Which actions by the staff of a mental health unit can lead to client violence

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Introduction 

Nursing staff encounter a range of potential hazards, often on a daily basis, but few are as distressing and difficult to manage as violence. 

You have a right to be safe at work irrespective of whether you are based in hospitals, in the community or other healthcare premises. Employers are required by law to identify hazards to which staff are exposed and take all reasonably practicable steps to eradicate or minimise them. This duty of care remains even where there are staffing shortages as a result of unsustainable pressures in the workplace.

RCN position on work related violence

We have produced a position statement regarding work related violence which also contains some helpful guidance.

What to do if you are assaulted at work

If you have been physically assaulted at work:

• Report the assault to the police immediately. This is important, even if you have been assaulted by a confused patient. If you do not, then any later criminal injuries compensation claim (see below) will be refused
• See your employer's policy which may also offer guidance and any specific processes you should follow
• If there is no policy where you work, report the incident to your manager and record it on your organisation's incident reporting system and keep a record.
• There may be occasions where there is an increased risk of violence due to staffing shortages as part of an overall increase in unsustainable pressures at work. It is important to raise these concerns and any incidents that occur as a result of this. 
• If you are asked for a statement, read our guidance
• Check your employer's sickness policy and our sickness advice, if you require time off because you have been injured -  also see information on NHS injury benefit information
• If you have been injured, read our advice on personal injury. While violence at work is not an 'accident', similar principles apply in relation to reporting incidents and what to do after an injury
• In some circumstances, you may be entitled to compensation from the Criminal Injuries Compensation Authority (CICA) if you were injured in England, Scotland or Wales. For injuries sustained in Northern Ireland contact Northern Ireland Criminal Injuries Compensation Scheme. Contact us if you would like to discuss making a claim
• Access emotional support. Being assaulted in work can be very traumatic and in additional to any physical injuries, you may be traumatised, stressed and anxious.

If you are concerned about the way your employer is handling a situation of violence or threats against staff or require support and advice on what to do, please contact us. 

Verbal abuse

Verbal abuse from patients and the public can be equally as distressing as a physical assault.  We encourage members to report incidents of verbal abuse using their organisation’s reporting processes and refer to your employer's policy.  Where the verbal abuse contains a threat to harm this should be taken seriously and reported to the police. Verbal abuse may also be discriminatory and you can read our guidance on discrimination.

Employers should also review cases of verbal abuse and take measures to address the issue.  Such measures may include behavioural agreements, formal warnings on behaviour and medication reviews

Third party sexual harassment and sexual assault

This is when a member of the nursing team (including students on placement) is sexually harassed by a client, patient or member of the public, whilst at work.  You can read further guidance in our publication, Third Party Sexual Harassment.

Sexual harassment can take several forms including:

• inappropriate touching
• unwanted sexual advances
• the use of social medial to share offensive images
• sexual assault.

Always report every incident including harassment, even if it may seem minor, using your employer’s incident reporting procedures. Keep a record of all instances of harassment. Please also see our section above on what to do if you have been assaulted. 

The RCN expects employers to treat all reports of harassment or assault seriously and to take appropriate steps as set out in the section on Employer’s duties above, in order to protect their staff. Further information can be found in our Prioritising Personal Safety guide. 

Please contact us for support. Support may include immediate advice on what to do, access to counselling services  and advice in pursuing a legal claim or, where applicable, NHS injury benefit. Also, if you are concerned about how your employer is handling a situation of sexual assault or harassment, please contact us. 

If you require support concerning any sexual violence, you can contact Rape Crisis and their helpline number is 0808 802 9999. Safeline offer a number of services. The RCN also offers an appointment based counselling service (please note this is not a crisis service). 

Your employer's duties

Under health and safety legislation, employers have an obligation to protect the health, safety and well being of their employees. The legislation also requires employers to assess the risk of violence towards their employees and put in place measures to reduce that risk. An effective system of risk assessment is therefore crucial. Some examples of measure that could be taken include:

• improvements to the physical environment
• alarms systems
• signage
• safe staffing levels
• training for staff.

