Violence shouldn't happen in hospitals. But, unfortunately, sometimes it does and in recent years the level of verbal and physical abuse against hospital staff has increased. The problem of abusive patients and visitors can affect many different staff, but all too often nurses are the ones at the receiving end of aggressive and intimidating behaviour. It was this experience that led John Wells, a staff nurse in Barts ITU, and other members of the Management Nursing Team to set up a subgroup to look at the issue of violence and abuse from the perspective of nurses.

The group started out with the aim of drawing attention to the concerns and views of nursing staff and of finding out more about the measures in place and support available to them in order to feed that information back. As well as working closely with the Trust's own Risk Management Department, the group visited King's College Hospital to see how the same issues were tackled there.

Based on this work, Chief Nurse Jonathan Asbridge (now Acting Chief Executive) asked the group to use the knowledge it had acquired to develop a Procedure for Care policy for the Trust. The policy (based on the Agreement for Care policy, which had previously stalled at draft stage) was progressed to its final form in consultation with the Risk Management Department, the Trust's legal advisers and other key people both inside and outside the Trust.

The policy defines the types of conduct that are unacceptable within Trust property, including excessive noise, threatening or abusive behaviour; drug or alcohol abuse, willful damage of property, and any form of violence against patients, staff or visitors. It also sets out the sanctions that can be applied, against both visitors and adult patients.

The policy applies to all adult patients and all visitors. Abusive adult patients are first warned informally - 'a quiet word' - then, if necessary, given a more formal verbal warning. If they continue, they are given a written formal warning, known as the yellow card, one copy of which is placed in the patient's notes and another is sent to their GP Copies should also be sent to the Trust Secretary and to the Security manager.

If, after this, the patient continues to behave in an unacceptable way, a senior manager and a senior clinician can request the exclusion of the patient from the Trust - known as the red card. The 'red card' letter is sent to the patient by the Chief Executive. The exclusion will last one year; subject to alternative care arrangements being made. Excluded patients who need emergency treatment will receive it, but, once stabilised, will be transferred as quickly as possible. If admission is unavoidable, a Trust security guard will remain in attendance as required.

Visitors who abuse and intimidate staff are also subject to warnings and, if their behaviour warrants it, can be ejected from the premises.

John Wells and Jo Pope, Senior Nurse in Haemodialysis, presented the Procedure for Care policy to the Trust Board on 6 September. To ensure that it immediately reached the frontline staff most likely to need it, members of the Violence and Abuse group hand-delivered copies to wards the following day. Members of the group have also given presentations on the policy to local primary care groups. GPs in particular have been extremely interested in what the Trust has done to tackle violence, as it is a problem which affects them also.

Since its introduction, the Procedure for Care policy has already been applied on a number of occasions and both yellow and red cards have been issued against patients whose behaviour has been deemed unacceptable. In addition to applying the procedure where appropriate, the Trust will press for the maximum penalties available in law against individuals guilty of criminal behaviour.

"The most important thing about this policy is that it is not just a piece of paper filed away in a dusty drawer; it is there to give real support to staff when confronted by an abusive patient or visitor;"

said John Wells.

"I've been a nurse with the Trust for over five years and so I've seen first hand what a problem this has become and what effect it has on my colleagues. This is what made me feel so strongly that something had to be done".

"Developing the policy was a real collaborative effort with everyone in the group pooling their experiences and their views on what should be included to make it work. We also got full backing from management. The one area that is not fully covered by the policy at the moment is Paediatrics and because of the special sensitivities there that will need a separate policy. But for everywhere else we've now got what we needed - a policy that spells out very clearly for staff, patients and visitors that we are not prepared to put up with violence and abuse and that we have the right to exclude people who refuse to respect that."

Members of the Violence and Abuse Subgroup who authored the Procedure for Care policy:

• Staff Nurse, Barts, ITU (chair)
• Senior Site Manager; Barts
• Senior Sister; Anne Riches Ward, RLH
• Charge Nurse, Cambridge Ward, RLH
• Project Manager; Head and Neck
• Internal Communications Manager
• Senior Nurse, Haemodialysis