Managing Health at Work Partnership Information Network (PIN) Guideline

This Guideline emphasises the need for employers to promote and support employee health and wellbeing and includes sections on issues that affect the health and safety of staff in their everyday work.


Guideline 6 Protecting against violence and aggression at work
6.1 Introduction

This guideline reflects the view that violence and aggression towards NHS staff is unacceptable. Staff have the right to expect a safe and secure workplace, and NHS organisations have a legal and ethical duty to do their utmost to prevent staff from being assaulted or abused in the course of their work. NHSScotland is committed to promoting a safe and healthy workplace culture, and NHS organisations should take a positive approach towards tackling the problem of violence at work.

Work-related violence has been defined as:

'Any incident in which a person working in the healthcare sector is verbally abused, threatened or assaulted by a patient or member of the public in circumstances relating to his or her employment.' (Health and Safety Executive 1997)

This definition reflects the fact that violence is not restricted to acts of aggression which result in physical harm. It also includes behaviour, such as gestures or language, that may cause staff to feel afraid, threatened or abused.

6.2 Principles and values

Within NHSScotland there must be a consistent organisational approach towards tackling the problem of violence at work. The following principles and values should form the backbone of developing strategies and policies for tackling the problem at a local level.

  • Organisations should develop and promote a culture in which the personal safety of all staff is valued and protected and where violence towards staff is seen as unacceptable.

  • Senior managers within organisations should show their commitment to reducing violence, make available the resources for putting policies into practice and make sure that it is clear who is responsible for each function.

  • All staff should expect that any risk to them or their colleagues will be reduced as far as possible by using effective risk-management systems.

  • Staff and their representatives should be fully involved in developing and putting in place local strategies and policies to reduce the problem of violence at work.

  • Effective support systems should be in place to support staff who do become victims of violence.

6.3 The scale of the problem and why we need action

Violence at work is a serious problem for all people whose work brings them into contact with members of the public. A report by the Health and Safety Executive (1997) on 'Self-Reported Work-Related Illness' showed that one in five workers (20%) were physically or verbally attacked by a member of the public while at work in the previous year.

It is difficult to get hold of accurate figures on the incidence of violence in health settings. This problem is made worse by:

  • differing definitions of what constitutes violence and aggression;

  • wide variations in reporting and data-collection methods; and

  • reluctance on the part of many NHS staff to report incidents.

There has been mounting evidence over the last ten years of a significant increase in violence within healthcare settings. Examples of such evidence include the following:

  • A study by the Industrial Relations Society (1998) showed that, overall, NHS staff are four times more likely to be victims of work-related violence than other workers. The study reported that almost one in ten staff had been physically assaulted at work in the previous year. Of these, 5% were attacked with a weapon and 10% of attacks had resulted in major injury.

  • Violence is now the third most common cause of injuries at work in the health service, after falls and needlestick injuries.

  • A survey by the NHS Executive (1998) found that, on average, seven violent incidents were recorded each month for every 1000 staff. This is equivalent to about 65,000 violent incidents against NHS staff each year.

  • The position appears to be more serious in community and mental-health Trusts where one in three staff reported having been attacked in the previous year, and 20% of victims suffered a major injury.

  • Violence against healthcare workers can come from many sources including patients, visitors, family members, intruders, and co-workers.

  • A broad range of health service staff are felt to be at risk. As a general guide, the risk of assault is felt to be directly related to the degree of face-to-face interaction between staff and the general public.

  • Nurses are felt to be particularly at risk, with incidents of attacks on nurses from members of the public reported by the Health and Safety Executive (1997) to be five times the national average. A survey by the RCN (1998) found that 50% of nurses had been physically attacked at work in the previous year, while 85% reported having been verbally abused.

Some researchers have suggested that the increase in assault rates within the health service reflects the overall increase in violence in society. What is clear is that healthcare workers are now common targets of violent behaviour and healthcare settings in general are becoming more violent places in which to work. The problem appears throughout hospitals and other environments where healthcare is delivered. It affects a wide range of healthcare workers and is a major occupational danger.

Violence to healthcare staff is believed to be related to the nature of the work as it involves contact with a wide range of people in often difficult circumstances. Patients and their relatives may be anxious and worried. Some patients may be predisposed towards violence.

