A critical or questioning approach

This means that you will ask if something is unclear, or tactfully challenge practice. It is important to develop the confidence to speak up if you do not understand or you think safety may be compromised. It is possible to discuss such concerns with mentors, senior clinical staff or university teaching staff, depending on the situation.

Recognize limitations of knowledge and skills, and seek support

Self-awareness is an essential skill for all nurses and knowing the limitations of your knowledge and clinical skills means that you are less likely to try something beyond your capabilities (which may go wrong). Where you are unsure, always seek support from mentors, read around the topic and speak to teaching staff if necessary.

Use of evidence-based practice

Nursing practice should be based on interventions that are known to be safe, effective and informed by research findings (see Ch. 5), clinical expertise and the patient’s/client’s own wishes.

Use of reflection during and after practice situations

Reflection (Ch. 4) is a valuable learning tool and helps to make sense of situations, apply the theory behind a topic, highlight the positive points and identify areas for future action.

Before moving on, complete the exercise in Box 13.1 to explore the relationships between nursing, health and safety.

Risk assessment principles

A hazard has been defined by the Health and Safety Executive (2003a, p. 3) as ‘anything that can cause harm, e.g. chemicals, electricity, working from ladders’ and a risk as ‘the chance, high or low, that somebody will be harmed by the hazard’. It is important to understand the relationship between hazards and risks. A lightning strike presents a serious hazard that can result in death but the risk, or likelihood, of it happening to an individual in their lifetime is very small. Even when you know what the hazards and risks are, other factors can increase or decrease a risk. Going out into wide, open spaces during a thunderstorm may increase the risk of being struck by lightning. Clinical practice can also illustrate this. When drawing up or giving injections, needles are never resheathed because of the potential hazard of a needlestick injury and transmission of blood-borne viruses, e.g. hepatitis B, human immunodeficiency virus (HIV) (see Ch. 15). The risk of a needlestick injury is greatly reduced if nurses adhere to the guidance, but lack of knowledge or understanding about the importance of this increases the risk of an injury occurring to the nurse. Before reading the rest of this section, complete the activity in Box 13.2.

It may not be possible to eliminate risks completely but by identifying the hazard, risk and associated factors the chances of harm occurring can be minimized. This process is called risk management and the first stage is known as risk assessment. There are several reasons why risk assessments are undertaken, including patient/client welfare and ethical and professional responsibilities, including a duty of care to protect vulnerable people (Ch. 7). The NMC Code of professional conduct (NMC 2004, p. 10) emphasizes nurses’ responsibilities in one of the key standards: ‘You must act to identify and minimize risk to patients and clients.’ Risk assessment is also an integral part of health and safety legislation (see p. 327).

The process of risk assessment may sound complicated, but it is essentially an examination of the factors that could cause harm to people in a care environment so that precautions can be taken to prevent injuries (HSE 2003a). The activity in Box 13.2 is the start of a risk assessment. There are usually five stages to risk assessment:

These stages are explored in a series of text boxes using a moving and handling example from each nursing specialty. The scenarios focus on hazards for staff and patients/clients and follow one of the basic principles, i.e. looking after your joints and your back (not stooping, twisting, reaching or lifting people).

Individual risk assessments

A person’s health and social care needs are unique and nursing assessment (Ch. 14) includes identifying actual or potential hazards that can affect their health. A wide range of assessment tools have been developed to help nurses and other healthcare professionals identify whether people are at risk of specific factors such as malnutrition or pressure ulcers (see Fig. 14.3, p. 357). Box 13.7 lists some of these tools and sources of further information. Most assessment tools offer a checklist and a scoring system, with the overall result giving an indication of the degree of risk, e.g. high, medium or low risk of developing pressure ulcers. The assessing nurse can then decide how to minimize those risks.

Fig. 13.3 Incident report form

Assessment tools are designed to help nurses in practice identify particular risks but they do not replace clinical judgement. For example, a nutritional assessment tool might indicate that a patient admitted for surgery is currently at a low risk of malnutrition (see Ch. 19). However, the patient will spend at least 4 hours fasting prior to surgery (Ch. 24) and thereafter may not be able to eat or drink for several hours or experience nausea and vomiting. They will therefore be at higher risk of developing malnutrition and this indicates the importance of regular reassessment.

