Going to work should not mean being subjected to physical or verbal assault, but this is the reality faced by thousands of frontline NHS staff.
Estimates suggest that around 15% of NHS staff in England experienced physical violence at work in 2017. Also, analysis of violence against NHS staff found that violence against most healthcare workers rose between 2015 and 2016.
To combat the issue, the UK government recently passed legislation that increases the penalties for anyone found guilty of assaulting an emergency worker, including healthcare staff in accident and emergency departments, urgent treatment centres, and all nursing staff. Alongside this, there is a stronger focus emerging on providing individual healthcare staff with violence de-escalation training with a view to help manage, reduce or prevent violence from occurring in the first place.
But before considering how best to use a de-escalation programme for NHS staff, including for ambulance and emergency department workers, it is important to know if such schemes work.
Workplace violence may derive from multiple sources but the focus of de-escalation training for healthcare staff is typically on violence from patients and those with criminal intent. A key area that may provide parallels is in the de-escalation training programmes already adopted by police and mental health workers. These programmes range from education about the causes of violent or aggressive behaviour to verbal and/or physical techniques for responding to it.
A recent RAND Europe study suggests that training staff in de-escalation techniques per se does not reduce violent or aggressive incidents or prevent them from occurring, but rather that de-escalation training may help staff to manage patient violence and aggression that occurs.
When staff have the appropriate knowledge, confidence, attitudes and skills to handle aggressive or violent patients, they are less likely to experience harm resulting from patient aggression.Share on Twitter
When staff have the appropriate knowledge, confidence, attitudes and skills to handle aggressive or violent patients, they are less likely to experience harm resulting from patient aggression.
Participants in de-escalation training programmes routinely report that they have greater confidence and knowledge around how to handle potentially aggressive or violent situations after completing the training.
The study also found that comprehensive and organisation-wide approaches seem to deliver the most sustainable results for reducing violent and aggressive incidents.
Such initiatives could include de-escalation training for staff as one component, but might also need to introduce systematic changes to organisational practice and culture such as additional security measures, 'zero-tolerance' policies that mandate the reporting of all violent incidents, or patient management systems to better control the flow of patients in emergency department waiting rooms.
There are other potential benefits to be realised from training frontline healthcare staff in de-escalation approaches. Evidence shows that the economic costs associated with staff time required for participation might be partially offset by a reduction in lost workdays, improved staff retention, reduced complaints and reduced overall expenditure. We also know that managers' commitment and engagement are key to a programme's success.
If de-escalation training is to be adopted as part of an approach to managing violence and aggression within the NHS, it will require engagement at all levels. It is this collaborative approach between frontline staff and managers that is most likely to result in positive impact and culture change.
A key point from the study is that there simply is not enough research yet about what works in specific healthcare contexts. The research provides those considering how to approach de-escalation training with the opportunity not only to test and evaluate their approach, but also to tailor their aims and objectives around what the report suggests are the likely outcomes.
Crucially, and given that we know programmes such as 'zero-tolerance' have been shown to have negative effects on students in educational settings, it could be critical that any programme of change is individualised, accounting for specific organisational, worker and patient needs.
Brandi Leach is an analyst at RAND Europe working in the area of innovation, health and science; Michael Whitmore is a research leader at RAND Europe, primarily developing initiatives and research into health and work wellbeing
This commentary originally appeared on Nursing Times on September 4, 2019. Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.