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Community nurses 'under attack'

Half of the community nursing workforce feel vulnerable at work, 63% have reported abuse over the last two years and a shocking 45% claim no action was taken following their complaint.

These statistics come from the recently released Royal College of Nursing (RCN) survey completed by 1,324 RCN members working in the community. The RCN calls for the vulnerable community nurse workforce to be recognised, as they say nurses are 'alone, afraid and under attack'.

A nurse participant from the survey recalls one specific incident: “I was locked in a family home, they refused to let me leave. I was there some time and received no call from the office to determine my safety and after the incident there was no follow up with the family, no additional safety plan, in fact it was down to me to visit again. I took a student for back up!” This is particularly alarming considering the NHS has had a 'zero tolerance' for violence policy in place since 1999.

Heather Henry, co-vice chair at the NHS Alliance's general practice nurse network says: “Personally I have been verbally abused, shouted at in the street, and harassed by residents who have been upset by my actions. I take each comment seriously, listen to what they say, respond as honestly as I can and report it to my manager. I also tell residents how they can complain to my organisation as complaints are an opportunity for organisational learning. My organisation, a social enterprise, takes all abuse seriously and asks residents to come forward if they have something to say. It certainly supports and listens to me, as does my union.”

Henry says that while she has never been physically abused or threatened “emotional abuse is just as damaging if not addressed”. She recommends lone worker training, a written policy in the community and, if necessary, says nurses should carry personal alarms.

Safety devices and training are considered key in keeping nurses safe by NHS Protect, an organisation that aims to keep NHS staff and patients safe by supporting and delivering services to NHS organisations.

A spokesperson for NHS Protect says: “A variety of safety procedures exist to keep nurses safe when working in the community and in any other healthcare setting. Lone worker devices, buddy systems and mobile phones are some of the practical and well-tested methods of reducing risk.”

The spokesperson also says that management systems and guidance from the employees' workplace are an important part of creating a safety culture.

They also emphasise that a risk assessment should be undertaken as part of a policy, which is as important as keeping a nurse safe as a lone worker device or mobile phone.

“Following up-to-date procedures is vital and if in doubt, speak to your local security management specialist, health and safety managers and human resource department for information, or you can speak to NHS Protect's lone worker protection service for on-going support and advice" states NHS Protect (see resources for contact details).

In 2009 the NHS funded and subsidised 30,000 lone worker devices to keep staff safe. This was due to an increasing number of NHS staff working alone in the community making them vulnerable to physical and verbal abuse and harassment. These included devices that appeared to be badges but could in fact be pressed to alert their base and take an audio recording of the situation.

The Department of Health (DH) say the funding provided was only ever intended to “get the programme off the ground”. Therefore, it was cut in 2012, which “had been planned”.

The DH explains that lone devices are still an option to keep NHS staff safe: “NHS bodies continue to take up this option though now they pay the full but competitive price themselves”.

Despite this, the RCN survey also claims that only a third of the members that completed the survey have received personal training and only 13% have access to a lone worker protection device.

Caroline Smith who is an advanced nurse practitioner and Unison representative for nurses with more than 20 years experience working in the community explains how devices aren't used by staff.

“We do not have any alarm devices for lone working. We previously had them but I think they were not felt to be worth the cost. Community workers have mobile phones and now also tablet devices so it would seem logical for something to be incorporated into them,” she says.

Smith adds that there is a rise in aggressive behavior from patients due to an increased incidence of dementia and mental health problems for people taking care of themselves in their
own homes.

She also claims that the situation is exacerbated by a cut in mental health and community psychiatric nurse preventative services that “is likely to have an increased impact on general community staff”.

Smith says that patients aren't the only problem. Verbally aggressive and demanding behavior can also be exhibited by relatives partly due to the stress of caring and “also due to the government's increased emphasis on patients as consumers, which makes them think they can make increased demands on nurses providing the service despite our lack of staff”.

Despite working in the community for nearly 20 years Smith has never received training on managing lone worker risks or a discussion of best approaches within teams for general staff safety and feels it's “a very neglected area”.

