cent
105
50
78
45
53
28
35
30
12
18
19
473
64
22.2
10.6
16.5
9.5
11.2
5.9
7.4
6.3
2.5
3.8
4.0
100.0
General Practitioner Hospital Doctor Total
7.6
32.3
48.5
11.6
100.0
13.2
31.2
39.8
15.8
100.0
10.8
31.7
43.5
14.0
100.0

Health Policy & Economic Research Unit
Table 5 Extent of violence as a problem in workplace by hospital specialty (%)
Surgery
General medicine (& medical oncology)
Psychiatry
Obstetrics & gynaecology
Paediatrics
Anaesthetics
Radiology (& clinical oncology)
Pathology
Geriatrics
A&E
Very much
a problem
Somewhat of
a problem
Not really
a problem
Doctors were also asked whether they thought that violence from patients has increased over the past
year in their workplace.
More than a quarter of doctors reported an increase in violence in the past year and 56% stated that
it had not changed. Only two doctors (0.2%) reported a decrease.
Table 6 shows that GPs were more likely to report increased violence in the workplace or indeed no
change in the past year, compared with hospital doctors. Among hospital doctors, those working in
A&E, anaesthetics and psychiatry specialties were more likely to report increased violence in the
workplace (Table 7).
Table 6 Whether violence has increased in workplace by type of doctor (%)
Increased
Decreased
No change
Not applicable
Total
11.5
4.8
34.0
6.9
4.5
15.4
7.4
0.0
0.0
51.4
46.2
24.8
16.0
37.9
38.6
21.2
40.7
18.2
55.6
2.9
32.1
48.6
48.0
41.4
40.9
53.8
29.6
9.1
33.3
45.7
Not a problem
at all
10.3
21.9
2.0
13.8
15.9
9.6
22.2
72.7
11.1
0.0
General Practitioner Hospital Doctor Total
30.0
0.5
62.8
6.7
100.0
27.7
0.0
51.2
21.1
100.0
28.7
0.2
56.2
14.9
100.0
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Health Policy & Economic Research Unit
Table 7 Whether violence has increased in workplace by hospital specialty (%)
Surgery
General medicine (& medical oncology)
Psychiatry
Obstetrics & gynaecology
Paediatrics
Anaesthetics
Radiology (& clinical oncology)
Pathology
Geriatrics
A&E
Doctors’ experience of violence
Whilst the survey shows that only 2 in 5 doctors (401/967) experienced violence in the past year, the
majority of these doctors were verbally abused or threatened a number of times, some as many as
twenty (figure 1).
Figure 1 Frequency of experience by type of violence (%)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Respondents who had experienced violence were fairly evenly divided between hospital doctors (41%)
and GPs (43%). Comparison with a study of workplace violence against GPs in Northern Ireland
undertaken in 2003 1
, shows that the reported incidence of workplace violence has not improved in the
last 3 years: 44% of GPs in 2003 compared with 43% of GPs in 2006.
Violence in the workplace – The experience of doctors in Northern Ireland
Increased Decreased No change Not applicable
23.1
24.8
34.7
28.6
31.8
36.5
25.9
9.1
11.1
41.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
57.7
60.0
55.1
50.0
52.3
40.4
40.7
18.2
61.1
41.7
19.2
15.2
10.2
21.4
15.9
23.1
33.3
72.7
27.8
16.7
Verbal abuse Threats Physical assault
None Once only 2-4 times 5-6 times 7-10 times More than 10 times
1 Health policy and economic research unit 2003 Violence at work: the experience of GPs in Northern Ireland. BMA: London.

Health Policy & Economic Research Unit
Figure 2 shows that doctors in the SHO hospital grade (63%) were more likely to report experience of
violence in the workplace, followed by GPs (43%), whilst only one in five academic doctors reported
workplace violence (table 8).
Four in five (79%) doctors experienced violence from patients and 52 per cent experienced violence
from patients’ families/relatives. Other respondents reported experiencing violence from patients’
friends or companions (14%) or from ‘others’ (3%). ‘Others’ included nurses and colleagues (Figure 3).
Figure 2 Reported experience of workplace violence according to current position (%)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
SHO GP Consultant Staff grade
& Assoc
Specialist
Table 8 Reported experience of workplace violence according to current position
Foundation year trainee
SHO
Specialist registrar
Staff grade and associate specialist
GP (incl. principals, non-principals and locums)
Consultant
Clinical academic
Other
Foundation
year trainee
% reported experience
of violence
36.4
63.0
34.2
36.8
42.5
37.1
20.0
30.0
SpR Other Academic
Total respondents (n)
Violence in the workplace – The experience of doctors in Northern Ireland 9
11
109
114
68
407
225
5
20
No
Yes

