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Community Nurses: In need of protection

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Community nurses are often at risk from those they are trying to help. Craig Kenny asks what is being done to protect staff better.

While nurses working in mental health, learning disabilities and A&E are still those most likely to be assaulted by patients, personal safety is fast becoming a serious problem for community nurses, as emphasis shifts to delivering care in patients’ homes.

In hospitals or clinics, colleagues or even security staff are on hand to help but community nurses are on their own. They are at risk as they travel to see patients - and can be even more so when they enter these patients’ homes.

In March 2005, the then health secretary John Reid pledged that staff who work alone in the community would be given a personal attack alarm in order to summon help should they feel threatened.

Two years later, an RCN survey of 1,000 community nurses found that only 3.5% of nurses had alarms, even though 85% spent more than one-quarter of their time working alone - half of this outside what would be considered normal working hours.

More than one-third had been harassed or assaulted in the previous two years, and two-thirds agreed that personal alarms, combined with better monitoring and training, would make them feel more confident about working alone.

The Healthcare Commission’s 2007 staff survey, which questioned 46,000 nurses, found that more than one-quarter of staff did not report assaults. One in 10 of those who did said their employer did not take effective action.

In the same year, health secretary Alan Johnson reiterated his predecessor’s pledge, promising that the 30,000 frontline NHS staff most at risk of assault would be given personal attack alarms.

But nurses are still waiting. An NT survey last week found that only one in five community nurses currently has a personal attack alarm - and this does not necessarily mean a goverment-funded device.

For these, nurses may have to wait until next spring at the earliest. Richard Hampton, head of the NHS security management service (SMS), expects to have contracts for 30,000 alarms signed by April next year.

But he says that trusts should not wait.

‘If a health body has identified a need to protect their staff, they should be providing it now,’ he recommends.

The 30,000 alarms will be free to NHS employers, along with a two-year maintenance contract. Recognising that 30,000 devices may not be enough to equip all staff at risk, he says the service is negotiating ‘the best price possible’ for additional alarms trusts may wish to buy.

Some of the alarms will be the Identicom devices that have been road-tested in recent years. Disguised as identity card holders, these devices have a panic button concealed on the back. Pressing the button opens an audio link to a control centre.

The devices will account for£29m of a£97m funding allocation for improving the safety of NHS staff, with the remainder to be spent on staff training and increasing the number of prosecutions against assailants.

Eighty community midwives at Guy’s and St Thomas’ NHS Foundation Trust have had trust-funded Identicom alarms for a year.

They cost£180 each plus£13 per month per device for call-centre operation and maintenance. ‘It’s expensive but not that much for peace of mind,’ says lead community midwife Mitra Bakhtiari.

However, there is a widespread view that personal alarm technology alone will not make lone working safer.

‘The problem with alarms is that it has taken attention away from the basics,’ argues Unison’s assistant national officer Robert Baughan.

‘Personal protective equipment doesn’t stop an attack happening. Even if an alarm goes off in a control centre and the police are called, someone still has time to get hurt,’ he says.

‘With alarms, the government can say: ‘We have solved the problem, this number of staff have been issued with alarms.’ But the only real solution is reducing the risk of staff being assaulted in the first place. You should look at eliminating risk with a proper risk assessment to identify those patients likely to be a danger,’ he adds.

Indeed, at Guys’ and St Thomas’, none of the community midwives has yet had to hit the panic button on their alarms - a fact that Ms Bakhitiari attributes to good use of risk assessments and occasional police escorts.

However, risk assessments rely on crucial information being shared between agencies.

‘We have found there is a lack of information sharing,’ says RCN senior employment relations officer Kim Sunley. ‘Social services may know of a potentially violent patient, relative or carer but that information isn’t always passed on. As the number of providers is increasing, it’s going to be challenging to share data between the NHS, voluntary and private sectors.’

Case Study: Mark was lucky to escape unscathed when a client lunged at him with a six-inch knife

The Norfolk and Norwich University Hospitals Foundation NHS Trust introduced a system for its community midwives that required them to text in at regular intervals.

In one incident, a community midwife had been locked inside a house while a family demanded she answer their questions about care. ‘There was no physical threat, and she kept her head,’ says the trust’s head of midwifery, Glynis Moore.

