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Violence at Work: The Experience of General Practice Receptionists   Back Bookmark and Share
Frank Chambers,M Kelly

Ir Med J. 2006 Jun;99(6):169-71




Abstract
Receptionists act as intermediaries between the General Practitioner and the public, and are often involved in conflicts between the GP and a demanding patient. However there is a paucity of research in this area. The aim of this study was to quantify the extent of violence directed towards GP receptionists and to categorise the type, frequency and impact of such aggression in two health board areas. A postal questionnaire was designed, piloted and sent to 400 randomly selected receptionists in the former Northern Area Health Board and the Western Health Board. We found that 62% (n=168) of receptionists experienced violence in the past. 99% (n=166) had experienced verbal abuse while 31% (n=52) had experienced threats of physical abuse. 6% (n=10) experienced physical abuse. In most cases the perpetrator was the patient 98% (n=160). 28% (n=75) of practices had a practice policy for dealing with violence while only 13% (n=34) of receptionists received education on dealing with violence. This study shows that violence is a major problem among GP receptionists in Ireland. Aggression during the day is a regular feature for a GP receptionist. There is a higher reporting of violence in the Northern Area Health Board compared to the Western Health Board. We suggest that further education, research and practice policy development is needed to help target this problem and improve the overall quality of healthcare.


Introduction
Violence in healthcare 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”.1 Violence and abuse of staff is both a civil and criminal wrong. It infringes on the rights that staff expect will be respected while they go about their daily work.1

Violent behaviour directed at health care staff continues to attract media interest, 2 however there is a paucity of scientific research into violence in the primary care workplace. Most surveys that have been carried out, in primary care to date, relate to incidents involving the general practitioner.3 Receptionists are arguably more at risk of violent behaviour than general practitioners as they are usually the first point of contact but there islittle work focusing on the scale of the problem that they face. A detailed literature review of the prevalence of violence in the primary care setting was conducted. The search revealed one previous study in Ireland on violence among general practitioners 4 and only one study of violence and GP receptionists carried out in England in 2004.5 O’Connell found a high level of violence among GP’s in Ireland and this was mainly in the form of verbal abuse.4

Method
A questionnaire was designed and posted to a random sample of four hundred GP receptionists in September 2004. The sample was picked randomly using the Irish Medical Directory 2004.6 Two hundred receptionists were located in the Western Health Board and two hundred in the Northern Area Health Board.

A short covering letter explaining the purpose of the study was included with a stamped addressed envelope for the reply. A reminder letter with a questionnaire was sent to non-responding practices three weeks later. A telephone call was made to all non- responders at four weeks encouraging them to respond. The principles of increasing response rates to postal questionnaires were applied.7

The questionnaire consisted of fifteen questions, the majority of which required the receptionists to tick boxes. It included a mixture of open and closed questions to elicit the views of receptionists in relation to violence. It was initially piloted to twenty practices and was modified accordingly. None of these practices were included in the final group.

The questionnaire sought information about demographic details, experience of violence, type of violence and the perpetrators of such violent incidents. Receptionists were questioned on the impact of violent episodes and support following such incidents. A series of questions were asked in relation to practice policy in respect of violent episodes.A further question was asked on level of education received on violence. Receptionists were given space on the questionnaire to express their views on how violence could be reduced and managed.

The returned questionnaires were annonymised and data was entered into a database. Results were analysed using Minitab tm statistical software. P values of < 0.05 were considered statistically significant.

Results
The results will be presented with the total response rate first, followed in square brackets by results from the Northern Area Health Board (NAHB) and then the Western Health Board (WHB) where they differed significantly from each other. Percentages are rounded to the nearest whole digit therefore when totalled may not always equal 100.

The overall response rate was 271 (68%) [NAHB 147 (74%), WHB 124 (62%), ?2 = 6.05, p < 0.05]. The majority of receptionists were female 266 (98%). The mean age was 38 years (standard deviation 9, range 19 – 65 yrs). The mean number of receptionists per practice was 1.8, while the mean number of years experience was eight. One hundred and fifty five (57%) of respondents work in a single-handed practice.

The majority of respondents 168 (62%) had experienced violence in the work place. There was significantly more violence experienced in the NAHB 101 (68%), than in the WHB 67 (54%), ?2 = 6.15, p < 0.05. Violence was also perceived as more of a problem in the NAHB with 49 (33%) of respondents from this health board reporting that violence was either a problem or very much a problem, compared with 19 (15%) in the WHB (?2 = 11.61, p < 0.01).

Table 1 shows how many violent incidents the receptionists had experienced. In total 70 (42%) [NAHB 53 (53%), WHB 17 (15%), ?2 = 17.52, p < 0.01] experienced more than five violent incidents in the workplace. A closer look at the types of violence experienced revealed that almost all had experienced verbal abuse 166 (99%), 52 (31%) had experienced threats of physical abuse while 10 (6%) had experienced actual physical abuse. In virtually all cases the perpetrator of the violence was the patient 160 (95%).

Table 1 Frequency of Violent Incidents Experienced by GP Receptionists

FREQ

TOTAL
n= 168

NAHB
n=101

WHB
n=67

Once

11 (6%)

6 (5%)

5 (8%)

2 4

87 (52%)

42 (42%)

45 (67%)

5 10

40 (24%)

31 (31%)

9 (13%)

> 10

30 (18%)

22 (22%)

8 (12%)

Figure 1 shows that the most common response following violence was no action 62 (34%), followed by help from staff 51 (27%) and patient removal from the practice list 38 (20%). The police were called in 31 (16%) of cases. Others, 6 (3%) included the patient being reprimanded, use of personal alarms and practice meetings being called. These responses were similar across both health board areas.

