Chris Luke: If we can't treat the causes of patient aggression, we'll have no medical staff left

The abuse of healthcare staff has been tolerated by the ‘powers-that-be’, writes Dr Chris Luke

The sad truth is that, after a while, many staff develop a siege mentality, constantly anticipating the next verbal or physical threat, grimly ploughing on while doing as little as possible to further enrage patients or their companions, and retreating periodically to the staff room to shed a few tears, and plan their escape. File picture: Stockbyte

When I think back to my medical student days, one subject that was noticeably left out of the curriculum was the aggression that many doctors were likely to experience in their workplace. And the issue is still glaringly absent in today’s modern medical training. 

This may reflect a detachment from frontline realities on the part of those in charge of the syllabus and I’m not convinced that the ‘great and the good’ (academic, political or managerial) have yet grasped the scale of violence faced by healthcare professionals of every sort in our hospitals and community care facilities.

Nonetheless, I hope this week’s submission to the Oireachtas Health Committee by the Irish Nurses and Midwives Organisation (INMO) will have raised the alarm among our lawmakers, not least about the reported exodus of 30 precious nurses from one of our children’s hospital’s emergency departments (EDs), due to the relentless hostility they face in already dire conditions of overcrowding, understaffing and therapeutic complexity.

The scale of belligerence towards staff should shock those who haven’t given the subject much thought. I’d even argue that there is an undeclared global pandemic of such aggression. Google ‘attacks on nurses’ (or doctors), for instance, and you’ll find nearly 800 million mentions. 

Even the relatively sparse Irish literature talks of a ‘trebling’ in these attacks in the late 1990s, with exponential growth ever since; the only thing that is ‘new’ is the recent spread to children’s hospitals and GP surgeries.

Looking back on a long career in medicine, my first encounters with serious aggression were predictably in the hectic ED of St James’s Hospital in Dublin, in 1983, with the intoxicated (or - with heroin users - those who’d woken up abruptly after receiving the life-saving antidote, Naloxone, for their opioid overdose). 

Over the succeeding years, the list of episodes lengthened: a junior doctor friend wrestling on the ground with a violent patient in a south Dublin ED in 1985, routine drunken abuse on night-duty in the Royal Infirmary of Edinburgh, the punch in the face my future-wife (then a young nurse) sustained from a woman she’d found robbing stock in the ED, and the many times I was threatened or ‘smacked’ in EDs in Liverpool and Cork, by the angry and the deranged.

I vaguely recall countless cases of spitting, screaming, threats, fights and waving of knives and guns in ED waiting rooms, but I vividly remember a few terrible cases. 

Like the two plastic surgeons stabbed to death in 1990 in Yorkshire by a patient who was ‘unhappy about the waiting time’ for his tattoo-removal, or the colleague whose nursing career was terminated by a devastating neck injury sustained when a drunk woman knocked her to the ground in one of Cork’s EDs. Sadly, in that latter hospital in recent years, there have been attacks on patients with CS gas and batons, security staff regularly struggling with violent ‘visitors’, and more recently the grotesque killing of a patient on a ward.

So how or why do staff keep going in the face of all this stuff, one might ask?

Well, to illustrate the ‘normalisation’ of aggression, my medical daughter recalled how, not long ago, a patient in an inner-city Dublin ED took a swing at her, which she managed to duck. She conceded she’d have been seriously injured if his big fist had connected with her fragile face. But then, as with her nurse-mother 30 years previously and, as with so many dedicated frontline staff, she just ‘moved on’ to other urgent cases.

However, the sad truth is that, after a while, many staff develop a siege mentality, constantly anticipating the next verbal or physical threat, grimly ploughing on while doing as little as possible to further enrage patients or their companions, and retreating periodically to the staff room to shed a few tears, and plan their escape. 

And this desire to quit has often been accentuated in the past by the way abuse of staff has been tolerated by the ‘powers-that-be’ (often there is an administrative or political desire to avoid ‘unpleasant’ media coverage, with little or no consequence for the perpetrators).

There was an exodus of 30 precious nurses from one of our children’s hospital’s emergency departments due to the relentless hostility they face in already dire conditions of overcrowding, understaffing and therapeutic complexity. File picture

The numbers relating to violence (and threats) to healthcare staff in the Republic are grim: roughly 4,500 attacks occur annually on healthcare staff (paramedics and nurses suffering the brunt of these) and the pandemic prompted a surge in such violence, as well as a not-unrelated subsequent increase in presentations to GP surgeries and EDs. 

But lest anyone think it is just ‘us’, it is worth remembering that medical staff from Australia to China face similar or worse levels of threat, and the causes are the same: they range from under-resourced facilities to thwarted patient expectations, fuelled by intoxication with drink and drugs, misinformation and a consumerist culture that has encouraged people for decades to ‘demand what you are entitled to, until you get it’.

And the cure? The cure is as simple as eliminating widespread intoxication and incivility, providing the resources that avoid patient frustration, and ensuring that people (especially patients and their families) are equipped with honest, accurate and real-time information about what they should expect when they arrive in a hospital or GP surgery, and - just as importantly - how they need to behave towards the staff. 

In short, the cure is as complex — and urgent — as any other challenge in healthcare. The only difference is that, without this cure, there may be no one willing to provide any healthcare in many parts of our country.

• Dr Chris Luke is a retired Emergency Medicine Consultant and a freelance writer.