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'Take a stand against violent behaviour in A&E'


Posters telling people not to be aggressive towards staff are commonplace in many organisations - the post office, train stations and yes, even hospitals.

It seems shocking that the one place where staff are under enormous stress - life and death type stress - and struggling to look after people that they should be subjected to spitting, swearing and physical assault. That was a view echoed by Simon Burns, the health minister who came to support the launch of the proposed redesign of A&Edepartments to reduce violence towards patients and staff at the Design Council last week.

The project involved frontline NHS staff in three pilot trusts, design experts, psychologists and behaviourists to understand the problem and try to fix it.

It did what many staff can’t do - look at the environment from the perspective of an anxious relative, or patients who are confused or intoxicated, or just frustrated by waiting.

The project has been applauded for its simplicity in redefining signage and making the wait more tolerable for patients by providing more information about when they’ll be seen, but it has also built in a greater degree of support for staff witnessing such events.

The nurses from the University Hospital Southampton Foundation Trust pilot said they had become accustomed to “low-level aggression”, and didn’t really see it as a problem. But by recognising it, challenging it and changing it, they had made A&E a safer place.

Nurses are typically resilient and stoical, dismissing bad behaviour as part of their job. But this project shows shrugging off the problem is not the best solution. Nurses have the knowledge to make a difference, now they need the confidence to say enough is enough.


Readers' comments (41)

  • One of my relatives went to A and E recently. He was assessed by a triage nurse and waited a while for treatment. He said at no point was he told what would happen next. Being a reasonably bright person he coped with this lack of information but wondered why the nurses who spoke to him couldn't have given just a little more information. Signage etc does not replace interaction with and reassurance from staff.

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  • michael stone

    Anonymous | 22-Nov-2011 2:13 pm

    'He said at no point was he told what would happen next.'

    That is an extremely common complaint, from the public. This 'not talking properly to people' happens all over the place, and is the root cause of many of the problems, confusions and confrontations which happen everwhere in both life and healthcare'. By coincidence, I just sent an e-mail to my local PALS office which included the following:

    Nick Clark's widow was talking about his death 5 years ago, on R4's PM yesterday just before 6 pm. Now, amongst her points were these 2:

    1) I'm not really sure if we both wanted to be told if Nick was going to get better, or to die - but we didn't actually ask, and nobody told us - until 2 days before his death, I was told, and I don't think Nick ever was told.

    2) Because we were not told earlier, we did not have a chance to 'say goodbye to each other properly'.

    His widow, who said 1) was a common experience amongst the bereaved spouses she had subseqently talked to, also pointed out that 'other people who saw Nick a few weeks before his death, could see he was dying - but I'm not sure that I could see that'. She now suspects, but can't be sure, that Nick also knew he was dying by then, but never actually said that to her.

    The problem here, is that I think clinicians don't like to admit that people are dying, until very near to death, because it sometimes upsets people, leads to arguments, lack of hope, etc. Which is one reason why 1) happens.

    But AFTER A DEATH, WHEN YOU ARE BEREAVED, what 'plays on your mind, FOREVER' is 2) - nobody told us, SO WE COULDN'T PREPARE FOR THE DEATH PROPERLY'.

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  • I do absolutely agree with this new plan to redesign a lot of A&E departments and creating an environment that is helpful to patients and relatives, but I think it is only part of the solution. It must also be coupled with an absolute adherence to the zero tolerance policy, I have worked in places where the policy was for all intent and purpose ignored by staff and it was horrendous. There is NEVER an excuse for violence or abuse toward staff, it really is as simple as that. WE are trying our best to help, but THEY have to play their part too.

    Yes improvements can be made to the departments etc, and perhaps we can communicate more, but the public need to realise what a highly stressful and hectic envioronment the department is for staff too. Dealing with unrealistic expectations, violence and abuse, stressful life and death decisions, and all with far too few staff and too many patients, is it any wonder that some things do not work perfectly? The public need to realise that too.

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  • michael stone | 23-Nov-2011 11:03 am

    If only it were that simple. The 'public' do not consist of 'like-minded' people who all want the same things from clinicians. Probably difficult for you to understand, but there are often reasons why people don't ask questions. People often know instinctively and don't need someone spelling it out to them. Some people genuinely don't want to know. I saw a doctor receive a punch in the face after imparting the reality of a patient's condition. His crime? According to the patient, it was because the doctor had taken away his hope. It isn't about clinicians not admitting that people are dying. It is nowhere near as simple as that. As for the radio interview quoted, that is only one side of the story. Without knowing the full circumstances of all the interactions, it is just too easy and unfair to blame the clinicians, who have no right of reply.

    Meanwhile back to the actual article, I agree that a re-design of A&E to protect staff and patients can't be a bad thing. However, it must be coupled with nurses ceasing to tolerate incidents and, most importantly, severe consequences for those who perpetrate these crimes.