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Health Policy & Economic Research Unit
Figure 3 Perpetrators of violence against doctors (%)
% of respondents
90
80
70
60
50
40
30
20
10
0
The majority of doctors who reported experience of violence in the workplace, experienced some form
of verbal abuse (96%), followed by almost half (46%) who experienced some form of threat and 10
per cent who had experienced some form of physical assault.
Respondents were asked about the number of times in the past year that they had experienced some
form of violence or abuse. The incidence of verbal abuse was the most frequent, with 25 per cent of
respondents experiencing this form of abuse more than 5 times in the last year. This was followed by
threats and physical assaults. The main forms of verbal abuse reported were swearing/abusive
language, shouting, verbal threats and personal intimidation (Table 9).
Table 9 Forms of verbal abuse experienced by respondents
Swearing/abusive language
Shouting
Verbal threats
Personal intimidation
Spitting
Sectarianism
Racial comments
Other
Patients Patients family/relatives Patients friend/companion Other
More than a quarter (27%-108/401) of doctors who reported experience of workplace violence,
experienced physical violence or abuse. These incidents ranged from being kicked, scratched, shoved,
urinated upon, hit and punched, to knife assaults and being threatened with a chair, a drip stand and
hot soup. Among those doctors who had experienced physical violence or abuse, a third (35%) stated
that they received minor injuries as a result of the incident and 3 per cent reported serious injuries.
Violence in the workplace – The experience of doctors in Northern Ireland
% reported experience Total respondents
89.5
73.1
48.4
34.2
9.5
9.0
3.5
3.5
359
293
194
137
38
36
14
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Health Policy & Economic Research Unit
Table 10 shows that for the majority of respondents, the violent incident took place in the hospital
ward (27%) or doctor’s office (23%). Among GPs, the majority of incidents took place either in their
office or waiting room, whilst for hospital doctors, the most frequently cited location was the hospital
ward or A&E. Other reported locations included out-of-hours clinics, community health centres or
outpatient clinics. Several respondents also reported verbal abuse over the telephone. In two-thirds of
cases (68%), respondents reported the incident taking place during working hours. However, a fifth
(21%) of doctors reported the violent incident taking place during out-of-hours (table 11).
Table 10 Location where violent incident took place by type of doctor (%)
Hospital-A&E
Hospital-ward
Hospital-public area
Your office
GP waiting room
Patient’s home
Other
Total
Table 11 Timing of violent incident by type of doctor (%)
During working hours
Out-of-hours
Both
Total
General Practitioner Hospital doctor Total respondents
3.7
2.3
0.0
41.6
26.0
12.3
14.2
100.0
28.0
45.5
6.1
7.9
0.7
0.4
11.5
100.0
17.3
26.5
3.4
22.7
11.8
5.6
12.7
100.0
General Practitioner Hospital doctor Total respondents
76.8
11.6
11.6
100.0
60.2
28.9
10.9
100.0
67.5
21.3
11.2
100.0
It is often suggested that racial or political motivations lie behind violent incidents. However, only 1
respondent stated that the incident of violence against them was politically motivated. Instead key
motivations included drugs, alcohol, mental illness and confusion. Respondents were asked why they
thought the violent incident against them had occurred. Table 12 shows that the most frequently
stated reason is that the perpetrator was dissatisfied with the service provided, followed by intoxication
with alcohol/drugs, health related/personal problems or a history of violence/abuse. Dissatisfaction with
the service provided includes patients’ high expectations of the NHS and frustration with long waiting
times, refusal to prescribe or admit for treatment and dissatisfaction with diagnosis received.
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Table 12 Perceived reasons for violent incident
Perpetrator was dissatisfied with service provided
Perpetrator was intoxicated with alcohol/drugs
Perpetrator has health related/personal problems
Perpetrator has a history of violence/abuse
Perpetrator received bad news
Perpetrator was provoked
Don’t Know
Other
Note: more than one response may apply
Two in five doctors (41%) reported knowing the perpetrator or the perpetrator’s family before the
violent incident took place, whilst 59 per cent stated that they did not know the perpetrator. This
differs somewhat by type of doctor, with two-thirds (66%) of GPs reporting that they knew either the
perpetrator or the perpetrator’s family prior to the incident, compared with less than a quarter (23%)
of hospital doctors.
In less than half of cases (45%), some form of action was taken following the incident. Where action
did follow a violent incident, three quarters of respondents reported the incident (124/166). This was
often to a line manager, senior consultant, medical director, practice manager or other senior staff
member in the workplace. In a third of cases (63/166), the incident was reported to the police and in
the majority of these cases (69%), some action was taken by the police. Following the violent incident,
support was received by less than two-thirds of respondents (58%). This was largely in the form of
peer support (36%). Managerial support (8%), debriefing (4%) and counselling service (1%) were
received by few respondents.
Doctors were asked whether the violent incident had affected their work. Around a third (31%) said
that their experience of violence had affected their work and in many cases the reported impact was
both psychological and physical. Impacts include greater awareness of personal safety, ensuring a
secure environment, increased anxiety and stress, loss of confidence and professional disillusionment.
All respondents, regardless of whether they themselves had directly experienced violence, were asked
whether they had ever considered withholding treatment from a patient due to the threat of abuse or
violence. More than a third (38%) of doctors had considered withholding treatment. Almost half of
GPs (45%) had considered withholding treatment due to the threat of patient violence, compared
with a third of hospital doctors (33%).
Violence in the workplace – The experience of doctors in Northern Ireland
Frequency % of total respondents
210
167
137
133
42
1
14
41
52.4
41.6
34.2
33.2
10.5
0.2
3.5
10.2

