Violence Against Nurses - what is the prognosis?

Abstract: the term violence is defined and  the causes of violent behaviour  described. An overview is given of how violence is experienced and how nurses could react. 13 references.

Contents.
  Violence at work.
What has changed for our profession?
Introduction.
What is meant by the term violence.
The RCN definition.
Who is carrying out violence and why?
Reactions to violence.
Conclusion.
References.

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The facts seem unbelievable. One in three nurses have been a victim of violence at work, compared to one in four police officers. (1)  Two months ago, a colleague and I were "assaulted" by a patient who, holding an open vial of his own blood, threatened to throw it in our faces if we approached him. The patient was being discharged and this was against his wishes. The doctor who had been treating him for an opiate overdose had left a full vial of venous blood in the patients cubicle. The patient was extremely angry and it was not an idle threat. He lashed out at my colleague, slapping him across the face.

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What has changed for our profession?

Do these situations sound familiar? - if so, that is because they are all true. Most nurses can recall a violent or potentially violent incident happening to or near to them. Frighteningly, the Health and Safety Executive  declared that nursing is now officially the most dangerous profession in Britain when it comes to dealing with the public. (1) Research carried out by the Health and Safety Executive (HSE last year revealed that 34% of nurses have been attacked whilst at work. This figure is higher than that for police officers, security staff, teachers and social workers.

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It appears that levels of violence (and aggression) aimed at nursing staff have become unacceptable. The possible reasons for this will be discussed later in this article. This increase in violence could be described as a recent phenomenon; traditionally only nurses who worked in mental health and Accident and Emergency departments could expect to be exposed to violence.  Wright cites June Andrews, Secretary for the Scottish Board of the RCN who suggests that "the nurses uniform doesn't mean anything any more". (2) By becoming more informal and approachable, have we as profession developed into "soft targets"? Alternatively, is it the patients and their families and friends that have changed? The NHS itself is very different today, with closed hospitals, fewer beds, and the seemly ever increasing waiting lists. Patients are frustrated by long waits, lack of facilities, poor staffing levels and their frustration turns to aggression against the very people that are their to help them.

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What is meant by the term violence?

Physical Assault- an assault with or without a weapon which results in actual physical harm e.g. bruising or lacerations. This includes sexual assaults.

Physical Abuse - an attempted assault that did not result in actual harm.

Threats - verbal or written threats that suggest harm to a person or property. This category includes sexual harassment.

Damage to Property- belonging to a person or organisation. (3)

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The RCN (1994) defines violence as:

"Any incident in which an NHS worker experiences abuse, threat, fear or the application of force by a member of the public arising out of the course of their work whether or not they are on duty". (4) This is an important point. The threat of or fear of violence can be just as damaging as the violent act itself. Additionally, if a nurse is targeted when off duty by someone who knows that she/he is a nurse, then this too is very disturbing. By way of illustration, this year, a nurse from The Trust, leaving work at the end of a shift, was followed out of the building and onto the street by an abusive and threatening relative. A very frightening experience.

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Who is carrying out the violence and Why?

Apart from obvious indicatiors such as alcohol or drug intoxication, it is not always easy to predict all of the likelihood of violence. However, McDonnell et al  suggest "most violent incidents usually have several predictable antecedents".(5) These may include high levels of arousal - e.g. frustration, anger, and some form of verbal confrontation.

"I was greeted by a very large and irate husband who pushed me against the wall and accused me of not doing enough to help his family" Philips et al. (6)

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Through images in the media, current affair programs and even soap operas, the public is much more aware of what happens in hospitals than ever before. The publication of the Patients Charter told the patients their "rights". If these expectations and rights are not upheld, people may feel angry and frustrated, which is then directed at the establishment - i.e. the nursing staff. This is certainly true in my experience, violence rarely seems to erupt unpredictably, there often appears to be a "build up". If the patients (or relatives) frustration is not handled skillfully by staff then aggression and violence may occur.

• Alcohol intoxication or drug abuse. The Health Services Advisory Committee Survey 1987 reported that in 83% of violent incidents against NHS staff the offenders were intoxicated.(7)
• Pain/being touched without consent or receiving treatment
• Hallucinations or thought disorders
• Verbal abuse/threatening behaviour
• Speaking very loudly and /or sudden silence
• Agitation/hyperactivity

Known violent behaviour/criminal behaviour - this has traditionally been problematic for Accident and Emergency nurses and Mental Health nurses. Wright  suggests that "criminal groups see hospitals as a soft target.(2) There are drugs and money available".

