Escalation of youth violence piles pressure on care providers
The epidemic of violence among young people is placing new demands on healthcare staff beyond the clinical
The epidemic of violence among young people brings new demands on healthcare staff beyond the clinical
- Emergency departments not already seeing young people with stab or gunshot wounds warned to prepare for them
- Less specialist, less resourced district general hospitals may need to learn lessons
- Worrying effect on staff having to deal with young, dying patients and distraught relatives
Treating young people with stab or gunshot wounds has become the new normal in some of the country’s major trauma centres, so much so that, in these large and specialist hospitals, staff are as equipped as they can be to deal with patients who have received the most severe violence-related trauma.
But, as the horrifying epidemic of youth violence continues to spread across the country, should less specialist, less resourced district general hospitals be learning lessons?
Senior nurses say managing the aftermath of youth violence has many considerations beyond the obvious clinical aspects.
Gunshot wounds and stabbings
At Queen Elizabeth Hospital Birmingham, part of University Hospitals Birmingham NHS Foundation Trust, emergency department (ED) matron David Hornsby says his staff are witnessing an increase in youth violence in the 16-24 age group.
‘There are no easy solutions and the problem is not going away; it’s only getting worse’
David Hornsby, emergency department matron
‘We are seeing three gunshot wounds a month, up from about one a month last year, and about one stabbing a day. There are no easy solutions and the problem is not going away; it’s only getting worse.
‘If EDs aren’t already seeing this type of patient then they need to start readying themselves, because I feel it is inevitable.
‘As a major trauma centre (MTC), we are always ready to receive major trauma, but district general hospitals may not be geared up for that.’
knife crimes in England and Wales (excluding Greater Manchester) in the year to last September, against 23,945 in the year to March 2014
Source: Home Office
Young male fatalities
Data analysis by the Office for National Statistics supports what Mr Hornsby says.
Its figures show that the number of fatal stabbings in England and Wales last year was the highest since records began in 1946, with 285 deaths by a knife or sharp instrument. Those stabbed to death were predominantly young men in the 18-24 age group.
Despite its size, London is not the worst place in the UK for this sort of crime. London’s Islington and Newham boroughs feature in the top ten worst places for killings, but the top spot is taken by Inverclyde, west of Glasgow. The list also includes Rochdale, Manchester and Boston in Lincolnshire.
Feelings of isolation
Mr Hornsby says staff need to receive training and information to understand the circumstances that these young people are coming from and the isolation they often feel.
‘If emergency departments aren’t already seeing this type of patient then they need to start readying themselves, because it is inevitable’
David Hornsby, emergency department matron
‘These kids feel they are in a war zone. They don’t feel like part of society,’ he says. ‘They feel they are battling and fighting every day, and they come in scared, feeling they are about to die.’
He says nursing managers need to be security ready.
‘Other gang members turning up in the ED is relatively common,’ he explains.
‘Sometimes we are successful in talking to them and de-escalating situations, but others come in expecting trouble and a fight, full of adrenaline and all keyed up.’
Increasing the stress
In these cases, he says, security and police sometimes need to be involved because it is impossible to lock the ED down.
‘It all adds stress to an already stressful department in terms of taking resources away from other patient care.
‘It is not uncommon for us to have participants from opposite sides, simultaneously being treated in the resuscitation room, which adds potential for more violence and aggression to escalate.’
Mr Hornsby says managers need to be ready for how people affected by youth violence can present to ED, as not all arrive by ambulance.
Trained to expect anything
‘It’s about having a plan in place for when an individual is pushed from the back of a car onto the doorstep, rather than arriving by ambulance.
‘Training for that enables staff to deal with it more confidently.’
Mr Hornsby says staff need support to cope with the effect on them of treating severely injured young people.
Debriefs are critical for the aftermath of such emotionally challenging incidents, he suggests. Such moments offer team members a chance to talk through what went well and what could be done differently, and then to signpost them to further well-being and support.
Stress and emotional consequences
‘Staff need to maintain resilience because EDs are incredibly stressful places and any long-term exposure to the emergency services' environment brings massive stress and emotional consequences to deal with.’
of the 44 police forces in England and Wales have reported a rise in knife crime since 2011
Source: Home Office
In London, King’s College Hospital NHS Foundation Trust sees an average of one or two people wounded by stabbing a day, says lead trauma nurse Carole Olding, although this can rise to as many as ten.
‘You do get used to it,’ says Ms Olding, who emphasises that people affected are not confined to the 16-24 age group. ‘However, I don’t think anyone remains unaffected.’
‘We are trying our best to save lives and sometimes we have saved people, but they don’t always have a great outcome and this has a huge effect on staff.
Distraught family members
‘If someone has his chest opened up and we save his life but then he has a catastrophic brain injury because he is so depleted in blood, staff ask if we did the right thing.’
She says dealing with ‘absolutely distraught’ siblings and parents can also be hard for staff, particularly when a patient dies. For one thing, staff have to explain to loved ones that it is impossible for them to see or touch their family member because he or she is now someone who has been murdered.
The trauma nurse team has four band 7 specialist nurses who look after trauma patients ‘from ambulance doors to resus’ and are actively involved in all aspects of their care.
‘It is happening in your community’
Nurse Michelle Cox, whose son survived a machete attack in Liverpool three years ago, says violent crime is an issue for everyone.