Factors which may increase the risk of violence include:

  • working alone;

  • working after normal hours;

  • working and travelling in the community;

  • handling valuables or medication;

  • providing or withholding a service;

  • using authority;

  • working with people who are emotionally or mentally unstable;

  • working with people who are under the influence of alcohol or drugs; and

  • working with people under stress.
    (Health and Safety Advisory Committee, 1997)

The cost (physical and mental) of violence against staff can be great. As well as the immediate physical effects of an assault, staff can experience psychological distress and confidence levels can be permanently damaged. Stress levels can rise, and the effects can undermine staff's overall effectiveness. The financial costs to the NHS resulting from violence at work can also be considerable and include:

  • sick pay if the staff member has to take time off work;

  • the extra costs of temporary or replacement staff;

  • fees for taking legal action;

  • treatment costs, including providing counselling and ongoing support for staff;

  • loss of experience and the cost of training if the member of staff leaves the service; and

  • the effect of negative publicity on morale, productivity and corporate image.

6.4 The legislative framework

The legislative framework within the UK obliges all employers to protect their employees from violence at work. The following legislation is relevant to incidents associated with violence at work.

  • Health and Safety at Work Act (1974);

  • Management of Health and Safety at Work Regulations (1999); and

  • Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) (1995).

Within this legislative framework all NHSScotland organisations have a duty to assess the risks associated with violence and must put in place measures to eliminate or reduce identified risks and protect staff from violence at work.

Control measures may include instruction, training, protective equipment, supervision and emergency procedures. NHSScotland organisations must take steps to check that control measures are actually in place and should review the risk assessment regularly to make sure that the control measures are adequate.

6.5 Recommended approach

6.5.1 Developing policy

Measures for dealing with violence need to be based on careful preparation and sound risk assessment. Unless the risk of violence is taken seriously at all levels within the organisation and the policy, management arrangements and culture are supportive, it is unlikely the problem will be reduced.

NHSScotland organisations can gain the confidence of their staff and show support and commitment to staff safety by developing local policies to tackle the problem of violence at work. Organisations should use the basic principles of partnership when developing and putting into practice strategies and policies. Staff and Trade Unions/Professional Organisations must be involved in developing local policies. Not only do they have an interest, their direct involvement will encourage their support.

Local policies should tackle a range of issues and should include:

  • a commitment to protect staff at work;

  • a definition of violence;

  • a statement of the aims of the policy;

  • details of employers' legal responsibilities;

  • details of managers' responsibilities;

  • details of staff's responsibilities;

  • information on risk assessment;

  • details of local prevention and reduction plans;

  • details of local emergency procedures;

  • details of staff training;

  • an explanation of local reporting procedures;

  • information on support after incidents of violence;

  • details on police involvement and organisational support for pursuing criminal charges;

  • information on support for legal help or compensation claims for injury; and

  • details of arrangements for monitoring and reviewing how policies are put into practice.

Policies must be translated into effective action. They should be supported by detailed procedures, by effective organisation and by a positive health and safety culture. More targeted policies may be required to tackle specific areas of risk, for example in relation to:

  • lone and isolated working;

  • escorting and transferring patients;

  • staff working outwith normal office hours;

  • staff travelling on their employer's business; and

  • staff working in high-risk clinical areas.

To further demonstrate commitment to staff safety, NHSScotland organisations should give staff regular updates and progress reports. This will help reassure staff that positive actions are being taken to address the problem of violence at work.

6.5.2 Staff competence and training

Staff working in NHSScotland should know that their safety comes first. They should not be placed in situations that make them feel unsafe. However, if they are, they need to know how to deal with these situations in a competent way. As a result, appropriate staff training is crucial.

The training of staff is a complicated issue, not least because different staff groups and grades of staff face different degrees of risk. However, it is possible to identify the risks and provide training of graded intensity (in terms of content and length) to suit the needs of different groups.

NHSScotland organisations should assess the risks to staff and analyse their training needs. Assessing risks will make it possible to measure the nature and type of training which staff need and which will equip them for their roles. It is important to make sure that the training is appropriate to the degree of risk the staff face.

In general, training programmes should cover:

  • theory (understanding aggression and violence in the workplace);

  • prevention (assessing danger and taking precautions); and

  • interventions (verbal and non-verbal strategies for dealing with aggressive people).

Training should be:

  • up-to-date;

  • relevant, and backed by evidence;

  • provided by people with relevant expertise; and

  • regularly reviewed and evaluated.

