In November we first met dental therapist Hayley Cokayne in BDJ Team when she wrote about her alternative career path. In this article Hayley describes the patient assault she experienced, and shares advice for other dental professionals.

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‘I was attacked by a patient.' Six simple words, but as I said them in a panicked call to my personal tutor, the events of that morning suddenly started to sink in. I broke down and could not stop crying. I can remember it like it was yesterday, in ultra clear HD and I must have replayed it over and over in my head hundreds of times.

We work in a profession where reflection is fundamental and since that day, I have reflected constantly, looking for any mistakes I may have made or warning signs I might have missed, but to put it simply, I was not at fault and what happened to me was not okay, even if it has taken me a while to accept this.

Violence within healthcare is not often talked about, with a general assumption of ‘it won't happen to me'. However, a 2020 study by New York University revealed that half of dentists questioned had experienced aggression.1 Furthermore, a parallel study carried out by the same team but this time focusing on dental students, discovered that 86% had experienced verbal aggression and 27% had experienced physical violence.2 When exploring the reasons behind healthcare related violence, R. R. Di Prinzio et al. (2022)3 found that the most common contributing factors to overt aggression were emotional instability, emotional intensity, and minor psychiatric disorder. Therefore, given the strong negative emotions that dental environments can trigger, it must be recognised that we work in a risky and sometimes unpredictable environment.

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I hope that by sharing my experience, I can encourage clinicians to reflect on their individual personal safety and potentially make changes to their current way of working.

The incident

I was a final year dental therapy student when the assault took place. I received punches to the head, face, and defensive bruising to my arms. It happened within seconds of the patient entering the room, taking everyone by surprise. Thankfully, staff members within the building heard shouting and came in to help. I was accompanied to A&E and given a probable diagnosis of a fractured orbital floor, which was later confirmed with a CT scan. However, it was the psychological side of things that impacted me the most.

In the weeks that followed the assault, I had trouble sleeping, low mood, headaches, pain, and double vision. My personal tutor and programme lead were incredibly supportive, checking in with me daily and trying to help however they could. Several lecturers kindly arranged for me to be seen by specialists. However, the stress of the assault triggered an acute flare up of alopecia and I lost all my hair. Occupational health deemed me unsafe for practice until my double vision resolved, which sadly resulted in me missing my final month of university. I still had online examinations to complete which I went ahead with and although I passed, they definitely weren't my best work.

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With the support of my tutors, GP, family, and friends, I improved. I engaged with wellbeing services, talked to people, and tried to get out of the house. I refused to let the assault continue to ruin years of dedication and the career I had worked so hard to achieve.

Important lessons

Training: Specifically, training in breakaway techniques and conflict de-escalation, even more so for students and those working in special care environments or lone working. In agreement with this is Rhoades et al. (2020)2 who concluded ‘training in how to prevent, de-escalate, and address aggressive behaviours from patients is clearly warranted as a component of dental education'. Breakaway courses are designed to teach people how to disengage from physical or aggressive situations.

Personal alarms: When I previously worked in mental health, we were provided with personal alarms that we clipped onto our lanyards which meant we could immediately attract attention regardless of where we were located. The alarms also acted as a deterrent. Panic alarms triggered via computer software are far from ideal; in my situation it was not helpful as I was trapped in a corner with my back against the computer; had I turned away from the patient I would have put myself at higher risk. Therefore, the accessibility and practicality of panic alarms should be considered. After all, it's no good having one if you cannot get to it.

Detailed history: I believe that simply ticking a box or stating a certain diagnosis is not sufficient. As clinicians, we need to have a clearer picture of the background so we can provide the best patient centred care possible. For example, if a medical history form states the patient has autism, we should be made aware if there are specific triggers, suggested communication adaptations and any historical aggression. I think the best way to implement this would be adapting routinely issued medical history forms to include several extra sections. When referring a patient, the referring GDP should take time to include a thorough history so the clinic can safely carry out a risk assessment.

I have reflected constantly, looking for any mistakes I may have made or warning signs I might have missed, but to put it simply, I was not at fault and what happened to me was not okay.

Having support and wellbeing services available: After the assault, I was actively supported by my university personal tutor who helped me with resources such as counselling. However, receptionists, registered dentists and dental professionals including therapists, hygienists and nurses will not have this system in place. Therefore, it would be helpful to assign a team member the responsibility of ‘wellbeing lead' - someone who can promote mental health awareness and monitor the wellbeing of staff - even more so after a traumatic situation, providing information on support services and being a first point of contact for anyone struggling.

Avoid lone working: Thankfully, there were three of us in the clinic room that morning - me, my clinic tutor, and my clinical partner. When I trained as a dental nurse before becoming a dental therapist, the importance of never leaving the dentist on their own with a patient was stressed. Understandably it is unavoidable in certain environments, but we need to be aware of how we can reduce risk. For example, if a dental nurse needs to leave the room for something, consider leaving the door open so voices can be heard. For hygienists and therapists lone working, there should be staff within proximity and at the very least a personal alarm provided.

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Today

After graduation, I declined a private hygienist role I had been offered prior to the assault and instead accepted a part time position on a foundation training scheme which helped to rebuild my confidence and refine my skills. I had ups and downs, including a big panic attack during a communication workshop, but gradually I started to feel comfortable being on my own in the surgery. I even managed to undertake a few locum hygienist shifts which I loved. After five months on the scheme, I was offered a great opportunity elsewhere which would still enable me to utilise my full scope as a dental therapist, so after a lot of thought, a few weeks ago I handed my notice in. I'm excited for what the future holds.

The biggest positives to come out of the incident are the strong relationships I have built with those who were there for me and an increased self-awareness around safety.

Every now and then, if a patient has similar mannerisms or appearance, the ‘butterflies' feeling creeps in, and I have to push through it. In my head I'm imagining the patient jumping out of the chair and coming towards me even though I know it's highly unlikely to happen again. I just keep breathing and try to relax.

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The biggest positives to come out of the incident are the strong relationships I have built with those who were there for me and an increased self-awareness around safety. All three of the practices where I work have reevaluated their safety and carried out in-house meetings on what to do in a similar situation, how to activate the panic alarm etc. I like to think that what happened to me may have inadvertently prevented someone else from being in the same situation and I hope after reading this, it helps you too.

Read Hayley's career story in BDJ Team: https://www.nature.com/articles/s41407-023-2022-z.