Nurses/care workers - Community mental health staff
Work-related violence case studies
Birmingham and Solihull Mental Health NHS Trust was formed on 1 April 2003 and is one of the largest mental health trusts in the country. This case study concentrates on the South Birmingham Mental Health NHS Trust (SBMHT).
The Trust provides mental health care, and its facilities range from inpatient wards to community mental health centres. It also provides many other services such as forensic services and regional special services (for example for eating disorders).
SBMHT employs around 1900 staff including doctors, nurses, psychologists and other health professionals; domestic, catering, portering and ancillary staff; and administrative and clerical staff. The majority are potentially lone workers. Around 1000 staff work within the community or make home visits, including doctors who provide general care and make assessments under the Mental Health Act; community psychiatric nurses (CPNs) who provide help and support, including assessment, counselling, general advice, and management of medications; outreach staff who help people who find it difficult to use the Trust's services; and home treatment staff. All these staff are mobile and most use cars to travel between appointments.
- Geographical area: staff have to visit inner city areas where the risks of violence are higher.
- Environmental factors: staff often have to visit clients in tower blocks or other similar buildings. Sometimes lifts are poorly lit and there are concealed spaces. Also, the public have access to buildings where staff may be working late at night.
- Working patterns and hours: many violent incidents occur in the evening and at staff changeover times. Doctors may have to visit peoples' homes late at night and sometimes require police support if there is increased risk.
- Staff as targets: doctors, CPNs and community nurses might be believed to be carrying drugs and may therefore be targets for assault.
- Resentment of support: outreach staff sometimes try to support people who do not want to be helped.
- Unpredictable client behaviour: most people who have a mental illness are not violent but a small number sometimes display violence as a symptom of their mental illness.
- Client acquaintances: these people are often not known to staff and may present additional risks, such as those related to drug use.
- Withholding treatment: this can put both staff and members of the public at risk of violence and abuse.
Examples of incidents
- Verbal abuse and harassment, including racial and personal abuse.
- Physical assaults.
- Threats of physical violence, including the use of weapons. Staff have also seen weapons or drug-related items in the homes of some clients. This can cause great concern.
- Intimidating behaviour.
- Staff being shut in a room and not allowed to leave.
Training and information
Relevant training: training is considered to be the most successful measure because it raises awareness, and builds teams and confidence. All staff groups are obliged to attend regular refresher courses. A high training profile helps to ensure good attendance.
Key training messages:
- You, as an individual, matter. Your safety is important.
- You can influence the outcome of a situation. There are three factors in a violent situation that interact: the aggressor, the victim and the context.
- Protect your own space.
- Be aware of the impact of your own behaviour on the client and the rest of the team.
- The emphasis is on recognition, prevention, and psychological responses and interventions.
Investment in trainers: The Trust has two full-time trainers who co-ordinate and provide the training programmes. They are supported by a professionally trained team.
Prevention and response techniques: Management of Actual and Potential Aggression (MAPA) training includes de-escalation, physical restraint and breakaway techniques.
Support at senior level: a risk manager was appointed at a director level on the Trust Board and is responsible for progressing the violence and personal safety agenda. The commitment at this level of the organisation is considered to be one of the main 'drivers' for the success of the programme. Senior staff also have dedicated roles, and there is a multi-disciplinary Violence and Personal Safety Group. This includes a trainers' and police liaison forum.
Risk assessments: there are risk assessments of specific premises and patients.
Periodic audits: audits of various facilities and lone worker strategies are conducted.
Violence policies, leaflets and associated guidance: these are developed by the Violence and Personal Safety Group and are given to all staff during training. A violence and harassment poster has been designed and worded in a clear, sensitive and appropriate manner.
Police liaison: the police are very supportive of the work of the Trust and provide advice and help for staff. The police have also been involved with producing guidance which includes collaborative working between the Trust and the police.
