Staff behaving badly

Considering what she has been through, paediatric nurse Rosie Purves is remarkably tolerant about being verbally abused by patients.

“There is no fear in the world like when your child is sick, and as a nurse, you have to understand that. Nurses are passionate about their jobs but you do get abuse from parents, and I know how to calm people down and deal with their fears,” she says. “But not racist abuse.”

Rosie had been a nurse at Southampton University Hospitals NHS Trust since 1974 when, in 1997, a patient refused to let her treat her baby because she is black.

This would have been bad enough but the situation was compounded by the reaction of the trust. Instead of supporting her, the family – who often had an equally racist friend in tow – was simply moved to other nurses, leaving Rosie feeling undermined and isolated.

Eventually, she became depressed and, from September 2003 to February 2004, was off sick.

In May last year, she was awarded 20,000 after an employment tribunal ruled the trust had been “effectively silent and complicit” in the racist demands made by the parent in question.

“There is generally very little support, you are generally simply required to keep a stiff upper lip,” she says, adding that the attitude was often one of ‘if you want to get up the career ladder, you’ll keep quiet’.

Rosie’s case is obviously an isolated incident but, if the latest statistics are anything to go by, verbal abuse is an issue that is getting worse in the NHS, and one that occupational health professionals have yet fully to get a handle on.

A survey by the Healthcare Commission in March reported that one in four said they had been harassed or abused by patients or their relatives in the past year. Just as worrying, this figure rose to 37% if bullying or harassment from colleagues was included.

When it came to physical attacks, 14% of those polled said they had been attacked by patients or relatives and 15% by colleagues.

And it is not the only evidence. A survey last autumn by the magazine Nursing Times found nine out of 10 nurses had suffered verbal abuse, with a quarter of the 2,500 nurses polled saying its effects had made them consider quitting their profession early.

A survey last May by the NHS in Scotland also found 90 out of 1,000 staff were subject to a violent or abusive attack in the previous 12 months.

While most trusts and OH departments are now well up to speed on physical violence and the need for zero tolerance, verbal abuse is still too often the poor relation, says Irene Bonnar, OH service manager for the Borders Occupational Health Service.

“The focus is still very much on the drunk patient who is physically violent, and there is little understanding or recognition of the insidious effect of low level, continual verbal abuse,” she argues.

Unlike the sudden shock of a physical attack – bad and unacceptable as it is – the ‘drip, drip’ effect of verbal abuse can wear someone down, both mentally and physically. Also, if everyone else around them seems to be coping, they can feel isolated, stressed, fearful, and anxious, and can easily tip over into depression.

But there are manifold difficulties here for OH professionals, not least of which is the reluctance of hardened NHS workers to admit there is anything wrong.

Nurses and doctors are both, to a degree, their own worst enemies in encouraging a culture of ‘coping’ or ‘getting on with the job’. This is particularly true in departments such as A&E and psychiatry, where verbal abuse is considered part of the job and just something people are expected to deal with.

A study by the British Medical Association (BMA) in October 2003 concluded that as many as one in three doctors had been either physically or verbally abused by a patient or their family in the past year.

“The reduction in waiting times has reduced the levels of verbal abuse,” admits Don MacKechnie, chairman of the BMA’s A&E sub-committee and an A&E consultant in Rochdale.

But that does not mean verbal abuse should be as tolerated as it is, he says.

While more visible security and clear warnings of zero tolerance do help, doctors and nurses need to get better at reporting such incidents, and the processes for dealing with them have to improve too.

Often nurses feel that all that happens is they spend a lot of time filling in lengthy forms, he argues.

“Occupational health and counselling for verbal abuse is not as readily available as it should be. But having said that, doctors and nurses, being the sorts of animals they are, do not tend to seek it,” he says.

“People can get worn down, and we find there is a high turnover. The nurses tend to get abused far more than the doctors because they are the first point of contact with the patient,” he adds.

The first point for OH, argues Bonnar, is an obvious one but worth reiterating nevertheless: the need to be both visible and proactive.
“You need to have training programmes in place and you have to enable people to access those programmes. You need to give them to skills that help them deal with those environments,” she explains.

This training can either be provided through OH or the training department, it doesn’t matter; the key is that it is provided, she argues.
Having a clear policy in place specifically on verbal abuse and, critically, ensuring it has been communicated to staff is also a very good idea. This shows it is an issue that is not just cultural and need not be tolerated any more than any other forms of abuse.

More difficult to implement, but just as important, is some sort of system to measure and monitor abuse levels, Bonnar suggests.

