• No results found

Preventing Violence

In document VIOLENCE INCLINICAL PSYCHIATRY (pagina 33-36)

In response to the problem of violence, successive governments have put forward a number of initiatives in an attempt to tackle the issues leading to violence and aggression in the NHS. These initiatives commenced in 1999 with the launch of the ‘zero tolerance’ campaign, which aimed to emphasise the issue of workplace violence as a key priority, sending the clear message that violence against NHS staff was unacceptable and would not be not be tolerated (Health Service Circular 1999/226).

Increasing awareness amongst NHS staff of the importance of reporting incidents of violence and / or abuse through the work of the ‘Zero Tolerance’ campaign, saw a massive increase in recorded violent incidents from 65,000 in 1998/1999 to 115,000 in 2002/2003 (Health Service Circular (1999). In response to this, in 2003 the Department of Health commissioned the NHS Security Management Service to oversee the management of health and safety issues within the NHS, with a view to reducing its levels of violence.

This was supported by a specific mandate from the secretary of state for health, who instructed health bodies to;

“Implement a series of initiatives designed to deliver an environment for those who work in or use the NHS that is properly secure, so that the highest possible standards of clinical care can be made available to patients” (NHS Security Management service, 2003).

Responding effectively to workplace violence is measured by an organisations’ ability to implement appropriate measures to prevent or minimise its’ occurrence. Contemporary thinking on workplace violence, stresses the need to address the problem in terms of one of a total organisational dimension.

The assertion is that a total organisational response to this phenomenon must reflect an organisation that is able to reflect both from a top down and bottom up perspective, continually learning from its current experiences in order to meet existing and future demands.

Within the organisational response is the need for clear leadership and the development, dissemination and implementation of a robust strategy on workplace violence. Any strategy needs to encompass three dimensions, these include; ‘primary’ approaches taken to prevent violence before it occurs such as risk assessments and staff training in conflict resolution and environmental management; ‘secondary’

approaches, where measures taken aim to prevent violence when it is perceived to be imminent such as ‘de-escalation’ and emergency responses, and ‘tertiary’ responses where action is taken both when violence is occurring and after it has occurred in order to prevent or reduce the potential for physical and psychological harm to the parties involved (e.g. restraint techniques) and also to inform primary and secondary prevention strategies through mandatory post-incident reviews that address the underlying reasons for violence.

Essential to this process is the need to define and understand the concept of violence. Defining violence is not an exact science but a matter of judgement, key to this judgement is the need for an operational definition. Within the literature there are many possible ways to define violence, depending on who is defining it and for what purpose. Consequently violence is often viewed as an extremely diffuse and complex phenomenon, which often negates attempts at implementing effective preventative measures.

For this reason the NHS focused on developing a universal definition that would allow all NHS health organisations and staff to be clear about what constitutes physical assault. Focusing their definition of violence within the framework of physical assaults, the NHS described violence as the ‘intentional application of force to the person of another without lawful justification, resulting in physical injury or

discomfort’ (Security Management Service, 2003). Whilst it is difficult to provide a comprehensive list of incident types that are covered under this definition, it is widely accepted that behaviours such as pushing, shoving, scratching, poking, the throwing of objects / liquids and spitting, can be included alongside the more obvious forms of physical assault such as punching and kicking.

Criticisms of this definition have typically highlighted the over-emphasis on physical violence, thereby omitting the notion of psychological harm and the deleterious effects that verbal aggression constitutes towards health workers. Ignoring the salience of non-physical aggression also serves to mitigate against the effectiveness of preventative measures, by ignoring important risk factors of physical violence. In reality physical assaults rarely occur in the absence of non-physical aggression and as such non-physical aggression is widely regarded as a salient predictor for physical violence (Stanza, et al 2006).

One possible explanation for the relationship between physical and non- physical violence is that the occurrence and tolerance of non-physical violence in healthcare settings creates or contributes to a culture of disrespect that, in itself, is conducive to the emergence of physical violence. Support for this view comes from studies of behavioural modelling that suggest that mild forms of aggression, if tolerated within any given setting, are predictably followed by more serious forms of violence committed both by observers as well as the original perpetrators (Kelley & Mullen, 2006).

Extending this theory to one of an organisational perspective, leads to the hypothesis that verbal aggression in the form of threats and abuse provides the context for the emergence of physical violence independent of whether or not these escalating forms of violence are perpetrated by the same or different individuals. As such, aggression and abuse represent an equally important intervention target for reduction with regards to preventing violence.