Staff training should not be seen as a 'one-off' exercise. The skills being taught are complicated and may involve psychological and physical techniques. Employers should therefore consider the need for updating and refreshing staff, and a time-limited certificate is recommended as a way of making sure their skills are up-to-date.

One of the main focuses of training should be preventative strategies. Training interventions might also be extended to incorporate programmes on customer care, assertiveness, and developing interpersonal skills. It is essential that training gives staff the ability to deal with the problems they might come across in the course of their work and makes sure that they develop the specific skills needed for their role.

Appropriate training and specialist support for managers on development of local procedures should also be provided (for example, training sessions on assessing risk and managing the difficulties experienced with regard to their local work areas).

The 'Good Practice Statement on the Prevention and Management of Violence' produced by CRAG (1996) provides detailed guidance on the recommended content of training programmes for staff facing different levels of risk.

Suggestions for a possible training programme are provided below.

  • Definitions, theories and models of aggression and violence.

  • Examples of aggression in healthcare settings.

  • Self-awareness - tolerance and responses to aggression.

  • Risk factors - relating to the attacker, staff, environment, and task.

  • Risk assessment - including warning signs.

  • Do's and don'ts of verbal and non-verbal interactions (theory and practice).

  • General and specific safety precautions.

  • Demonstration and practice of breakaway and physical-restraint techniques.

  • Local policies and procedures.

  • Reporting and debriefing after incidents.

  • Legal issues - using reasonable force.

  • Dealing with weapons.

6.5.3 Environmental considerations

The environment in which staff work, patients are treated and other members of the public visit can have a significant influence on behaviour. The environment and associated work practices can trigger or make worse a stressful situation and increase the risk of violence. Danger can be inadvertently built into the environment or work practices, for example by:

  • making it difficult for people to use services or facilities;

  • alienating people with a 'them and us' set-up, or restrictive notices;

  • exposing people to noise, crowding, boredom or discomfort; or

  • providing access to objects or equipment that could be used as weapons.

The aim should be to have an environment and work practices that create an atmosphere which is safe but not oppressive and which reduces the risk of violence as far as possible. Organisations need to assess the environment and work practices to see whether the layout, d├ęcor, or general routines could actually increase the risk of violence.

Factors to consider include cleanliness, light, temperature, space, control of access, signs, privacy, toilets and smoking areas. Areas that may need particular attention include reception and waiting areas, and interview rooms.

Modifications to the work environment that can help reduce the risks include:

  • redesigning buildings or the layout of rooms;

  • moving activities such as reception or treatment areas in order to make them more secure;

  • installing door-entry systems;

  • improving lighting (inside and outside);

  • installing alarms and panic buttons;

  • fixed seating and fittings;

  • improved facilities (for example, access to snacks, smoking areas, phones, recreational materials, private space);

  • improved signs; and

  • installing CCTV.

As well as changing the environment staff may need personal protective equipment, mobile phones or personal attack alarms, if a risk assessment has shown this to be appropriate.

6.5.4 Staff support

Given the nature of its work activities, the NHS is unlikely to be able to prevent all violent and aggressive incidents. So, it is essential that all NHSScotland organisations have appropriate procedures to support affected staff in case of a violent incident occurring at work. NHS managers need to be aware that they are responsible for making sure that adequate levels of support are in place to help reduce the effects experienced by staff who have been involved in an incident.

Arrangements for supporting staff should include procedures for:

  • rapid access to medical treatment if necessary;

  • time off work to recover from the physical or psychological effects of an incident;

  • debriefing to get details of the incident and provide emotional support;

  • access to qualified psychological support such as that which may be available through occupational health departments, in-house or independent counsellors;

  • support from management when dealing with the police and with any subsequent court proceedings; and

  • providing information, support and practical help in making compensation claims through the Criminal Injuries Authority (CICA) or the NHS Injury Benefit scheme.

6.5.5 Withholding treatment

In some cases the threat of violence and intimidation from patients and visitors may be so serious that it becomes necessary to withhold treatment and bar visitors. The withholding of treatment from violent and abusive patients will always be a last resort, but it should be an option made clearly available to staff. It is also important that patients and those accompanying them are fully aware of the standards of conduct expected of them and of the sanctions that may follow unacceptable behaviour.

