A quarter of all workplace violence occurs in healthcare environments (Iennaco et al, 2013) and ambulance staff are the most vulnerable group of all, with 31% reporting the experience of physical violence from service users, their families and other members of the public in 2014 (NHS England, 2014). This is more than double the number reported by other NHS staff (14%) and interestingly, even higher than rates reported by those working in mental health in this particular report (17%) (NHS England, 2014), despite mental healthcare settings being among the most dangerous workplaces by far (NHS Protect, 2013).
The National Institute for Health and Care Excellence (NICE) recently commissioned updated guidance from the National Collaborating Centre for Mental Health (NCCMH) on the short-term management of violence and aggression that was published earlier this year. The guidance emphasises the importance of appropriate organisational policies, training and risk assessment skills, as well as relevant support post incident for staff in order for them to effectively deal with its physical and psychological consequences (NCCMH, 2015). However, the problem of violence and aggression against ambulance staff and other health professionals is not limited to the UK and is in fact a global issue. South Australia (SA) Health is campaigning against this very issue, reporting that SA Ambulance has seen a 74% rise over the last 3 years in incidents such as being spat on, physical assault such as kicking, biting and punching, threats of violence, and aggressive behaviour sometimes involving use of a weapon (SA Health, 2015a).
Factors of vulnerability
According to SA Health (2015b), challenging behaviour with the potential to physically or psychologically harm another person can occur anywhere but tends to take place more commonly in cases where patients have conditions such as mental illness or substance abuse, in emergency, traumatic, stressful or emotional situations, and in environments where there may be limited access to assistance for workers. Unfortunately, all of these factors commonly apply to ambulance services and begin to shed some light on just why they are such a vulnerable group in terms of workplace violence and aggression.
Not only are ambulance staff thrown into unfamiliar and often highly volatile environments on a regular basis, they also may not report violent acts because they are seen as being ‘part of the job’ or are mediated by compassion for the patient and their circumstances (SA Health, 2015a). As SA Health importantly points out, however, such aggressive or violent behaviours are in no way an acceptable aspect of ambulance work—despite the apparent tolerance on the part of staff, such incidents will contribute to decreasing staff morale and self-worth (SA Health, 2015a).
Impact on staff
Ambulance staff who are working hard to help others cannot do their jobs effectively if they are worrying about their own safety and their physical and mental wellbeing. It is also reasonable to assume that over time, they may begin to feel discouraged and disillusioned in a job where they are trying to save lives, yet others are verbally and physically abusing them. As previously mentioned, staff morale and self-worth are likely to decrease as a result of being on the receiving end of such aggression (SA Health, 2015a), and feelings such as anger, fear and depression are also reasonable responses to being abused.
In addition, evidence indicates a clear link between violence and aggression and staff sickness absences, turnover and lost productivity (National Audit Office (NAO), 2003). The NAO (2003) estimated the direct costs of work-related violence and aggression to be at least £69 million per year and this number did not take into account human costs such as physical and psychological pain, stress levels, and the impact on staff confidence and retention. The same number was quoted in the recent NICE guidance which said that human costs continue to rise (NCCMH, 2015).
Addressing the problem
One of the biggest barriers to addressing the problem of violence and aggression against ambulance workers and other health professionals, appears to be the underreporting of incidents (NAO), 2003). While the NHS zero tolerance campaign policy made some progress in raising awareness of this issue among health professionals resulting in higher reporting, many concerns about reporting incidents were still expressed by staff, including the following (NAO, 2013):
‘Ambulance staff who are working hard to help others cannot do their jobs effectively if they are worrying about their own safety and their physical and mental wellbeing’
Awareness, appropriate training and policies, and an organisational culture in which staff feel safe to report an incident and where they know they will be supported is vital to addressing this situation. The recent NICE guidance specifies that ambulance Trusts should ensure they have up-to-date policies on how to manage violence and aggression in people with mental health problems and on lone working in community and primary care settings (NCCMH, 2015). It also recommends that ambulance Trusts should consider training their staff in methods of avoiding violence, such as anticipating, preventing and de-escalating it, as well as breakaway techniques (NCCMH, 2015). Ambulance Trusts should also ensure that their staff are able to undertake a risk assessment for violence and aggression, and such assessments should be shared with other health and social care services and partners such as police services (NCCMH, 2015).
Conclusions
All staff have the right to a safe working environment. In the case of ambulance workers whose environments are usually unknown and carry the potential to be extremely dangerous, ambulance Trusts carry additional responsibility to minimise risk to their staff as much as possible and ensure that they are reasonably equipped with the necessary tools to anticipate, prevent and manage workplace violence and aggression (NCCMH, 2015). They also must ensure that staff feel safe and supported, and work in an organisational culture where reporting an incident is perceived to be a strength rather than a weakness. Appropriate post-incident support must also be available for all staff and there must be a culture of acceptance rather than stigma around seeking such support. Ambulance staff do the invaluable job of keeping members of the public safe—the least we can do is contribute to their protection.
