Violence is Never the Answer, But What Is the Answer to It?

 

England has been in the grip of far-right riots, in the previous week, following the horrible murders of three young girls. These riots were stoked by racist lies, mostly online, but fizzled out when confronted by large and peaceful counter protests. So many people were threatened and injured in these riots, so many people have had their businesses and livelihoods destroyed, and many NHS staff were also the victims of these riots.

Two Filipino nurses were attacked in Sunderland. They were sharing a taxi to work. GP Practices and other healthcare clinics closed early, during the riots, to enable staff to get home safely. NHS staff have received threatening messages, clinics have closed early because staff feared being trapped in themby rioters, staff were afraid to use public transport and were not going onhome visits. So many NHS staff were affected by these riots, directly and indirectly. So many NHS staff were feeling very afraid by these riots, and afraid clinicians don’t deliver the best care, and that isn’t their fault.

The new Health Secretary Wes Streeting, in response to this, said: “I will not tolerate, under any circumstances, NHS or social care staff in any health or care setting being subjected to intimidation, harassment or racist abuse.

“We have a zero tolerance policy in the NHS and we'll take a zero tolerance approach in social care too.

“People who are abusing NHS staff can be turned away, and should be turned away, if that is the way that they are treating our staff."

But Wes Streeting wasn’t right, there is no specific NHS zero tolerance policy to violence against staff. Many NHS trusts have zero tolerance policies but NHS England does not have one. In 2018, the then Health Secretary, Matt Hancock, announced the Stronger protection from violence for NHS staff policy. This announced a “violence reduction strategy”, which included:

• NHS to work with the police and Crown Prosecution Service to get prosecutions in the “quickest and most efficient way”.

• the Care Quality Commission (CQC), as part of their inspections, to monitor the level of violence against staff in a trust.
• training for staff to deal with violence.
• prompt support for staff.

What this didn’t contain was a zero tolerance to violence against NHS staff policy.

In 2020, NHS England released Violence prevention and reduction standard, which stated that it was part of an NHS employer’s duty of care to protect staff against violence and abuse at work, but this didn’t contain a zero tolerance policy either.

The Royal College of Nursing (RCN) summarised what NHS staff are allowed to do if they are faced with a violent and/or abusive patient. The nurse (or other NHS clinician) can refuse to treat a patient who is threatening or being violent. But care cannot be automatically withdrawn from the patient, it should be delivered while the patient’s violence is “managed”. Any violent situation must be discussed with the clinician’s manager and assessed. The clinician’s employer has a duty to the clinician but also has a duty to provide care to the patient, even if they are violent to healthcare staff. But an employer cannot dismiss or discipline a clinician for refusing to treat a violent patient. The emphasis is on managing the patient’s violence and ensuring the patient still receives care.

The Nursing and Midwifery Council (NMC), the nursing regulator in Britain (Find a discussion of their duties here), on 9th August, sent an email to all professionals on their register, about the current riots. They first reminded readers that, under the NMC’s Code of Conduct, “that professionals should prioritise people and put the interests of people needing or using health and care services first.” If faced with a violent patient, a nurse “should escalate your concerns as soon as possible. Your health and safety at work is your employer’s responsibility.” The NMC’s language is clumsy but their point is clear, nurses should put the patient first. If they are faced with a violent and/or abusive patient, they should still be treated and later “escalated” for management to decide what to do. There was no mention, nor any discussion, of a zero tolerance policy.

While I worked as a nurse, I was the recipient of violence and abuse from patients and/or their relatives, far too many times, and even more times I supported colleagues who had been the victims of violence and/or abuse at work, especially racist abuse. Only one time was I supported by a manager. As a ward nurse, a patient’s relative had threatened me with a knife. He also threatened a porter. My manager called the police and had the relative arrested for his actions, she also had the patient discharged that day too because he encouraged the attacks. But this was the exception. I have watched managers bend-over backwards to accommodate abusive patients. When I worked as a District Nurse, we had a patient who had physically and racially abused so many nurses that the whole team refused to visit her. Senior management repeatedly put pressure on us to visit her and they went out of their way to arrange a plan so she would get the care she wanted. She suffered no repercussions for her behavior. Senior managers seemed to be far more afraid of violent patients complaining about not getting the care they want, then about the effect of violence and abuse against staff.

I still see that attitude in the current policy about violent patients. NHS staff have to find a way to treat abuse patients. There is still no zero tolerance to violent patients. Would this be tolerated in other professions? If a constituent was violent and abusive towards an MP, would the MP bend over backwards to meet that constituent’s demands?