Inadequate staffing may also lead to an unsafe working environment risking the health and safety of staff particularly since the pandemic, leading to unsustainable pressures at work. Please see the RCN’s Nursing Workforce Standards for more information.  

The importance of your safety is equal to that of your patients. You need support to identify and avoid working in unsafe conditions that may put you at risk. You need to know how to manage situations that become unsafe.

Once you have reported an assault, violence or the threat of violence to your employer, your employer should:

• Carry out an investigation, if necessary, and an assessment of the risks to health and safety through a risk assessment (or review current risk assessments)
• Decide on the arrangements which must be implemented to prevent an assault occurring again and put in place protective measures
• Provide information and training to employees for example, what measures need to be taken if caring for a patient with a history of violence towards staff.

The Health and Safety Executive provides guidance to employers on how to manage the threat of violence in the workplace.

Refusal to treat a patient

You may refuse to treat a patient if there is a serious threat of violence but this needs careful consideration. It may be possible for care to be given whilst the patient’s violence is managed.

Each situation needs assessment and you should discuss this with your manager and the rest of the care team. Read your employer's policies on managing violent patients. Remember that your employer has a responsibility to ensure the safety of both you and the patient.

Your employer cannot dismiss or discipline you for leaving your workplace because of danger which you believe to be "serious and imminent" and which you could not be reasonably expected to prevent. This includes taking any appropriate steps to protect you or others from danger.

Read our advice on refusal to treat.

Lone working

As a lone worker, your organisation must assess the risks from lone working activities and take measures to reduce the risk of injury and harm including violence and abuse.  In turn, you have a responsibility to follow safe working practices. Please see our guide on prioritising personal safety for more information. 

If you often work alone and there is the threat of violence, or you are aware that more violent incidents are taking place, read the guidance in Personal safety when working alone: guidance for members working in health and social care

The NHS Staff Council provides a range of guidance for lone workers including a guide for lone workers. This guide makes in clear that staff who work in a building with others, may be considered lone workers in certain circumstances.

Always remain watchful for your own safety and that of your colleagues. If you feel that your employer is not dealing with the issue sufficiently, please contact us.

Mental health nursing

Although some types of violence may be related to the patient's clinical condition, anger or fear are just as likely to lead to violence in mental health settings. Training should be provided to help you to deal with physical violence and verbal abuse. It should also help you to prevent verbal abuse developing into physical violence (de-escalation). 

Do not accept verbal and physical violence as an inevitable part of your job. 

Always report incidents and discuss them with your manager, the wider care team and your RCN Safety Representative. If you feel that your employer is not dealing with the issue sufficiently, please contact us. 

Sickness absence if you've been injured at work

Check your employer’s sickness absence policy for any exceptions to normal rules for absence management and/or the payment of occupational sick pay following injury at work. You may be entitled to certain NHS injury benefits or allowances if you work in the NHS.

You can also read our sickness advice guide.

Raising concerns

Guidance on how to raise concerns and on the actions to take if you are unhappy with your employer’s actions, can be found in our Prioritising Personal Safety Guidance. This also includes model letters that you can use to raise concerns about your personal safety in relation to your working environment. 

We also have raising concerns guidance if you have any concerns about safety or risks to staff or patients. You can also see our unsustainable pressures page for other guidance if you believe that this has contributed to any assault that has happened in work.

Further information

The Health and Safety Executive provides guidance to employers on how to manage the threat of violence in the workplace.

Legislation specific to assaults on health care staff:

England and Wales - Assaults on Emergency Workers (Offences) Act 2018 introduced a specific offence of assaulting workers providing NHS funded care in England and Wales. 

Scotland - Emergency Workers (Scotland) Act 2005 (Modification) Order 2008, has been in place in Scotland for a number of years. 

Northern Ireland - no equivalent act and there are discrepancies for those working in the independent sector or not providing NHS funded care.

Unsustainable pressures

The COVID-19 pandemic has intensified existing pressures on staffing and resources in all health and care settings.

This resource has been designed to support members in delivering safe and effective care and with the difficult decisions they make every day.

For which client illness would airborne precautions be implemented?

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