When I joined a psychiatry training programme, a part of me accepted and expected that facing violence and aggression by patients would be part of the job. Unfortunately, my experience has proved to be far from unique.

A 2019 meta-analysis by Liu et al revealed that 43% of physicians and nursing staff reported experiencing non-physical violence, with 24% facing physical violence, and 12% encountering sexual violence or aggression from patients or their families in the past year.

The analysis found that these rates were notably higher in emergency departments and psychiatric hospital settings.

Meanwhile, a joint report by The BMJ and The Guardian into sexual abuse within the NHS revealed 35,606 incidents of sexual abuse, harassment, and stalking between 2017 and 2022, with nearly three-quarters of these incidents occurring in mental health trusts.​

Furthermore, rates of violence and aggression directed at healthcare workers have escalated since the pandemic, fuelled by fear, misinformation, and discrimination, with my workplace, the South London and Maudsley NHS Trust, seeing violent incidents rise by 35% during the first lockdown​.

The impact of workplace violence and aggression on staff is considerable and can lead to various emotions, including anger, sadness, feelings of worthlessness, emptiness, fatigue, and disturbances in sleep or eating patterns.

As well as impacting health and wellbeing, these experiences of violence and abuse can cause staff to question their competence and confidence, potentially taking a toll on workforce numbers.

Indeed, the 2019 report ‘Understanding Career Choices in Psychiatry’ has highlighted how violence and aggression from patients towards staff has resulted in attrition from the speciality.

The financial impact is equally concerning with the cost of violence in NHS settings amounted to nearly £83m in legal claims comprising compensation, staff absences, legal fees, and the turnover associated with burnout and mental health injuries​.

Yet despite their prevalence and impact, many incidents of violence and aggression in the NHS go unreported.

Findings from the 2023 NHS Staff Survey revealed that 23% of respondents answered no when asked whether they or a colleague had reported the most recent incident of physical violence against them, with 43% responding that they did not report harassment, bullying or abuse at work.

Barriers to reporting

For healthcare professionals, there are often many barriers to reporting incidents of violence and aggression.

Staff frequently feel they do not have the time to complete detailed reports, particularly during or immediately after a crisis when their primary focus is on stabilising the situation and patient care.  

There is also the fear of being blamed or facing repercussions, with many professionals worried about disciplinary actions or reputational damage following incident reporting.

Recent research has also identified reporting barriers unique to mental health settings.

For example, staff may underreport incidents when behaviours like verbal aggression are viewed as typical symptoms of certain diagnoses, leading to inconsistent reporting.

Additionally, the prosecution process can be frustrating, especially when patients are perceived as lacking capacity, which can hinder legal action, and delays in processing reports further discourages staff from reporting, leaving them feeling unsupported.

Cultural aspects of the medical profession, such as a focus on resilience, empathy, and sympathy, also reinforce these challenges.

Healthcare professionals are frequently expected to exhibit high levels of empathy and patience, even when faced with challenging behaviours from.

This culture of resilience, though valuable, can sometimes have a negative side effect: it may normalise abusive behaviours not only in professional settings but also within personal relationships.

Research suggests that these expectations can lead healthcare professionals to minimise or dismiss abusive behaviours as a normal aspect of their role, inadvertently blurring boundaries in their interpersonal relationships outside of work as well​.

Fortunately, the legal landscape surrounding assaults on healthcare professionals has evolved, particularly with the introduction of the Assaults on Emergency Workers (Offences) Act 2018, which provides greater protections for emergency workers, including those working in mental health services.

Despite this however, the workplace culture around reporting incidents is lagging behind the legislation.

SLAM's pilot and pathways

To address these barriers, SLAM (South London and Maudsley NHS Foundation Trust) has developed a pilot support pathway to standardise responses to incidents of workplace violence and aggression.

This initiative, led by Rowena Carter, seeks to provide a consistent approach to managing and supporting healthcare staff following such incidents.

The pathway, highlighted in Figure 1, includes immediate measures, such as psychologically safe spaces and follow-up meetings within 72 hours, to ensure that impacted staff receive timely support​.

Moreover, SLAM has embedded trauma-informed approaches and provides tailored resources for those affected. This includes options for peer support groups, regular supervisor meetings, and access to external resources such as psychological support.

Research has shown that peer support offers emotional validation and reduces feelings of isolation and burnout among staff, and can contribute to the resilience of healthcare professionals, helping them manage the emotional aftermath of violent incidents.

Furthermore, by co-ordinating with supervisors, the HR department, and occupational health, SLAM attempts to ensure a holistic response that addresses both physical and emotional needs​.

While these steps are important and necessary steps to try to address these barriers, it is important to acknowledge that these interventions trialled are in their infancy stages and have not yet been evaluated to measure their efficacy within the trust.

It should also be noted that while there are many examples of good practice around supporting staff facing violence and aggression, the scale of and access to these services can vary enormously.

As well as being iniquitous, these inconsistencies in support could leave staff in some trusts without the resources they need, and developing a more consistent and standardised approach across NHS mental health services is essential.

Resources for support and further guidance

The BMA offers guidance for managing incidents of discrimination and violence from patients through the Managing Discrimination from Patients and Guardians report, which outlines steps healthcare professionals and employers can take, including legal protections under the Equality Act 2010 and strategies for creating safer working environments.

Additionally, it provides practical advice on handling discriminatory requests, dealing with harassment, and understanding the legal rights of doctors to refuse treatment in cases of abuse.

Dr Rowena Carter has compiled a list of available resources that can offer confidential support to healthcare professionals dealing with mental health challenges resulting from workplace stress and incidents​. (table 1)

Idura Hisham is a psychiatry core trainee and Rowena Carter is a consultant psychiatrist based at the South London and Maudsley NHS Foundation Trust