There are 75,000 physical and verbal attacks on NHS staff each year yet only 2.4% of these assaults ended with the attacker being cautioned or charged bythe police, let alone found guilty by the courts. This 2.4% could be an over estimation because only half of trusts responded to this survey. How is this zero tolerance of anything?

Punch a nurse and you’ll probably get away with it, scot-free.

 

Drew

#HelloMyNameIs

 

“Hello, I’m Drew; I’m one of the nurses looking after you...”

This is how I always greet new patients, or patients’ relatives or carers, when I first meet them. I tell them who I am and what my name is. This is what I have always done, throughout my career, because it was the way I was trained to and because I always want to introduce myself, its only common courtesy.

I was horrified when I heard about the twitter campaign #HelloMyNameIs. It was started by Kate Granger, herself a doctor, who is undergoing cancer treatment.

My initial reaction was “Oh great, another patronising twitter campaign”, and I was about to dismiss it when I heard what was behind it.

While an inpatient, Kate Granger had experienced care and treatment from a whole string of different clinicians, none of whom had told her their name. Basically, they were anonymous strangers and they were delivering her care and treatment.

Knowing someone’s name is the beginning of forming a relationship with them. How many of our friends, how many of our colleagues do we know well and yet not know their name? We need to have a good, working relationship with our patients to be able to give them the best care we can. How can a patient trust us and open up to us if they don’t know our name? How can a patient trust a nurse’s clinical skill when they are giving them an injection or taking their blood when the patient doesn’t even know the nurse’s name? How can a patient open up to a nurse about the pain they’re in or the symptoms they’re having, especially embarrassing symptoms, when they don’t even know the nurse’s name? These questions can go on and on but they all boil down to the same thing, how can a patient trust us when they don’t know our name?

Our names are very important, they’re how we’re known to the world, they’re how people remember us and how they identify us. We know our patients’ names already, but by not giving them our own name we immediately set our working relationship as unequal, and we’re telling our patients to trust us when we don’t even trust them with our name.

What are we afraid of by withholding our names from patients? It creates such a poor image of nursing when we do this. How can we demand an open culture in healthcare when we aren’t being open with patients ourselves, when we don’t even tell patients our name?

My partner’s a Clinical Nurse Specialist. A few weeks ago, in the middle of the afternoon, he was carrying out a ward audit, which involved talking to patients about their care. He went up to a patient, told her his name and role, and explained why he was there. The patient then exclaimed; he was the first person to introduce himself to her all day.

How can we have good therapeutic relationships with our patients when we don’t tell them our names?

(This was originally published as a comment piece in Nursing Standard magazine in February 2015)

 

Postscript

I wrote the above out of shock and anger when I heard of the #HelloMyNameIs. I was so angry that there needed to be this campaign, why weren’t healthcare professionals already doing this?

That was eight years ago. Every NHS Trust now has its “Hello My Name Is” policy, or similar policies requiring staff to introduce themselves to patients, and everyone who has a patient-facing job, to any degree, wears an oblong, yellow badge, with their name written on it (like the picture illustrating this blog). So why am I resurrecting an old piece of writing, published years ago?

Over the last year, my situation has changed and I’ve been a patient far more than I’ve been a nurse. At first, I was shocked and now I’m just frustrated at the low percentage of healthcare professionals who introduce themselves to me, without being asked, telling me their name and job title. And I am really tired of the large number of them who get angry at me for asking, especially when I have to repeatedly ask them. They know so much about me, they know my name, age, and often a lot of my medical history, and yet I don’t even know their name. As I wrote above, it is impossible to trust someone who’s name I don’t even know. Also, when someone doesn’t give me their name, I always have the thought “what are you hiding?” I’m immediately on the defensive, what kind of bad care am I going to get from this person.

So many healthcare professionals seem to feel their yellow Hello My Name Is… badge is all they need, it does the job of introducing themselves, so they don’t have to do it. They can just get on with their jobs. But it isn’t a substitute, it doesn’t even come close to it. Even if you have good eye sight, those badges are not easy to read, especially when the person is already talking at you, and they don’t state the person’s job title.