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  • michael stone

    Anonymous | 23-Nov-2011 5:41 pm

    I have also sent, having heard this chap yesterday, the following to my 'e-mail discussion partners' today:

    'Apparently PM has had ‘hundreds’ of e-mails, and it will be mentioning them on Friday – I think it said about 5-45pm.

    Yesterday, they had a retired consultant on ‘for the other side’s view’. He said that the conversations ‘need approaching gradually’, because people cannot ‘take in’ a really bad diagnosis ‘in one go’. But it did seem, that ‘trying to delay the discussion’ was the reality, of the behaviour he was describing.

    This chap apparently had a pain in his leg as a teenager, which the NHS sorted out – it was a spinal tumour. But he kept asking ‘what’s wrong with me’ and nobody would ever tell him – they all told him to stop asking. It was years later, when he was a medical student, that he came across someone who had treated him, and finally got the answer !

    I also think the fact that NHS care tends to be ‘conveyor belt’ and ‘episodic’ if you are a clinician, but must necessarily be seen in ‘holistic’ terms if you are a patient or relative, is a factor.

    I think paramedics, if they resuscitated father, would NOT then see the rest of father’s life, be it short in hospital, or longer (and perhaps ‘distressed’).

    If doctors and nurses annoy you, I think PALS tends to get in the way of what you actually want to do: you probably don’t want to tell PALS your problem, so they can get answers to what they think the problem was – you want the clinicians who you think did something wrong to be placed face-to-face with you, so that you can then say ‘Why did you do …. ?’

    And if you have a bad experience, and end up with ‘bereavement services’, again, I’d guess you are not talking to the people who you think caused the distress you think was unnecessary, but instead to someone else.

    How is the EoLC Strategy, dealing with this ‘you lot see only ‘your individual bits of my experience, but I saw IT ALL’ aspect ?'

    As for my original piece, about what Nick Clark's widow said, the reply from 'someone who should know' was:

    'This is an absolutely central element of the End of Life Care Strategy.
    Evidence suggests that no-one wants to start the conversation for fear of
    the other's emotions, but whoever does start it the other is glad and it
    tends to be productive and positive. This applies to both public and professionals. Dying Matters is doing GP training which finds the same thing. GPs are reluctant at first but when they have the confidence to
    discuss end of life issues with patients both benefit.'

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  • michael stone

    mike | 23-Nov-2011 11:25 am

    Andy Hamilton recently said 'when someone says 'we have a zero tolerance policy', I translate that to 'we are ludicrously over-sensitive'.

    He then went on to describe airport staff taking away a tube of his toothpaste, returning 5 minutes later with a very mangled tube of toothpaste, and placing it back in front of him. So he said 'If you like it that much, you can keep it'. Some other member of staff came over, and said 'We have a zero tolerance polciy to abuse'.

    Andy said 'That wasn't abuse - that was a complaint. If you would like me to, I can demonstrate abuse for you'.

    The problem, is that violent drunks are definitely a problem - yes, obviously. But 'getting wound up, because we have been waiting forever, and nobody is telling us what is going on' is not resolvable by a 'zero tolerance policy' (that approach leads to escalation, there), but calls for better communication with the people who are 'getting annoyed'.

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  • michael stone

    Anonymous | 23-Nov-2011 5:41 pm

    This is difficult for me to 'understand' - the points you made, seem obvious to me.

    I have experience, when my 'peacefully comatose and terminal' mother died at home, of a paramedic claiming that 'her death was sudden, because I was called' DESPITE my pointing out that the GP had told me to tell any cover GP, that the death was expected.

    I also have problems with the Police, and that paramedic, who apparently think that after you have agreed to phone a GP when someone dies at home, you should automatically phone someone immediately - logically, absurd (almost everyone will phone someone immediately, for most home deaths - but perhaps not when it is 40 minutes before surgery hours, and you ahve spent 4 days watching a comatose relative 'finishing dying': you might check the person has died, as I did, under those circumstances).

    I also don't understand this. When at home, EoLC patients can talk to their relatives, before talking to anyone else - why do so many 'professionals' think things which are not recorded, apaprently cannot ahve happened ? madness !

    But I digress - yes, I DO understand the potential problems of honestly telling patients their prognoses. But I'm not sure that all clinicians, understand the problems caused by NOT doing that !

    You need to analyses these things from ALL perspectives, to make progress.

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  • michael stone | 24-Nov-2011 2:58 pm

    Isn't this about the redesign of A&E? Once again, yet another debate about Eolc!!!!
    For every single story (lifted from the media!) you recount in the demonstration of a point, we could tell a hundred demonstrating many other views and realities. No. You don't understand the realities of a clinician's work. Simple as that. After all, aren't you the one who constantly makes the bizarre claim that nurses can't properly understand what it is to be a patient, because of their job?!

    You need to analyses these things from ALL perspectives, to make progress.