Margaret Stubbs who has several years experience as a practice nurse and is now a community diabetes specialist nurse in Surrey says: “The only [safety] device is a mobile phone, nothing else. I have been on the receiving end of verbal abuse on a number of occasions, especially as a practice nurse, when emergencies can make you run late on appointments.

“I have been accused of not knowing what I was doing. Patients who are quite vulnerable, often take this out on the nurse, as they are frightened in my experience. Often it is those who feel they no longer have control over what happens to their health that can be the most abusive. Also patients can become abusive when we no longer have any answers for them, and it is time they took responsibility for their own health.”

NHS Employers, an organisation representing NHS workers, released a guide named Improving the safety for lone workers in 2009 stating that all employers have a duty to protect lone workers as do lone workers have the responsibility to keep themselves safe.

Additionally, NHS Protect says the protocol that should be followed if an incident occurs is: “When a nurse is abused in the community, their line manager and local security management specialist should be informed, and the incident should be reported via the security incident reporting system (SIRS).” SIRS is an electronic tool used to report security incidents by NHS health bodies to NHS Protect.

But abuse rate continue to rise. In 2013/2014 there were a reported 68,683 assaults against NHS staff according to NHS Protect's national summary, which in comparison to previous figures: 61,571 in 2012/2013 and 59,744 in 2011/2012, shows a sharp increase.

NHS Employers states that abuse is not tolerated in any form saying: “Any level of violence or aggression towards NHS staff is unacceptable. We have worked in partnership with staff side colleagues to produce guidance for NHS organisations and managers, which focuses on improving safety for staff who are working on their own."

As Henry says her organisation has supported her, this has therefore improved her safety while nursing, so nurses should report any abuse to their managers and receive appropriate support. But only 22% of the RCN survey participants claimed their managers knew where they were when working in the community alone.

A nurse who participated in the survey explains how she has been held against her will while working in the community saying: “I was verbally abused by a patients' relative. I informed the office - still had to visit and no further action was taken other than documenting it on patient notes. I did not feel supported, was wary about visiting that patient due to the relative. But felt I had to, because I would have failed my patient by not giving them the treatment they required.”

So why has this become a problem? The RCN survey highlights that 44% of lone working staff feel that over the last two years the risks within their role have increased for the following reasons: an increased caseload, lack of staff, increase in work out of hours, substance misuse issues and antisocial behavior in the areas visited by staff and patient relatives having increased expectations.

Dr Peter Carter who was the RCN chief executive and general secretary at the time the survey was released said: “There are times when a patient or relative can be aggressive or disruptive due to a medical condition, but there are still things that can and should be done to keep nursing staff safe. Nursing staff should feel able to raise concerns about the situations they face, and either visit in pairs or have access to a safety device to raise the alarm.”

Following the survey results the RCN say its plan of action is to continue working with organisations such as NHS Protect to ensure employers are implementing good policy to keep staff safe. A spokesperson for the RCN says: “Violence is a risk for all nurses, but lone workers are certainly more vulnerable. The objective [when releasing the survey] was to raise the profile of this issue and [now] we want [safety] to remain high on organisations' agendas.”

NHS Employers remain determined to keep staff safe saying, “Ensuring the safety of staff and their patients is a priority for
NHS organisations who work hard to provide safe working environments for staff.”

NHS Protect says it will continue to clamp down on abuse towards NHS staff. “We are working with a number of key stakeholders to address how we tackle physical assaults for all staff not just nurses working in the community.”

It is adamant that the NHS Lone Worker Protection Service will continue to “support and provide guidance on lone working provisions and good practices to mitigate the risk to lone workers in the NHS and commissioned services”.

It says the service aims to ensure lone health workers are aware of the control mechanisms used that could “prevent, deter and protect them from violence and aggression while working alone”.

A spokesperson added: “Wherever possible and legally permissible, NHS organisations should share information with us on known risk relating to lone working so that we can work together to improve the information sharing protocols in reducing the risks associated with lone working, and more increasingly in the community, mobile working.”


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