The overwhelming majority of contacts with patients and the public in the healthcare setting take place in a safe and supportive atmosphere. But healthcare professionals will be all too familiar with reports of violence or threats against colleagues who are simply doing their job. A joint HSJ/Unison report published in April 2018 found there was an absolute increase of 9.7% in physical assaults against NHS staff in the preceding two years.

This increasing threat to those working in the public sector, including NHS staff, has been recognised in legislation with the Assaults on Emergency Workers (Offences) Act 2018 coming into force on 13 November 2018. This creates a specific offence, with the policy behind the legislation being that attacks on staff such as fire, ambulance and health personnel should be punished more severely than if they involved an 'ordinary' person.

Specific health service guidance

One of the consequences of the abolition of NHS Protect in November 2017 was that its successor organisation no longer had a remit to deal with issues of violence against staff, and therefore advice issued previously no longer applied and training was no longer offered. However, the Secretary of State for Health and Social Care announced on 31 October 2018 that a new NHS violence reduction strategy would be put in place and will reinstate the principle of zero tolerance against NHS staff. The new strategy will include cooperation between agencies to secure prosecutions where appropriate and will require CQC to scrutinise how NHS organisations handle violence against their staff.

The announcement also highlighted two key features that will be valued by healthcare staff:

• training for staff to deal with violence (including circumstances where this is more likely, such as staff treating with patients with mental health concerns or dementia)
• prompt support for staff who have been victims of violence.

Timescales for the development of the new strategy and the roll-out of training and guidance have not yet been defined. Consequently, until there is substantive progress with the violence reduction strategy you may wish to be aware of other relevant and useful sources of information.

Other sources of guidance

One source of guidance and principles that may be of help is the NICE guideline, Violence and aggression: short term management in mental health, health and community settings. Although much of the guidance is aimed at the mental health setting, for those working in primary care there is a recommendation that training should be offered to help reduce the risk of violence erupting (such as anticipation, prevention, de-escalation and breakaway techniques). There should also be policies, the NICE guidance says, focused on lone-working and risk assessment of individuals identified at risk of being violent.

As well as NICE, the Health and Safety Executive has identified situations where healthcare professionals are more at risk of violence, and these include:

• working alone (a risk also highlighted in the NICE guidance)
• working after normal working hours
• working and travelling in the community
• handling valuables or medication
• providing or withholding a service
• exercising authority
• working with people who are emotionally or mentally unstable
• working with people who are under the influence of drink or drugs
• working with people under stress.

Situational awareness is helpful, but there is a need to understand how best to mitigate the risk of violence where it cannot be completely eliminated. Helpfully, the HSE guidance identifies actions staff should take when assessing risk in particular circumstances and lists principles that should be covered in basic training:

• causes of violence
• recognition of warning signs
• relevant interpersonal skills (for example verbal and non-verbal skills)
• de-escalation techniques (see also the NICE guidance, above)
• details of local working practices and control measures
• incident reporting procedures.

The aftermath of a violent incident

It is vital that once the situation is controlled that appropriate action is taken to both support the staff member subjected to violence and to ensure that other agencies, such as the police, are involved.

Report

Even if the incident is relatively minor, such as hair-pulling, if the staff member does not want formal action to be taken against the individual, it is still important that a full report is made of what happened. This helps provide accurate data about incidents to inform national statistics and can help preventatively as well.

Although not every incident will lead to a criminal prosecution of the perpetrator - for example, because the patient has severe dementia - many will. Healthcare staff can sometimes be concerned about duties of confidentiality where violence occurs, such as during a consultation.

Be assured that it would not be a breach of confidentiality to provide a report to the police about the actual violent act, including identifying the perpetrator and where and when it took place, and it won't usually be necessary to provide confidential medical information about the person. If you think that you may need to disclose medical information then it is best to seek advice from the MDU's team of medico-legal advisers.

Support

Do not underestimate the effect a violent episode can have on those who experience it. Be alert to the possibility of injury and treat or refer as appropriate - once the emotional shock of the incident has begun to wear off, other injuries may become apparent. Take advantage of any counselling services your organisation may offer. The HSE guidance suggests that a group debriefing can be of benefit to staff, as often there is more than one involved, providing mutual emotional support.

Forensic

In some instances it may be appropriate to call the police, who may ask that the staff member assaulted is examined by a forensic physician so that injuries are fully recorded and necessary samples taken. Being a witness or victim in the criminal justice system can be daunting, and the Ministry of Justice has put together a useful webpage of resources and information. There may also be help and assistance available from your organisation.

Although this article deals with violence against staff, there are also many instances of unacceptable behaviour that fall short of this. The MDU's Dr Ellie Mein provides a useful perspective on 'Dealing with aggressive patients' in primary care here.