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The HSE is clear: 'If risks from violence and aggression are to be managed successfully, there must be support from those at the top of the organisation, no matter what size'. This can be expressed in a clear statement of policy, supported by organisational arrangements, to ensure that the statement is implemented. Key elements include recognition of the risks; commitment to introducing precautions to reduce that risk; a statement of clear roles and responsibilities; an explanation of what is expected from individual employees, and a commitment to supporting people who have been assaulted or suffered verbal abuse.
Paterson, Leadbetter & Miller (2005) suggested three groups for measures that address violence and aggression: primary, secondary and tertiary.
Primary or proactive risk reduction measures include organisational policies and procedures, details of roles and responsibilities, assessment of risks, provision of adequate staffing levels, provision of training to individuals commensurate with their role, assessed level of risk and training needs analysis; alarm systems and technical solutions, and the provision of appropriate environments. This last factor is reinforced by recent work by the Design Council (2011) which identified nine triggers for violence in A&E departments, seven of which can be influenced directly, either positively or negatively, by the physical environment.
Undertaking work in the areas outlined above particularly in combination can have a positive effect on the incidents of violence and aggression in an organisation and by their pre-emptive nature can be invisible to users of the service in question if appropriately implemented.
Secondary responses to violence and aggression refer to the interpersonal skills that staff can bring to the often escalating situation caused or exacerbated by an organisation failing to address issues highlighted above. An awareness of what triggers can cause anxiety, frustration and, if unchecked, aggression, can be vital for staff in undertaking efforts to reduce the likelihood of that frustration escalating into violence.
It is easy to appreciate how factors such as fear, pain, embarrassment or confusion could occur in a healthcare setting but other factors, such as rudeness, being patronised or feeling ignored clearly have no place in an environment intended to promote healing. Staff awareness of emotional triggers can be demonstrated by displaying an empathetic approach to individuals, maximising positive communication by employing a communication model such as LEAPS and being fully alert to the potential barriers to communication that can exist in any interpersonal exchange and which can be exacerbated by the intense emotions that can be triggered in healthcare settings with their hierarchical nature and often by necessity, procedurally-focused approach.
Despite an organisation focusing on primary measures and staff displaying positive awareness of all the attributes required to be a positive, effective communicator, situations will occur where frustration and aggression spills over into violence; either in the form of verbal abuse or direct physical assault.
When this situation is reached it is necessary to focus on the third tier of measures. These focus on physical responses, which may include staff physically extricating themselves from potentially dangerous situations or in certain circumstances employing appropriate physical intervention techniques, (which of course will be documented in an organisations primary risk reduction measures along with the provision of appropriate training).
Simply making a situation safer by removing yourself from it or employing risk-assessed safer holding/breakaway/physical intervention/restraint techniques or equipment is only one element of the necessary tertiary measures. It is crucially important that following an incident a number of activities take place. These can include providing post incident support to the victim; reporting and recording details of the incident; rebuilding relationships, (particularly important in settings where delivery of care to the individual will continue), and learning from what happened and sharing good practice.
Most large organisations will have processes in place intended to cover these aspects but we should consider just what some of these tasks entail. Post-incident support for victims covers a range of things, from supporting an individual through immediate reactions, such as shock, anger or embarrassment, to simply ensuring they get any treatment for physical injuries they may have sustained.
It is important to acknowledge that there is no 'right' or ‘wrong' way to react, and support will need to be tailored to an individual’s needs. Medium term responses to an incident can last for a number of days or even weeks and can include feelings of anxiety about returning to work or encountering similar situations, or even the perpetrator.
Other individuals may deny any effect and be keen to get back to work. Where individuals suffer longer term reactions to workplace violence then organisations should ensure that they have adequate measures in place to support these individuals and professional support can often be accessed via occupational health departments or providers.
When reviewing incidents it is helpful to use the experiential learning cycle to discover what happened, why it happened and why it happened in the way it did, as well as how things could be improved if it happened again.
One NHS Trust uses a system based on questions as its basis for developing learning from incidents. What was expected? What actually happened? Why was there a difference? What can be learned? The key factor here is that learning from incidents is then shared in such a way that it contributes to the primary risk reduction measures that are in place and ensures they develop over time to meet developing needs, identify trends or highlight deficiencies in practices or procedures.
Often experiential learning at a team level is relatively simple to achieve but as the team grows in size or complexity and involves multiple smaller units with their own specific roles, as is common in large healthcare organisations, the ability to communicate effectively and ensure best practice is effectively shared becomes increasingly complex.
Why is this process important?
The cost of keeping healthcare staff safe from the risks they face is not insubstantial. In 2010 NHS Protect put the cost to the NHS of physical violence at £60.5m, this figure of course cannot include the emotional cost to the staff involved. In 2011 the published figures for physical assaults on NHS Staff in FY 2010/11 stood at 57,830.
In 2003 The NAO published figures suggesting that the cost to the NHS caused by physical violence and verbal abuse was some £69m which, given inflation and the fact that it incorporated physical and non physical violence suggests that the NHS Protect figure fails to account for the full potential costs to the NHS of violence towards staff. In the year before the NHS Protect figures was collated the BBC Panorama programme put the figure at over £100M per year, and stated that this was enough to fund the salaries of over 4500 nurses. But these figures only account for the NHS.
Whilst the NHS is the largest employer of staff involved in health and social care in the UK, employing in excess of 1.3m staff, a substantial additional number of staff are employed in the delivery of healthcare by private companies and other providers, including local authority social care services, raising the figure above four million people employed in the sector according to figures published by the ONS in Feb 2012. If the cost to the NHS of £69m is extrapolated that gives a potential cost to the healthcare sector from violence and aggression of approximately £214m per year.
Given the vast cost of violence in healthcare settings it is clear that cost-effective, evidence-based and targeted solutions could have a substantial role to play in times of pressure on budgets.
As has been shown above the areas encompassed by primary risk reduction measures include environmental design, communication and information systems, alarm and other technical safety solutions, risk management solutions, staffing, equipment and training. For businesses operating in the healthcare sector with products or services in these areas they may find that the recession is affecting budgets in the healthcare sector not violence but if they can demonstrate deliverable results which reduce the impact of violence both at an individual and organisational level they may well have a persuasive argument for spending to save.
Simon Whitehorn is a member of the National Association of Healthcare Security.