In this context, monitoring physical abuse is much easier, as you can simply pick up on reported incidents. Verbal abuse is much more problematic.

“You need to screen people and follow up those who have either been abused physically or try to pick up patterns of repetitive low level abuse,” she suggests.

Getting staff involvement and engagement can also be a good idea, particularly when it comes to breaking down the stigma surrounding the issue.

When Ulster Community and Hospitals Health and Social Services Trust wanted to crack down on violence and abuse, for instance, its first step was to circulate a questionnaire to some 500 staff asking whether they had experienced either verbal or physical aggression within the previous two years.

This was followed up by the creation of a multi-disciplinary working group, setting consistent standards in handling aggression and the development of a trust training pack for all staff.

As the trust put it at the time: “Each staff member will be equipped with a repertoire of knowledge, values and personal skills to manage aggressive behaviours.”

After an incident, there is a firm policy of having a debriefing assessment, looking at how the situation was handled and the specific needs of the member of staff.

As with other professions (see box above), the key appears to be giving the victims of verbal abuse some sanction with which to deal with the situation, whether it means arresting the person (police) or exclusion (teachers).

For nurses, sanctions such as with-holding treatment are obviously problematic but at least knowing that your trust, managers and colleagues are behind you, that the issue is being taken seriously and that there is training and support available should the worst happen is a great help.

For Rosie Purves, while the situation has much improved and her trust is now much more sympathetic than it once was, there are still scars.
For a long time she was scared to come into work, and would use the back entrance just in case ‘they’ were there. But she was still determined to overcome the racists and get back to the job she had loved for so long.

“Verbal abuse is often over-looked in a big way. But you can only change things from the inside,” she says.

How other professionals fare

According to the NASUWT teaching union, teachers are verbally abused on average every seven minutes, both by children and parents.

For most teachers, the effect this has depends largely on the reaction of the school and the firmness and support of the head teacher in cracking down on such behaviour.

Most schools do have some form of behaviour policy in place, but many teachers complain support is variable.

The NASUWT also has a teacher support network and counselling available.

One veteran teacher contacted by OH described verbal abuse as being “endemic” and getting worse.

Even dealing with the most minor incidents can lead to a torrent of abuse, with a knock-on effect on your confidence and ability to teach. “It becomes so draining,” she adds.

As a rule, police officers expect a certain level verbal abuse and swearing on their day-to-day beat. But, particularly with, say, racial abuse, it can eventually wear down even the most street-hardened copper.

One of the big differences for police officers compared with nurses is that, obviously, they have the sanction of arresting someone who is abusing them.

There are also well-established mentoring networks that officers can turn to. Various associations, such as the Black Police Officers’ Association, can provide support and there is a welfare helpline, access to crisis counselling and all forces have active occupational health departments.

Much like the police, the prison service is a ‘hard’ profession, where officers expect to have to deal with an aggressive, confrontational atmosphere, sometimes mixed with over-crowding.

While verbal abuse is simply ‘part of the territory’, it should not be ignored, argues the Prison Officers’ Association (POA) union.

Stress-related illness within the service is high, says the POA, and there is the problem of a macho, stigmatised culture.

Prison staff do have access to welfare departments, which can provide counselling, and each prison operates a peer group support system, essentially a network of officers trained in listening skills.

Financial services
Call centre workers, often working for big banks or utility companies, are regularly on the receiving end of some of the worst verbal abuse around.

Customers who already have a grievance and are then left on hold or have to work through a series of ‘menus’ can find it all too easy to explode without having to worry about the consequences.

What’s less well known, argues the banking union Unifi, is that when someone hangs up a call, whether it’s ended abusively or not, the operator commonly only gets two seconds to recover before the next call is put through.

The union is arguing for better systems to be put in place so operators can, by pressing a button, take themselves out of the loop for a few minutes at least to sort themselves out.

Similarly, it’s calling for a warning to put on lines that verbal abuse will not be tolerated and for operators to be given the authority to end a call where the caller is being abusive.

What used to be occasional is now becoming a daily occurrence for many retailers and shopkeepers, argues retailers’ union Usdaw, which has been running a ‘Respect for Shopworkers’ campaign.

Figures from the British Retail Consortium published in September last year suggested that verbal abuse rose from 70 incidents per 100 outlets in 2002 to 159 in 2003.

At the same time, threats of violence had increased from 18 per 1,000 staff to 47 per 1,000 staff in 2003, and physical attacks were also up from six per 1,000 staff in 2002 to seven in 2003.

Isolation and a sense of lack of support can be major problems for retailers, particularly small and independent store-owners, says Usdaw.

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