Danny Lascelles, Lecturer (Mental Health Nursing) at Glasgow Caledonian University talks about whether nursing should take a ‘zero tolerance’ approach to violence and aggression.  

Whilst working as a lead practitioner for violence reduction in the NHS (National Health Service) in Scotland, I have often heard people say ‘but we have a zero-tolerance policy’ towards violence and aggression more times than I could count. The phrase seemingly originated in 1982¹ and has remained in use to the present day – promoted as the key strategy needed to eliminate the violence and aggression risk and to keep staff safe. 2,3,4 Although, in 2015, 20% of nursing staff in Scotland reported incidents of physical violence within the previous 12 months. ⁵ By 2021, there were a recorded 17,557 assaults on NHS Scotland staff between 1st April 2021 – 31st March 2022.⁶ Violence and aggression is highly emotive and it can be very damaging to those exposed to it. Nursing staff often describe feelings of frustration, fear, guilt, anxiety, and sometimes shame when talking about their exposure to violence and aggression in the workplace. Violence and aggression can also result in physical injury and pose genuine threats to life. Little wonder then that Scottish and UK (United Kingdom) Governments used the phrase ‘zero tolerance’ when promoting their own violence reduction campaigns because it appeals to staff, it sounds supportive, and it sounds strong.  

The problem is, ‘zero tolerance’ policies for violence and aggression do not work and for me, there is a deeper issue. Zero tolerance is unethical and only acts to increase risk to patients, nurses, and the nursing profession itself. Nurses and patients should expect risks to be managed, but is it possible to remove all risk of violence and aggression? Nurses need to know their rights and responsibilities – including those emotive ones that relate to the use of force for self-defense. Nurses also need to have their concerns heard and be properly supported and trained to deal with violence and aggression. 

Is ‘zero tolerance’ unethical? 

Zero tolerance establishes a premise that blame, can be put, solely, upon those displaying violence and aggression. This, in turn, helps to enable the development of a ‘them and us’ culture, where nurses can separate and project all the ‘badness’ into those individuals displaying violence and aggressive behaviour. Then, those people risk being labelled as ‘dangerous,’ ‘anti-social’ or ‘violent.’ Adverse labels tend to stick and the effects they can have upon health and social outcomes are well documented. ⁷ This can also lead to nurses feeling no need to reflect on their own actions regarding violence and aggression incidents. After all, why should they? If it has already been established that the ‘aggressor’ is the one in the wrong and that nurses should not be exposed to violence and aggression, so why should nurses consider their own actions? Given that reflection is a foundation of nursing practice this is a difficult position to defend.  

Furthermore, I believe ‘zero tolerance’ can pose a fundamental risk to nature of nursing itself. As well as being extraordinarily complex, violence and aggression is a health and safety risk. It is a health and safety risk where the hazard is always another human being, and we want to believe people should respect nurses. I think, then, that when other human beings assault nurses, this is perceived as the fundamental attack upon nursing. If my thinking is accurate, then such an assault, would be difficult to tolerate and must be removed altogether. The false promise of zero tolerance is that it presents a route that nurses believe they can follow to do this. That nurses can remove the therapeutic relationship, as it need not apply and there is no worth in extending it to those violent individuals. In other words, those individuals can be excluded from receiving our care.
The issue here is that those ‘violent people’ are likely to be patients and will still require care and treatment. If they are exposed to an adverse culture, that reduces them to being no more than a violence and aggression risk, then they are, ironically, more likely to become aggressive. To my mind, this would strike a far more fatal blow to nursing. It would enable a culture that actively goes against the values of nursing, by adversely judging people and exposing them to discriminatory care. To make matters worse this situation would have been our own doing and a result of ‘zero tolerance’ approaches, which are unethical and can harm patient care and the nursing profession.

Concluding thoughts  

My views about zero tolerance aside, violence and aggression towards nurses remains a significant, multi-dimensional problem. Proponents of alternative strategies, for example those outlined in the Scottish Public Health Network’s ‘Violence Prevention Framework’ or NHS Protects ‘Meeting Needs and Reducing Distress’ guidance document will outline far more ethical and sustainable options for violence and aggression reduction, which propose that staff are fully supported and prepared to manage the risk, uncover its root causes and work to support those same patients – but that is a discussion for another day.   

References  

1. Wilson James Q, Kelling George L. Broken Windows: The police and neighborhood safety. Atlantic Monthly. 1982;249(3):29-38. 
2. Ashton RA, Morris L, Smith I. A qualitative meta-synthesis of emergency department staff experiences of violence and aggression. International emergency nursing. 2018;1; 39:13-9.
3. Bond P, Paniagua H, Thompson A. Zero tolerance of violent patients: Policy in action. Practice Nursing. 2009;20(2):97-9. 
4. Rimmer A. Staff shortages and long waiting times are fueling abuse against doctors, says MPS. BMJ. 2023;381:1441. 
5. Royal College of Nursing. Violence and aggression in the NHS: Estimating the size and the impact of the problem (interim Report). 2018. 
6. UNISON. Violent assaults NHS staff in Scotland survey 2022. 2022;  
7. Norman I, Ryrie I. The art and science of mental health nursing: Principles and practice: A textbook of principles and practice. McGraw-Hill Education (UK); 2013.