Working in the community provides many challenges and opportunities. When placed in non- hospital settings as a student nurse or embarking upon a career as a community staff nurse, it is timely to reflect upon personal safety. This chapter is not intended to deter nurses from choosing to work in a community setting, but to ensure that practical and reasonable steps are taken to ensure their safety.
The first section of this chapter examines safety relating to the prevention and management of violence and aggression.The second part focuses upon manual handling, as the safety of both nurse and patient may be compromised if careful thought is not given to this issue before home visiting. The principles remain the same wherever the nurse is working, but some consideration needs to be made when moving into community settings. Finally, issues of reporting and bringing incidents to a resolution will be explored.
SAFETY AT WORK
The 1974 Health and Safety at Work Act and the 1992 Health and Safety at Work Regulations charge employers and employees with responsibilities in risky situations. Assessment of risk is a requirement to minimise potential harm and community nurses need to consider safety issues from both practical and professional perspectives.
Sadly, violence and aggression are an increasing problem in hospitals around the United Kingdom (Health Services Advisory Committee 1997, Royal College of Nursing 1998, Whittington and Wykes 1996). This is also the case for those nurses working in the community who are often working alone (Jackson, Clare and Mannix 2002) despite the Zero Tolerance Campaign launched in 1999 by the government.
This campaign sought to reduce the incidence of violence against nurses by 20 per cent. It has proved difficult to achieve (RCN 2001). It is very important to spend time considering how to prepare for community work and be aware of potential problems.
This includes developing knowledge of the area of work, developing self-awareness and understanding why and how aggression can escalate.
First, learn the geography of the area, whether that is a town, clinic or surgery. Become familiar with the layout of rooms and buildings and note the position of exits. Find out what is known about the community. Without falling into the trap of stereotyping people, investigate what reputation the area has, find out about crime rates, for example. Talk to your colleagues about safety. It is strongly recommended (Leiba 1997) that visible security measures, involving personnel and technology, should be evident in health centres and clinics.
There may be areas within the surrounding locality that are considered to be high risk. Sometimes community staff visit these in pairs. Find out if the remit of the post involves visiting after dark. It is good practice to gather as much information as is possible before setting off to a patient or client’s house.
PREPARATION FOR HOME VISITING
This section will focus particularly upon home visits, as there are particular features that could, potentially, compromise personal safety. Bearing this in mind, read carefully any records or notes pertaining to the visit. Talk to colleagues, who may know the situation and should make sure that concerns are shared. Look at the location of the visit – think about how you will get there.
Always remember that home visits, however welcome to the patient or client, are an invasion of that individual’s space. Table 4.4 outlines some of the things that should be considered when arriving at someone’s home.
The community nurse is a visitor in the patient’s home and must wait to be invited in. It is good practice to discourage patients from leaving notes (for example: ‘Please come round to the back – door open’) and hanging keys on strings behind letterboxes. These, obviously, put patients at risk from unscrupulous opportunists. In addition to these measures, the community nurse should offer personal identification.
When visiting in other people’s homes, self-awareness is crucial. The conditions in which some people live can be upsetting. Monitoring facial expressions and choosing words carefully are a must (Leiba 1997). This may not prove to be easy. If so, take the opportunity to discuss your feelings with other members of the team after visits that leave emotions heightened.
The majority of home visits are very welcome to the patient or client. Relationships between community staff and the people that they care for can be very positive and a rewarding aspect of working in primary care. With thought, observation and self-awareness many potential problems may be avoided.
Table 4.4 :Entering a Patient’s Home
Considerations – Rationale
- Remember that you are the visitor. – It is the patient’s space that you are invading – it is unknown what is or has recently been happening in that person’s home.
- State clearly who you are and why you have come. Show your identity badge. – Don’t assume that the person will recognise a uniform (if one is worn) or will be expecting the visit. It is good practice to encourage patients and clients to ask to see identification. This protects them as well as the professional.
- Wait to be invited into the house and ask in which room the patient or client would like you to carry out the purpose for your visit. – Being pushy can make people irritated and angry. It may not be convenient for the patient or client to allow you into a particular room. This may be for good reason, e.g. if an unpredictable dog is shut in there!
