RCN position on work related violence in health and social care

Definition 

The RCN supports the Health and Safety Executive’s definition of work-related violence as any incident in which a person is abused, threatened or assaulted in circumstances relating to their work.  This can include verbal abuse or threats as well as physical attacks (Health and Safety Executive 2021).

The RCN acknowledges that in health and social care, the approach to tackling work-related violence is nuanced and that ways of reducing the risk of harm to staff may vary in different clinical environments and with different client groups. 

Domestic abuse and bullying and harassment at work falls outside of the scope of this position statement but is none the less important. Violence towards patients is also outside the scope of this work, however by addressing the risks to staff it is likely that the environment is made safe for everyone, including patients and visitors. 

Background

Work related violence is a significant occupational hazard for nursing and midwifery staff. The RCN’s survey of its membership in 2017 found that over a quarter of all nursing respondents working in the NHS stated they had experienced physical abuse in the previous 12 months. NHS Staff Survey’s from the four countries that make up the UK, continue to show high levels of both verbal and physical abuse towards NHS Staff. We also know that nursing and midwifery staff with one or more protected characteristics are more likely to experience work related violence.

Data is not centrally collected specifically for the independent sector but the Health and Safety Executive (HSE) report that health care professionals and health and social care specialists have a high risk of assaults, almost three times the average risk across all occupations.

The damage done by workplace violence is not just physical. It can be psychologically debilitating and lead to stress, burn out, anxiety and depression. Such violence can also lead to diminished job satisfaction, lower commitment to work and increasing levels of absence.

The damage can be further compounded by an inadequate response by employers or the police and criminal justice system to an assault. The RCN’s report identified a number of cases where follow up support was deemed as inadequate. However, in terms of legal remedies and tougher sentences for those who assault nursing and midwifery staff such as those within the Assaults on Emergency Workers (offences) Act 2018, this is only one part of the picture and the RCN believes that the focus should be on prevention.

The RCN principles on the prevention and management of work related violence:

The RCN recognises that different approaches may be taken by the devolved nations and their respective governments in tackling work-related violence but has identified the following key principles which should underpin any national approaches to the prevention and management of work related violence.

Central to any work on work related violence in health and social care is the importance of employers and other key stakeholders working in partnership with the RCN at both a national and local level to tackle the issues, including work with local safety representatives.

The RCN’s approach is one with a focus on prevention, provision of adequate support following an incident and appropriate sanctions when incidents occur.

Prevention

• Prevention of work-related violence should be part of an overall strategy to address the health, safety and wellbeing of nursing and midwifery staff, including the retention of the nursing and midwifery workforce. 

• The causes of work-related violence in health and social care can be complex and multifactorial. For example, perpetrators may be under the influence of drugs or alcohol or may display violent behaviours due to underlying conditions. In health and social care environments, it may not be possible to completely eradicate work related violence towards staff, however employers have a duty under health and safety legislation to assess the risks and take measures to minimise the risk of harm. Measures to address and mitigate work related violence need to be tailored for each type of environment and client group. However, sufficient numbers of nursing and midwifery staff with the right skills and knowledge, should be central to the prevention and mitigation of work related violence. 

• Employers have a legal duty under health and safety legislation to provide a safe place of work for their employees; for contractors working on their site and patients under their care. This is particularly important for our members contracted to provide care in a workplace under the control of another employer e.g. prison nurses or those working in custody suites and agency nursing and midwifery staff. Employers and host organisations must communicate and co-operate on the identification of risks and measures to tackle work related violence.

• Data on the number of physical assaults towards nursing and midwifery staff should be collated at both a local and national level and where appropriate, to the regulator. Incidents of verbal abuse should also be captured locally.  Local and national data should be scrutinised to identify trends and hot spots and to inform appropriate action. Data should also be collected and reviewed in terms of the protected characteristics of staff assaulted including, sexual orientation, disability, race and religion. Data is essential to identify staff who are disproportionately affected, to tailor responses,  measure the impact of preventative measures and sanctions including criminal prosecutions. 

• Further research into what initiatives work in terms of violence prevention and reduction is needed. This is especially important with the emergence of new technology such as body worn cameras.

• Training can play an important role in reducing the risk of violence. Training needs should be considered as part of the risk assessment and appropriate to the risks encountered e.g. personal safety training for lone working staff.

