Discussion
This review examined evidence of patient-initiated aggression towards receptionists in general practice settings. This phenomenon is not new, as our review uncovered evidence for at least the past four decades and likely beyond.26 The International Labour Organisation highlights that workplace violence is a global phenomenon, and that no country, industry or occupational group is free from workplace violence.10 Statistics into global prevalence are scarce and where data are available, they are difficult to compare rigorously as studies are typically ad hoc, use non-standardised definitions of workplace incivility and under-reporting is suspected.10 34 The findings of our study reflect these phenomena and confirm a significant gap in understanding the prevalence, severity and impact of patient aggression in general practice. Our review also uncovered the use of variable terms and definitions of aggression, hostility and violence, different and mostly unvalidated survey tools used for detection and measurement of prevalence, and a tendency to use proxy participants to report on behalf of general practice receptionists.21 24 It is therefore not surprising that this challenge for general practice has persisted over many years.
Patient-initiated abuse of medical, nursing and ancillary staff in general practice and other medical settings has been reported.24 Unfortunately, general practice receptionists appear to experience verbal abuse almost ubiquitously24 33; so frequently that some general practice stakeholders and receptionists accept it as an occupational hazard.21 Verbal abuse is common across all workplaces, especially for those in frontline roles. For example, in Australia alone, 48% of fast-food restaurant, 50% of tertiary education, 67% of healthcare, 68% of juvenile justice and 81% of taxi workers report being verbally abused at work.35 Comparatively, physical violence is less prevalent than instances of verbal abuse against receptionists in general practice, with studies reporting figures between 0.5% and 8%.8 18 24 27 33 Across other sectors mentioned previously, physical violence is reported by approximately 1% of fast-food restaurant and tertiary education, 10% of taxi, 12% of healthcare and 17% of juvenile justice workers.35 While this challenge is clearly prevalent across industries, unique circumstances exist for receptionists in general practice related to the emotional labour of empathising with patients’ volunteered accounts of abandonment, grief, loneliness, discomfort and disease-related feelings. These factors are relatively unrecognised in typical reception duties,6 but could put general practice reception staff at increased risk of related adverse psychological impacts.7 36
Client-initiated hostility is beginning to be recognised as having greater impacts on workers than even internally perpetrated workplace bullying.10 37 38 For general practice receptionists, reported impacts of patient aggression including hostility included reduced work satisfaction,19 increased workplace stress,24 absenteeism,24 burnout,24 thoughts of leaving the profession,24 32 emotional distress7 8 16 17 and even lasting psychological15 18 23 29 32 and physical harm.24 28 These impacts are identical to those reported in other industries, especially hospitality and service industries.39 It is important to recognise that physical forms of aggression and violence do not necessarily mean more severe impacts. Non-physical forms of violence alone can cause not just psychological but also physical harm to employees. These physical harms include sleep disruptions and somatic pain, and a higher risk of sustaining musculoskeletal injuries.37 This potential to significantly affect life outside the workplace suggests potential wide-ranging societal impacts.10 34 39 Despite the rare case where physical violence has resulted in serious injury28 32 or even homicide,24 it is safe to assume that the majority of negative impacts to worker well-being is likely largely driven by non-physical forms of aggression and hostility simply due to the sheer difference in prevalence between the two forms.
Patient aggression could also negatively impact health service delivery and access.21 22 33 For example, receptionists who reported experiencing aggression in turn began to feel the process of communicating abnormal patient test results to be intimidating and anxiety provoking, with some receptionists suggesting they tried to avoid the task altogether.22 The study suggested that this could lead to inefficiencies in communicating important health information to patients.22 Banning a hostile patient from the general practice clinic, while an understandable approach to managing the local risk of hostility, will ultimately impact health service access for that patient and many others who might ‘act out’.31 33 In some instances, patients might ‘act out’ in desperation or because of personal or social circumstances21 27 and illnesses21 26 28 34 40 41 outside their control. However, it is imperative to recognise that most cases of violence are perpetrated by people who do not have a mental illness and violent people with a mental illness are not common among the wider population.40 41 Further impacts to patient care come from the risk of reduced service capacity as aggression can reduce workforce retention and staffing numbers.21 24 33
There are gender imbalances when it comes to the impacts of client-initiated hostility across many industries.39 42 The retail,43 hospitality44 and healthcare sector, particularly in reception45 and nursing,46 are sectors that are most at risk, but they are also sectors more likely to be dominated by women at the frontline. This increases the exposure to hostile aggression for women workers. Furthermore, women are more frequently the target for client-initiated hostility, particularly verbal and sexual abuse, compared with men.40 47 In our review with participant receptionists who were almost exclusively women, those who were the targets of patient aggression reported the emotional exhaustion they experienced to maintain their composure despite feeling angry and upset.7 15 Experiencing emotional exhaustion and incivility is a predictor for retaliatory incivility back to clients or reciprocation through counter-productive behaviours such as client sabotage,48 intentional rule breaking or procrastination.42 Risk factors for retaliatory incivility include power distance between potential perpetrator and victim, victim gender (men are more likely to retaliate than women) and unfair social or cultural expectations to quietly accept incivility (women, for example, are socially expected to do this) and be skilled in emotionally laborious tasks in healthcare.42 49 The clinic receptionist is already recognised as being one of the lowest ‘prestige’ positions in the general practice workforce,15 with little authority,26 and the sector is far from achieving gender parity with an extreme over-representation of women.45 Although our review did not find any obvious evidence of retaliatory incivility, the impacts of this type of incivility on patient access, experience, quality of care and subsequent behaviour towards other medical team members need to be better understood and documented before they can be appropriately addressed.
