Stemming the tide of violence towards NHS staff
With the 'threat of violence a daily reality', measures are being taken by government to protect staff
With the 'threat of physical violence a daily reality', measures are being taken by government to protect staff
Violence against NHS nurses is on the rise, but cancer nurses say verbal aggression, stemming from people’s distress about treatment or diagnosis, is a bigger challenge for their specialty.
During 2015-2016, NHS Protect, which collected figures on rates of violence against NHS staff in England until its abolition last year, reported a 4% increase in physical violence against staff on the previous year.
In April this year, Unison released a report with Health Service Journal which – analysing data collected under freedom of information laws – found the trend of rising violence in England had continued in 2016-2017.
The data from the 181 organisations that responded shows 56,435 reported physical assaults on NHS staff. This compares to 51,447 attacks at the same organisations during 2015-2016.
of RCN members experienced verbal abuse from patients or relatives of patients
(Source: RCN employment survey 2017)
Furthermore, the most recent NHS staff survey reveals that more than one in eight health service employees experienced violence in the past year – the highest figure for five years.
Cancer Nursing Practice recently ran a poll of cancer nurses on Twitter to see if they recognised this national picture.
Of the 29 nurses who responded, only four said they had never experienced violence or abuse from a patient or relative when providing care.
The nurses explained that negative experiences they had with patients mostly took the form of verbal abuse and were usually due to a patient’s reaction to their diagnosis, treatment or quality of care.
The Royal Marsden NHS Foundation Trust nurse consultant Natalie Doyle explains.
Dr Doyle says that – as a specialist cancer hospital – the Marsden does not experience much violence or physical aggression towards its staff, unlike acute hospitals with emergency departments, which have seen a massive 21% increase in assaults between 2015-16 to 2016-17.
But she emphasises that people’s reactions to a cancer diagnosis may be out of character and are more likely to involve verbal aggression: 'People will cry and sometimes get angry if they feel responsible or they want someone to blame,’ she explains.
‘Or there may be a situation where someone has been misdiagnosed, or had to wait a long time to get a diagnosis and they may be very distressed and blame the NHS or their GP.’
De-esculation technique training
Crucially, Dr Doyle says staff need to be skilled in de-escalation techniques to ensure they don’t inflame situations where patients or their families are very distressed and emotional.
‘Excellent communication skills are needed to manage that distress and if you are junior, you may never have seen that type of situation before.
‘It is important there are people around to help more junior nurses manage that kind of situation.
‘Role modelling is important – giving bad news is an opportunity for a more junior nurse to sit in and watch what other people do and learn from them.’
Dr Doyle says clinical supervision, Schwartz rounds, team debriefs, access to counselling and mentors are all key in supporting staff, but she worries that budget cuts at some organisations may affect nurses’ access to such opportunities.
‘Newly qualified nurses may find it harder to access clinical supervision because of working 12-hour shifts, but taking opportunities for support is important.’
She suggests that nurses should enquire about what opportunities for support are available at their workplaces and also ask someone more senior if they could act as a mentor, whether in a formal or informal way.
physical assaults on NHS staff each and every day
(Source: NHS Protect 2015-16)
Dr Doyle also believes that 'observing and absorbing' human distress on a daily basis can take its toll on cancer nurses and mentions The Language of Kindness: A Nurse’s Story, the latest book by Christie Watson as being her own personal catalyst for understanding this.
The book takes the reader through the author’s 20-year career working as a nurse in London’s hospitals.
‘I have nursed for 35 years and after reading this I cried like I have not cried in years,’ says Dr Doyle. ‘It made me think about how much I had seen and had to absorb over the years.’
Dr Doyle adds that self-care is important to help counter the accumulative effects of working with distress from people affected by cancer.
Bart’s Health NHS Trust Macmillan director of nursing for cancer and palliative care Barry Quinn agrees, acknowledging there can be a risk of burn-out for some.
‘The emotional burden of working with cancer can be really difficult and our specialist nurses are all given the opportunity to undertake clinical supervision.’
But Dr Quinn also cautions that similar emotional burden is shared with nurses in other fields of practice.
‘Nurses who work in the emergency department (ED) see stabbings on a regular basis and young people dying.
‘Whether it is a death in the ED or in the hospice, how can we support one another by recognising as a nursing workforce we are all dealing with this?’
Dr Quinn says that sometimes families of people with cancer may have an unrealistic view of the kind of community resources there might be available, and disappointment at a perceived lack of support can lead to verbal upset.
He suggests that junior recruits coming into cancer nursing need good preceptorships and induction programmes which develop and support them to navigate tricky situations, and he strongly advocates mentoring for all grades of nurse.
‘Throughout my own career, I have always had supervision and currently I take part in peer mentoring.
‘Often mentoring can be just paid lip service by organisations, but they need to provide resources for people to leave the clinical environment and support and encourage it.’
NHS Employers chief executive Danny Mortimer says people often use the NHS at 'the most vulnerable and distressing moments in their lives'.
He adds that clinical conditions or the discovery of life-altering diagnoses can affect patient behaviour.
‘We must do all we can to support staff and their patients to deal with these situations.’
Last month, health and social care secretary Matt Hancock announced that the NHS will adopt a ‘zero tolerance’ approach to violence against its staff and prosecute offenders quickly.
NHS violence reduction strategy
He unveiled the first NHS violence reduction strategy, with a series of measures to protect NHS workers in England, including better training to deal with a violent situation, prompt mental health support for staff who experience violence and a new system to enable staff to record assaults, abuse or harassment.
The strategy will enable the health service, police and Crown Prosecution Service to work together to ensure that people are supported to give evidence to achieve swifter prosecutions.
The new maximum prison sentence for anyone who assaults a nurse or emergency worker under new laws
(Source: Ministry of Justice, September 2018)
RCN national officer Kim Sunley said: ‘Nurses and healthcare workers understand their roles aren’t risk-free but, to many, it still seems as if the threat of physical violence is a daily reality.
‘These measures will increase the accountability of employers for the safety of their staff and ensure that those who wilfully assault healthcare workers feel the full force of the law.’
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Case study: 'They are frightened for the person they love'
Last year in the House of Commons, Scottish National Party MP and consultant surgeon Philippa Whitford gave her own insight of being on the receiving end of aggression in the NHS in a breast cancer clinic.
Dr Whitford argued that NHS staff need enough time to deal properly with such situations.
‘I was warned by the nurses before I went into the room that the husband was angry, not at anything I had done, but at something on the way that had upset him.
‘That is often the situation. It is not necessarily someone who would normally be violent or worked up.
‘They are frightened for the person they love. That can be in the emergency department, where they have been sitting for hours and people are going past them, or it can be in the situation I had.
Dr Whitford said the challenge of de-escalating such situations was ‘enormous’ and required training, support, back-up and time.
'More than anything else, it requires time, so that when we spot something emerging, we can put the time into that person to explain their situation and what will happen next and to look at what they are worried about.
‘If everyone is rushing to someone who is more ill, that situation will spiral out of control.’