The discussion on generic risk assessments above highlighted a common issue across all nursing specialties, namely moving and handling. For individual assessments a number of branch-specific issues arise. Risks are taken as part of growing up and everyday life as we develop and learn. This may occur on many different levels, e.g. crossing a busy road, smoking cigarettes or drinking alcohol, starting a new relationship or embarking on a career, and these can often be a case of trial and error. Risk taking is a natural part of life and if people who have learning disabilities or mental health conditions are overprotected, this can lead to social exclusion and infringement of their rights and dignity (Alaszewski & Alaszewski 2000).

To promote social inclusion, people need to be allowed to take reasonable risks to aid their development by promoting independent living and social activities. The regulatory body that preceded the NMC, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, published guidance on risk management for people with learning disabilities and mental health problems (UKCC 1998). The guidelines suggested that risk assessment should consider client care, the care system and the local environment. Risks still need to be reduced to a minimum and agreed by the multidisciplinary team and client but the value of risk-taking should be recognized. Box 13.8 presents a case study and an opportunity for reflection on a number of issues discussed here.

Maintaining safety and promoting health

Wide-ranging legislation exists to promote public health and safety including:

Governments also publish specific public health strategies such as Saving Lives: Our Healthier Nation (DH 1999a) and Choosing Health: Making Healthy Choices Easier (DH 2004) which focus on reducing death rates from cancer, coronary heart disease and strokes, mental health illness and accidents (see Ch. 1). Specific documentation and targets have followed in the form of National Service Frameworks, e.g. for children, older people, mental health, coronary heart disease, diabetes, cancer (see www.dh.gov.uk for publications).

One government target is to reduce death and injury rates from accidents in the home by 20%; another is a 40% reduction in road accidents (including a 50% reduction in the number of children seriously injured on roads). The proposals seek to reduce the 10000 lives lost per year to accidents and focus on the main causes within each age group:

The preventative measures proposed include an increase in traffic calming measures, design of safe play areas for children, changes in building regulations, the use of safety glass for doors and road safety training for children. The National Institute for Health and Clinical Excellence (NICE 2004) provided guidance on assessment of older adults with the aim of preventing falls and minimizing their recurrence. Falls prevention campaigns have also been launched, aimed at educating older adults. Where accidents do occur, the target is for faster diagnosis and effective treatment to improve health outcomes. By undertaking the activities in Box 13.9 you will find out more about assessment and prevention of falls in older adults.

Nurses across all specialties may have a number of roles to play in accident prevention as they come into contact with people at various stages of their lives for health promotion and treatment measures in various settings including the community, hospitals, clinics, schools and walk-in centres. This may be as part of a local education or screening programme on accident prevention for patients/clients or their families. Nurses are also heavily involved in people’s care after accidents have occurred and this provides opportunities for assessment and education to prevent further accidents.

Health and safety in healthcare settings

The Health and Safety at Work Act (1974) is the main piece of UK legislation that places specific responsibilities upon employers to protect the welfare of people at work and the public. Under this Act, many subsequent regulations have been issued which deal with specific topics such as manual handling and the safe use of equipment. Although employers are responsible for providing a safe working environment, employees have responsibilities for:

Health and safety is essentially everyone’s responsibility. This section presents the main legislation that applies to clinical practice (Table 13.1) and summarizes the key points.

Table 13.1 Main health and safety regulations under the Health and Safety at Work Act (1974) (based on HSE 2003b)

The Health and Safety Commission (HSC) and the Health and Safety Executive (HSE) enforce health and safety law in the UK under criminal law, as opposed to civil law, which focuses on personal claims for compensation (see Ch. 6). This means that employers may be heavily fined, or worse, for failing to comply with health and safety regulations. The HSW Act (1974) laid out general duties for employers to:

The Management of Health and Safety at Work Regulations (1999) were more specific and requires employers to carry out:

These two pieces of legislation provide the background and general principles for health and safety but is useful to look at some of the more specific regulations highlighted in Table 13.1 and their implications for clinical practice.

