Reducing Violence and Aggression: Joining the Dots

Dr Natalie Fairhurst, Dr Mohsin F. Butt and Dr Natalia Barry*

*North Middlesex University Hospital NHS Trust, Sterling Way, London, N18 1QX natalia.barry@nhs.net

Introduction and aims

Half of all reported violent incidents in healthcare settings occur in the emergency department (ED) (1 ) The British Medical Association have reported that over 40 % of doctors have seen physical violence or verbal abuse in the workplace (2 ), making this is an occupational hazard

The anxiety and stress endured by patients and carers is typically compounded by long waiting lists, which can fuel hostile behaviours towards staff (3 ) Workplace violence can result in lack of confidence, anxiety, increased use of alcohol and post- traumatic stress disorder (4 ), which highlights the importance of reducing this threat in the ED It was clear from our Datix system (the NHS system for reporting incidents) that staff were experiencing frequent episodes of violence and aggression from visitors to our emergency department, with likely underreporting of levels . As such, our primary objectives were as follows:

(a) To assess the extent of violent and aggressive behaviours within the department over a 4week period

(b) To remind colleagues of the importance of not accepting these behaviours as or an acceptable part of daily work

(c) To implement changes to the patient experience with a view to reducing the incidence of aggression towards staff in our department

Summary of Stage 1 of the Quality Improvement Project:

Data analysis revealed that the highest incidence of workplace violence in the emergency department occurred in the reception area

A working group was established to develop interventions that would enhance the patient experience in the waiting room and reduce violent acts

Interventions included:

Information on current waiting time

Artwork describing the triage process

Providing information in multiple languages

Structural adjustments to the main waiting area

Information on levels of violence and aggression toward NHS workers

Methodology and PDSA cycles

Workplace violence was defined as "any incident in which an employee is abused, threatened or assaulted in circumstances relating to their ( 2)

Numerous safety crosses (Figure 1) were displayed around the three central areas of the department : (a) the reception (b) adults ED and (c) paediatric ED All staff members in the emergency department were made aware of this visual data collection tool and were asked to record all incidents of violent behaviour Staff were requested not to duplicate their entries on multiple safety crosses

Data analysis (Figure 2) revealed that the highest number of workplace violence events occurred in the reception area, which allowed us to prioritise interventions that would reduce violent behaviour in this specific area

To this end, a working group was established along with help from NHS Patient Experience Group (PEG) to identify factors that contributed to patient experience within the ED The PEG, reception staff, nursing staff and a group of local sixth form students (London Academy of Excellence, Tottenham) helped design interventions (Figure 3) to reduce violent acts in the reception area.

What did we learn?

Violence and aggression towards staff is a common occurrence and incidents are drastically under- reported

The focus of work going forward should be to address the contributory factors but also to highlight that violence is an unacceptable part of the daily staff experience

Our audit has exposed these issues and reinforced the need for solutions

Primary interventions have been made including the use of posters/artwork in the main waiting area which clarify the ED procedure, alongside more generic additions (plants, water fountain, clocks and waiting time board)

Our work is currently in progress and shall be re- audited in 6 months after all interventions have been introduced

Factors contributing to aggressive behaviours and interventions