Violence in general practice: perceptions of cause and implications for safety.

OBJECTIVE: To explore GPs' opinions about the causes of occupational violence in general practice. DESIGN: A cross-sectional qualitative study. SETTING: Three urban divisions of general practice in New South Wales, Australia. PARTICIPANTS: A total of 172 GPs: 18 GPs participated in focus group discussions and a further 154 provided written responses. METHOD: Purposive sampling was used to recruit GPs to participate in focus groups. Discussions were audiotaped and transcribed; each transcript was separately coded by all members of the research team. Focus groups were conducted until thematic saturation was achieved. Further qualitative data were obtained by offering GPs the opportunity, during completion of a written questionnaire sent to all GPs practising in the 3 urban divisions, to provide additional comments regarding their experiences and perceptions of violence. A modified grounded-theory approach, employing thematic analysis of the focus group transcripts and written responses from the questionnaires, was used. MAIN FINDINGS: All focus group participants and 75% of questionnaire respondents had experienced episodes of violence during their general practice careers. Key themes that emerged in data analysis were used to construct a schema of participating GPs' perceptions of the causes of occupational violence. Elements in the schema include underlying causes, proximate causes, and GP vulnerability. Perhaps the most noteworthy findings within this structure were the emergent constructs--culture of fear, "naïve" practice culture, and GP vulnerability. To date these themes have not been evident in general practice literature on this topic. CONCLUSION: An understanding of GPs' perceptions regarding the causes of violence will be useful in planning general practice service provision and promoting GP safety.

General practitioners' assessment of risk of violence in their practice: results from a qualitative study.

RATIONALE, AIMS AND OBJECTIVES: Clinicians' means of stratification of risk of violence has been previously studied in health settings, but not in general practice. This study aimed to investigate the means by which general practitioners (GPs) assess risk of violence in their clinical practice. METHOD: A qualitative design using focus group interviews and written responses on a subsequent questionnaire. Focus group discussions were audiotaped and transcribed. Questionnaires were sent to all members of three Divisions of General Practice offering the opportunity for respondents to make qualitative comments. The focus group transcripts and qualitative questionnaire responses were coded independently by members of the research team and subjected to thematic analysis. The setting was three Urban Divisions of General Practice in New South Wales, Australia. Participants were one hundred and seventy-two urban GPs - 18 participants in four focus groups and 154 GPs providing written responses. RESULTS: Assessment and stratification of risk by GPs conformed to a schema based on the physical environment of the consultation, individual characteristics of the patient, individual characteristics of the doctor, and characteristics of the doctor-patient relationship. Despite this, risk assessment and risk stratification were often on the basis of ad hoc, subjective decision making. An aspect of the ad hoc nature of risk assessment was the pre-eminence afforded 'instinct' or 'intuition' in subjects' responses. CONCLUSION: A schema of factors involved in GPs' assessment of risk of violence is presented. An appreciation of these will be of clinical and policy importance.

Effects of occupational violence on Australian general practitioners' provision of home visits and after-hours care: a cross-sectional study.

RATIONALE, AIMS AND OBJECTIVES: Occupational violence is increasingly recognized as a problem in general practice, and has been suggested as adversely affecting general practitioners' (GPs) provision of services to patients. The aim of this study was to investigate the association of experiences of violence and perceptions of risk of violence with provision of after-hours GP care and home visits. METHOD: A questionnaire-based cross-sectional survey of GPs in three Australian Urban Divisions of General Practice was used. RESULTS: Five hundred and twenty-eight GPs completed the survey (response rate 49%). Of the GPs surveyed, 63.7% were subjected to some form of violence in the previous 12 months. Risk of violence influenced 10.2% of GPs' delivery of in-hours home visits and 22.0% of GPs' delivery of after-hours home visits. A further 4.7% of GPs reported not performing after-hours home visits at all during the previous 12 months because of safety concerns. On logistic regression, gender, location of practice and country of medical qualification were significantly associated with provision of in-hours and after-hours home visits. Experience of violence during the previous 12 months was not significantly associated with provision of home visits. CONCLUSIONS: This study's finding of GPs' self-reported restriction of practice and withdrawal from home visits and after-hours calls in response to risk of violence represents a significant primary health care issue. GPs' decision to provide after-hours calls and home visits is complex, and the finding of lack of significant association of experiences of violence with provision of home visits and after-hours calls is likely to be due to the cross-sectional nature of the study.