Control of Substances Hazardous to Health (COSHH)

Chemicals and other substances used at work can be hazardous to people’s health and employers must control exposure to prevent harm occurring (HSE 2003c). Hazardous substances include chemicals, gases, dust and biological agents (blood and blood products, microorganisms) that can cause illnesses ranging from mild allergic reactions to occupational asthma and death. Risk assessments are therefore carried out and precautions put in place, including:

• Educating staff

• Providing personal protective equipment

• Health surveillance

• Formulating policies for dealing with hazardous substances, e.g. disposal, spillages and emergencies.

Manufacturers must also supply information and warning labels on hazardous substances, both domestic and industrial (Fig. 13.1). These highlight whether the chemical is an irritant, corrosive, highly toxic or flammable and it is important to be familiar with these (Box 13.10).

Fig. 13.1 Hazard signs

(reproduced with permission from HSE 2002a)

Box 13.10 HEALTH PROMOTION

Recognizing hazardous chemicals

The hazard signs in Figure 13.1 appear on chemicals and toxic substances used at home and in placements. You should always read the labels on products you are using.

Student activities

• Identify these hazard signs on domestic cleaning products.

• Locate these hazard signs in your placement, e.g. on handwashing products and disinfectants.

Reporting of Incidents, Diseases and Dangerous Occurrences Regulations (RIDDOR)

Accident statistics, covering the period 2001–2004 (HSE 2004a), are shown below:

• 235 people lost their lives at work (2003/4)

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• 154430 people experienced other injuries at work (2002/3)

• 2.3 million people experienced an illness that began or was worsened by their work (2001/2).

In 2002/3 injuries for the health services included:

• Slips and trips – caused 667 serious injuries to staff and patients, and were the most common injuries to nurses

• Moving and handling – caused 53% of staff injuries (HSC 2004).

Figure 13.2 illustrates the areas of the body affected by handling accidents. The government and the HSC have set a target for a 10% reduction in health service accidents between 1999/2000 and 2009/2010.

Fig. 13.2 Sites of injuries lasting over 3 days caused by handling accidents (2001/2)

(reproduced with permission from HSE 2004b)

RIDDOR aims to ensure that accidents and near misses are documented and reported to the HSE so that these can be investigated if necessary and harm reduction measures implemented. Reportable incidents include a patient/client, visitor or member of the public or staff experiencing one of the following:

• A dangerous occurrence that happens in practice, e.g. collapse of equipment or explosion

• An injury that lasts for more than 3 days or a work-related disease, e.g. a severe allergy

• A major injury, e.g. fracture, amputation, or injuries leading to acute illness, unconsciousness or death.

In nursing practice, all accidents and near misses are documented using the local NHS electronic or paper incident forms (Fig. 13.3) which health and safety representatives of the healthcare organization then review and report to the HSE as necessary.

In addition to the general targets for reducing accidents in the health service, the government established the National Patient Safety Agency (NPSA) to reduce the estimated 900000 patient safety incidents and near misses every year. As well as advising on particular universal issues, e.g. intravenous infusion pumps, the NPSA collect and analyse incident reports from across the country. This information is used to advise on preventative measures and to build a culture of safety and learning within the health services (NPSA 2004) (Box 13.11).

Box 13.11 REFLECTIVE PRACTICE

Reporting incidents in placements

Student activities

• Locate the safety or adverse incident forms used in your placement.

• Discuss the types of incidents and events that are documented with your mentor.

• Find out what happens to these forms after they are completed.

• Access the National Patient Safety Agency website (www.npsa.nhs.uk) and review current recommendations for practice.

Manual Handling Operation Regulations 1992 (amended 2002)

Moving and handling includes lifting, lowering, pushing, pulling, carrying or moving loads such as inanimate objects, and helping people to move. Nursing involves many of these activities on a day-to-day basis and using incorrect techniques or failing to use equipment provided puts practitioners at high risk of injury. Musculoskeletal injuries occur frequently at work in the UK and have considerable economic implications (see Box 13.12). Many of these injuries are preventable and the Manual Handling Operation Regulations lay out the requirements under health and safety law and the responsibilities of employers and staff.

