NHS Security Info – Free Download #6 – This brief is a review of the new, NHS Violence Prevention and Reduction Standards by Jim O’Dwyer, Senior Consultant at AEGIS Protective Services.
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The new, NHS Violence Prevention and Reduction Standards published by NHS England and NHS Improvement, in association with the Social Partnership Forum, are claimed to provide a ‘risk-based’ framework that supports a safe and secure working environment for NHS staff, safeguarding them against abuse, aggression and violence.
All NHS commissioners and all providers of NHS-funded services operating under the NHS Standard Contract 2021-22 will be required to ‘have regard’ to the violence prevention and reduction standards and to provide board assurance that they have been met twice a year.
Commissioners are also expected to undertake compliance assessments as part of their regular contract reviews, twice a year as a minimum, or quarterly if significant concerns are identified and raised.
Note: References to “Security Management” in Service Condition 24, will be removed and instead a provision is to be added to General Condition 5 relating to the new NHS Violence Prevention and Reduction Standards, as described above. Pending publication of new Guidance, the NHS Security Management Standards and guidance on security management previously published by NHS Protect remain as a guide to good practice only.
Like many others, I have been eagerly awaiting the arrival of the NHS Violence Prevention and Reduction Standards (VPRS). However, I have to say that my expectations have been far from realised and in my view, it is misleading to have included the word ‘standard’ in the title.
Whilst the document may provide NHS managers with a (loose) framework to work to, it is plain to me that it is not designed to define a common ‘standard’ best practice way to effectively manage the risk of violence.
In fact, if anything, it’s going to result in widening variation in the way responsibilities are discharged across the NHS and this conflicts with the government’s stated intention to ‘ensure violence and abuse data from across the NHS is reported nationally, so as to determine which staff are most vulnerable to violence and allow for appropriate action to be taken’.
In other words, the VPRS are, “Not fit for purpose.”
1. A ‘new’ definition of violence?
The introduction to the new NHS Violence Prevention and Reduction Standards references the World Health Organization definition of violence:
“The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either result in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”
However, nothing in the Standards document requires or encourages NHS Trusts to adopt the WHO definition and that beggars the question ‘Why refer to it?’ It just muddies the waters!
If the authors of the new NHS Violence Prevention and Reduction Standards wanted all healthcare providers to adopt a WHO definition, why didn’t they choose the WHO definition of workplace violence?
“Incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being, or health.”
The WHO definition of workplace violence is not too far off the Department of Health definition of workplace violence, which all NHS Trusts were required to adopt back in April 2000, which is:
“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.”
The HSE definition of Workplace Related Violence was originally:
“Any incident where an Employee is abused, threatened or assaulted in circumstances relating to their work’, involving an explicit or implicit challenge to their safety, well-being or health.”
However, the legal definition of ‘employee’ meant that agency workers, sub-contractors, and part timers were unintentionally excluded from the definition.
So, it then became:
‘Any incident in which a PERSON is abused, threatened or assaulted in circumstances relating to their work’.
It’s important to note that the latest HSE definition still doesn’t reflect that employers have a duty to protect others besides people who are ‘at work’, (for example, service users and other visitors – even unwelcome intruders, etc.) So, adopting HSE’s definition could complicate reporting and controlling these risks.
The definition of violence chosen for policy purposes provides a template for everyone (staff, service users and other visitors) to use to determine what is ‘reportable’ and what isn’t.
It can be a mistake to eliminate the prospect of gaining vital information by ‘defining it out’ in the definition you choose.
Maybe try this definition instead?
‘Any incident in which a person is abused, threatened or assaulted in circumstances relating to the workplace.’
I also prefer the term ‘Behaviour Management Plan’ to ‘Violence Prevention and Reduction Plan’.
2. Recording incidents
The VPRS makes it clear that providers of NHS-funded services are expected to be recording certain information about staff involved in violent incidents, including their age, sex, ethnicity, disability and sexual orientation; and also analysing incident records to identify any patterns or trends.
N.B. This may mean that some healthcare providers will need to amend their Incident Reporting procedures and forms accordingly.
However, the new VPRS neither prescribes nor suggests how incidents should be classified or categorised. This permits free interpretation at individual sites and effectively rules out the possibility of meaningful future comparison of ‘performance’ across different sites.
The new VPRS requires healthcare service providers to frequently analyse ‘violence data’ using ‘primary metrics’ and it also requires that a process exists for auditing violence prevention and reduction performance and ensuring that associated systems are effectively managed and assessed regularly. However, it neither specifies or, suggests what the ‘metrics’ should be. It also doesn’t provide or specify a process for auditing violence prevention and reduction performance. This obviously allows for (wide) variation in the ‘assessment of performance’ of the violence prevention measures.
3. Risk Assessments
The VPRS require that ‘violence risks’ are co-ordinated across the organisation and that risk assessments are made available to managers, their staff, trade union representatives and other relevant stakeholders.