However, the texting system is rarely used now. ‘It became very onerous,’ explains Ms Moore. ‘We now go by risk assessment, so it will be used if they are going to a child protection visit or to see a known drug user or into a block of flats that’s a bit dubious.’

Another way to reduce risk is to make sure staff do not work alone. Lucy Botting, who is setting up a nurse practitioner service for urgent care in West Sussex, says their staff always go out in pairs or with a driver. But as Mark’s case shows (p16), a colleague is not the same as a bodyguard.

And while technology can improve the safety of lone workers, it is not infallible.

‘There are so many dead areas in the UK where mobile phones don’t work, especially in rural areas,’ says Anita Ralli, policy officer for the Community District Nursing Association (CDNA). Since personal alarm systems, including the Identicom system, rely on mobile phone technology, the same limitations apply to them.

‘I have yet to meet a district nurse who has got an alarm,’ Ms Ralli says.

‘Often there’s a lone worker policy on the shelf but it’s not been implemented and followed through. So you are going
into people’s homes completely blind. We have had nurses with knives held at their throats, and threatened with pistols and even a samurai sword.

‘If someone has been discharged from hospital you are not warned if they have very dangerous pets, which can make the job very nasty,’ she adds.

One encouraging fact is that the number of assaults against NHS staff has decreased in recent years - down from 60,295 in
2004-2005 to 55,709 in 2006-2007.

However, official figures almost certainly underestimate the scale of the problem because staff often do not report attacks. The SMS plans to counter this with a November campaign to encourage reporting.

One reason for nurses’ reluctance to report attacks is that they think nothing will be done. The low rate of prosecutions against people who assault nurses suggests they may be right - in 2006-2007, fewer than 2% of all reported assaults resulted
in prosecutions.

Mr Hampton argues that the prosecution rate has improved drastically, from only 51 cases in 2002-2003 to 869 in 2006-2007.

He attributes most of this change to joint agreements on tougher measures in dealing with offenders that have been signed
with the Crown Prosecution Service and the Association of Chief Police Officers.

‘It’s not always the police or the CPS that takes a decision not to prosecute,’ he says. As many as three-quarters of assaults are in the mental health or learning disabilities sectors, he explains. The perpetrator might not be deemed responsible for their actions and sometimes the person who has been assaulted does not want to take action.

Nursing organisations agree that progress has been made but say that some employers’ attitudes still need to change.

‘I’m not convinced there’s been a downward trend in attacks on staff,’ says Mr Baughan. ‘There’s now a recognition of the problem and evidence that trusts are taking it more seriously but it’s very patchy.’

He says that ‘stark variations’ between assault rates in similar trusts can only be attributed to poor local management.

The Healthcare Commission’s staff survey seems to bear this out. While the average rate of attacks on staff at mental health and learning disabilities trusts was 21%, a few had rates around 35%, and Calderstone NHS Trust in Lancashire had 48%. By contrast, only 4% of staff at South Downs NHS Trust in Sussex reported assaults.

Ms Sunley says that employers must back up nurses who avoid unnecessary risks. ‘There’s often a lot of pressure to deliver care,’ she says.

‘But if you feel something is not going to go right in the environment, get back in your car,’ she adds. ‘You should feel supported to say to your employer that you felt at risk.’

Recent Serious Incidents      
2005 2006 2007 2008
  • Nursing student Nicola Dobson fought off an attacker who held a knife to her cheek as she walked home from Peterborough Hospital.
  • Nurse Cheryl Moss was stabbed to death while taking a cigarette break in a park behind St George’s hospital in Hornchurch, Essex.

  • A 54-year-old district nurse was bitten four times by a German shepherd dog while treating a patient at home in Clacton, Essex.

  • A district nurse in Middlesbrough, Teeside, was forced from her car one afternoon by a gang of youths armed with a screwdriver. They got into her car and drove at her as she fled.
  • A community midwife was knocked to the ground and robbed of her medical bag after checking on a newborn baby at a block of flats on the Welland Estate, Peterborough.

  • A gang of youths hurled bricks and lumps of concrete at a car driven by hospice nurse Sue marsh in Hastings.

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