The need to protect staff must be properly balanced against the need to provide healthcare to individuals. If a decision is made to withhold treatment, it must be made in the context of a defensible local policy and procedure applied to the facts of the individual case. In developing a policy on withholding treatment, NHS organisations should:

  • seek the views of staff, their representatives and patient representatives on the introduction of the local policy;

  • consider arrangements for notifying other local NHS service providers and as a matter of good practice other agencies of patients who may be subject to the effect of the withholding of NHS treatment; and

  • clearly define behaviours which are unacceptable, the sanctions available to staff when faced with such behaviours and the point at which such sanctions will be triggered. Local policies must recognise that withholding treatment will only be appropriate where violent or abusive behaviour is likely to:

  • prejudice any benefit the patient might receive from the care or treatment; or

  • prejudice the safety of those involved in giving the care or treatment; or

  • lead the member of staff offering care to believe that s/he is no longer able to undertake his or her duties properly. This might include incidents of racial or sexual abuse; or

  • result in damage to property inflicted by the patient or as a result of containing him/her; or

  • prejudice the safety of other patients present at the time. All local policies on withholding treatment should, as a minimum:

  • state that each case will be looked at individually to ensure that the need to protect staff is properly balanced against the need to provide healthcare to individuals;

  • describe the action staff should take in response to less serious or "one-off" incidents; for example, alerting hospital security or informing the police;

  • include an explanation of the sanctions which will apply to violent or abusive patients. These should include the following:

    • a verbal explanation by a staff member of what is unacceptable behaviour and the possible consequences of any further repetition of unacceptable behaviour. A copy of the policy and/or explanatory leaflet with information on withholding treatment could be given at this stage;

    • a formal written warning with details of organisational policy and procedures on withholding treatment to be sent by a manager, Clinical Director or senior nurse and copied to the patient's GP;

    • as a last resort, a final written explanation of exclusion from the premises and the withholding of treatment. This letter, which should be sent by the Chief Executive, should notify the patient of the period of the ban and be copied to the patient's GP; and

    • under exceptional circumstances, the immediate withholding of treatment.

  • state that a decision to withhold treatment must be based on a proper clinical assessment and the advice of the patient's consultant or senior member of the medical team (on-call team for out-of-hours);

  • make clear that withholding treatment is time-limited for a period of no more than 12 months;

  • make clear the links to other relevant procedures and organisational policies, for example, consent procedures and clinical procedures for handling patients with learning disabilities and/or patients with mental health problems, such as the need for a secure area for treatment. Neither this guidance nor individual policies are intended to take the place of the legal requirement relating to consent;

  • set out clear lines of accountability on instigating the withholding of treatment. A senior clinician should provide advice, following a clinical assessment, to the Chief Executive or his or her deputy to issue a formal letter withholding treatment;

  • include details of the mechanism for seeking a review of a decision to withhold treatment; for example via local patient complaints procedures;

  • include details of the procedure to be followed where treatment is withheld from a patient who is also on a waiting list for non-emergency treatment; and

  • make clear that treatment will not be withheld from a patient as a result of the behaviour of a person accompanying or visiting a patient. The following action should be taken after the decision has been reached to withhold treatment from a violent or abusive patient.

  • The decision should be recorded in the patient's medical and nursing notes and the patient must be informed of this. Data Protection law must be complied with.

  • Where appropriate, other local NHS service providers and, as a matter of good practice, other agencies should be informed of the decision to withhold treatment from the patient. There will be circumstances where it will not be appropriate to apply policies on withholding treatment. All local policies and procedures should provide for exceptions in the following cases:

  • patients who, in the expert judgement of a relevant clinician, are not competent to take responsibility for their action, for example an individual who becomes violent and aggressive as a result of an illness or injury;

  • patients who are mentally ill and/or may be under the influence of drugs or alcohol;

  • patients who, in the expert judgement of a relevant clinician require urgent emergency treatment; and

  • other than in exceptional circumstances, any patient under the age of 16. Copies of local policies and procedures for withholding treatment should be made available to all managers and staff. Managers should also ensure that patients, relatives and other visitors are made aware of organsiational policies and procedures, copies of which should be displayed in waiting rooms and other public areas. NHSScotland organisations must make sure that where they do provide treatment or care to violent and aggressive patients, staff are aware of local procedures for doing so. These might include the use of medication, physical intervention or a requirement for organisational security staff to be present and/or the involvement of the police.

6.6 Putting the policy into practice and reviewing it

6.6.1 Recording and collecting data

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) place a duty on employers to record and report violent assaults against their staff. However, there is evidence that the problem of under-reporting runs throughout the health service.