The VPRS also require that violence prevention and reduction workforce and workplace Risk Assessments are managed and reviewed as part of an ongoing process and documented in the appropriate organisational risk registers. Significantly, the VPRS does not stipulate a methodology for conducting a Health and Safety Risk Assessment for Violence. Instead, it is left to providers of NHS-funded services to decide. The VPRS also does not direct or suggest who should carry out the Violence Risk Assessments.
Commonly in the NHS, responsibility for conducting Risk Assessments for Violence and Aggression is devolved to Department Managers. However, this can result in problems in the event of complaints and litigation that call into question the ‘competence’ of the Department Managers to conduct such assessments.
The Management of Health and Safety at Work Regulations 1999, S7(5) states:
“A person shall be regarded as competent for the purposes of paragraphs (1) and (8) where he has sufficient training and experience or knowledge and other qualities to enable him properly to assist in undertaking the measures referred to in paragraph (1).”
Risk Assessment is the foundation element of any violence reduction strategy and key to identifying risks.
The Risk Assessment process will also determine what precautionary measures (including staff training) need to be put in place. So, it’s essential the designated Risk Assessor is appropriately qualified for the task.
4. Consultation with staff
Risk Assessments need to be a ‘suitable and sufficient’ assessment of the risks. Meeting this legal expectation is impossible if the staff facing the risks have not been consulted as part of the process.
Involving and collaborating with staff is the best way to ascertain the level of risk (or perceived risk) being experienced and staff are often best placed to suggest how the risks could be mitigated.
It would be an error of judgement not to involve the staff and other stakeholders (including patients and visitors) in the process of Risk Assessment and identifying risk mitigation solutions.
Having the (signed and documented) agreement of staff and/or their safety representatives that ‘everything reasonable and practicable’ had been done to minimise the risk of violence is powerful evidence when defending a claim of negligence.
Note: The VPRS require that the recognised trade unions are consulted and involved in the development of violence prevention and reduction objectives and reference the legislation (see below) requiring employer organisations to consult with the workforce and workforce safety representatives, unions, etc.
5. Monitoring inequality and disparity in experience
From my reading of the VPRS, NHS England and NHS Improvement are clearly focused on identifying whether or not violence and aggression is experienced disproportionately by groups with protected characteristics.
The VPRS require that a ‘diversity lens’ is applied to violence prevention and reduction objectives development, to provide due diligence for Public Sector Equality Duty and that this is validated by a Subject Matter Expert, pertaining to the Equality Act 2010. The VPRS require that inequality and disparity in experience for any staff groups with protected characteristics to be addressed in the violence prevention and reduction plans and this is clearly referenced in the equality impact assessment – which needs to be made available to all stakeholders. Violence prevention and reduction arrangements also need to be “triangulated” with NHS Workforce Race Equality Standard (WRES) and NHS Workforce Disability Equality Standard (WDES).
The VPRS also requires senior management to be kept informed about any disparity trends for violence and aggression against groups with protected characteristics.
6. Staff Training
The VPRS requires that a training needs analysis (TNA) informed by the Risk Assessment for Violence to be undertaken and suitable and sufficient training and support are accessible and provided to all staff. However, no methodology is suggested or provided for how to carry out the TNA.
Since 2004, NHS Trusts have been ‘expected’ to provide all ‘frontline’ NHS Staff with Conflict Resolution Training (the ‘national’ syllabus designed by NHS Protect) and to refresh the training every three years. Many NHS Trusts also supplement CRT with Breakaway Skills aka Assault Avoidance Skills training.
Now, NHS Trusts are ‘free’ to determine for themselves what training different staff groups need to have. It’s a great opportunity for Violence Prevention and Reduction leads to review the research that has been carried out into the effectiveness of violence prevention training in healthcare settings – and exploit the chance to re-examine and re-define training objectives.
Check out the links below.
This report was published two years after NHS Protect had required all NHS Trusts to provide frontline staff with CRT and provides an insight into its ‘effectiveness’.
See ‘SUMMARY OF KEY FINDINGS’ (Page 27)
“In general, training in violence management across Healthcare organisations is having positive, but limited, short term benefits. It is fundamental to the success and effectiveness of such training that programmes are designed or selected and delivered on the basis of a sound understanding of what is actually needed. What is clear from the research is that where training does not reflect a sound understanding of need, the impact of training is at best negligible and at worst negative (i.e. staff are leaving training feeling less capable in dealing with violence and aggression in the workplace)”.
In the video, Bill Fox of Maybo said:
“I don’t think everyone is receiving the proper training and today we have debated what is the proper training with research from Glamorgan University and from other studies, there’s a question about the actual validity of some of the training – of Breakaway Skills for example, which is a very old fashion term that explains training to get away from harm, much of which the research is saying and it’s certainly my view as well, is actually a lot of time and money wasted, because we are teaching skills to deal with situations that rarely if ever occur. We are not addressing the real risks, very often we are teaching what we think people need, and staff forget those skills. So, I think quite rightly they are being challenged.”
Note: For information on conducting a Training Needs Analysis, see pages 29 and 47 of HSE Research Report 440
7. Promoting a reporting culture
Management is reliant on staff to report violent incidents and safety concerns, so as to be able to mitigate the risks. However, under-reporting of violent incidents and especially verbal abuse remains endemic across NHS services.