Health Policy & Economic Research Unit
The government has called for training of NHS staff to deal with violence from patients, however the
majority of doctors (64%) had not received any such training. This does vary somewhat according to
type of doctor, with more than half of GPs (53%) reporting receiving some form of training on how to
deal with violence from patients, compared with less than a quarter (23%) of hospital doctors.
Figure 4 shows that more than half of respondents (57%) were very or fairly worried about potential
violence from patients, whilst a quarter (25%) were not worried at all. Doctors working in general
practice were more likely to be worried about patient violence (67%), compared with doctors working
in hospitals (49%). Two in five respondents (41%) had taken precautions against potential violence.
Again, this was more likely to be the case among GPs (62%), compared with hospital doctors (25%).
Panic alarms/buttons were the most widely adopted precaution, but others included room layout,
chaperoning and CCTV.
Less than 10% of doctors reported having access to a secure facility in which to treat violent patients.
Hospital doctors (11%) were more likely to have access to such a facility, compared with GPs (4%).
The vast majority of doctors (90%) agreed that there should be a register of violent patients set up in
each Health Board area.
Figure 4 Concern about potential violence from patients by type of doctor (%)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
GP Hospital Total respondents
Very worried A little worried Moderately worried Not at all worried
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Violence in the workplace
More than half (57%) of respondents reported that they had witnessed violence from patients directed
at others in their workplace in the last year. This was largely directed at nursing staff (31%) and
receptionist/administrators (32%) and was in the form of verbal abuse (54%), threats (19%) or assault
(10%). According to table 13, violence towards nursing staff and other doctors was more likely to
occur in a hospital setting, whilst the incidence of violence against receptionists/administrators was
more likely in general practice.
Table 13 Work colleagues at which abuse is directed by type of doctor (%)
Nursing staff
Receptionist/administrator
Other doctors
Porter/cleaner
Other
Total
Note: more than one response may apply
The government has launched a Zero Tolerance campaign to reinforce the message that violence against
health service staff will not be tolerated. Doctors were asked whether there was a clear policy on zero
tolerance to violence in their workplace. Only half of respondents (52%) reported the presence of such a
policy. GPs (70%) were more likely to have such a clear policy in their workplace, compared with hospital
doctors (36%). Respondents were also asked whether as doctors, they thought that it was possible to
adopt a zero tolerance to violence. Less than half of respondents (48%) stated that it is possible, and a
further third (33%) did not think that it is possible to adopt a zero tolerance to violence. GPs (61%) were
more likely to be positive about adopting a policy of zero tolerance to violence compared with hospital
doctors (38%). Respondents who agreed that it is possible to adopt a zero tolerance to violence were
generally of the opinion that any form of abuse or violence is not acceptable and rules should be put in
place to enforce this. Many also stressed that the zero tolerance policy must be made clear to all patients
and members of the public if it is to be effective.
Violence in the workplace – The experience of doctors in Northern Ireland
General Practitioner Hospital doctor Total respondents
13.6
65.0
19.4
0.9
1.2
100.0
46.2
15.3
30.1
2.7
5.6
100.0
33.7
34.4
26.0
2.0
3.9
100.0

Health Policy & Economic Research Unit
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Violence in the workplace – The experience of doctors in Northern Ireland

Health Policy & Economic Research Unit
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© British Medical Association, 2006 CODE:
BMA 47050 / AG / HP&ERU / 15.08