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. 2002 Mar 30;324(7340):788. doi: 10.1136/bmj.324.7340.788

Violence in the workplace

Delirium should be considered

Siobhan MacHale 1
PMCID: PMC1122716  PMID: 11923167

Editor—The account of an assault on a nurse in the course of her work is distressing, and familiar to NHS staff.1 The clinical picture is of an agitated patient trying to leave the ward at night, within a day of admission with diabetic ketoacidosis. He was deemed unfit to be discharged, to the extent that the police were called to ensure his return to medical care. There may have been several causes for the violent outburst, for which the patient may rightly be held culpable. I was concerned, however, that all three commentaries failed to raise the possibility of delirium being relevant to the outburst.2

I encourage staff to press criminal charges when they are assaulted at work, as they would when out on the street or in their homes. But appropriate medical advice also needs to be available to police and staff if a patient is not legally responsible for his or her actions due to an acute confusional state secondary to his or her physical condition.

Explanations to staff members, with adequate training, robust protocols, and support proactively provided within the trust, may help to ameliorate the additional sense of distress engendered by a perceived failure of the legal system to prosecute in such cases.

References

BMJ. 2002 Mar 30;324(7340):788.

Mentally ill patients are responsible for their actions

L M Tuddenham 1

Editor—Goss writes in his commentary that a substantial majority of the violence against NHS staff is caused by “mental patients not responsible for their actions.”1-1 He admits that this is slim comfort for the victims. It might be, if it was true. Most mentally ill patients are responsible for their actions (violent or not) most of the time.

Repeating the myth does not do any favours for staff, patients, or society at large. It encourages the minimisation of violent incidents in mental health settings, which leads to under-reporting by staff. It teaches the patients that their violent behaviour will be tolerated, and they escape the usual sanctions of the criminal justice system.

If the recommendations of the “zero tolerance campaign” are followed, patients accused of assaults on staff will face prison sentences.1-2 The issue of mental illness affecting criminal responsibility would be considered then if pertinent during the court process. This avoids exculpating mentally ill patients because of a paternalistic belief that they lack responsibility.

Goss later states that the man who assaulted the nurse should have been considered for a custodial sentence, presumably because he had a physical illness and was therefore more responsible for his attack than a generic “mental patient.” Prejudging these patients by the above attitude would be unfair to both.

References

  • 1-1.Violence in the workplace [with commentaries by P Gough, RM Goss, and S Jordan] BMJ. 2001;323:1362–1364. (8 December.) [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Department of Health. Zero tolerance zone: we don't have to take this. London: Stationery Office; 1999. [Google Scholar]
BMJ. 2002 Mar 30;324(7340):788.

Zero tolerance is not helpful in mental health

Chris Jones 1

Editor—In his commentary Goss states that “a substantial majority” of violent acts in healthcare settings are committed by mentally ill patients not responsible for their actions.2-1 The first part of this statement may be true, but the assumption that “mental patients” by definition are not responsible is certainly false.

The vast majority of psychiatric patients are responsible for their behaviour, both morally and legally, as shown by the vanishingly small numbers of individuals ever found not guilty by reason of insanity in court. Even actively psychotic patients usually remain legally responsible for their actions and able to exercise choices in their behaviour.

Holding them responsible for their behaviour is another matter. It is now government policy that those who assault staff should receive custodial sentences. It also remains government policy that mentally disordered individuals who commit offences should not receive custodial sentences but should be admitted to hospital.2-2 The contradiction is manifest, except to those who make such policies.

The “zero tolerance campaign” proposes excluding patients from treatment in extreme circumstances, yet a central function of community mental health services is to maintain contact with patients, particularly those who display antisocial behaviour. Society increasingly demands that mental health services protect the public, sometimes at the expense of patients' autonomy. The care programme approach, assertive outreach programmes, and other initiatives are explicitly designed to impose care on individuals who may be unwilling to receive it. Not surprisingly, some become hostile or aggressive in response, and frontline staff pay the price.

A minority of patients are treated unwillingly under the Mental Health Act. Telling detained patients who do not wish to be in hospital that they will be excluded from treatment if their behaviour is extreme enough seems likely to increase, not reduce, violence to staff. If mental health is where the majority of the problems arise, as Goss claims, then responses are needed that are appropriate and workable.

No one will condone violence towards NHS staff, although most of us will have witnessed or been the victim of such violence. But zero tolerance is no way forward, certainly in mental health. NHS staff deserve genuine protection, not soundbite policies that sound tough but are incompatible with the realities of practice.

References

  • 2-1.Violence in the workplace [with commentaries by P Gough, RM Goss, and S Jordan] BMJ. 2001;323:1362–1364. (8 December.) [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Home Office. Provision for mentally disordered offenders. London: HO; 1990. . (HO66/90.) [Google Scholar]

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