Most studies we reviewed discussed current or possible management-initiated strategies for reducing the incidence and impact of patient aggression towards reception staff. However, only five explored specific strategies4 18 25 30 31 and none of those objectively evaluated their effectiveness. Rather, they relied on assumed or perceived changes in incidence and severity of both instances and consequences. A wide variety of anticipatory strategies to address patient aggression were suggested, including education and training (eg, training on managing and de-escalating hostility), organisational interventions (eg, reporting mechanisms, trialing open access clinics, enacting policies and procedures to better govern risky situations such as after-hours care) and workplace design (eg, modification of physical waiting room layout). These types of strategies appear common across the healthcare industry.50 In the tourism sector, Boukis et al51 demonstrated that supervisor support and particularly an empowering leadership style can moderate the emotional exhaustion, stress, morale and turnover of frontline staff arising from customer aggression.
Education and training type strategies typically resulted in reception staff feeling safer and more confident in dealing with hostile behaviours. Although this is a relevant outcome for the well-being of general practice receptionists, there was no evidence that training reduced the incidence of hostile behaviours.18 19 21 23 24 29 This is also true across many other industry contexts and serves to ensure workers are equipped to deal with violence, but does little to prevent it from surfacing in the first instance.38 Interestingly, Dixon et al27 evaluated the outcomes of a campaign to educate the public about patient-initiated hostility as a way to prevent it in the first place. However, they found no effect in reducing incidences of hostility towards receptionists.27 At the time of writing, little published evidence of mass media education campaigns against violent behaviours exists, and evaluating such interventions against violent behaviours is difficult to perform and thus uncommon.52 However, public campaigns are known to be a catalyst for social change and broader public discussion.39 52 Zhou et al found that across hospitality literature, public messages suggesting injunctive consequences (eg, ‘hostility can be subject to criminal penalties’) were more effective in preventing hostility compared with descriptive messages (eg, ‘please be mindful of your words and actions’).39 There is a clear opportunity to rigorously test a range of initiatives that aim to prevent and manage hostility and aggression in general practice.
The apparent reliance of general practice clinics on receptionists to develop their own de-escalation strategies and independently build resilience against patient aggression is concerning. Several studies mentioned that part of a receptionist’s role, either formally or informally, is to engage with patients positively despite circumstances, de-escalate challenging situations, keep patients calm and maintain composure.15 16 29 30 Studies from hospitality literature describe that good client rapport reduces instances of client misbehaviour, yet prioritising this as a de-escalation tool is ineffective long term and actually led to clients misusing their rights later.39 Furthermore, Morrison15 and Strathmann et al16 found receptionists reporting this strategy adds to the emotional labour associated with the role, which in turn could lead to consequences discussed earlier such as retaliatory incivility and burnout.15 16 Although raising questions of health access equity, Zhou et al reported that removal of the problematic client was considered effective, and this was reported as a strategy in some of the studies we reviewed.31 33 39
This review has notable limitations. Our study included research conducted over a 40-year period, with the reviewed studies indicating significant changes to the duties of the general practice receptionist, necessitated by the development of technology to automate clerical tasks and changes to telecommunication methods which, in turn, may have influenced the circumstances predicating patient aggression. While greeting patients and arranging access to medical professionals has remained the main role of the general practice receptionist, another significant limitation is that the external precursors of patient aggression and types of actions interpreted as aggression are likely to have changed with social and professional norms, with older studies probably having less relevance to understanding patient aggression today. Issues identified with the shifting and varied definitions of patient aggression represent potential limitations to the likelihood of capturing all the relevant published literature, but the search terms were intentionally broad and multiple databases were used to minimise this factor. Concierge services in the hospitality and tourism industries have experienced increases in client-related hostility and aggression over recent years, exacerbated by the COVID-19 pandemic. Receptionists in general practice settings were similarly affected by the safety precautions necessary during the COVID-199 pandemic so patterns of patient aggression may have changed but are not yet apparent in the literature. Our study has highlighted that the experiences and well-being of general practice receptionists are under-studied in general, and even in research about general practice reception, receptionists are under-represented as participants. Accordingly, this is a limitation of the current research but should also provide the impetus for enhancing the rigour of research in this sector.