People who work alone, at night, or in high crime areas are subject to greater personal risk in the form of acts of abuse and violence.
On occasion, one, two, or all three of these criteria will be experienced by doctors during their work.
Although assault and injury are risks to doctors on call, few take precautions.
The use of training, chaperones, panic buttons, electronic notifications, tracking devices, and vetting patients that may pose a higher risk of initiating aggression and violence, serve to reduce the danger to the doctor, but the costs associated with all but the last of these measures often hinder their introduction.
The following provides practical guidance for doctors attending home visits concerning their personal safety that are relatively straight forward and cost effective to implement.
One of the most effective measures to counter potential threats to personal safety when on a home visit is to be prepared. The most straightforward action by the doctor is to call the patient before the visit to better establish what the problem is, and through this conversation gauge the patient’s attitude and composure. The call can also discuss the patient’s environment with particular attention given as to whether there are any pets. The doctor can then request the pet is not be present in the treatment room at the house as the doctor will need the room to be as clean and free from potential sources of bacteria as possible.
Time devoted to high quality training is another effective way the doctor can be prepared for the different kinds of risks they may come across on a home visit. The resistance to investing in training is twofold: perceived low risk, and cost. It may be that few if any direct and serious personal threats have taken place in a given practice, and the mindset of the practice may be similar to an individual’s resistance to paying for insurance cover. When an event that threatens personal safety does occur, those who have received training will always fair better.
Take one narrative that serves to make the point.
A doctor is sent to visit an elderly patient in their eighties who has fallen. Their job is to assess whether the patient requires further medical investigation, or whether pain relief and rest will be sufficient. On the face of it this home visit presents little risk, however when the doctor enters the house he is met by the bark of an aggressive dog coming from the next room. With appropriate training the doctor would call on the strategies he learned to better ensure his personal safety. Without training, the doctor needs to think on the spot about their risk, and inevitably, they will not focus as well on the care they give to their patient.
Good preparation in the form of training for various scenarios, from problems with pets to dealing with aggressive and abusive patients, will not only help doctors operate from a less stressful baseline and serve to protect their safety, it will increase the care provision and quality of practice patients.
People who work alone, at night, or in high crime areas are subject to greater personal risk in the form of acts of abuse and violence. On occasion, one, two, or all three of these criteria will be experienced by doctors during their work.
Doctors need to recognize potential conflicts that may begin simply as a sudden change of body language, eye contact, or disruptive behaviour like a patient raising their voice, or offering resistance to complying with social norms.
The following checklist presents a base level skill set, however this is not exhaustive and should only be the start of a doctor’s learning and training of de-escalation techniques:
If de-escalation is not working at any time, stop and leave for help.
· Be aware of the exit points and have a plan of escape. · Be as calm as possible and speak in an even tone of voice.
· Take a slow breath and remain calm, no matter the insults that fly. Taking slow breaths while under stress causes your brain to more easily deal with complex tasks.
· Give the patient enough personal space so they do not feel trapped, and maintain this. At the very least two arm’s lengths.
· Be aware of your circumstance including any objects that are in the room that could be used violently if the incident escalates.
· If the patient has a weapon ask them to calmly put it down. The doctor should never ask the patient to hand over their weapon.
· Use the patient's name when you speak with them.
· Maintain limited eye contact.
· Try to be as non-threatening as possible in your demeanour and voice.
· Place your hands in an open, relaxed position, and do not use sudden movements with your body or make gestures like pointing a finger.
· Encourage the patient to sit if possible. If they insist on standing, remain standing.
· Listen empathically. Show that you are listening and thinking about what they say.
· Ask the patient what they think will make things better and discuss this. Quite often conflict in patient’s arise from a sense that they are not being listened to or cared for.
· Record notes about what the patient tells you. This shows you are taking them seriously.
· Talk about and include the patient in future plans that are designed to meet and address the issues the patient has raised.
· Try to encourage the patient to agree to a course of action.
Note that most assaults occur when restraints or sedation is attempted. De-escalation is far less costly and time consuming.
Medical practices should provide resources and training in conflict de-escalation to doctors as a matter of routine. Those doctors who do not enjoy support of this kind are strongly recommended to review the resources available for them in their country’s medical association web site and documentation.