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Preventing knife crime in our communities: the nurse's role

George Coxon RMN
Director Classic Care Homes (Devon) and Independent Health Care Advisor/Nurse
Mental Health Specialist Advisor, Newcare Ltd
Devon Mental Health Nursing Association (MHNA)

The effects of knife crime are far reaching and have a direct and indirect relevance to healthcare provision at primary and secondary care level. What role is there for primary care nurses in in delivering support?

With 107 teenage deaths in five years and almost 7,000 incidents each year it is hard to ignore the impact and tragedy of violence related to gang culture in our towns and cities across the UK.¹ A recent report, No Excuses, looked at educational exclusion and describes the climate of fear in schools where "weapon carrying ... is rife".²

We have become all-too familiar with the latest report of another loss of life and the consequences for family, friends and local communities. The stories are sad and tragic, and have a huge impact on the lives of those left behind, creating a climate of fear and threat in the places in which we live.

A first impression might be that the role for primary care is limited in terms of dealing with the growing concerns and incidence of knife crime affecting young people; particularly teenaged gang members in our inner cities. So far this year 16 teenagers have been knifed to death in London alone. The numbers of 13-24 year olds admitted to London hospitals after being assaulted with a sharp object has risen to 634 compared with 493 the previous year.

There are many media led-stories of teenage turf wars with young people struggling to resist neighbourhood gang pressures, and living in a culture of fear, attempting to find their place in the hierarchy and establish respect from the group. The difficulties associated with adapting and surviving in such situations are immense and carry a paradoxical dilemma for children as they become adults, with the need to 'fit in', and gain status and approval with peers while retaining confidence and self-esteem. This struggle is perhaps at the heart of the problem and one that needs to be considered. Peer group pressure influenced by a need to have an identity and loyalty to family and/or local groups may also be part of the context leading to violence. Addressing the influence the media has in promulgating a sub-culture, where certain lifestyles including gun crime, drug wars and celebrity chic are seen as attractive, is extremely hard to change.

Who is at risk?
The simple answer to this question is that we all are. Data on hospital admissions and episodes of care can be regarded as a valuable indicator of risk and prevalence of knife assaults and fatalities. Although the Tackling Knives Action Plan report in 2009 concluded that incidence of such assaults had reduced from previous years (possibly to do with heightened attention as part of the government's response to these events) there is, undoubtedly, still a high financial as well as emotional cost to violent knife crime.³

In 2007/8, 15% of hospital admissions of under-19 year olds for assault involved knife attacks, compared to 44% of the over-20s. The NHS Operating Framework in 2009 placed greater emphasis on primary care trusts in monitoring activity and actions to address the issue.⁴

A study by the Trauma Audit Research Network (TARN) at Manchester University looked at all penetrative trauma injuries resulting in immediate admission to hospital for three days or more or death within 93 days.⁵ There were a total of 1,365 admissions to half of all hospitals in England and Wales between 2000 and 2005. In 2008, TARN estimated the cost of knife injuries to the NHS in England and Wales to be £7,699 per case. It looked at all the costs involved, including ambulances, surgery Much of the publicity focuses on larger cities such as London, Birmingham, and Manchester with higher ethnic demographic populations, but it would be wrong to assume that all areas are not susceptible to knife attacks and crime.

What role for primary care?
There are well established, supportive relationships offered to families in primary care where parents and young people will come to the attention of GPs and nursing staff in receiving a wide range of primary care. General assessment skills in maintaining an interest in the wider context of concerns that parents may have about their children as they grow into their teenage years may be a useful starting point. Informal conversations may have a part to play in enabling the concerns of parents to be explored. Should parents have concerns there is a good chance they will approach their family doctor or nurse to seek advice and support. Signposting for help and expert advice in these situations will be important and services such as Connexions (counselling for young people) can play a useful part in helping resolve anxieties and worry.

How to help
A simple guide to have in your toolkit for providing advice and support can be an essential part of a nurse's ability to support parents and young people at risk. We all have a part to play in accessing the hard-to-reach groups in our communities. Although perhaps controversial, young people who are choosing to immerse themselves in identities that glamourise gang culture need careful attention to help them reduce risk without losing face or status among their peers. Media publicity and stereotypes tacitly and inadvertently sanction carrying knives as an expectation in some groups, and local rivalry adds further risk to assaults and attacks. Raising the profile of local action plans and developing, for example, a local practice-based campaign to address risk such as the Daily Mirror campaign to 'Stop Knives, Save Lives' may well be a valid option to support a local implementation plan.

Multi-agency working
The Home Office announced earlier this year that £18m would be spent over the next two years on prevention of knife, gun and gang crime. To make maximum impact with this investment there will be a need for strong multi-agency links and integrated work on making sure positive progress and action is made, including the impact on healthcare services and resources. Although the criminal justice system, local community groups and education services might be seen as prime movers in addressing the need for change and support, healthcare across the care pathway has a key part to play.

The Association of Surgeons of Great Britain and Ireland is calling for all hospital A&E departments to share information about knife crime with the police as standard practice - including non-anonymised data, such as the victim's identity.