• When incidents occur, they should be investigated, and risk assessments should be reviewed to see if any further measures are necessary to reduce the risk of reoccurrence.

• RCN safety representatives working through organisational health and safety committees play a key role in supporting the development of preventative strategies and must be consulted on risk assessments and any measures the employer is taking to prevent and minimise the risk of work related violence including the introduction of new technology e.g. lone worker devices and body worn cameras.

Support

• Employers must have policies in place to support nursing and midwifery staff who are in immediate fear of their safety from a threat of physical assault and allow them to take immediate steps to minimise the risk of assault e.g. withdrawing to a place of safety and calling for back up support. 

• Employers must make incident reporting procedures accessible and clear for all members of their nursing and midwifery staff including those working in third party premises or out in the community.  Nursing and midwifery staff should be supported and not discouraged from reporting an assault both internally and to the police. 

• Nursing and midwifery staff have a duty to report incidents of work-related violence to their employer and where necessary to the police service. In the case of registered nurses, midwives, health visitors and nursing associates this may extend to a professional duty under the NMC code through the requirement to highlight any risk of harm to colleagues and other patients. 

• Where assaults occur, employers have a duty of care towards their staff by providing timely and effective post incident support. Examples of initiatives include debriefs, supervision and TRIM (trauma risk management), to access to counselling service and psychological therapies. The effectiveness of support mechanisms should be periodically evaluated in consultation with staff.

• Incidents of both verbal and physical abuse should be responded to at an organisational level and timely feedback given to the member of staff as to what actions have been taken to prevent a reoccurrence.

• The RCN is committed to supporting nursing and midwifery staff who have suffered a violent assault at work. Support may include immediate advice on what to do, access to counselling services and longer term support and advice in pursuing a legal claim or, where applicable, NHS injury benefit. 

Sanctions

• Justice does not stop at the hospital or health centre’s gates. The police service’s role in responding to and investigating reports of physical violence should be objective, regardless of the setting in which that assault occurred or the health status of the perpetrator. The initiative taken by the NHS in Wales ‘Obligatory responses to Violence’ and local initiatives such as Operation Cavell in West Sussex provide a framework for an appropriate response to violence at an organisation and police service level.

• In situations where there has been verbal and/or physical abuse and the continued provision of care is necessary, it will be appropriate to speak to patients and their families/carers about what behaviour is acceptable. Organisations should have a policy for dealing with inappropriate behaviours including an escalation process and, in circumstances where the behaviour continues and is not deemed by a clinician to be due to a physical or mental health issue, it may be appropriate to withdraw all but emergency care.

• Before this decision is reached, alternatives such as relocation of care from home to a health centre or training up carers to delivery medications should be considered. Where an assault is deemed by a clinician to be due to a significant physical or mental health issue e.g. in cases of dementia, it will be for the appropriate authorities to determine whether a prosecution or sanction is appropriate for such individuals. RCN members should still report assaults in such situations to their employer and the police. A full review of care must take place, including medication review; identifying triggers and measures that can be taken to reduce anxiety or distress in individuals.

• Robust penalties are necessary for those who intentionally assault nursing and midwifery staff in the course of their duty. The Assaults on Emergency Workers (Offences) Act 2018 introduced a specific offence of assaulting workers providing NHS funded care in England and Wales. A similar Act, The Emergency Workers (Scotland) Act 2005 (Modification) Order 2008, has been in place in Scotland for a number of years. No such Act exists for Northern Ireland and there are discrepancies for those working in the independent sector, not providing NHS funded care. The RCN wants to see parity for all health and social care staff in terms of coverage of any Act to strengthen penalties against those who assault nursing and midwifery staff.

Summary

The RCN’s survey of violence shows that assaults against nursing staff remain high and there remain a number of shortcomings in the way these incidents are dealt with.  While there has been some progress in terms of the respective Acts in England, Wales and Scotland, prevention of assaults against nursing and midwifery staff must be the first objective for Government’s and health and social care employers.  Where assaults occur, actions taken by employers and the police service following such incidents are crucial in terms of protecting the mental health of the employee; prevention of further incidents and in seeking justice.

Further information can be found via our prioritising personal safety advice guide.