- Note the layout of the house – exits, telephones.- In case a speedy exit is required.
- Be careful with people’s property – protect their belongings. – Spillages, breakages or rough treatment of belongings will irritate – remember the visitor status.
- Be alert – monitor moods and expressions during the visit. – Changes in the demeanour of the patient or client could indicate potential conflict developing.
- Be self aware – monitor the manner in which information is given and care carried out. Do not react to conditions, which may seem unacceptable – dirty, smelly environments, for example. – The nurse should not provoke feelings of anger. Remember that this is the patient’s home.
- Trust instinctive feelings. If it feels that leaving quickly is the thing to do – go. – Often assessment of situations takes place on many levels. If uncomfortable feelings are building up don’t wait until there is an incident.
- If prevented from leaving – try not to panic – see the section relating to interpersonal relationships. – It may be possible for you to de-escalate the situation.
Working in a community setting involves being mobile. In some localities bicycles may be an entirely appropriate way to get around; in busy cities public transport is often the best option. For most community staff, however, it would be impossible to function effectively without a car.
Some practical measures need to be undertaken relating to car safety (Table 4.2). Areas between car parks and clinic/surgery buildings should be well lit.
In addition to the above, it is helpful to plan the route to the destination with care. As the geography of the area becomes more familiar, this will become easier. Try not to give the impression that you are unsure of the way. Some police experts are now recommending that car doors are kept locked whilst driving in more dangerous areas. Good preparation for the journey makes it more likely that the nurse will arrive feeling calm. It is better to avoid road rage – especially if it is your own.
Walking between car and house, community nurses should appear purposeful, confident and in control. Walk towards the kerb side of the pavement and away from alleyways and hedges. Footwear should be comfortable and allow for speed, if necessary. It is not a good idea to wear jewellery at work for many reasons. Chains may catch or be pulled; rings and wristwatches are a hazard to patients and clients if physical care is needed. In addition to these (well known) considerations, wearing jewellery could catch the attention of muggers.
Table 4.2 Car Safety
Consideration – Rationale
- It makes sense to ensure the vehicle is well maintained. – Not only is it inconvenient, it may be hazardous to break down in a remote place after dark. Well worth the expense of servicing and looking after the car.
- Try not to run out of petrol. – The car will not be happy and again this could leave you stranded in remote or unsavoury places.
- Park with thought. – Look for safe parking places. In the dark it is helpful to find a streetlight to park under. Try to park near to your destination.
- Take out breakdown cover. – At least someone is coming to assist you. Always state that you are alone and make it clear if you are female.
- Keep any nursing bags out of view – in addition to any personal valuables. – Some people may believe that nurses carry drugs in their bags – prevent temptation.
INTERPERSONAL RELATIONSHIPS AND NON-CONFRONTATIONAL BEHAVIOUR
In spite of the preparations suggested above, it may be that tensions rise whilst visiting. Confrontation may occur between patient or carer and nurse. Communication skills are crucially important in all fields of nursing; however, some issues need careful thought when visiting patients and clients in their own homes.
Households vary tremendously and staff new to community working may be surprised or shocked by the conditions in which some people live. An open mind needs to be cultivated in terms of the possible relationships that may be encountered – there are many variations of family life. It is necessary to communicate respect for all patients and clients, whatever thoughts may be experienced. Nabb (2000) found many incidences of family and carers assaulting nurses – remember that the giving and receiving of information should always be carried out courteously and sensitively.
Table 4.3 Interpersonal relationships – Non-Confrontational Behaviour
Considerations – Rationale
- Be aware of how you are feeling and how you may appear to others. – If you appear worried or defensive you may cause worry or fear.
- Try to look calm and relaxed. – Never try to domineer or act in an arrogant fashion. Attempts to belittle those who are angry are extremely dangerous.
- Speak clearly and quietly – speak in a low pitch if possible. –
- Listen to responses. Use non-verbal communication (such as nodding the head) to convey understanding. – This is a two-way process. Demands and commands should not be issued.