At the moment about 100 A&E departments in the UK (around two thirds of the total) have started logging details of violent injuries and sharing this information with the police, although only 50 are sharing their data fully.⁶ One of the most difficult aspects of healthcare actions and responses is the role in sharing data and details of incidents involving knife crime. This issue must be considered in relation to local policies on data protection and confidentiality before information is shared with other agencies including the police.

Raising the profile and addressing the cause
Actress Brooke Kinsella, the sister of Ben Kinsella who was killed in a knife attack in 2008, was appointed a government advisor earlier this year and has called for more education of children as young as ten. The excellent report she produced for the Home Office makes a strong case that barriers between formal services, including police and health, need to be broken down.⁷ She offers many examples of initiatives and programmes supporting improved outcomes and reduced knife attacks across the UK.

The notorious street unrest and riots across the UK earlier this year revealed the scale of potential lawlessness among many groups of the so-called 'disaffected youth' and indicated still further the potential for criminality that can at any time be triggered. As a societal problem our collective capability must to be address embedding positive values and attitudes in all exchanges with patients in a non-judgemental way.

The skills needed to enable this to be possible are in part counselling/humanist skills but also relate to balancing tolerance with empowerment to enable individuals to act as decent responsible citizens contributing to family and community life. Influential role models to achieve this will unquestionably include nurses often seen as highly respected figures in localities.

Having an awareness of how preventive steps that can make a difference to potential knife crime risks as well how to deal with the consequences of assaults, are important. It should be the case that doing nothing is not an option.

One of the section headings in the Home Office report on tackling knife crime is 'Understanding your youth knife crime problem'; and although one can be excused the accusation of making assumptions about certain groups, the need for better insight into, and appreciation of, pressures and influences is vital to helping families and individuals.⁸ The report, primarily aimed at the police service, describes a clear set of principles on suggested actions, and includes reference to the part health and hospital services can play in helping address knife crime risk.

A small-scale exploration of young people's perspectives
I asked my 12-year-old son, who attends an all-boys' school in the south-west of England, to do some low-key survey research seeking the opinion on knife crime in a random cross-section of friends and peers. The questions that formed the survey were:

  • What is the first word that comes to mind when thinking of knife crime?
  • Can you foresee a time when you might carry a knife when socialising?
  • How would you deal with a situation where your friends decided to carry knives?
  • What ideas do you have for tackling the growing incidence of knife crime?

The findings were, in many ways, predictably responsible with the respondents a little shocked at the suggestion they might be vulnerable to carrying knives.

While generating much discussion from this perhaps-unrepresentative group of boys, the fact that none of those questioned could foresee a time when they would carry a knife when socialising was reassuring for me on a personal level. It was possibly suggestive of an innocence not universal in some communities. I am not complacent regarding risk, however. The risk from knife crime is a universal threat and regardless of local demographics and commonality, knife carrying is becoming all too common and can be seen as an accessory liable to lead to serious, often fatal, consequences.

The future
A wide range of recommendations from reports, many cited in this article, include mention of healthcare services and practitioners taking a closer interest in the prevention of knife crime. This must include other associated risk factors, such as gang culture and bullying in schools and neighbourhoods. Being gang crime-aware and having knowledge and skills, such as links with local support networks, signposting awareness and assessment competence, is surely a must for all healthcare professionals.

Knife crime risk is a reality across all communities, however ostensibly 'low risk' the populations may seem. Attacks, events and, in some cases fatalities, will continue to cause catastrophic pain and distress to families in all sections of our society. Healthcare professionals have a proactive and preventive role, as much as a reactive one, in dealing with the impact of knife crime. Developing a special interest in being able to help more effectively should be considered to compliment these roles both now and for the future.

References
1.    National Audit Office. Knife crime statistics: UK map. London: NAO; 2011.
2.    Centre for Social Justice. No Excuses: A Review of Educational Exclusion. London: Centre for Social Justice; 2011.
3.    Kynaston H. Tackling Knives Action Programme. London: Home Office; 2008.
4.    Department of Health (DH). The NHS in England: The operating framework for 2009/10. London: DH; 2008.
5.    Trauma Audit Research Network. Hospital Admission Review Report. Manchester University; 2011.
6.    Cole A. Surgeons call for identity of knife crime victims to be shared with police. BMJ 2010; 341:c6579.
7.    Kinsella B. Tackling Knife Crime Together. A Review of Local Anti-Knife Crime Projects. London: Home Office; 2011.
8.    Home Office. Tackling Youth Crime. London: Home Office; 2010. Available from: www.nationalarchives.gov.uk/ERORecords/HO/421/2/cpd/jou/tyc.htm

Further Reading
Centre for Social Justice. Breakthrough Britain. Dying to Belong: An In-depth Review of Street Gangs in Britain. London: Centre for Social Justice; 2009.
Home Office. Tackling Knives Action Programme Factsheet. Available from: http://webarchive.national-archives.gov.uk/20100413151441/http:/www.crimereduc- tion.homeoffice.gov.uk/tacklingknivesb.pdf