Is a computer questionnaire of childhood asthma acceptable in general practice?

OBJECTIVES: To determine whether a previously-validated touch screen computer program of symptoms and management of childhood asthma is acceptable to parents who accompany their children to consult a GP, and to examine whether any parent characteristics are associated with acceptability. METHODS: Conducted in general practice in Newcastle, NSW, Australia. A cross sectional pen and paper survey was given to parents of children consulting a GP after completing the computer questionnaire on childhood asthma in the waiting room. Measurements were frequencies of Likert scale responses to statements concerning the computer questionnaire, compared with demographic and personal characteristics. RESULTS: High levels of acceptability of the asthma computer questionnaire were reported by the 198 respondents, with most being willing to do the same program once or twice a year (87%), or to do similar programs on other topics (91%). Most respondents (81%) agreed that the computer program was enjoyable, and very few (8%) would have preferred to answer the asthma questions by pen and paper rather than by computer. Two or more children accompanying the parent was the characteristic most associated with less positive responses. CONCLUSIONS: Overall the high acceptability of this questionnaire suggests that this computerised format is an appropriate method of screening children for asthma and determining their current management. As a large component of underdiagnosis of asthma is lack of reporting to the doctor, this valid and acceptable diagnostic aid has the potential to improve detection of unreported asthma, and also to identify high-risk individuals.

Experiences of occupational violence in Australian urban general practice: a cross-sectional study of GPs.

OBJECTIVE: To establish the prevalence and characteristics of occupational violence in Australian urban general practice, and examine practitioner correlates of violence. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional questionnaire survey mailed to all members (n = 1085) of three urban divisions of general practice in New South Wales in August and September 2004. The three divisions were chosen to provide a range of socioeconomic status (SES) demographics. MAIN OUTCOME MEASURES: Occupational violence towards general practitioners during the previous 12 months. RESULTS: 528 GPs returned questionnaires (49% response rate). Of these, 63.7% had experienced violence in the previous year. The most common forms of violence were "low level" violence - verbal abuse (42.1%), property damage/theft (28.6%) and threats (23.1%). A smaller proportion of GPs had experienced "high level" violence, such as sexual harassment (9.3%) and physical abuse (2.7%). On univariate analysis, violence was significantly more likely towards female GPs (P < 0.001), less experienced GPs (P = 0.003) and GPs working in a lower SES status area (P < 0.001), and among practice populations encompassing greater social disadvantage (P = 0.006), mental health problems (P < 0.001), and drug- and alcohol-related problems (P < 0.001). Experience of violence was greater for younger GPs (P = 0.005) and those providing after-hours care (P = 0.033 for after-hours home visits). On multivariate analysis, a significant association persisted between high level violence and lower SES area (odds ratio [OR], 2.86), being female (OR, 5.87), having practice populations with more drug-related problems (OR, 5.77), and providing home visits during business hours (OR, 4.76). More experienced GPs encountered less violence (OR, 0.77) for every additional 5 years of practice. CONCLUSION: Occupational violence is a considerable problem in Australian urban general practice. Formal education programs in preventing and managing violence would be appropriate for GPs and doctors-in-training.

Are the components of the Asthma Management Plan important in managing childhood asthma? A survey of general practitioners.

AIM: To gauge the importance and relevance placed by general practitioners on components of the National Asthma Campaign's 'Six step' Asthma Management Plan for childhood asthma. METHOD: A cross sectional postal survey of a national randomised sample of 824 GPs. RESULTS: Each component was considered to be 'quite' or 'very' important by at least 70% of respondents. All 11 components were rated to be either 'quite' or 'very' important by 44%, and 91% of respondents considered eight or more of the components to be 'quite' or 'very' important. Two characteristics were consistently associated with the rating of importance: gender, (women GPs generally showing higher ratings), and reported frequency of use of the Asthma Management Plan (frequent users rate importance more frequently). CONCLUSION: There were high levels of endorsement of the Asthma Management Plan for children with asthma.