- Try to accept how the other person is feeling. Ask for further clarification. – Even if the issue is difficult to empathize with, people own their feelings. Don’t argue.
- Be polite in the face of provocation. – Avoid becoming over-emotional. It is better to be brief and professional if tensions are mounting.
- Try to ensure that the other person has an escape route. – If people are angry and feel crowded or cornered, aggression can be triggered.
- Stay seated if the other person is seated. – It can be dangerous to tower over others – the aim is not to provoke.
- Don’t stand too close. – Leave reasonable personal space to avoid crowding.
- Watch carefully to plan your exit. – Try to close the conversation if possible.
Table 4.3 suggests guidelines for non- confrontational behaviour to minimise the risk of provoking or encouraging aggression or violence. Some of the suggestions may appear to be ‘common sense’. In situations of potential conflict, however, it is easy to feel anxious and behave inappropriately. Try to think carefully about the considerations and rationales before a difficult visit occurs.
Remember that there may be indicators that a person is potentially aggressive, such as using a raised voice, clenching their fists and threatening assault (Leiba 1997).
Aggression has been defined as:
Any incident in which a health professional experiences abuse, threat, fear or the application of force arising out of the course of their work, whether or not they are on duty. (RCN 1998: p.3)
This definition is useful, as actual abuse does not have to occur in order for aggression to be felt. Fear is a powerful enough experience to warrant action. The Royal College of Nursing’s definition also does not differentiate between on- or off-duty situations. It is important to remember that insurance cover from employers relates to the duration of the shift.
Under the 1974 Health and Safety at Work Act, employers have a duty to provide a safe working environment. Along with the responsibilities for employers there are also requirements, which need to be carried out by employees. Firstly, locate any policies and procedures, which exist locally relating to health and safety (RCN 1994). Study these carefully and note the reporting arrangements that are laid down for staff to follow.
Many primary care trusts (PCTs) offer training in assertiveness and dealing with aggression and violence. The Health and Safety at Work Regulations (1992) charge employers with provision of training in these fields. Take up the opportunities on offer. If there doesn’t seem to be any training available ask if this could be arranged.
It is good practice to contact the work base at the end of the day to let someone know that visits are complete. The team leader will delegate visits to each member of staff and will co-ordinate the team. The order in which visits are carried out may not be predictable, but someone knows where each nurse should be visiting on a daily basis.
Many community nurses have the use of a mobile telephone, which can be useful in difficult situations. It may not be possible, however, to access the phone at the very time that you may need it. Mobile phones do not ensure safety, but they help. The use of personal alarms may be useful, to
frighten, disorientate and debilitate an attacker. The Suzy Lamplugh Trust (see useful addresses) advises holding up the alarm directly to the ear of the attacker and running away as fast as possible.
In addition to all of the above, there is a potential threat (even in a ‘caring profession’), which may not manifest itself in the homes or streets of the community served. Personal safety may be at risk in situations of harassment and bullying. Reported incidents are rising (Jackson, Clare and Mannix 2002; Rippon 2000) and it is important to be aware of ways to deal with bullies.
Bullying has been defined as the misuse of power or position (RCN 2001) and includes aggressive behaviour, ridiculing or humiliation, public criticism and exclusion from opportunities open to others.
Bullying may occur in any NHS setting and is, unfortunately, becoming more prevalent in many societies (Jackson, Clare and Mannix 2002). Many studies have found that aggression between staff is more upsetting and difficult to deal with than assaults from patients (Farrell 1999, 2001).
It is important not to keep bullying quiet – talk to other people (family, friends, trusted colleagues) and document what is happening. Employers are charged with the task of developing a culture of intolerance towards bullying and to deal with incidents effectively (DOH 2002). It is always better to try to address issues informally and directly at first – the person may not realise the effect that they are having. If, however, this does not work, then a formal complaint may be made. It is strongly advised that advice be sought from union representatives if a formal complaint is to be made.
A further requirement of the 1992 Health and Safety at Work Regulations is that of risk assessment in the workplace, which should be followed by planning, organising and monitoring both protective and preventive measures. The Health and Safety Executive (HSE) have issued a five-stage framework for risk assessment. This applies to all situations, which could lead to harm and is used also to evaluate needs relating to manual handling.
