An exploration of the role of substance misuse nurses in Scotland
Chapter 8: Health and safety at work
Key points in this chapter Sixty four percent (64%) of nurses had been physically or verbally abused by clients. Half of those who had been subject to abuse felt current safety provision was insufficient. Greater use of personal alarms and alarms in consultation rooms, use of mobile phone, and specialised training were suggested to improve safety. The majority of consultations take place in clinics/consultation rooms rather than clients' homes. The safety of staff was considered to be a high service priority in most areas but there was evidence this was still lacking in some areas. The feeling was commonly expressed among nurses that their work could be stressful and this was seen as being due to paperwork, excessive caseloads and working in isolation.
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In the questionnaire 64% of nurses reported that they had been threatened physically or verbally by a patient. Of the 122 nurses who had been threatened, 65 (54%) felt that there was inadequate safety provision at work should a threatening incident occur. Nurses who felt that safety provision at work was adequate were significantly more likely to be Grade G and above (p<0.01). There was no significant difference in perceived safety at work by age or gender of nurse.
In the questionnaire nurses felt their safety could be improved by the availability of personal alarms, emergency alarms in consultation rooms and better security arrangements when visiting a drug misuser's home. Other suggestions included the use of mobile telephones and provision of specialised training, such as managing aggressive behaviour. Most nurses met their patients/clients in the clinic (see Table 11).
Table 11: Location of patient/client contact
Location | Always
N % | Most of the time N % | Occasionally
N % | Never
N % | Total
N % |
Clinic | 41 (25.6) | 72 (45.02) | 42 (26.3) | 5 (3.1) | 160 (83.3) |
GP Surgery | 17 (11.7) | 36 (24.8) | 57 (39.3) | 35 (24.1) | 145 (75.5) |
Hospital | 11 (8.3) | 6 (4.5) | 90 (68.2) | 25 (18.9) | 132 (68.8) |
Drug Misuser's Home | 1 (0.7) | 33 (22.0) | 84 (56.0) | 32 (21.3) | 150 (78.1) |
Personal safety
In interviews nurses were asked if they had concerns about their personal safety when dealing with drug misusing clients. All nurses indicated that they were usually aware of issues as this information would be requested from the client's GP:
"I would hope that the referring GP would highlight any safety issues. If I get some new referrals, some of the people you know who have been put off another GP's surgery list and there is a history of them maybe being aggressive." Nurse 19, G Grade
Not all services seemed to treat personal safety as an important issue. Nurses working in such surgeries/agencies, although they did not feel that they were in any danger, did point out the implications of this:
"if I did a home visit last thing on a Friday it would be first thing on the Monday before anyone would realise I had not turned up for work." Nurse 13, G Grade
Many nurses had previously conducted initial assessments in clients' homes and would consider doing so again. However, if they had the choice almost all would conduct initial assessments within a clinic. Others, especially those located in rural areas, indicated that home visits were conducted on a routine basis, but where possible first time assessments would usually be conducted in a central location, such as a GP's surgery or within their service. A home visit would be conducted if a client requested one, had childcare issues, was disabled in any way or if had travel difficulties.
Nurses who conducted home visits were asked if they were concerned about their personal safety. All were aware of the guidelines set out in the 'Orange Book' concerning home visits, which they felt were helpful. However, many of these nurses felt they were very observant and were aware of potential dangers and when visiting clients in their homes relied heavily on their own commonsense and intuition. One male nurse explained:
"I am selective about whose home I would go into, I wouldn't just offer to go and see anybody to be honest. …. If I am going to see somebody who is not toeing the line in terms of their behaviour or if they were quite confrontational then I wouldn't see them again in their home. I'd insist that they come to the surgery for their future visits." Nurse 17, E Grade
Surprisingly not all nurses who visited clients in their homes indicated that they were concerned about their personal safety. One nurse stated:
"No I've never, I've never felt threatened by the clients. I mean I've thought a lot about that and I don't know how much of that is approach or who we are as people but we've never had any hassle, any problem and in the thirteen years I've been working for drug using clinics I've been verbally abused." Nurse 7, H Grade
Safety provision varied between services. Most nurses felt that there were adequate guidelines and procedures set out by their agencies and that their personal safety was considered to be paramount by their management teams. One nurse said:
"We have quite a sophisticated phone system where before we go into a house we have to phone we select say fifteen minutes and if we don't cancel the call or phone within fifteen minutes then they will call us. If they don't get a reply it will go straight to the police." Nurse 7, H Grade
Stress of job
From questionnaire data 56% agreed with the statement "I find working with drug misusers stressful". It became apparent from interviews that it was not necessarily working with drug misusers themselves that was the source of stress. When asked if work caused them stress some responded by pointing out the job satisfaction they experienced:
"I think the easier question to ask is "Do I enjoy my work?" and I do…if you've got contentment with your work then I think that's quite important". Nurse 18, H Grade
Many nurses pointed out that stress relating to the work was often not to do with clients per se but to do with other factors such as paperwork and even taking holiday:
"You get odd days you feel really harassed and it's usually not the patients, it's usually trying to get all the pieces to fit together which involves prescriptions, computers, bits of paper, things like that are actually more harassing to me". Nurse 6, G Grade
"It's difficult at times if you go off on holiday because of the nature of the relationships you have with clients. When you come back and you feel things have slipped a bit … you are often left feeling a bit frustrated". Nurse 14, G Grade
Isolation, particularly when combined with a high caseload, was also a factor as working in the community means sometimes not seeing colleagues for days:
"I have worked in addictions for 15 years and this is the loneliest job I have ever had…If you have a very busy clinic with 25 people sometimes and you are on your own doing it. It is quite lonely that way and you are away for days on end and you don't come into the office 'til Friday usually". Nurse 22, G Grade
Some people had adapted to the work patterns. Coping with the stress of the job was facilitated by two factors: having the support of the team; and having the ability to separate work life from home life. Generally, nurses described having informal support from colleagues and formal support through supervision:
"We've got quite a good supervision sort of network set up both organisational and personal, so we've got the organisation one in which we use a colleague for good practice as well as things that are annoying". Nurse 3, G Grade