As readers will no doubt be aware, violence against healthcare workers is increasing year on year—and not just in the UK (Vento et al, 2020). Ambulance trust staff are particularly at risk, with 33.4% of ambulance staff reporting violence in the workplace, compared with 14.5% in other NHS trusts (NHS, 2020). A key part of the NHS Long Term Plan is to prevent violence against paramedics through rolling out body-worn cameras (BWCs) to act as both a deterrent, and a prosecution tool (NHS, 2019). However, BWCs pose serious ethical and practical questions for the profession, which deserve greater consideration before they are adopted into widespread use.
To understand why BWCs pose an ethical question, it is first important to consider the role of the paramedic in society, the role of surveillance, and to examine some of the predictive factors for patients who can be violent. Paramedics are autonomous professionals who deliver care across the boundaries of healthcare, social care, public health and public safety (College of Paramedics, 2021). Paramedics are also required to shoulder a number of ethical obligations (Health and Care Professions Council (HCPC), 2016) including delivering care to all those who need it, upholding the rights and dignity of all service users and always acting in their best interest.
Surveillance and prosecution are tools of social control, primarily associated with policing and the justice system (Foucault, 1975). BWCs are a surveillance tool, being introduced, at least in part (NHS, 2019) to aid in the prosecution of offenders. Violence against healthcare workers is a complex issue, with a variety of factors influencing its likelihood, including (but not limited to): patient stress, drug and alcohol use, mental illness, and previous offending (Crilly et al, 2004). Additionally, other factors such as long wait times and feelings of a loss of control or of not being listened to, all influence the likelihood of violence (Gates, 2004). It is no coincidence that these are many of the same factors we associate with health inequalities, and the inequitable distribution of resources in society (Lown and Setnik, 2018). The question then, is whether the use of BWCs interferes with our ethical obligations to vulnerable groups.
It is clear that paramedics are under no obligation to provide care to someone who is actively trying to harm them (at least until they are no longer trying to do so). What is not clear is whether BWCs interfere with the ethical obligation to always act in the best interest of patients. Use of BWCs as a de-escalation tool is reliant on the threat of prosecution (Ariel et al, 2018). Their use is complementary to a relatively recent legislative change to increase maximum sentences against those convicted of violence against healthcare workers from 6 months to 1 year (GOV.UK, 2018). Unfortunately, the short sentences proposed by the Government's 2018 law fail to rehabilitate or reduce re-offending rates, and often exacerbate poverty and social exclusion (Johnston and Godfrey, 2013). In fact, the justice system as a whole—and prisons in particular—often aggravate health inequalities and the issues of poverty that result in contact in the first place (Health and Social Care Committee, 2019). Given paramedics' obligation to always consider the best interest of their patient, is it right to threaten patients with prosecution and entanglement with a justice system that can worsen their health outcomes?
There are alternatives to this judicial approach to reducing violence against ambulance staff. The Scottish Violence Reduction Unit (SVRU) is a Scottish Government and Police Scotland collaborative initiative applying principles of public health to societal violence (SVRU, 2021a). The fundamental tenet of the SVRU is that violence is preventable, not inevitable. The SVRU works directly with communities to highlight the consequences of violence, has developed programmes of monitoring for violence risk factors, established programmes to improve the inequalities that result in violence, works with ex-offenders to understand the reasons for violence, and many other interventions (SRVU, 2020). In pursuing this strategy, Scotland saw a reduction in reported violent crime between 2005 and 2019 of 48% (Scottish Government, 2020). Crucial to the success of this approach is collaboration across disciplines and areas of public life because, as SRVU (2021b) recognises, violence is not solely an issue for the police. Instead of considering this complex approach, we have BWCs being sold as the solution, despite the existing evidence on their effectiveness being unclear (Lum et al, 2020). Some studies suggest that BWCs may even increase the number of assaults (Ariel et al, 2017). Sadly, despite an NHS (2012) report that centred on the need for a public health approach to tackle violence, including violence against NHS staff, this approach seems entirely absent from the NHS Long Term Plan.
It is difficult to imagine what a public health approach to this problem might look like. However, any public health approach always starts by seeking to fully understand the reasons a problem exists, something which Landau et al (2018) have done with some success. Landau et al (2018) examined the emotions of patients and accompanying persons in an emergency department in Israel, and confirmed their hypothesis that negative emotions act as fuel for violent outbursts. They found the major predictor of negative emotions was perception of care quality (a broad term which encompasses wait times, actual care standard, staff attitude, lack of privacy, lack of explanation of circumstances and other factors). In line with other studies (Lown and Setnik, 2018), they suggest that investment in training (to develop interpersonal skills in emergency department staff, assist with recognition and management of emotionally charged situations, and developing staff's reflective ability as well as their ability to exercise compassion when under stress) could reduce incidents of violence. This deeper understanding of the causes of violence allows Landau et al to recognise that without investment at the structural and systemic level, there can be no decrease in violence at the individual level. However, while this information is useful and no doubt has parallels for the UK ambulance services, it is not directly applicable due to the system differences between the two countries. Therefore, it is beholden on the NHS and academics to examine these issues here, so we can develop our own system-specific solutions.
Ultimately, violence in the workplace is a complex issue which will require complex solutions. Paramedics have an ethical duty to their patients, and the current violence reduction strategy of BWCs has the potential to undermine this duty. This is particularly troubling when there are alternatives, which would seek to address the issues causing violence in the first place, rather than merely reacting to it. More needs to be done to ensure that paramedics work in safety, and this must start with the NHS and researchers asking the right questions— and using the answers to shape policy.