HSE’S FIVE STAGES OF RISK ASSESSMENT
These apply to all situations that have potential for risk. It is the case that many interventions carried out by nurses carry risks of harm to patients, the nurse and the general public. Dale and Woods (2001) state that these risks include clinical issues such as infection control, needlestick injury, inappropriate skill mix and staffing levels. There has been a rise in MRSA (methicillin-resistant Staphylococcus aureus) infections in community settings (Cookson 2000). This is of great concern and should mean that the highest standards are maintained in terms of hygiene.
Measures such as hand cleansing need to be carefully considered, particularly in patient’s homes – not every household will have hot running water and soap, for example. Consult local policies for advice as to how to deal with this problem. There are many solutions for hand cleansing, in addition to traditional soap and water – these should be used as prescribed by the manufacturers. Uniforms and clothes worn for work need to be changed daily and laundered properly (RCN 1999b) to protect nurses and patients alike. Chronic understaffing puts nurses at risk. In addition to personal safety issues, health and safety within clinics and patient’s homes needs consideration.
We shall now look at, each of the five stages of risk assessment and relate them to potentially threatening situations of violence or abuse.
1. Identify the hazards
This includes reports of threats and abuse, not only of actual physical violence, by patients, carers or others. Remember that this could be whether the nurse is on duty or not. The community staff nurse must report any incidents by following local policies.
2. Identify who is at risk
Specify who could be harmed by the risk. This could include other members of the nursing team, other professionals and lay people.
3. Evaluate the risk
Assess the seriousness of the situation. Identify what can be done to minimise or eliminate the risk to protect those who could be harmed. Senior nurses will carry out the assessment of the risk with contributing evidence from the team. However, it is everyone’s responsibility to identify and report potentially hazardous situations.
4. Record the findings
Decisions taken and workable measures to minimise the risk will be documented.This provides a working plan for staff and managers outlining all of the above in addition to steps, which may still need to be taken. Be sure to record events accurately (NMC 2002).
Poor communication of risk can result in misunderstanding and failure to pass on vital information to other colleagues. Documentation needs to be comprehensive and accurate, containing a full account of intervention and assessment of the situation (NMC 2002, Woods 2002). Avoid the use of jargon and abbreviations.
5. Review and revise the assessment
Assessment is a dynamic process. It is important to revisit the document, particularly after incidents are reported. Staff training and communications should also be reviewed. It has been said that a major source of risk is uncertainty by members of staff about what is expected of them, especially in emergency situations (Dale and Woods 2001). Policies and procedures need to be current, available to those who need them, and comprehensive.
In order not to compromise patient care, care plans need to be regularly reviewed and updated so that staff are clear what has been found on assessment and what interventions are required.
The above stages also apply to other areas of practice – in the interests of patients and nurses it is important to think about manual handling situations arising in non-institutional settings.
MANUAL HANDLING IN THE COMMUNITY
The potential for safety to be compromised in manual handling situations in patients’/clients’ homes is very real. The inclusion of this issue within this chapter is in recognition of the fact that over 30 per cent of nurses suffer work-related back pain each year (Institute of Employment Studies 1999).
Although the principles of manual handling remain the same wherever the nurse is working, community visiting gives rise to particular issues. By revisiting the five tenets of manual handling some of these are presented.
There will be manual handling issues in many nursing procedures undertaken in the home (see Table 4. 4). These include moving patients in bed, helping patients get out of bed and standing up. Toileting and dressing should be approached with thought, as should bathing and washing procedures.
As in many settings, patients can be heavy and unpredictable. Paralysis, confusion or pain may make the patient a particular challenge.
When handling a load it is important to hold that load as close to the trunk as possible. Think about a patient in the middle of a double bed. This bed is low and not very firm. Immediately problems for safety (both for nurse(s) and patient) are apparent.
