Violence and Aggression in the Workplace

A Practical Guide for All Healthcare Staff

Paul Linsley

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781857757842
• eBook ISBN:
  9781315342467
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This is a practical guide that will support primary care members through the process of change towards PCT status and assist those with PCT status. The contributors present real solutions to the many unique issues faced in this new stage of NHS development. Endorsed by the National Association of Primary Care it is an authoritative guide for the present and for future development. All members of the new primary care organisations and those supporting them will find this handbook to be an enlightening and indispensable guide.

Chapter 1

Violence and aggression

Introduction

The level of violence and aggression against healthcare staff has become an important issue in recent years.¹ Indicators would suggest that anyone who works for the health and social care sector and who has contact with the general public is at risk from such behaviour.² This is not a new problem and reflects wider concerns about violent crime in society generally. More and more healthcare staff face the prospect of violence and aggression in the workplace, not only from the people that they care for, but from strangers and within families.³

People who behave in ways that bring them into conflict with others make special demands on a service and its staff who are already under pressure.⁴ Violence and aggression raise special concern because they significantly increase the risk of injury and harm. This can have an impact on staff confidence and morale as well as patient care. Threats, aggravation and tension caused by potential aggressors can lead to stress-related problems, emotional burnout and result in some staff leaving the service altogether.⁵

Appropriate interventions from healthcare staff are crucial to the immediate physical and psychological safety of themselves and those that they care for.⁶ As with other risks, reducing violence and aggression requires a systematic approach involving a number of strategies. Measures to reduce violence and aggression need to be based on sound risk assessment and risk management, underpinned by effective strategies worked out in collaboration with other agencies such as the local police department and prosecution service.⁷

Defining violence and aggression

One of the difficulties in addressing violence and aggression is that they are not easy to define.³ Violence and aggression are subjective terms that mean different things to different people and groups. This means that the same kind of violent incident may have quite different impacts according to the individual involved. Because of this, healthcare organisations and staff groups have defined violence and aggression in different ways for different purposes. However, in order to recognise, address, and prevent violence and aggression, healthcare staff must have a clear understanding as to what these terms mean. This requires a description that encompasses the different forms that violence and aggression can take, while allowing for personal interpretation and understanding. In doing this, it allows staff to take ownership of the problem and goes some way to acknowledging their concerns.

The Department of Health has defined violence and aggression as being:

Any incident where staff are abused, threatened or assaulted in circumstances relating to their work, involving an explicit or implicit challenge to their safety, well being or health.⁸

This is similar to the definition used by the Health Development Agency, which is as follows:

Any incident in which a person working in the healthcare sector is verbally abused, threatened or assaulted by a patient or member of the public in circumstances relating to his or her employment.⁴

The two definitions reflect the fact that violence is not restricted to acts of aggression that may result in physical harm but incorporates behaviour, including the use of gestures and language, that may cause the subject to become afraid or feel threatened and abused. Threats may be perceived or real, and there does not have to be physical injury for the violence to be a workplace hazard.

In a further definition, the International Labour Organisation defines violence at work as being:

All forms of behaviour which produce damaging or hurtful effects, physically or emotionally to staff in the course of their work.⁷

This definition suggests that harm could be caused unintentionally. This could occur with certain cultural differences as much as personal preferences in the way in which staff members or the public wish to be treated.

Lastly the Counter Fraud and Security Management Service (CFSMS), a special health authority within the NHS, who have overall responsibility for the management of violence and aggression within the healthcare sector, use the following definition:

The intentional application of force to the person, without lawful justification, resulting in physical injury or personal discomfort.⁹

This, however, fails to take into account unintentional violence which may be the result of a patient having received a head injury following a road traffic accident.

Whatever definition is eventually decided upon should have meaning for those that are going to use it, and ensure recognition of the problem. Promoting the issue of violence and aggression within the healthcare setting is as important as defining it, if not more so.

The different forms that aggression can take

Whatever definition is used, it is clear that in a working-life context violence and aggression vary considerably. It is therefore useful to consider the various forms these can take.

In general terms, aggressive or violent acts can be seen as being:

• uncivil behaviour: lack of respect for others
• physical or verbal aggression: intention to injure
• assault: intention to harm another person.⁵

Buss offers the following classification system in which he describes aggression as a mixture of physical/verbal; active/passive; or direct/indirect:¹⁰

• physical/active/direct: one-off, acute incidents that usually include physical violence, for instance, a drunken fight, a mugging, a confused patient lashing out, or routine and chronic incidents, such as being physically or sexually abused or bullied
• physical/active/indirect persuading someone else to do harm, such as advocating smacking as a form of discipline
• physical/passive/direct physically preventing someone from attaining a desired goal, such as a senior colleague deliberately blocking access to a post
• physical/passive/indirect refusing to perform necessary tasks
• verbal/active/direct using insults or being derogatory about another person, for example being sworn at, or made the target of racial or sexual abuse
• verb al/active/indirect: spreading malicious gossip about others or undermining confidence by belittling their capabilities and appearance
• verbal/passive/direct refusing to speak or answer questions
• verbal/passive/indirect failing to take responsibility for contributing vocally, such as not speaking up in another’s defence when he or she is unfairly criticised.

Using this framework, aggression can be seen as being any form of behaviour used with the intention to harm or injure another person. However, as has already been pointed out, acts of aggression can also be unintentional in nature. In addition to this, acts of aggression can be directed either outwardly towards others or inwardly at the individual, for example self-harm. Property damage is also a form of violence. While it may not threaten the safety of staff it can be stressful and distressing to witness. Consequently, aggressive acts can be seen as existing on a continuum from verbal or emotional acts to serious physical harm (see Figure 1.1).¹¹

It is also important to recognise at this point that aggressive acts can be enacted in writing, via email and over the phone, allowing greater access to staff than ever before.

Figure 1.1 Escalating aggression.

Activity 1.1

What do the terms violence and aggression mean to you? Reflect on any incidents from your work. What types of aggression have you experienced and which of these have you found most distressing and why?

Box 1.1 lists other words associated with healthcare violence and aggression.

Box 1.1 Other words associated with healthcare violence and aggression, and their definitions^{12, 13 and 14}

• Assault: a violent attack; an unlawful physical attack upon another; an attempt or offer to do violence to another, with or without battery.
• Battery: an assault with actual touching or other violence upon another.
• Controlling behaviour: preventing someone by force from acting freely. This can include keeping them from seeing relatives and friends, not letting them have a job or not letting them spend money or have access to their personal belongings.
• Emotional abuse: saying things on purpose to frighten the other person or putting them down to make them feel bad.
• Harassment: any action, whether verbal or physical, single or repeated, delibe...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• About the author
• Acknowledgements
• 1 Violence and aggression
• 2 Theories of aggression
• 3 Managing violence and aggression: risk reduction and prevention
• 4 Managing an aggressive incident
• 5 Staff support
• 6 Special considerations: care in the community
• 7 Special considerations: gender, violence, health and healthcare
• 8 Special considerations: legal issues
• Index