'Towards a Safer Healthier Workplace' (Occupational Health & Safety Services, 1999) states that all NHS organisations

'must encourage, facilitate and require staff to record all accidents and incidents which lead to injury, with the aim of a 100% recording of accidents and incidents to staff, patient and visitors to NHS in Scotland premises'.

So, it is essential that all NHSScotland organisations take a positive approach in encouraging staff to report all incidents and near misses in relation to violence and aggression at work.

All NHSScotland organisations should set up robust and clear reporting procedures that are easy to use and do not take too much time. Improved reporting may lead to an initial increase (in the short term) in the number of incidents but it should be recognised that low incident rates do not always mean that good practice is being followed.

All NHSScotland organisations must also keep to the Minimum Dataset on reporting. Under this dataset, each year organisations must publish the number and rate of RIDDOR-reported incidences of violence and aggression by occupational group. It should cover all staff directly employed by the organisation and also those not directly employed such as contractors, self-employed, or students.

Reporting systems should also include appropriate ways of providing feedback. This will mean that staff know what action the organisation has taken to prevent a reported incident happening again in the future.

6.6.2 Monitoring

There must be effective monitoring in place to help control violence and aggression. Furthermore, there must be support and commitment from senior management and very clear local management responsibilities. The policy on violence and aggression should include a timescale and way of carrying out an annual review by the Local Partnership Forum and local Health and Safety Committee. There should also be the opportunity for other reviews if this is necessary. All NHSScotland organisations should

  • identify local quality indicators to reduce violent or aggressive incidents as a matter of good practice; and

  • analyse information on reported incidents and use the results as the basis for future reductions in the number of aggressive and violent incidents towards staff.

6.6.3 Communication

All NHSScotland organisations must make sure that they set clear systems to tell all staff and others working within the organisation (such as agency staff, students, volunteers, or independent contractors) about the organisation's policy on violence and aggression.

In order to communicate the organisational policy on violence and aggression:

  • there needs to be clear commitment and support from senior managers for the policy to be fully adopted within the organisation;

  • briefing sessions should be held for managers when the new or amended policy is launched;

  • managers must make sure that current staff realise their individual responsibility to keep to the policy; and

  • new staff must be made aware of the policy and their responsibilities as part of their induction.

Details of the policy, or particular sections of the policy, could also be publicised throughout the organisation by using a range of communication channels. These could include:

  • a letter from the Chief Executive;

  • a poster campaign;

  • booklets and wallet cards;

  • regular staff newsletters;

  • regular team briefings;

  • attachments to payslips;

  • policy manuals;

  • focus groups;

  • training and induction;

  • management seminars; and

  • e-mail (for example, an open network notice board).

NHSScotland organisations should also consider how to pass on their stance on violence towards staff to users of the service. Using 'zero tolerance' posters is one option. One example of a 'zero tolerance' poster campaign is:

'We will not tolerate violence, physical aggression or verbal abuse towards our staff. If this happens, we will take legal action.'
(Tameside & Glossop NHS Trust)

NHSScotland organisations should recognise that staff morale and confidence can be improved if staff see that their employers and other agencies are genuinely committed to prosecuting cases of assault. NHSScotland organisations should therefore publicly commit themselves to taking legal action against all those who assault a NHS staff member.

6.7 Measuring success

Real change takes time to achieve. However, NHSScotland organisations can effect change on an ongoing basis and should measure this change each year. Measures to see if an organisation is successful in preventing and managing violence towards its staff include:

  • a Managing Violence and Aggression policy based on a full risk assessment, reviewed each year within the Local or Area Partnership Forums and Health and Safety Committees;

  • appropriate and thorough training programmes for all staff based on local risk assessment and including refresher training;

  • staff counselling and support systems for staff who have been the victims of aggression while at work; and

  • robust and effective reporting systems that encourage staff to record all incidents of violence and aggression.

In summary, all NHSScotland organisations must be able to show that everything practical is being done to eliminate or reduce, as far as possible, violence and aggression towards NHSScotland staff. The major measure of success will be a reduction of at least 25% in the number of injuries, accidents and incidents resulting from violence and aggression by 2006 as compared to a base of 2000/01. This will be achieved by using best practice and a combination of training, increased awareness and improved audit in line with the requirements laid down in 'Towards A Safer Healthier Workplace'.

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