I have seen the knock-on effect of this attitude too often, clinicians only seeing me as a collection of symptoms, as merely a task to be completed quickly, as only “a patient”, not as a person. And why should they go out of their way to help me? Why should they see me as an individual, instead of just the same as all the other patients? Why shouldn’t they just do their task quickly and move on from me? The nurse who conducted an assessment of me but didn’t take her eyes off the computer screen in front of her, not looking at me once. The clinician who shouted at me, “I’m not here for your benefit!” because I couldn’t lay flat being too breathless. The nurse who refused to help me, because she said she was too busy with paperwork, not even asking what help I needed. The Multi-Disciplinary Team (MDT) meeting, I wasn’t allowed to attend, where seven different consultants decided what treatment I would be considered for, but only one of those doctors had met me, and they couldn’t even get my symptoms right.

I would hope that those incidents wouldn’t have happened if those people had introduced themselves to me, but I just don’t know. I do know that they mightn’t have happened if those people saw me as a person, not as just a task or a group of symptoms.

“No Decision about me, without me”, was first coined in 2011 in the Department of Health consultation Liberating the NHS: No decision about me, without me. This was a call for shared decision making, where clinicians involve patients in clinical decision making, when deciding on treatment plans and options. Asking patients what they want from healthcare, what is their priority for their care. I remember this report because, at the time, it gave me a great phrase to remember, “No Decision about me, without me”. I was already working outside of the hospital environment and I’d already learnt the value of involving people with any decision about them, of discussing treatment plans with people, of tailoring it to their lifestyle and encouraging people to understand the need for it. I needed to work with the person because I was only seeing them once or twice a week and the rest of the time they would be managing their care, I needed to be working alongside the person.

But am I asking too much, am I being naïve? In our modern, busy, over-stretched and under-staffed NHS, do clinicians have enough time to introduce themselves to patients and listen to them? Do clinicians only have enough time to treat patients as tasks on a conveyer belt?

My GP practice is a typical, busy East London practice, with a turn-over of staff that can be sometimes breath-taking. But every time I see or speak to someone there, whether they are a doctor, nurse, pharmacist, paramedic or Healthcare Assistant, they always introduce themselves and tell me their job title. Even if it is only a five-minute telephone call, they always listen to me and act on my concerns. In return, I trust their care because of the way they treat me.

Am I really asking too much…

 

Drew Payne

With Pride, July 2019

 

Something New Every Year

 

(July 2019)

The other Saturday, I did something I’d never done before. At my age, it isn’t often I get to do something as new as this, but the other Saturday I marched in the London Pride March openly as a nurse.

I’ve marched in the Pride March many times before, with friends, with LGBT organisations, but never before openly as a nurse. This year, a group of staff in my Trust’s LGBT Network organised to take part in the London Pride March and we had the blessing of our Trust.

On Pride Saturday, all of us in bright yellow tee-shirts (with our Trust’s name and logo emblazoned across them) and all wearing our security bracelets, we took our place in the march. We were LGBT staff and our straight allies gathered around our placard that announced who we were, Whittington Health Staff Inclusion Network.

Marching in Pride openly as NHS staff was one thing, but the reaction we received from the crowds along the route was amazing. People smiled and waved at us, they clapped and cheered us, people were so happy to see us. All we were doing was marching.

The NHS is still not an inclusion or safe place for many LGBT patients. A recent Stonewall report found one in four LGBT people have witnessed homophobia from NHS staff and one in seven of them have avoided treatment because of fear of discrimination from NHS staff (1). Yet how much has the NHS done to reverse this situation? Very little. This isn’t the first report by Stonewall, there have been many over the years, all reading the same, and yet the NHS does so little to change this.

In the four years between 2014 and 2018, LGBT hate crime rose by 144% (2) and yet the NHS is still not a safe place for LGBT patients.

What my colleagues and I did at Pride was not a great step forward and for most of us did not require a large amount of effort, yet the reaction of the crowd was almost breath-taking. Those people cheered us on because they were happy and grateful for us being there, and our presence told them that our Trust was working towards providing care in a safe place.

Taking part in London Pride fired all of us up, our WhatsApp group has gone crazy, and we are already making plans for next year’s Pride and getting off the ground an LGBT Staff Network. We need to work hard at making our Trust an inclusive organisation, a safe place for all, but we are starting.

We talk a lot about person-centred care but are we just paying lip service to it when so many LGBT people do not feel able to be open with us about themselves for fear of discrimination?

Every long journey starts with a single step, but who would have thought that step would be marching at Pride? So why aren’t more NHS Trusts taking part in the different Pride celebrations around the country? Our presence would say so much to the LGBT people there.

 

(This was originally published as a comment piece in Nursing Standard magazine)

Drew Payne

 

Find out more about this short blog series here