Figure 1: This shows the type of
action taken following the violent
incident

Seventy eight (46%) respondents state that they received no support following the violent incident. In a further 77 (46%) cases the main form of support was from staff. Only 5 (3%) received counselling and 9 (5%) report other forms of support such as debriefing, managerial support and support from family. Again, there was no significant difference in these responses across the health board areas. In total only 11 (7%) have taken time off work due to violence.

Figure 2: GP receptionists were asked
about the existence of a practice policy
for dealing with violence in the
workplace.This graph compares the
response in the Northern Area Health
Board compared to the Western Health
Board

Receptionists were asked about the existence of a practice policy for dealing with violence in their workplace. Figure 2 shows that in total 75 (28%) of practices had a practice policy for dealing with violence in their workplace [NAHB 55 (37%), WHB 20 (16%), ?2 = 15.23, p < 0.01]. In total 34 (13%) of receptionists had received education on dealing with violence at work, this was not significantly different across the two health boards. The most common resource of education was the Irish College of General Practitioners practice management course followed by general practice principals.

Discussion
This study is the first to identify violence as a major problem among general practice receptionists in Ireland.

The strengths of this study include the response rate of 68% to the postal survey. Possible weaknesses include relying on receptionist’s recollections of incidents rather than prospective recording. Also as there was a higher response rate from the NAHB there is a concern that receptionists who suffered violence were more motivated to reply and therefore are over represented in the sample.

This survey shows that aggression during the working day is a regular feature for a general practice receptionist with almost two thirds (62%) of GP receptionists having ever suffered violence. The vast majority have encountered violence on more than one occasion. The findings of this survey are similar to Dixon et al 5 who reported 68% of receptionists in a UK survey experiencing violence in the previous year. O’Connell found that that the incidence of violence amongst general practitioners is 21.2% per annum in Ireland with 80% of incidents occurring on the surgery premises.4 This obviously is of relevance with respect to the safety of
reception staff.

This paper found a significantly higher reporting of violence in the NAHB (68%) as compared with the WHB (54%). Further work is necessary to determine the reason for this. A possible explanation is that the NAHB is more urbanised. Ness et al 8 reported a higher incidence of violence amongst general practitioners working in deprived areas around Leeds. Myerson 9 also found that inner city GPs and staff were more vulnerable to violent episodes.

In general there is lack of education on violence in the workplace with only 13% ever having received training on dealing with violence. It was worrying also to note that less than a third (28%) of practices had a practice policy for dealing with violence. This is a requirement under Irish Health and Safety law 10 and as employers GPs have responsibility for the health and safety of their staff. The lack of education and absence of practice policies may explain why there was so little response to the violence and such little support for practice staff. Lack of support and education may lead to underreporting of violent incidents.3

Bradley 11 recommends that violence in the primary care setting can be managed by addressing both the structural risk factors for violence, such as poor building design, lack of policies and/or training, and the interaction at the individual level between receptionist and patient. Strategies aimed at improving the structure of primary care so that it can manage threats of violence in an effective manner are needed.1

Researching cause and effect of violence towards health care staff remains important. 4 Consideration also needs to be given to improving compliance with the need for practice policies regarding violence and the ongoing education and support of practice staff.

In summary, the implications of this study are that awareness for the need of a practice policy re violence in general practice must be raised. There is a need for education of practice staff on how to avoid/deal with and respond to violence in the workplace. Finally, a prospective study needs to be carried out on this topic to gain a better understanding of it.

References

  1. British Medical Association. Violence at work: the experience of UK doctors. Health Policy and Economic Unit 2003. British Medical Association, London.
  2. GPs need more security. The Irish Medical Times, 3rd April 2004.
  3. Wright NMJ, Dixon CAJ, Tompkins CNE. Managing violence in primary care: an evidence based approach. BJGP 2003; 53:557-562.
  4. O’Connell P, Bury G. Assaults against general practitioners in Ireland. Family Medicine 1997; 29 (5): 340-343.
  5. Dixon CAJ, Tomkins CNE, Allgar VL, Wright NMJ. Abusive behaviour experienced by primary care receptionists: a cross sectional survey. Family
    Practice 2004; 21:137-139.
  6. The Irish Medical Directory. Medical Information Systems 2004.
  7. Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002; 324:1183-1185.
  8. Ness GJ, House A, Ness AR. Aggression and violent behaviour in general practice: population based survey in the north of England. BMJ 2000;
    320:1447-1448.
  9. Myerson S. Violence to general practitioners and fear of violence. Family Practitioner 1991; 8(2): 145-147.
  10. Rochfort A. Managing Health and Safety in General Practice. Irish College of General Practitioners, Dublin 2001.
  11. Bradley C. Aggression now part and parcel of general practice. Forum 1999. June 48-49.
Author's Correspondence
Frank Chambers, De Bille House, Main Street, Newport, Co. Mayo. Email: francisrichardchambers@hotmail.com
Acknowledgement
The authors would like to acknowledge the support and assistance of Drs. Genevieve McGuire and Pat Durcan and Ms. Aoife Berry, Western Training Programme and Professor Andrew Murphy, Department of General Practice, National University of Ireland, Galway. We also would like to thank all the General Practice receptionists for completing the questionnaires.
Other References
No References
   
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