Ms Cox says the experience was the most traumatic time of her life and she warns against people thinking that youth violence has nothing to do with them.
‘It is happening in your community, so you have to be part of the solution,’ she says.
‘I still find it difficult to talk about the details, but I can remember the horrific injuries, emergency surgery and blood transfusions, followed by months of dressing changes, physiotherapy and rehabilitation to rebuild the tendons that had been slashed.
‘As nurses we know how to show care and compassion, but we also need to be empathetic.
‘The ripple effect on families, communities and employers is not fully acknowledged.’
A holistic approach is taken by the team in looking after patients. It includes everything from safeguarding to adult-child liaison while working with the rest of the multidisciplinary team.
‘Looking after these patients for some time on our trauma ward has a huge effect on staff, and we support building up relationships with other disciplines,’ Ms Olding explains.
‘The NHS can work in silos but in the trauma nurse team we have cut across lines. We have lots of contact with neurosurgeons, cardiovascular surgeons and others.’
Ms Olding advises nursing managers that gathering good data on these types of ED attendances is crucial for care providers.
Questioning in the right way
She says managers should also ensure their staff are questioning young people in the right way and are suspicious of stories that fail to stand up.
‘The NHS can work in silos but within the trauma nurse team we have cut across lines. We have lots of contact with neurosurgeons, cardiovascular surgeons and others’
Carole Olding, lead trauma nurse
‘If you have got a 15 year old who comes in at 11pm and tells a story about a play fight with his friend involving a Stanley knife, it might sound insignificant.
‘But look at the patient’s age and the time of presentation and what they are saying. We are good at picking that up, where a local district general hospital might not be so aware of that because they are busy.
‘If you don’t do something about the minor injury, it is going to escalate. I think about every single little injury that someone aged 15, 16 or 17 is coming in with into urgent care.’
Listen and question
Ms Olding adds: ‘Listen to the story and ask “What is the time of day or night?”. Make sure you are questioning them in an appropriate way and make the right referrals. There is an opportunity to stop it then.
‘That is why I feel sorry for a lot of local emergency hospitals and trauma units, as they don’t necessarily have the support that big centres have.’
Homerton University Hospital NHS Foundation Trust in London has implemented a zero-tolerance approach to violence against staff or patients.
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Chief nurse Catherine Pelley explains: ‘Recently, we had someone threaten members of staff with a knife. This person is now no longer welcome on the premises, unless in an emergency.
‘We cannot allow staff to think that they have to accept a level of verbal and physical abuse. When you are in a leadership position, you have to take that responsibility.
Recognising signs of violence
‘We have launched a partnership with the Metropolitan Police about recognising the signs of violence and highlighting that we will take action against those who are violent and aggressive through the criminal justice processes.’
‘Lots of nurses and doctors find it difficult to say they won’t treat someone, but sometimes you can’t do it safely without putting staff at risk’
Catherine Pelley, chief nurse
Ms Pelley adds: ‘Lots of nurses and doctors find it difficult to say they won’t treat someone, but sometimes you can’t do it safely without putting staff at risk.
‘It is not about them not doing their job well. It is about the organisation doing its job well and protecting them.’
Homerton has a clinical site manager, a senior nurse who helps to manage difficult situations, and the security team wear body cameras.
Some important security staff are based in the ED and in the waiting areas, and there is also a police officer and CCTV on the site.
But what many trusts say has been most useful in supporting staff to deal with the impact of youth violence in their EDs and on their wards is the work of youth charity Redthread.
‘My staff have a youth work background and know how to relate and to have youth-friendly conversations’
Lucy Knell-Taylor, programme manager for youth charity Redthread
The charity runs a youth violence intervention programme in EDs in partnership with major trauma centres and works in Nottingham and Birmingham as well as London.
Small teams of specialist youth workers are embedded in EDs and work alongside clinical staff to engage young victims at the point of admission.
people died due to knife crime in England and Wales in the year to March 2018, the highest figure since 1946
Source: Office for National Statistics (2019)
London programme manager Lucy Knell-Taylor says this is the ‘teachable moment’ and it can be the point at which these young people’s lives can be turned around, with the right support.
‘At this point they are in hospital and alone, removed from their family and peers, and often coming to terms with the effects of injury, and we are looking to capitalise on that,’ she says.
Behaviour and choices
Young people can then question what behaviour and choices have led them to be in a hospital bed, and with specialist youth worker support they can pursue change they have not felt capable of before.
‘My staff have a youth work background and know how to relate and to have youth-friendly conversations.’
Ms Knell-Taylor says the youth workers help clinical colleagues to work better with these complex adolescent cohorts.
‘Most clinicians are often seeing multiple patients at a time, but we are able to come down to meet that young person and be with them for the entirety of their time in ED, and be that consistent, compassionate presence.’
Important work with a demonstrable impact
She says youth workers also act as advocates and ensure that young people understand what is happening to them in hospital and that they have the right support.
Beyond this, the charity works with young people to make healthier choices, and to disrupt the cycle of violence that leads to reattendance, re-injury and devastated communities.
Ms Knell-Taylor adds: ‘We know the work we do is important, and has a demonstrable impact, not just for young people and families but also for the health system.’
Stephanie Jones-Berry is a health journalist
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