Violence against NHS staff is still at unacceptable levels, with incidents often unreported and perpetrators uncharged. Emma Dent reports

Imagine being assaulted in your job 15 times in 13 years. Few of us would be willing to put up with it yet for many working in the NHS, aggressive behaviour is a fact of working life.

It is also too often a part of NHS life accepted both by those working for the service and those whose role it is to punish assailants through the criminal justice system.

King's College Hospital foundation trust clinical site manager Cathy Koubis's experiences are typical. A former nurse, she has suffered assaults while working in the community and at a hospital trust, but believes she has suffered most at the hands of aggressive patients and relatives while working as a manager (see box, page 26).

After her most recent attack, in accident and emergency, Ms Koubis was supported by senior nurses and the trust's security staff but police were reluctant to arrest her assailant. Only when her attacker then assaulted a police officer was an arrest made.

Others have found their employers to be less supportive -' Dorset primary care trust local security management specialist Will Smith left his previous post as a nurse after being attacked by a patient.

His experiences tally with that of the 2006 Healthcare Commission staff survey, published earlier this month; only half of those questioned felt their employer would take action if they were physically attacked at work.

Although the numbers of NHS staff reporting violent and aggressive incidents have remained steady -' with 31 per cent experiencing violence or abuse in 2006 compared to 30 per cent in 2005 -' that still means almost a third of the workforce have experienced abuse from patients, carers and relatives. It is also feared that under-reporting is rife, with many staff believing such behaviour is part of the job. 'The official figures are just touching the surface; they do not give the full picture,' claims Mr Smith.

Changing the mindset

NHS Counter Fraud and Security Management Service head of security management Richard Hampton admits there is under-reporting. 'NHS staff should not take abuse or violence as part of the job; the service is made up of the caring professions who perhaps accept too much,' he says..

NHS security specialists agree that some staff are too accepting of violent or aggressive behaviour.

.'No-one comes to work to get assaulted, that mindset needs to change,' says University Hospitals Coventry and Warwickshire trust local security management specialist Mo Swinscoe (see box, page 26).

As a former mental health nurse who quit the profession after being attacked by a patient, fellow local security management specialist Mr Smith has first-hand experience of what his organisation's nurses can go through. He is currently suing his former employer, which cannot be named for legal reasons, for negligence after being attacked by a service user.

'The patient who attacked me had a forensic history, which was a good indication that he could be violent,' Mr Smith alleges.

Although police were called, they were reluctant to press for a prosecution because of the patient's long history of mental health problems. Both the police and the Crown Prosecution Service are often reluctant to press charges when the assailant's capacity to understand what they have done could be in doubt. No charges were brought.

The experience drew Mr Smith towards his current role. 'We are there to protect assets and staff are the NHS's biggest asset,' he says. 'They have the right to work in a safe environment as patients do to be treated in one.'

Exceptions to the rule

He agrees that acceptance among staff is the biggest issue to deal with.

'Raising security awareness is vital. There are too many staff who see violence as part of the job and too many managers who think you should be able to deal with it,' he says. 'But think of the cost: there is sick pay, time spent on investigations, the need to bring in agency cover, possible negligence claims and loss of staff. The NHS trained me and then lost me.'

Mr Hampton says that before the foundation of the Security Management Service in 2002, different organisations had different definitions of what constituted physical and non-physical assault, and how it should be reported. 'We cannot know what the solutions are until we know the extent of the problem. There can be instances where a local policy has caused the problem in the first place,' he says.

There is also an issue about what can be considered acceptable. People whose reduced capacity is as a result of treatment, such as when coming round from an anaesthetic, or mental illness, can be considered exceptions to a zero-tolerance approach. With organic conditions such as dementia, for instance, a patient may be completely unaware of their actions and should be treated differently to someone who lacks capacity because they are drunk. But other mental health conditions can leave a service user still capable of understanding that it is unacceptable to lash out at anybody, including those providing care to them. Although mental capacity is down to medical interpretation, for many working with such risks the issue is whether the act is deliberate.

With three-quarters of the incidents recorded in the 2006 staff survey taking place in mental health and learning disability settings, there is still much to be learned, adds Mr Hampton, about what caused those assaults and what can be done to prevent them happening again.

Practitioners also point out that work can be done, even with patients who lack capacity, to reduce the risk of them becoming aggressive. Mr Smith cites the example of one of Dorset PCT's elderly care units, which noticed a high number of incidents occurred at meal times and when medication was being given.

'When qualified nurses were not available, healthcare assistants and student nurses were giving out medication; when we changed the skill-mix to include more staff and agency nurses there was a huge drop in incidents.'

Where prevention can work in those circumstances, deterrents and punishments are needed in others.

As in Mr Smith's experience there has traditionally been reluctance by the criminal justice system to prosecute people with a mental illness amid concerns that a prosecution could not be secured. Cathy Koubis's experience suggests the police sometimes behave as if NHS staff should expect to sometimes be at the receiving end of aggressive behaviour.