As a concept, violence is typically viewed as an inevitable part of the human condition; ‘a fact of life to respond to rather than to prevent’ (Butchart 2004). This position has resulted in many health organisations framing the problem of violence as an ‘occupational hazard’ and a predominantly ‘frontline staff problem’

(Leadbetter 2004). A consequence of this somewhat pervasive attitude has been a predominant focus on crisis management, rather than an emphasis on strategic service delivery aimed at preventing violence.

In reality violence in a healthcare setting is a multifaceted and complex issue with no single causal factor.

Research into this area recognises that its’ occurrence is frequently the result of the interplay between a number of contributing risk factors. Accordingly, the development of any preventative strategy will require a clear understanding of the problem and the context in which violence occurs, from a situational, environmental and interpersonal perspective (Wiskow, 2003). To conclude, any effective approach at reducing violence needs to reflect that complex and multi-faceted nature, with regards the interplay between the various components that contribute to the occurrence of violence.

Summary

Violence within healthcare settings is an endemic problem. Violence within mental health environments is particularly prevalent and creates problems with regards to staff and patient safety and the provision of a therapeutic environment where effective treatment can be delivered. Approaches to violence in healthcare settings have shifted from those of a responsive nature, to those of a preventive emphasis and this has been reflected in the adoption of a public health model by many NHS organisations. However, the complex and multifaceted nature of violence means that any organisation developing a strategy aimed at preventing violence, needs to acknowledge and recognise the interaction between the assailant, the potential victims and the context in which the interaction occurs, integrating those factors into whatever approach is adopted.

References

Bulatao E,VandenBos GR (1996) Workplace violence: its scope and the issues. In:VandenBos GR, Bulatao II, eds. Violence in on the Job. American Psychological Association, Washington,DC

Daffern, M. and Howells, K. (2002). Psychiatric Inpatient Aggression: A review of the Structural and Functional Assessment Approaches. Aggression and Violent Behaviour 7; 477-497.

Di Martino, V. (2003).‘Relationship Between Work Stress and Workplace Violence in the Health Sector’, Workplace Violence in the Health Sector, Geneva: International Labour Office.

Estryn-Behar, M., van der Huijden, B. and Camerino, D. (2008) Violence Risks in Nursing: Results from the European

‘NEXT’ Study. Occupational Medicine (London) 58(2):107-114.

Health Service Circular. (1999). NHS Zero Tolerance Zone Campaign: Tackling Violence in Primary Care, Ambulance, Mental Health, and Community Settings. Department of Health, London.

Home Office (2012) Findings from the British Crime Survey and police recorded crime (2nd Edition) http://www.homeoffice.

gov.uk/science-research/research-statistics/crime/crime-statistics/british-crime-survey (accessed 10th April 2012).

Kelley, E., & Mullen, J. (2006). Organizational response to workplace violence. In E. K. Kelloway, J. Barling, & J. J. Herrell, Jr. (Eds.), Handbook of workplace violence (pp. 493-515). Thousand Oaks, CA: Sage.

Lanza, M. L., Zeiss, R. A. and Rierdan, J. (2006). Non-Physical Violence: A Risk Factor for Physical Violence in Health Care Settings.

Leadbetter D (2004) CALM Associates Training Manual. CALM, Menstrie.

NHS Counter Fraud and Security Management Service (2003). Protecting your NHS: A Professional Approach to Managing Security in the NHS. Department of Health, London.

NHS Counter Fraud Service (2007). Cost of Violence against NHS Staff: A Report Summarising the Economic Cost to the NHS of Violence against Staff. Department of Health, London.

NHS Security Management Service (2011). Physical Assaults against NHS Staff 2009/10: National Summary by Sector Type.

Department of Health, London.

Nordin, H. (1995). Occupational Injury Information System, Swedish Board of Occupational Safety and Health.

Richter, D. and Whittington, R. (2006) Violence in Mental Health Settings: Causes Consequences, Management. Springer Science and Business Media, New York.

Satcher D (1995) Violence as public health issue. Bulletin New York Academy of Medicine 72: 45–6

Wiskow, C. (2003). Guidelines on Workplace Violence in the Health Sector: Comparisons of Major Known National Guidelines and Strategies. Geneva, International Labour Office.

World Health Organization (2002) Framework Guidelines for Addressing Workplace Violence in the Health Sector. Geneva, International Labour Office.

Correspondence

Mr. David W. Jones Consultant Nurse

Lead clinician (Chair) for the Violence Reduction Strategy for Nottinghamshire Healthcare NHS Trust david.jones@nottshc.nhs.uk

Improvement of risk assessment and risk

In document VIOLENCE INCLINICAL PSYCHIATRY (pagina 33-36)