Box 13.12 Musculoskeletal injuries in the UK and NHS

[From DH 2002]

• Across all industries in the UK, 1.1 million people suffered musculoskeletal disorders in 2001/2, most commonly back injuries (see Fig. 13.2)

• This accounts for half of all work-related ill health, an estimated 12.3 million lost working days and £5.7 billion in costs to society (HSE 2004b)

• In the NHS, moving and handling injuries are responsible for 40% of all sickness absence, accounting for £400 million a year

• One in four nurses has had time off with a back injury sustained at work.

This section introduces the principles of safe practice but moving and handling must not be undertaken without completing a specific course that addresses the theory of safe handling and allows practice of techniques (Box 13.13). Readers should refer to Chapter 18 for further guidance on helping patients and clients to move.

Box 13.13 Recommended components of moving and handling training

[Based on DH 2002]

• Functions of the spine

• Importance of back care, posture and risk factors contributing to back pain and injuries

• Current legislation and professional guidelines

• Assessment of risks:

– tasks

– individual capability (own and that of others)

– loads (inanimate and human)

– environment

• Importance of ergonomic approach

• Local policies

• Principles of normal human movement and promotion of client independence

• Safe handling of inanimate loads

• Handling strategies for clients with impaired immobility

• Dealing with unpredictable occurrences

• Use of equipment

• Problem-solving.

There are five key stages to planning and executing a handling manoeuvre to reduce the risk to the handler and patient/client.

1. Avoid unnecessary handling: Is the manoeuvre really necessary? Can the person do it themselves if given enough time, adequate instructions or the right equipment? Is it necessary to move equipment or boxes?

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2. Assess the risk: If the task cannot be avoided then assess it using ‘Task, Individual, Load and Environment’ as a framework (TILE, see p. 330).

3. Plan the move: Decide on the most appropriate posture or technique.

4. Prepare for the move: Gather the right equipment, number of people required and make sure they are all clear about the technique and the instructions.

5. Perform the manoeuvre: Ensure that smooth controlled movements are used and your back is in a natural vertical position (Fig. 13.4).

Fig. 13.4 Anatomy of the spine

(reproduced with permission from Waugh & Grant 2006)

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Moving and handling require an approach similar to other health and safety issues and one of the first stages is a risk assessment. This may be:

• Generic, i.e. referring to a group of people and a particular task, or

• Specific, i.e. relating to a particular patient/client and their individual handling needs.

The TILE framework

This helps to think through the move using biomechanics (the study of human movement) and ergonomics (the science of design and fitting the work environment to the worker). Both of these disciplines contribute to the understanding of how to prevent injuries. TILE is discussed below based on the guidance from the HSE (2004b) and Johnson (2005).

The task (T)

Assessing the task means identifying the factors that may cause injury and eliminating or reducing them. The HSE (2004b) suggest that the following questions be asked:

• Does the task involve holding or manipulating loads at a distance to the trunk?

Holding an object close to the trunk means that it is easier to control and there is less risk of back injury compared to holding it at a distance or at arms’ length.

• Does the task involve twisting, stooping or reaching upwards?

Stooping, twisting and reaching greatly increase the risk of injury because they place stress on the lower spine. These actions must be avoided in moving and handling tasks by using legs and feet to move rather than twisting at the trunk and by remaining close to the load or patient/client.

• Does the task involve excessive carrying of inanimate objects across a distance or excessive lifting or lowering?

Carrying objects over long distances or repetitive lifting or lowering can cause fatigue and increase the risk of injury. Equipment, such as a trolley, reduces the risk of injury from carrying. Also, heavier items should be stacked on shelves at waist height so they are not lifted from the floor or high shelves.

• Does the task involve pushing and pulling?

Pushing and pulling may be a safer technique than lifting but it can still put the handler at risk of injury. For example, pushing a heavy load along an uneven surface or up a slope could be unsafe.

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• Can the load suddenly move?

If the contents of a half full box are not secure they may shift during movement so the load needs to be secure to be safe. If the task involves people, there is always a risk of unexpected movements so the likelihood of this occurring is reduced by making sure the patient/client knows their role and what to expect so they do not become frightened or uncooperative.

• Are there sufficient rest periods for handlers?