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  • My hospital claims zero tolerance , but no notices are displayed. We do have a lot to answer for as nurses- we need to inform patients regarding care and delays, we need to restict the number of people accompanying the patient into the area (A & E), where there are spectators it insites people to be abusive and aggressive. Yes we have a red card policy,which uesd to work , but it was changed without consultation with staff, persons who now are responsible for initiating the card have not be trained or are not available and who has time to make a call when a colleague is being atttacked. Guess what I was acosted when leaving one night and chased to my car- security, not interested, and nothing could be done because i failed in my fright to say to the man- excuse whats your name and address. Incident form was completed.

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  • I read some statistics in the BMJ the other day. It was something like over 50,000 attacks on NHS staff last year ad not much over 100 prosecutions. So there we have it, no deterrent to the yobs who want to give us a punch.

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  • michael stone

    Anonymous | 25-Nov-2011 10:28 pm

    I did say 'but I digress'.

    And I do indeed claim that nurses cannot understand the experience of being a patient, without their understanding being influenced by the fact they are also a nurse - it must be true, logically. HOW INFLUENCED is a legitimate question - but I do not believe the answer is 'not at all'.

    I also agree that there are too many attacks on hospital staff, and that some patients are unreasonably confrontational, and that it is not I who am being attacked in A&E, so I have no experience of that.

    But I have a problem when complaint becomes confused with confrontation - just not helpful !

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  • It's all very well and good having a zero tolerance policy but we do need to be careful not to overlook the fact that many medical conditions as well as symptoms such as chronic pain, can lead people to act in aggressive or violent ways.

    Michael is quite correct when he says that one of the problems is that complaint becomes confused with confrontation. I would actually go further than that and say very often a simple question, such as how long a wait will be is often confused with confrontation.

    There is absolutely nothing wrong with Michael talking about end of life care in this context either, as he was talking about poor communication which as we know is a large pre disposing factor to aggression and vilolence.

    I suspect he would've been able to make the point if he was a nurse and the lowest the low: a member of the public

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  • michael stone

    Geeze | 29-Nov-2011 1:09 pm

    Thank you Geeze, I was digressing a bit into EoLC but as you pointed out, it si connected to bad communication and my persoanl experience of the problems that can cause were during EoLC.

    I am heartened that some nurses, do understand that treating a complaint as de facto 'aggressive' can cause confrontations - but, I fully accept that a violent drunk, is de facto a problem !

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  • Another debate down the toilet.

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  • As an A&E nurse, I feel obliged to point out that the highly qualified and experienced staff in many A&Es are very well aware of the reasons, medical and otherwise, for challenging behaviour AND how to deal with it. Interesting that this discussion has been hijacked by a couple who obviously know little of the reality of this behaviour, or how to deal with it appropriately. The so-called Zero Tolerance policy is (as ANYONE who actually works in A&E knows) a joke. Suggesting that the levels of violence and aggression faced by A&E staff on a DAILY basis are in large part due to poor communication, is stupid, downright insulting and displays stunning ignorance! Obviously, neither of you are nurses.

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  • Zero tolerance to eolc interrupting every debate about every topic on this website intended primarily for clinical professionals.

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  • Anonymous | 2-Dec-2011 8:09 pm

    Hear Hear!

    Anonymous | 2-Dec-2011 7:01 pm

    At last, someone who agrees that violence against nurses isn't actually our fault or should be tolerated!!

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  • Anonymous | 2-Dec-2011 9:47 pm

    problem is that it falls on deaf ears despite the comments of quite a few readers following other articles. Such behaviour disappointingly just kills all discussions between professionals.

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  • Half of those who pitch up in A&E are NOT emergencies and could be better managed by dealing with problems sooner (themselves) and/or by attending their GP. They are often the ones who clog up the system in the first place. Then they get aggressive with the staff because they have to wait, whilst staff are dealing with genuine emergencies. So lets stop kidding ourselves that this is down to the staff. I have absolutely no problem with a zero tolerance policy. The trouble is management never implement it or support their staff.

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  • Anonymous | 3-Dec-2011 4:36 pm

    are there clear guidelines for the general public to help them make the decision whether they need to attend A&E or there GP? I get the impression that this is not the case so the blame should not lie with them. I would imagine that GPs work office hours only and on an appointment system. If an individual is worried, anxious or feels it would be harmful to wait for appointments offered or they are unable to be attended to for other reasons then they will go to A&E. If they need attention out of hours then presumably A&E is the only alternative.

    Zero tolerance is not a means of helping a patient find a solution to their problems and helps nobody. It is merely a concept which has originated in 'clever' America and from general management theory which normally everybody in the NHS and patients associated with it hate so much. It can exacerbate the situation which may have otherwise been alleviated by good problem solving skills, by showing tolerance and understanding and by offering adequate care and attention. Causes or anger and aggression among sick or injured individuals and those in their entourage are well documented and do not need to repeated here where space is limited.

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