Nursing patients in their home environment is very different from doing so in a hospital ward. Hazards could include cluttered rooms with little space for manoeuvre, slippery polished floors, loose rugs and poor lighting. These are a problem for both patients and staff. It is important to address these hazardous conditions with tact and sensitivity. When rapport and trust have been developed between patient and nurse, suggestions for improving home safety will be better received.
Nurses come in all shapes and sizes. The same is true of carers, who tend to be more involved in giving direct care in home settings. Older people who are carers may not be in the best of health themselves. It is important not to make assumptions about the abilities of others.
Policies and procedures relating to manual handling must be studied carefully (Chambers 1998). Mandatory updates in PCTs are necessary to ensure the safety of staff and patients. There may be unfamiliar equipment in patients’ homes. Don’t use unknown manual handling aids until training has been carried out.
Inadequate staffing levels can put nurses at risk. The number of staff at any given time will affect directly the workload of each nurse. Tired staff are more vulnerable to injuries, accidents and mistakes (RCN 1996, 1999a).
In addition to the above, keeping fit and healthy can reduce the possibility of back problems developing. By valuing and safeguarding his/her own health the community nurse can contribute to the risk reduction process.
Table 4.4 Occasions when manual handling procedures must be carefully considered:
1. Moving patients in bed
2. Helping them to sit or stand
3. Toileting and dressing
Note the following:
- A full assessment will be carried out as required according to the Manual Handling Operations Regulations 1992.
- The sister or charge nurse will assess patients. Measures to reduce the risk of potential injury will be put in place, e.g. a hospital bed may need to be provided.
- The assessment will be documented in the care plan. Any changes in circumstances must be reported to the team leader.
Nurses are required to report issues relating to safety under the Health and Safety at work Act (1974). If injury occurs as a result of manual handling procedures, then this must be reported. There is evidence that a large majority of nurses believe that a certain level of aggression is part of the job (Leiba 1997, Unison 1997). This acceptance of abuse seems to be particularly widespread amongst older nurses. In their campaign to ‘stamp out violence’, the Nursing Times received 1000 replies to a questionnaire on the subject (Coombes 1998). In nurses aged over 55 years, 92 per cent felt that violence and aggression was part of the nurse’s lot.
Amongst nurses aged between 26 and 34 this view was held by 76 per cent. Undoubtedly this leads to an underreporting of incidents, which is worrying. It will not be possible to gauge the size of the problem if nurses are reluctant to speak up. It is also unfair to colleagues to keep quiet. Today might have included verbal abuse from a relative, tomorrow (particularly if the situation is poorly handled) may lead to something much worse.
The report should be made as soon as is possible. Events should be clearly and comprehensively stated.
SUPPORT AND COUNSELLING
People who have been involved in aggressive or violent incidents need to be supported at work. Reporting the events can be traumatic and it is helpful to have assistance from a colleague when completing the necessary documentation (RCN 1998). It may be helpful to discuss what has happened with other members of staff. A debriefing should take place with the people concerned. The actual events should be explored, including any possible triggering factors and the feelings of those who took part. Ways of preventing recurrence should be considered.
Commonly, following verbal abuse or physical attack feelings of fear, guilt or anger may be experienced. These can manifest themselves in taking the ‘blame’ for provoking aggression, wondering if the experience will be repeated or anger towards the aggressor, the organisation or even oneself.
It may take time for a victim of abuse or violence to regain the confidence to visit alone again. Support may be offered by occupational health, professional organisations or counselling services. Support may also be needed for others involved, including the aggressor.
After careful consideration of the issues addressed within this chapter, turn back to the learning outcomes at the beginning and think about each one in turn. Look back at the notes made for the first exercise at the beginning of this chapter. Is there anything that you would like to add to them?
If this chapter has raised any concerns for practice, it is important that they are discussed with an experienced community nurse, either informally or through clinical supervision channels. Some useful addresses can be found at the end of this section.
Remember that the majority of staff working in community settings enjoy a close partnership with their patients and clients. The health centre or surgery is at the heart of the local community and relationships may build over a number of years. Visiting patients and clients in their homes is a privilege that greatly enhances the experience of community nursing. Taking practical precautions and taking time to think about safety can better prepare the community nurse for difficult situations that could arise.