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An end to violence?

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It is now nearly 10 years since the government launched its Zero Tolerance campaign to put an end to violence against NHS staff. Richard Staines investigates whether the health service is now a safer place to work for nurses

Last week Conservative leader David Cameron pledged to crack down on violence against nurses and other NHS staff. His is the latest in a long series of such public promises from politicians since 1999.

The violence experienced by many NHS staff in their everyday work in caring for patients is highlighted regularly by local and national media coverage of attacks against nurses.

Additionally, the issue continues to be discussed annually at union conferences (see table, right), often accompanied by rousing words from MPs on a renewed commitment to tackle the problem.

It is seemingly an issue that never goes away, and one that is perhaps too easily viewed by some as ‘part of the job’ for frontline NHS staff, especially those working in A&E and mental health settings.

In 1999, and with much fanfare, a recently elected Labour government launched its Zero Tolerance campaign aimed at cracking down on violence against NHS staff. This consisted of a publicity drive to educate the public about the unacceptability of violence or aggression towards healthcare staff. It also included guidance for staff on dealing with the problem and called on trusts to issue local policies on when to withhold treatment from violent patients.

At the campaign’s launch, then health minister John Denham said: ‘It is unacceptable that caring NHS staff can be rewarded with intimidation and violence.

‘The cost of violence against staff is great. Victims can suffer physical and psychological pain. Confidence can be irrevocably dented and stress levels rise,’ he said during a visit to an A&E department at University College London Hospital as part of the initiative’s launch.

Since then the mantra ‘zero tolerance’ has been echoed by ministers across the UK – including Welsh health minister Jane Hutt in 2001 and Scottish health minister Malcolm Chisholm in 2004. 

And, just last week Mr Cameron added his name to this list with his speech to RCN Congress in Harrogate, saying that he intended to meet violence against NHS staff with tough legal action.

‘We are going to take a zero tolerance approach to those who attack NHS staff. That means proper protection as standard procedure and for it to be regarded as an aggravated offence,’ he told delegates.

But, despite all the good intentions, the figures on violent and aggressive incidents – and the reporting of them – over the last 10 years make it hard not to question what has really changed.

At the same time as Zero Tolerance was launched, the DH published Working Together: Securing a Quality Workforce for the NHS, which required trusts and health authorities to have systems in place for recording incidents of violence and aggression and to set targets for reducing such incidents by 20% by 2001 and 30% by 2003.

These targets were subsequently incorporated into the Improving Working Lives standard, launched in October 2000, which all acute, mental health and ambulance trusts were required to put into practice by April 2003.

As part of the Working Together initiative, the DH undertook two national surveys to try and quantify the number of reported incidents of violence and aggression – including both physical and verbal abuse – against acute, mental health and ambulance staff. The first, conducted in 2000–2001, identified 84,214 incidents. The second, in 2001–2002, showed an increased figure of 112,000 incidents.

Figures from the DH for 2002–2003 – given by then health minister John Hutton in reply to a parliamentary question – revealed 116,000 reported incidents – a 3% increase on the previous year.

While these figures may reflect that the DH achieved its aim of encouraging nurses and other staff to report incidents, they give no indication of any success in reducing incidents.

But Richard Hampton, head of the NHS Security Management Service, argues that the quality of this data is open to question. He says that before the creation of the SMS in 2003, there was no standard definition of abuse and no robust process for collecting data on NHS attacks.

‘It is important to note there was no standard identification of what was going on. The first thing we did was to define what physical violence was, because the NHS was using something like 20 different definitions and we were not comparing like with like,’ he said.

A year later, in August 2004, Nursing Times launched its Rule Out Abuse campaign - with the support of the SMS - to highlight and tackle the continuing problem of verbal abuse against NHS staff.

Since then the NHS SMS has attempted to reduce violence by standardising security and reporting procedures within the NHS.

Mr Hampton said: ‘The responsibility rests with each individual trust. What we have now is a standard where each trust has a professionally trained dedicated security management specialist. There is also a named individual at board level who is a security management director to promote security within the trust.

