Nurses/care workers - Community midwives

Work-related violence case studies

Norfolk and Norwich University Hospital NHS Trust is a large, newly built hospital on the outskirts of Norwich. The Trust employs approximately 4900 staff. Among them, community midwives, dieticians, physiotherapists, social workers, engineers and some administrators carry out their duties alone up to 95 percent of their time.

This case study concentrates on the 64 community midwives in the Trust whose work involves visiting clinics and clients' homes. They mainly do post-natal work, with some antenatal duties and 'parent craft' (teaching parenting skills). They can spend up to two hours with a client whom they typically visit every other day. The midwives cover an area of 1200 square miles including inner city, council estates and rural areas.

Key risks

• Visiting clients at home.
• Visiting certain locations, for example poor or run down council estates.
• Teaching 'parent craft' in clinics/health centres in the evenings and on Saturdays, when there are normally fewer staff around.
• Dealing with unknown people and situations involving domestic violence or drug abuse.
• Travelling, for example on remote country roads and in unknown areas.
• Working and travelling at night.

Examples of incidents

• During a parenting class, a drunken male became very disruptive and sarcastic. This made the midwife feel nervous and at risk.
• Teenagers throwing stones and threatening midwives while travelling between clients.
• A client became abusive when asked to turn off a mobile telephone during a parenting class.
• During a home birth a midwife had to call for assistance because the client's partner started to fight with a neighbour who was complaining about the noise of the birth.
• On one occasion a midwife was held hostage, but this kind of incident is very rare.

Successful measures

Training and information

A three-stage violence and aggression training programme: all community midwives must attend this training. The main themes of the training include:

• How to defuse violence and aggression before an incident occurs, for example by persuading clients that the employee is there to help them.
• Good customer care.
• What to do if employees feel uncomfortable in a client's house.
  For example:
  • 'Keep your wits about you';
  • Do not sit down;
  • Do not spread belongings out;
  • Make excuses to get out if you feel at risk, eg needing something from the car;
  • Keep escape routes clear. Ensure you can get to the door quickly.

Issue of policies, procedures and guidelines: the Trust provides staff with information, including: Guidelines to promote safer working practices in the community; Prevention and management of aggression: Guidelines and reporting procedures; Lone working policy; and Procedure for care of individuals who are violent or abusive.

Incident report form: staff are encouraged to report incidents, no matter how small (eg telephone abuse). This helps to establish what the problems are and to develop appropriate prevention/management measures.

Early warning system: Potential problem areas or problem clients are recorded. Midwives visiting them receive early warnings so joint visits can be arranged if necessary.

Work environment and equipment

Lone worker mobile phone system: Midwives use a mobile phone central message system. They log on to the system when they leave home in the morning and send text messages during the day detailing where they are going and how long they will be. This process continues until the end of the day. If a midwife takes longer than anticipated at a job and does not check in at the expected time, an alert is sent to the midwife's mobile phone. The midwife then has to send a text to confirm that they are OK. If this does not happen an escalation procedure is put into place whereby the midwife is called every few minutes. Eventually, if the midwife cannot be located the police may be contacted. The mobile phones also have an emergency button.

Personal attack alarms: Staff are provided with personal alarms if they need one.

Other security measures used by hospital staff: these include CCTV and panic alarm buttons. The Trust also employs security staff.

Job design

Doubling up: two midwives are now sent to night-time calls, depending on the location and proximity of midwives.

Timing of classes: Adapting the time of parent craft classes so that the caretaker of the health centre is around and can help a midwife should an incident arise.

Risk assessment: all staff and management are encouraged to do risk assessments of their jobs and the situations they encounter.

Less successful measures

Keeping the diary system up to date can be difficult because work plans often change significantly during the day.

There are some difficulties with the lone worker mobile phone system:

• Some staff feel that it is a management device to check on staff rather than a safety measure.
• Some midwives do not use the system or forget to log on so it is not known where they are if an incident occurs.
• Text messaging can be time-consuming. If in a car, it can make midwives appear more vulnerable and put them in danger.
• If the midwife takes longer than anticipated at a job and the mobile alert sounds, this may be seen as invasive by clients and cause annoyance.
• If staff do not check in, alarms sound at the control room and only stop when the midwife logs in by text. Text messaging can be difficult if the midwife is in the middle of a delivery!
• If an incident happens midwives may not be able to press the emergency button in time.

The benefits and the costs

The benefits

Confidence: staff feel happier and more confident in their work.

More awareness: staff have greater awareness of potential violence and aggression.

Feeling valued: staff feel more supported and valued by a caring management.

Involvement: staff feel involved because they can contribute views on the systems and the content of training programmes.

Management information: incident reports give a better understanding of the type and scale of incidents so that management can take appropriate action.

Lower staff turnover: has been noted.

Fewer incidents: the Trust has had only a few incidents of violence.

The costs

• The main cost of the measures is time, which is difficult to quantify.
• The mobile phone system is expensive costing thousands of pounds per year while text message bills are rising. But this and other systems are not expensive compared compensation costs should the Trust fail to provide a safe environment for its staff.
• The benefits of violence and aggression training outweigh the costs of the courses. The Trust's input into the course ensures that it truly meets training needs and is cost-effective.