Health and social care workers have a right to expect a safe and secure workplace. But reports indicate that they can be up to four times more likely to experience work-related violence and aggression than other workers.
The term ‘violence’ covers a wide range of incidents, not all of which involve injury.
HSE defines work-related violence as: ‘Any incident in which a person is abused, threatened or assaulted in circumstances relating to their work.’
Staff should not accept incidents of aggression or violent behaviour as a normal part of the job. Employers and employees should work together to establish systems to prevent or reduce aggressive behaviour.
In both the health and social care sectors, violence and aggression is the third biggest cause of major injuries and over-3-day injuries reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). Slips and trips and manual handling are the first and second most frequent.
In healthcare, HSE received 1414 major and over-3-day injury reports as a result of physical assaults in 2009/10. This is a small decrease from the 2008/09 figure of 1423. In social care, HSE received 980 major and over-3-day injury reports as a result of physical assaults.
There is a high level of non-reporting within this sector, as many accept acts of aggression as part of the job. We know this because of the huge difference in numbers of RIDDOR reports collected by HSE and data collected by NHS Protect.
NHS Protect collects data on the number of physical assaults from NHS organisations in England. In 2009/10 there were 56,718 assaults, up from 54,758 in the previous year, a rise of 3.5%. Some 38,959 were in the mental health and learning disability sector, 13,219 were in acute hospitals and 1,262 were against ambulance staff. Another 3,278 occurred in primary care, including GP surgeries.
The main factors that can lead to violent or aggressive behaviour and create a risk for employees are:
Health and safety law applies to risks from violence, just as it does to other risks from work activity. Relevant legislation includes:
If risks from violence and aggression are to be managed successfully, there must be support from those at the top of the organisation, no matter what size. This can be expressed in a clear statement of policy, supported by organisational arrangements, to ensure that the statement is implemented. Key elements include:
You must manage the health and safety risks in your workplace. If there is a risk of violence and aggression or challenging behaviour in your organisation, you must manage that risk. To do this you should undertake a risk assessment, which will help you to:
The risk assessment process for managing the risks of violence and aggression may not be as straightforward as that of other risk assessments you have completed. You may need to have a number of different types of risk assessment in place, for example:
It is important to involve all staff (clinical and others) in the risk assessment process.
These assessments should consider the overall needs of the organisation, for example:
Where individuals pose a risk of violence and aggression, an individual risk assessment should be completed and regularly reviewed as part of the care planning process. This should consider:
All staff likely to be exposed to potentially violent individuals should know the potential trigger situations and the prevention measures identified by the risk assessment. These should be recorded in the person’s care plan. Particular care is needed when:
Organisations with several units or departments may need to have specific risk assessments for different departments. They may have different risks and therefore require different control measures.
HSE has guidance on completing risk assessments to help you assess the risks in your workplace.
Identify appropriate control measures as part of your risk assessment process. Suggested precautions you can take to help prevent or control aggression / violence towards staff are given below. (This is not an exhaustive list and it is important to make sure the measures identified adequately control the risks in your organisation.)
Training in the prevention and management of violence / aggression can provide staff with appropriate skills to reduce or defuse potential incidents. Training should be available to all employees in contact with service users, including ancillary staff such as cleaners, maintenance, temporary or agency staff.
The right level of training will be identified through your risk assessment process. Basic training in the principles of managing challenging behaviour should include:
Note: In England, NHS Protect provides specific guidance on the training requirements for NHS staff.
All staff who have the potential to be involved in an aggressive incident should receive the basic level of training. However, you must ensure the level of training provided to staff reflects the specific needs of their work activities. For example, those caring for people:
Confidence and capability are important when dealing with a potentially aggressive or violent incident. Staff will need refresher training from time to time to update their skills. Training requirements should be documented.
Many staff accept incidents of violence and aggression as ‘part of the job’ and may need encouragement to report incidents, particularly those that don’t cause serious injury, such as hair pulling, pinching or verbal abuse.
For detail on what incidents are reportable under the RIDDOR visit the RIDDOR website.
Although not all incidents of violence and aggression are reportable under RIDDOR, it is important that staff report all incidents and understand why this is important. For example, quite often a number of minor incidents can escalate to a major incident.
Helping staff after an incident
It can be useful to bring staff together after an incident to discuss what happened. This process of debriefing has two potential functions: to establish the details of what happened; and to provide emotional help and support. It is sometimes appropriate to supplement debriefing with confidential counselling.
You may improve staff morale and confidence if there is a visible, genuine commitment from employers to pursue prosecution in cases of serious assault.
These case studies were developed by the Health and Safety Laboratory (HSL). They demonstrate how employers have actually tackled the problem of violence to lone workers.
NHS Protect content (previously NHS Security Management Service) leads on work to identify and tackle crime across the health service. The aim is to protect NHS staff and resources from activities that would otherwise undermine their effectiveness and their ability to meet the needs of patients and professionals.
HSE recognises NHScontent Protect as an influential stakeholder in tackling the risks of violence in healthcare services in England. As a result we have a concordat with NHS Protect which provides a framework to enable liaison and co-operation between the two organisations on areas of mutual interest.
Through national and local liaison meetings, we identify opportunities for joint working and share information and intelligence about practices across the NHS. HSE contributes to NHS Protect’s evolving guidance for the NHS on managing the risks of violence.
We are committed to continue with our collaborative activities with contentNHS Protect. We believe that this will contribute to significant improvements in tackling the risks of violence against NHS staff and ultimately create a safer working environment.
Partnership for Occupational Safety and Health in Healthcare (POSHH)
The Partnership for Occupational Safety and Health in Healthcare is the occupational health and safety sub-group of the NHS Staff Council. The membership of the POSHH sub-group includes NHS employers plus:
The purpose of the group is to raise standards of occupational health and safety in healthcare organisations and promote best practice across both the NHS and the independent sector.
POSHH has a sub-group to work in partnership with NHS Protect on an agreed programme of action on violence and aggression. The group has produced two publications on improving the safety of lone workers:
Research Report RR440 – HSE published a research report on 23 March 2006 which investigated the effectiveness of training in the management of violence and aggression in healthcare. The research was undertaken by the Institute of Work, Health and Organisations, Nottingham University.
A further report, RR495, was published on 12 October 2006 in collaboration with the NHS Security Management Service. This identifies the competencies that make for an effective violence management trainer and reviews the practices and procedures associated with the selection, development and management of trainers. A competency framework identifies the competencies considered necessary to deliver violence management training effectively, underpinned by a practical toolkit to help all parties involved in the decision-making process.
The cost of violence research project by NHS Protect measured the costs to the NHS of violent physical assaults against NHS staff. They published a summary report in November 2010.
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