‘There should be a non-executive director – as they are freed from the day-to-day financial concerns, they can challenge people,’ he added.

However, despite these efforts the latest set of results for last year suggests that a promising early reduction in incidents is not necessarily being sustained.

According to figures published in the NHS Staff Survey, the total number of reported physical assaults – not including verbal abuse – on all NHS staff was 60,385 in 2004–2005. This fell to 58,695 in 2005–2006 and to 55,709 in 2006–2007, but rose by 284 to 55,993 in 2007–2008.

However, Mr Hampton is confident that the overall decline in incidents reported since 2004–2005 suggests that the approach taken by the NHS SMS is working.

Mr Hampton points out that the service has not adopted a single initiative but has employed a raft of policies aimed at clamping down on violence.As a result of conflict resolution training many staff are now able to use de-escalation techniques and are therefore better equipped to prevent violence from breaking out.

Figures from the latest NHS Staff Survey in 2007–2008 show that 53% have received such training, with 28% having received it within the last 12 months.

‘Fundamental to the scheme is conflict resolution training. It is worth pointing out that since we launched conflict resolution training [in April 2004] up to March last year, 428,000 frontline staff have received that training,’ Mr Hampton said.

‘The approach to actual violence and aggression has to be prevention. What the training does is give staff the skills to recognise potentially violent situations. It also gives them the skills to diffuse those situations,’ he told Nursing Times.

Tough new legislation is also being introduced in line with this prevention strategy, with the Criminal Justice and Immigration Act 2008 coming into effect this year. Anyone causing actual violence could face fines of up to £1,000 and sentencing guidelines instruct judges that violence against public sector workers should lead to longer prison sentences.

Kim Sunley, RCN senior employment relations adviser, said: ‘If you look at the staff survey, you can see that there is a lot being done. But there is still a danger of under-reporting.

‘In England now we have named security management specialists in each trust and that has started to make a difference. But there is still a low level of assaults that end in prosecution,’ she said.

The introduction of lone worker alarms is also a step forward, especially for those staff who work in community settings – often seen as particularly vulnerable to attack.

As previously reported by Nursing Times, from this month, the NHS SMS will begin delivering 30,000 personal alarms to organisations across the NHS.

However, Mr Hampton has admitted that the alarms service is already oversubscribed. ‘We have had bids for more than 50,000 but we will be rolling out 30,000 this year,’ he said.

Ms Sunley said that this potential shortage of devices needed to be carefully monitored. ‘The devices that are being rolled out must be getting to the staff that need them,’ she said.

She added: ‘What I would like to see is more information sharing about dangerous clients and relatives of patients out there in the community. It comes down to good risk assessment.’

Other strategies tried by individual NHS organisations to tackle violence have included a brand-new, state-of the-art security control room at Leeds Teaching Hospitals NHS Trust – which opened in August, and the stationing of police officers in A&E departments.

In November last year the Royal Preston Hospital in Lancashire reopened its A&E department with a special space for police officers. The unit is primarily intended as a base for officers to help with patients injured in road accidents or assaults, but there is also a hope that the physical presence of police officers could help prevent assaults. A similar scheme has also been introduced at Chorley and South Ribble Hospital in Lancashire.

However, Andrea Spyropoulous, RCN council member for the North East, is cautious on such initiatives, as they can ‘create emotional barriers between nurses and their patients’.

‘While police presence may be required in some urban A&E departments at 3am on Saturday night, there presence might send the wrong message to people in healthcare environments,’ she said.

‘You must put people in a calm environment with natural light and an environment that is conducive to [care]. Appropriate use of colours can actually calm people down, it is well researched,’ she added.

Although it is unlikely that the risk of violence for NHS staff will ever completely be eradicated, there does appear to be some progress being made. However, it has taken a long time – too long.

Speaking to Nursing Times after Mr Cameron made his pledge on zero tolerance, RCN general secretary Peter Carter said:  ‘We’re really pleased Mr Cameron has committed himself to doing everything possible to eradicate violence not just to nurses but to all NHS staff

‘We will hold him to that because what we want is action not words,’ he said.

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