The greater the physical effort, the greater the risk of injury, and inadequate rest periods mean that muscles and joints do not get a chance to recover.

• Is the correct equipment available?

As part of the risk assessment, the equipment available for the task needs careful consideration. There is a wide range of aids available, from sliding sheets that reduce friction and help people move up in bed, to electric beds and hoists that assist people to sit up, transfer or stand (see Ch. 18). During your moving and handling practical training, you will have the opportunity to practise with a range of equipment used in placements. Equipment must be well maintained and checked before each use. It is important to be aware that all equipment has a safe working load, i.e. an upper weight limit for use, usually marked on larger pieces of equipment such as hoists. This is why it is important to document patients’/clients’ weight as part of nursing assessment (Ch. 14). Infection control precautions also need to be considered, e.g. whether equipment can be disinfected with alcohol wipes or if special laundering arrangements are necessary.

Individual capabilities (I)

This refers to the assessment of handlers’ abilities. Nursing activities should not require great physical strength but general fitness and regular exercise are important as these reduce the risk of injury. We must also assess our ability to be involved in moving and handling on a daily basis. Classroom trainers or clinical staff must be alerted to any pre-existing or current injuries that could prevent you from being involved in safe moving and handling. People with existing injuries and those who are, or have recently been, pregnant require an occupational health assessment.

Inappropriate clothing can restrict movement during handling manoeuvres or encourage adoption of awkward postures to protect the handler’s dignity, and both situations increase the risk of injury. Most uniform policies include trouser suits that allow freedom of movement and footwear that is flat and provides plenty of grip. It is therefore important to follow local uniform policies.

The load (L)

The manual handling guidelines identify a number of factors for consideration regarding the load (if it is an inanimate object) or the patient/client involved. For objects, it is important to have an indication of their weight. This is often printed on boxes or can be judged by gently rocking the item before deciding whether to lift it. The size of the load is considered and whether it is possible to split it in two to make handling easier. Other areas to consider are the type of grip to use and whether the item could be too hot or sharp to handle.

Patients/clients should not be lifted because of the risk of injury to the person and the handlers. Nurses must assess people’s capabilities and then determine the best technique or equipment to help them move. One difficulty is that people do not come as a standard size, with handles, or with their height and weight printed on the side. Many people receiving healthcare have the added complication of ill health and attachments such as intravenous infusions and urinary catheters. Therefore specific assessment must be carried out for each patient/client before carrying out manoeuvres. Care settings including NHS Trusts should have their own moving and handling assessment documentation as part of the nursing care plan; some of the key areas that require consideration are outlined in Box 13.14.

Box 13.14 Summary of the TILE assessment for moving and handling

Task (T)

Assess and minimize the risks that cause injury, e.g. holding the load or person away from the trunk, twisting, stooping or reaching, considerable lifting, lowering or carrying distances for objects and pushing or pulling. Assess the need for team handling and think about the range of equipment available including its safe working limits, its condition and last recorded service.

Individual (I)

Assess the capabilities of staff, e.g. their age, gender, height, physical fitness, previous injuries, current or recent pregnancy, training, knowledge or experience, and wearing of restrictive clothing or inappropriate footwear.

Load (L)

• Objects: Assess the weight, dimensions, contents (loose, heavy at one end), bulky, harmful (hot or sharp) and whether it is difficult to grasp

• People: Assess their mobility and ability to weight bear, physical health, history of falls or confusion, understanding and concordance, attachments (intravenous infusions, catheters) and risk of moving unexpectedly, e.g. first time out of bed, prone to muscle spasms or seizures.

Environment (E)

Assessment includes adequate lighting, temperature (especially extremes of heat and cold), flooring (for slippery or uneven surfaces, carpet, gradient), obstacles and weather conditions if outdoors.

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The environment (E)

There are many factors in the environment that can increase or decrease the risk of injury to handlers and patients/clients. It is important to assess whether there is adequate lighting; non-slip flooring; a floor gradient or potential obstacles, e.g. doors, furniture, stairs. Extremes of temperature can also alter people’s concentration levelsand physical abilities. Moving and handling need to be planned to ensure that none of these factors contributes to an injury. There must be sufficient space to avoid awkward postures or techniques and it is important to be alert tohazards that may cause you and the client to slip or trip.

