| Workplace design |
Poor delineation between staff-only area and patient area Lack of controls in accessing staff-only and patient areas Overcrowded, uncomfortable or noisy waiting rooms Poor access to exits, toilets and amenities Poor lighting, blind spots without surveillance Unsecured furnishings that can be used as weapons
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| Policies and work practices |
Increased waiting times Poor customer services from staff Deficit in staffing levels or inadequate skills mix Working alone Lack of violence-prevention programmes Lack of staff empowerment and shared governance Lack of follow-up of violent episodes by management Poor safety culture: ‘broken window principle’ Ineffective mechanisms to warn and ultimately deny service to patients with repeated behaviours of concern Lack of staff training in de-escalation techniques Lack of staff training in aetiology and treatment of various pathologies associated with violent behaviour Use of physical restraints Mismatch between expectations and services offered: for example, demands for classified drugs Presence of drugs, cash or valuable items in the office Presence of weapons Refusal to provide a prescription or a sickness or disability certificate On-call shifts/house visits
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| Patient factors |
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Current illness with physiological imbalances or disturbances:
Head trauma Encephalitis, meningitis, infection Encephalopathy Metabolic derangement: Hyponatraemia, hypocalcaemia, hypoglycaemia Hypoxia Thyroid disease Seizure (postictal) Exposure to environmental toxins Toxic levels of medications
Active intoxication, substance dependence, misuse or abuse Psychosocial stressors Previous poor experiences with healthcare services Past history of violence Psychiatric disorder Personality, interpersonal style of control or dominance Frustration, perception not being respected, not being listened to or being treated unfairly Stress, agitation Loss of situational control Unexpected or high costs of healthcare Complex family relationships
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| Physicians factors |
Being unprepared Lack of education and training on violence: being unaware of own body language, not knowing how to de-escalate, not knowing how to escape Inadequate medical skills Poor communication skills Less years of experience Physicians own emotions, anger, anxiety, countertransference Overworked, stressed Interpersonal style: for example, assertive style by the physician may challenge the patient’s sense of dominance and lead to discomfort and frustration Gender: no difference in overall risk of violence, increased risk within younger, male GPs for physical assaults Vulnerability in being a source of risk with respect to legal or licensing matters, for example, with information to third parties beyond direct patient care Vulnerability : where does the duty of care end in the face of potential violence? Personality traits with increased risk: low agreeableness, high neuroticism, high negative affect, low extroversion, low conscientiousness, low self-esteem
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| Societal causes/social context |
Poverty, unemployment and social dislocation Reduced respect for authority, patients are having a greater sense of entitlement than in the past and as a consequence frustration in not getting response to demands potentially leads to violence ‘Bowling for Columbine effect’: spiral of fearfulness, suspicion leading to pre-emptive defensiveness, confrontation and ultimately a greater risk of violence Population density Language barriers Cultural differences
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