Incident reporting: it is important for staff to report incidents. The Trust is currently involved in a pilot for the National Patient Safety Agency (NPSA) National Incident Reporting System. This has resulted in proposed changes to the definition of reportable violent incidents.
Work environment and equipment
Environmental features: these have been highlighted through environmental audits and research by the Royal College of Psychiatrists. The information is being used in the design of a new building.
Mobile phones: all community staff are issued with mobile phones.
Lone worker pilot project using special phones with satellite positioning: the Trust is piloting this in partnership with other Trusts, the ambulance service and an external organisation. Satellite positioning locates staff at the exact address after they trigger the emergency alarm. The ambulance service provides the first response. The alarm opens a communication channel which is also recorded. Workers can decide what they want their emergency response to be. During the pilot there have been few emergencies requiring its use but the Trust feels that this could be an important safety mechanism for certain staff groups.
Personal panic alarms: the alarms are currently issued to staff who need them.
Building alarms: the building alarms are activated when staff press buttons on their personal alarms.
'In' and 'out' boards: these help keep track of staff movements.
Photo books: the books contain staff photographs, details of car registrations, home phone numbers and next of kin. If a problem arises, police or others can use this information and photographs to help to locate them. Procedures are in place locally if staff do not return when expected.
Staff in the community do not wear uniforms: this reduces the risk of being identified and becoming a target, for example in the case of CPNs who may be thought to be carrying drugs.
Working with other professionals: doctors required to do mental health assessments late at night are encouraged to visit jointly with a social worker, arriving at the house together rather than separately.
Post-incident support: all staff receive staff support following incidents and a confidential service is available. Staff are also allowed to do light duties after a violent incident.
Withdrawal of service: the Trust is considering whether to use this option for extremely violent or abusive clients. It is very difficult for staff to do, as it goes against their professional and moral duty of care.
Working with the police: The Trust has an improved system for working jointly with the police.
Alternative mobile phone system: the Trust is considering a mobile phone system that requires staff to text their location to a centre before a visit. This is less expensive than the satellite positioning mobile phone system, but does not enable an immediate response or the exact position of the member of staff at the time of an incident. This approach may be used for staff who are at a lower risk of violence.
Less successful measures
Some measures are less effective than others. For example, staff shortages occasionally make it difficult to release staff for training. Some staff do not value training because they feel they already know it all.
The benefits and the costs
Increased confidence: staff report an increase in confidence and personal safety because of the measures.
Increased awareness: so that staff are better equipped to deal with incidents.
Belief in the Trust: staff believe that the Trust actively seeks to identify solutions to deal with violence, takes their concerns seriously, and really cares about their safety and welfare.
Empowerment: staff feel they are able to influence policy, so they actively encourage and support their teams to take preventive action.
Changed attitudes: the high profile of violence prevention and management within the Trust helps staff to lose the 'mind set' that violence is an inevitable part of their job.
Improved joint working: The Trust now has a system in place through the Community Safety Bureaux to agree policies with the police and to work jointly with them.
Improved training attendance: the volume and attendance of training doubled between October 2001 and October 2002. Staff evaluation of the training programmes has been very positive.
More incident reporting: the reporting of near-miss incidents has increased. This enables the Trust to analyse the causes of these incidents and to take preventive action before a serious incident occurs.
Improved working relationships: as a result of the measures staff are working in closer partnership with each other.
General: the Trust has an income of £70 million. The costs of preventing violence are affordable given the necessity of protecting staff and maintaining services.
Trainer costs: two senior nurses are employed full time to co-ordinate training, plus venue costs to equip training room initially and for ongoing hire.
Satellite positioning phones: currently these are £450 each and there is an additional cost associated with the ambulance response service (this may be reduced in the longer term). Approximately 100 phones are needed for high-risk staff.
Panic alarms in building: the cost varies depending on need - up to £100 000 for very large inpatient buildings.
Personal alarms for use in buildings: these are £150 each for staff-held devices. Sensors in the ceiling of panic-alarmed buildings would be an additional cost.