Moving and handling procedures cannot be completely risk-free but the TILE framework allows major hazards to be identified and reduces injuries to staff and patients/clients through using the correct technique and equipment. Figure 13.5 illustrates a good handling technique for lifting an inanimate load and Chapter 18 examines specific techniques for helping people to move.

Fig. 13.5 Handling technique for inanimate objects

(reproduced with permission from HSE 2004b)

Dealing with emergencies and prioritizing

Emergency situations can be difficult to deal with as people may be distressed, in pain or confused and there may be more than one injury or a number of people involved. However, it is important that you remain calm and apply some simple principles (based on Mohun et al 2002) that will help to organize your thoughts and decisions on the most appropriate action. The principles of first aid are listed in Box 13.16 and described below.

Dealing with burns and scalds

Around 100000 people attend Emergency Departments in England and Wales annually because of burns. Most are caused either by dry heat (e.g. flames) or moist heat (e.g. steam, hot liquids or fat) (DTI 2003), although industrial and domestic chemicals can also cause burns along with high and low voltage electrical sources, radiation (including sunburn, X-rays and radioactive sources) and extreme cold (e.g. frostbite).

The skin is the largest organ in the body and is discussed in more detail in Chapter 16. The epidermis and dermis make up the two main layers of the skin and burns can involve both layers; in severe cases, the underlying subcutaneous fat and muscle layers are also affected.

Burns are classified according to the depth and percentage of the body surface area involved. Box 13.17 illustrates the three depths of burn injury: superficial, partial thickness and full thickness.

The extent of burns may initially be estimated using the ‘rule of nines’ (Fig. 13.6): the greater the area affected, the greater the risk of shock caused by fluid loss. In adults, medical attention is needed for anything more that a minor superficial burn. A doctor should see children with what appears to be a superficial burn. Medical attention should always be sought for burns affecting the face, groin, hands and feet. When more than 15% burnsin adults is present specialist burns care in hospital is necessary. This figure is 10% burns in children where a modified chart is used to calculate the extent of burns because of the different sizes of children (Fowler 2003). Box 13.18 describes the management of burns and scalds.

Fig. 13.6 Estimating the extent of burns and scalds in adults and children: A. Adults: the rule of nines

(reproduced with permission from Waugh & Grant 2006). B. Children up to 5 years (reproduced with permission from Hockenberry et al 2003). C. Older children (reproduced with permission from Hockenberry et al 2003)

Fig. 13.7 Resuscitation face shield

Dealing with poisoning

A poison is any substance that enters the body in sufficient quantities to cause temporary or permanent damage. Poisons may be accidentally or deliberately ingested, inhaled, splashed on the skin or injected. Signs and symptoms vary according to the amount and type of poison involved and its route of entry. Box 13.19 shows the principles of dealing with a suspected or known poisoning.

In clinical areas, healthcare practitioners have access to one of six UK centres that comprise the National Poisons Informati on Service (www.npis.org). This service includes a 24-hour emergency helpline and a toxicology database of known poisons and recommended treatments.

Minimizing violence and aggression

The reasons why violence and aggression occur are usually complex; for an in-depth discussion, refer to Mason and Chandley (1999) who examine the wider issue of violence in society. For healthcare practitioners there may be a number of additional factors that contribute to an increased risk of witnessing or being involved in an incident. People receiving healthcare may be anxious, tired, in pain, confused, frustrated by waiting times, under the influence of drugs or alcohol, have mental distress or a history of violence – and all of these predispose to unpredictable behaviour. Nursing often takes place in stressful situations and treatment or facilities may be granted, denied or delayed (RCN 2003a).

Over recent years there has been increasing concern in the nursing media and general press about increases in violent incidents towards healthcare staff. However, this is difficult to illustrate because previously there was no clear definition, as well as considerable underreporting (Bibby 1995). The national media also focus heavily on serious incidents and often on individuals with mental health problems; however, it is important to be mindful of the stereotypes that can arise from this. Most people with mental health conditions are at greater risk of harming themselves than other people (Jones & Jackson 2004).