The main reasons why nursing staff don’t report violent incidents are, the patient’s clinical condition and sympathy and consideration for the patient or their relative.
Another difficulty is that many NHS staff still appear to accept abuse and mistreatment as ‘something that goes with the job’ and they don’t want to make a fuss.
Other common reasons for not reporting violent incidents include:
- Lack of clarity about what constitutes a reportable incident, particularly verbal abuse.
- The situation was resolved or, was considered not serious enough.
- Staff perception that the reporting process is complicated and time consuming to complete.
- Staff perception that involvement in a situation would be seen as their individual failure, and/or their mishandling of the situation and professional incompetence.
- Some staff are so distressed that they do not want the attention a report would bring.
- Staff won’t report incidents if they believe no action will be taken to address the root cause.
A number of initiatives have proved successful in encouraging staff to report incidents and safety concerns.
- A documented policy that unambiguously requires staff to report all incidents that meet the requirement to report.
- Making the reporting form or procedure easier to use.
- Actively promoting the need to report incidents during induction sessions and other training and through the use of posters, presentations, workshops, etc.
- Educating staff about their statutory duty (s.14 MHSW Regs 1999) to report incidents and safety concerns and the possibility of retrospective criminal prosecution by HSE for failure to report, plus the prospect of immediate dismissal for gross negligence.
However, any improvement generated will likely only be temporary without continuing and highly visible senior management support (and, especially if a ‘covert culture of non-reporting’ exists at the department or worksite.
8. Feedback to staff
Nothing extinguishes staff motivation to report incidents and concerns faster than an absence of feedback or change/improvements. The VPRS recognises this and ‘requires’ that staff receive timely responses to incident investigations, and where this may be prolonged by process requirement, this is recorded and communicated to staff, senior management and relevant stakeholders.
The VPRS also requires that identified violence risks and their mitigations/controls are communicated to all staff in regular bulletins.
9. Next steps
Violence Prevention and Reduction leads should:
- Review the organisation’s Policy on Violence and Aggression (including the definition of violence to be used) together with the Withholding of Treatment Policy.
- Parties to involve in the review include, the Security Lead, the Safeguarding Lead, the HR Manager (as the person responsible for overseeing the investigation of allegations of inter-staff violence and aggression), the Patient Experience Lead and patient group representatives.
- Identify the kinds of violence and aggression that may be expected to arise in connection with the workplace and decide how best to categorise each kind of violence (clinical, non-clinical, physical, non-physical, etc.)
- Decide (and record) who should have ‘primacy of responsibility’ for each particular category of violence.
- Ensure the Incident Reporting process is clear, unambiguous and as easy as possible for staff to use (with suitable prompts provided for all the information required.)
- Devise a reliable mechanism for conveying the policy message to staff about what and why they are required to report, how to make the reports and how reports will be dealt with.
- Ensure the reporting process will result in staff receiving timely responses to incident investigations, (and where this may be delayed, this is recorded and communicated to staff, senior management and relevant stakeholders.)
- Ensure the Reporting Mechanism results in ‘RIDDOR reportable’ incidents being promptly communicated to HSE.
- Ensure that individuals designated to conduct Risk Assessments for violence and aggression are ‘competent’ to undertake the task.
- Engage with and consult staff, workplace safety representatives, police and legal advisers on Risk Assessments and the suitability and sufficiency of the safety arrangements being relied on to reduce identified risks, including setting appropriate minimum safe staffing levels (and skill mix) as well as staff training. Be satisfied that ‘everything reasonable and practicable’ has been done to eliminate or at least minimise the risks (i.e. complying with H&S legislation.)
- Ensure appropriate arrangements are ready in place (Occupational Health) to help mitigate the effects of a violent incident including, professional counselling and other support to staff who have been victimised.
- Establish (and closely monitor) the extent and reasons for work-related sickness absence and the cost of work-related ill health retirements, the legal fees incurred and compensation awards due to incidents of violence and aggression.
- Staff satisfaction is the best indicator that the safety arrangements are adequate. So, as frequently as practical, conduct departmental staff surveys (including provision for anonymous responses) that include questions about the impact of violence and aggression, any constraints to reporting incidents and levels of satisfaction with the way incidents are dealt with by management – and ensure relevant data is fed back into the Violence Prevention and Reduction plan.
- Check that staff exit interviews are designed to elicit cases where staff leave due to experience of violence and aggression, in any form – and ensure relevant data is fed back into the Violence Prevention and Reduction plan.
- Identify a Subject Matter Expert in Diversity (i.e. pertaining to the Equality Act 2010) to validate due diligence and compliance in respect of the Public Sector Equality Duty, which requires public bodies to have ‘due regard’ to the need to eliminate discrimination, advance equality of opportunity and foster good relations between different people when carrying out their activities.
- Contact other local/similar NHS service providers to arrange a two-way ‘peer review’ of the violence prevention and reduction arrangements, to ensure parity.
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I hope the information above is useful to you. If you would like to discuss any aspect of it, please feel free to give me a call.
AEGIS Protective Services
T: 01202 773736