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Reactions to Violence

1. Staff Safety.
2. Staff attitudes/Training.
3. Police involvement.
4. Legislation/national awareness.

1. Staff Safety - this is paramount. Employers have a legal duty to provide a safe area to work for their employees. Violence has implications for both the individual and the Trust. Violence may be costly in  both terms of securitysystems and time off work through sickness absence. Obviously there cart be no guarantees that staff will never be faced with violence, however managers should take action to protect their staff.(8) In the Royal Hospitals NHS Trust the Security service has close circuit cameras placed strategically throughout the Trust which are watched by security staff.

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2. Staff attitudes/training - Leiba  states that whilst it would be impossible to eradicate all violence or aggression, staff do need to know how to handle aggression effectively.(9) It is vital that nurses learn to recognise warning signs of aggression and how to deal with the situation. It is all too easy to "take it personally" and become angry when faced with aggression. This will only escalate a situation. It is essential to try to stay calm and let the person "get it off their chest", especially if they are frustrated/in pain etc. However, if someone is then not able to calm down, it is advisable that the nurse backs off and avoids a. confrontation. Training for dealing with confrontation and violence should be on offer for all nursing staff. (4) In addition to techniques for the prevention of and handling of violence, the training should also include the examination of staff coping mechanisms and reactions to stressful situations. In the Trust, the risk management department offers training for the handing violence and aggression. Some clinical groups e.g. Surgery, have also tailored training programmes to meet their own needs.

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3. Police involvement/Criminal Prosecution; as mentioned earlier, it is vital that the police are called to a violent incident and that accurate documentation from the victim and any witnesses is completed. If legal proceedings are to be followed in the future, it is essential that the facts are clearly recorded. It should be remembered that reporting the incident to the police might not always result in a prosecution. The person may be removed from the premises and cautioned. In the Accident and Emergency department, we will always call the police to a violent attack. In 1997, a man assaulted a nurse, rupturing a tendon in the nurses' finger. He was successfully prosecuted, resulting in a jail sentence. The judge at the hearing was appalled to hear of the level of abuse suffered by a nurse from a patient. Involvement in a legal proceeding can be however a very daunting prospect -adding to the upset and anxiety caused by the incident itself. Staff will need sensitive support from their colleagues and managers during this period.

Some Heath Care Trusts have erected signs stating "the Trust will not tolerate violence against its staff. If you become verbally or physically threatening, then legal action may result". The complaints and litigation department in the Trust is unable to offer financial support for civil prosecutions. This is because the department only has a budget for pursuing personal injury claims and medical negligence cases. The Nursing Times quoted Sue Parker, head of nursing services at the Medical Defence Union  who argued that nurses should have the right to refuse to treat dangerous and abusive patients.(10) Obviously this would need very careful consideration from the Trust Board, the legal department and the clinicians themselves This is a huge subject with many moral, professional and ethical questions, which are pertinent for the NHS in the 1990's but are beyond the scope of this article.

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4. Legislation and National Awareness; much has been made of violence against nurses and health care staff by the Health Secretary, Frank Dobson. The department of Health is working with the Health and Safety Commission and the Royal College of Nursing, looking at plans to counteract the growing levels of violence against NHS staff. Stop press! An RCN guide for nurses entitled "Dealing With Violence Against Nursing Staff" has just become available from the RCN. (11)

Nationally the problem has been recognised in both nursing and medical journals and by the media. The British Medical Association (BMA) in 1997 suggested a two pronged attack against violence by increased training for all staff and increased staffing levels.(12) Obviously both of these suggestions have massive financial implications for a financially beleaguered NHS.

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Conclusion

Nursing is now officially the most dangerous profession. It is seen by some as "inevitable". Managers must be aware of the threat that violence holds for the profession. Low morale and high sickness rates are two of the more obvious effects. Every year 30,000 nurses leave the profession. (13) This is not solely caused by the rise in violence and aggression, but these factors cannot help recruitment problems.

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References

1.  The Independent on Sunday. Health & Safety Executive Report into violence against staff who work in the public sector. 7 December 1997.

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