NHS Trusts have explicit strategies for reducing the number of violent incidents towards staff and systems for recording these events. Violence and aggression in the workplace have an immediate impact on individuals involved, their colleagues and also potential long-term consequences. Employers have a duty of care under the HSW Act (1974) (p. 326) to identify risks and take preventative measures. A risk assessment must involve all staff and key stages of the process (see p. 322). NHS Trusts must focus on specific areas including the environment, education provided to staff and methods of communication (DH 1999b).

Improving communication and preventing incidents

Safe nursing practice includes promoting effective communication between staff and patients/clients at all times (Ch. 9). Observation and interpersonal skills are often the key to preventing or defusing a situation by firstly looking for verbal and non-verbal cues that suggest that people may be agitated (Box 13.26).

Awareness of factors that can predispose people to violence and aggression (p. 339) is useful. Mason and Chandley (1999) remind readers of the need to be mindful of stereotypes and prejudices that may arise. For example, not everyone with dependence on alcohol or mental distress becomes violent, and external appearances, e.g. tattoos, piercing, do not represent particular attitudes or behaviours.

Interpersonal skills and non-verbal behaviour can help to resolve situations and prevent them from escalating. Key to all situations is the need to maintain respect and dignity for the people involved and to appear calm and confident (Mason & Chandley 1999). Box 13.27 identifies good practices that may help to prevent or de-escalate a situation.

If more critical situations arise, these principles still apply and a confident, calm approach is still needed although it may not be appropriate to intervene. When possible, withdraw from the situation and think about moving other people away from the area too. Being aware of the environment you work in is also important – knowing how to summon help (e.g. other members of staff, security, police) and the general layout of the area along with the exit points. Avoid talking to people in confined spaces or corners if you recognize that a situation may become hostile. It is a good idea to suggest that all concerned move into a more suitable area to discuss the issue. Communication between staff is equally important to ensure everyone’s safety. Always inform staff when you are leaving a clinical area, where you will be and when you will return. This is good practice so that if an emergency occurs, e.g. fire or cardiac arrest, colleagues are aware of your location.

Staff working in the community may have specific needs as they usually work individually or as part of a small team. Risk assessments are still carried out, as in other clinical areas, and specific arrangements made for times when practitioners are out on duty. This should include the use of mobile phones to keep in contact, a system of informing other staff where they are and the approximate time they expect to return. The NHS Security Management Service (2003) introduced a pilot scheme for community staff where they carry identity cards with built-in mobile phone technology. If staff feel threatened they can press a button on the back that covertly records interactions, which can later be used as evidence, and a device that allows their whereabouts to be located in emergencies. Other arrangements may include a ‘buddy’ system where two members of staff are present during the initial client assessment or it may take place in a local clinic (DH 1999c).

Communication between agencies such as emergency departments, police, GPs and social services is also important. The RCN and NHS Executive (1998) describe a case where a district nurse was requested to visit a patient in their home to re-dress a dog bite wound. The gentleman’sGP notes revealed reports from the emergency depart-ment recording several attendances there following dogbites from his son’s bull terrier and also after being involvedin fights. Social services documentation revealed that his grandchildren were also on the Child Protection Register. As a result of the communication between agencies, the district nurse arranged wound care at the health centre rather than visiting him at home and advised the gentleman to return to the emergency department for out-of-hours care if necessary in order to maintain her own safety.

Dealing with and reporting violent incidents

Much of the discussion on violence and aggression has dealt with preventing incidents and defusing or de-escalation. Unfortunately, because of the complex nature of violence it can still occur despite the use of these techniques. The actions required in these incidents focuses on the immediate responses and then detailed follow-up and evaluation (RCN 2003a).

Immediate responses involve dealing with the emotional and physical needs of the practitioner(s) affected. In the case of violent assault, this may mean first aid and people usually experience a range of emotional reactions. This could include a ‘crisis’ phase where people feel shocked and numb but after the adrenaline has subsided, they feel physically and mentally exhausted (RCN 2003a). People need to feel that they are not alone when incidents have happened and healthcare organizations should have support mechanisms in place for staff who have experienced violence. This may include debriefing sessions for staff and patients/clients involved to make sense of events, long-term counselling and follow-up.