Mr Hampton says that view might be starting to change due to work carried out with the Association of Chief Police Officers and the Crown Prosecution Service to make police more likely to arrest -' and the CPS more likely to prosecute those who attack staff. Prosecutions have gone up from just 51 in 2003 to around 850 last year. There are other avenues, too: where the CPS chooses not to prosecute, a small but increasing number of private prosecutions have been brought by the NHS Security Management Service's legal protection unit (see box, below).

The Security Management Service aims to have local specialists like Mr Swinscoe and Mr Smith in every trust by April 2008 to co-ordinate local violence and aggression work. With almost 300 in place, another 110 are currently being trained. -

Have you been assaulted at work? Do you think the NHS is too accepting of violence and aggression from patients and relatives? Is enough being done by trusts to prevent violent incidents? We want to hear. your views and experiences. E-mail hsjfeedback@emap.com or emma.dent@emap.com in complete confidence.

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Key points

- Violence against NHS staff is rife -' one manager has been assaulted 15 times in 13 years.

- NHS staff often lack confidence that their employer will take action if they are physically assaulted.

- The NHS should adopt a zero-tolerance approach, ensuring all incidents are reported to the police.

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Action man: the specialist's story

Getting deliberately run over while on duty was one of the last things former police Mo Swinscoe had happen to him while at University Hospitals Coventry and Warwickshire trust. Armed with that experience he now works as the trust's local security management specialist.

Formerly a trainer with the NHS Security Management Service after leaving the police force, Mr Swinscoe wrote the service's national syllabus on conflict resolution training before moving to work at the trust. He now liaises with the site's current two beat police officers (four police community support officers are also based on the site), collates and reports to the SMS all reports of assaults in the trust and co-ordinates work related to violence prevention, support and investigation in the trust......

'The most challenging part is putting all the areas of work together. This is such a large organisation [the trust has around 500,000 patients and relatives through its doors annually] and everyone needs to know about our security policies. Most people do everything that needs to be done but incidents are not always documented,' he says.

While in his current role, Mr Swinscoe has again been the subject of violent behaviour. More recently, while working for the trust, he was attacked while escorting a disruptive former patient off the site with a security manager.

'After the ward decided to discharge this person, she insisted on walking down the stairs although she said she was having difficulty walking, then flung herself to the floor, kicked out at me and stamped on my ankle.' The attacker was found guilty of assault and is awaiting sentencing.

'After getting run over here it was a bit surreal coming back to work but this was exactly the role I was capable of doing,' says Mr Swinscoe.

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Moral dilemma: the manager's story

The NHS Security Management Service's legal protection unit can act to bring private prosecutions against people who attack NHS staff and property if the CPS decides not to prosecute.

Such action was taken after Colin Reynolds, manager of Somerset Partnership NHS and Social Care trust's Wyvern Court unit, was attacked by a service user.

Wyvern Court is a rehabilitation unit for people with very complex and severe needs and challenging behaviour, but Mr Reynolds says the service user's behaviour was unacceptable.

'They had been abusive towards staff for some time. They would pinch and kick staff in unprovoked attacks. They had also damaged property on the unit. They would often retort that we could not do anything about their behaviour because of where they were. We had involved the police but they said it was not in the public interest to pursue the case.'

Somerset Partnership trust's security management team decided to bring a private prosecution instead, while the person was still a service user on the unit.

The service user was fined£400 and given a conditional discharge.

'The public might think someone detained under the Mental Health Act is not of sound mind but they can take decisions to act in a way that they understand they are doing.

'Some people might think they are untouchable but our decision sent a message that staff can act to moderate the behaviour of clients,' says Mr Reynolds.

There have been no further assaults on the unit.

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Worse than for a nurse: the manager's story

Fifteen assaults in 13 years as an NHS employee. That is what King's College Hospital foundation trust clinical site manager Cathy Koubis believes she has suffered.

'I've been assaulted on the wards, in the community, by patients and by relatives, but most incidents have occurred since I became a manager, it never happened when I was a nurse,' she says.

'As a site manager, my role means we often get called in when incidents are getting out of hand, in order to mediate. You can have patients who are confused and lashing out when on medication or angry relatives who become aggressive.

'Patients who are drug users or drunk are the minority; the majority are reacting to what is happening while they are in the system.'

Yet despite her experience, when Ms Koubis was most recently attacked in her current role, she admits it took her by surprise.

'I was in accident and emergency with the sister in charge. There were a group of girls who had accompanied someone to A&E and were starting to cause problems, so we asked them to leave and were accompanying them to the exit. I had my eye on one of them, but it was not her who attacked me but her friend; she went for me.'

Ms Koubis was reluctant to call the police but says the nursing sister insisted they did. Even then it seemed unlikely that the police would do anything about the attack.

'Hospital security were very positive and supportive but it was not until the gang started to attack the police that the police reacted,' she says.

Ms Koubis's attacker was charged and later prosecuted for assault but in her experience it is rare for police to act on such incidents.

'It all depends who attends and how positive they are about tackling such incidents. Although I was reluctant to do anything, now I would encourage others to do so, even if at the end of a 12 and-a-half-hour shift the last thing you want to do is pursue it.'

While she admits that there are some exceptions -' 'I can tolerate it when someone has been put into a confused state by the effects of drug treatments, or coming round post-theatre' -' Ms Koubis believes a firm line should be taken.