An important part of the evaluation is documenting and reporting aggressive and violent incidents using appropriate documentation so that follow-up action can be taken, hopefully preventing further incidents. However, staff may not want to document incidents for a number of reasons. These were highlighted by the National Audit Office (2003) who found that some staff thought:

A number of campaigns and education programmes aimed to address these concerns have highlighted that violence and aggression are not acceptable and do not reflect upon either the individual concerned or their skills.

Details of incident documentation include:

It may also be necessary to complete health and safety forms associated with RIDDOR. Given the emotional nature of events, the person completing the form should always receive help from senior staff to recall and document the incident (RCN 2003a). It may also be appropriate to inform the police.

The continued care of someone who has become violent is often not considered. They too may be shocked and upset by their behaviour and may wish to discuss the event from their perspective (RCN 2003a). Agreements can be drawn up between patients/clients and healthcare organizations regarding anti-social behaviour, discussing terms and conditions under which they will receive healthcare. These written agreements may mean that care is withdrawn if violent behaviour continues; however, it must always be made clear that it is the behaviour that is being rejected, not the person (Taylor 2000).

In extreme circumstances, e.g. a client is seriously endangering their own safety or that of others, other methods may be used to protect them and others. In specialist areas such as forensic mental health nursing, ‘time out’ and seclusion are used for short periods to help divert aggressive behaviour, reduce sensory stimuli, encourage internal control and disrupt the source of provocation (Mason & Chandley 1999).

However, if more extreme measures are employed, such as observation and restraint, healthcare providers must have clear policies regarding their use and practitioners involved require specialist training. These techniques remain controversial because they prevent a person doing what they want to do, restrict their liberty and, when used inappropriately, can be considered a breach of human rights and abuse (NMC 2002, RCN 2004). Unfortunately, people have also been injured or have died during physical restraint, which has led to a number of investigations and recommendations for practice.

Where techniques such as observing people at regular intervals (see Box 13.28) are used because people have become aggressive or are at risk of suicide, the emphasis is on a therapeutic intervention (rather than a custodial approach) and encouraging positive interactions. A balance needs to be struck between ensuring people’s safety and maintaining their privacy, dignity and autonomy (Jones & Jackson 2004).

Fire risk assessment

A fire risk assessment must identify all the fire hazards (e.g. sources of fuel, ignition) and the people at significant risk, especially those who have impaired mobility, sight or hearing. This information is used to identify improvements needed and to formulate an emergency evacuation plan (Home Office et al 1999).

Fire detection and warning systems

All large buildings must have fire detection systems that trigger an alarm system or alarms that can be activated at fire points, usually by breaking the safety glass. There may be different fire alarm sounds, e.g. continuous for the immediate area and intermittent for other sections, so it is important to know the local arrangements.

Emergency plans and means of escape

Hospitals are often organized into compartments that provide fire-resistant walls, ceilings and floors for a specified period of time. This reduces damage to buildings and increases survival rates, as initial evacuation is usually horizontal into the next compartment rather than down stairs (Home Office et al 1999). Emergency plans should discuss evacuation of people of differing mobility and availability of equipment such as evacuation chairs and ski sheets for immobile people on mattresses (see Fig. 13.9). Local training enables you to understand the arrangements for specific placements.

Fig. 13.9 Emergency evacuation equipment: A. Ski sheet to be placed under a mattress. B. A ski sheet in use. C. An evacuation chair that can be used on stairs

Facilities for fighting fire

Healthcare premises must provide facilities for fighting fires such as sprinkler systems and hose reels. In addition, fire extinguishers and fire blankets are located in appropriate areas such as kitchens so that people who have been trained to use them can tackle small fires. Figure 13.10 illustrates the different types of fire extinguisher.

Fig. 13.10 Types of fire extinguisher (based on The Home Office et al 1999)

Fire safety training

This section has introduced the basic principles of fire safety but within your nursing programme and throughout your career, fire training should be undertaken annually. This ensures that you are aware of local procedures, any new changes and can rehearse emergency situations. Carrying out the activities in Box 13.31 will highlight your fire safety awareness.