Irish studies

There are few published studies concerning the safety of psychiatric trainees in Ireland. Meagher et al ^{Reference Meagher, Quinn, O'Mahoney, Morgan and Byrne3} reported that 27% of trainees had experienced violence at work. A follow-up study showed that 16% of trainees had experienced violence at work, but more than two-thirds had no training in ‘breakaway’ techniques, only 25% were aware of a critical incident debriefing service in their area and most were dissatisfied with the induction training provided by their employers. ^{Reference O'Mahony and Corvin4} Younger psychiatrists were at an increased risk of assault compared with older psychiatrists. ^{Reference O'Sullivan and Meagher5}

In 2006, a national survey was conducted by our working group which examined the experience of trainees in psychiatry in the Republic of Ireland. ⁶ It found that 16% of psychiatric trainees had experienced physical assault. However, in contrast to the previous study, ^{Reference O'Mahony and Corvin4} 85% of trainees reported that they had received breakaway training and 88.5% had been offered an induction course at the start of their current placement.

International studies

Community psychiatry

The shift from hospital to community-based psychiatry has had an impact on risk to trainees. The Collegiate Training Committee of the Royal College of Psychiatrists recommends the use of mobile telephones, joint assessments and personal alarms, and stresses the importance of the base knowing the whereabouts of staff during work hours. ^{Reference Linsley, Slinn, Nathan, Guest and Griffiths16} Despite these recommendations, a third of specialist registrars had been asked to do emergency assessments in the community on their own. ^{Reference Sipos, Balmer and Tattan9}

Trainees’ gender - a factor?

Most studies report no difference between male and female trainee psychiatrists in the risk of experiencing violence. ^{Reference O'Sullivan and Meagher5,Reference Chaimowitz and Moscovitch12,Reference Schwartz and Park14} However, Milstein ^{Reference Milstein17} found that female psychiatric trainees were more likely to be assaulted than their male colleagues (45 v. 35%), whereas Davies ^{Reference Davies15} reported that male psychiatric trainees were more likely to experience both verbal and physical violence.

Trainees v. consultant psychiatrists

In a study by Davies, ^{Reference Davies15} the most junior psychiatrists in training were statistically at greater risk of violent assault than were consultant psychiatrists, which may have been caused by the former's inexperience.

Psychiatric trainees and other medical trainees

Coverdale et al ^{Reference Coverdale, Gale, Weeks and Turbott2} studied 135 postgraduate trainees in psychiatry, general medicine, surgery and obstetrics/gynaecology: 64% of psychiatric trainees had been physically assaulted compared with 25% of trainees in other specialties, and 92% of psychiatric trainees had been threatened verbally compared with 53% of trainees in other specialties.

Local policies and training

Many studies indicate either a lack of education of trainees concerning local policies, procedures and written guidelines or a lack of training in managing violent incidents. In one study, only 27.3% of trainees were aware of written hospital guidelines for the management of violent incidents; ^{Reference Kidd and Stark18} in another, although 63% of the respondents were aware of local safety policies, only 37% were actively included in procedures such as active monitoring of their absence from the community base. ^{Reference Sipos, Balmer and Tattan9} A survey of Canadian resident psychiatrists found that 51.5% of the respondents had received practical training in dealing with violent patients but only 24% considered this training adequate. ^{Reference Chaimowitz and Moscovitch12} However, vulnerability to violence may not be influenced by courses on management and prevention of violence. ^{Reference Dhumad, Wijeratne and Treasaden19} A study in Wales reported a high uptake of induction and breakaway courses by psychiatric trainees, but it also highlighted deficiencies in the physical work environment such as poor access to panic buttons, personal alarms and appropriate interview rooms. ^{Reference Chubb20} Of concern is the finding that the process of audit did not lead to an improvement in the safety of interview rooms. ^{Reference Osborn and Tang21}

Underreporting

In a study of assaults on staff in a state hospital, five times as many assaults occurred as were formally reported. ^{Reference Lion, Snyder and Merrill22} Similarly, 82.2% of assaults on psychiatric junior doctors were not reported to consultants or managers. ^{Reference Kidd and Stark18} Even the most recent Irish national survey in 2007 revealed that the rate of violent incident reporting to management is only 38%. ⁶ Still, this is an improvement on the previous rate of 7%. ^{Reference O'Sullivan and Meagher5}

Irish legislation

The Health and Safety at Work Act 2005 implements the European Union framework directive on safety and health. It focuses on the prevention of occupational accidents and ill health, reaction and enforcement responses and a basic principle of inclusion of both employer and employee responsibility in workplace safety. It provides a legislative framework for the Health and Safety Authority.

Employer and employee responsibility

Employer responsibilities as described in the 2005 Act are extensive and include the responsibility to provide a safe physical environment, and to make available information, appropriate training, suitable equipment and supervision to all workers regardless of their employment or contractual arrangements. ²³ It also mandates the reporting of significant incidents to the Health and Safety Authority.

Employees are required to use protective equipment where necessary, to cooperate with their employer, to look out for colleagues and not to do anything which would put themselves or others at risk.

Health and Safety Authority

The Health and Safety Authority is the statutory body in Ireland with responsibility for protecting health and safety at work. It is involved with the development of new laws, the inspection of workplaces and the investigation of incidents and complaints. It can take enforcement action (up to and including prosecutions). A review of the website shows that no prosecution has been taken by this agency against the health boards or the Health Services Executive at the time of writing. (There is no publicly accessible record of complaints made to or cases investigated by the Health and Safety Authority; only prosecutions are reported on the website.)

Health Services Executive

The Health Services Executive is the national administrative body for the health service in the Republic of Ireland. The guidelines and operational policies for clinical practice by Health Services Executive employees are informed by the 2005 Act.

Royal College of Psychiatrists

The College has issued the following reports related to safety.

1. 1. Safety for Trainees in Psychiatry (CR780) ²⁴ provides recommendations for development and maintenance of a safe working environment for trainees, including safety training, induction courses, local policies and procedures and what to do in the case of an assault.

2. 2. Safety for Psychiatrists (CR134) ²⁵ endorses the recommendations of CR78, addresses a number of broader clinical issues and includes discussion of situations that require sensitive handling, in particular racial and gender matters.

3. 3. Not Just Bricks and Mortar (CR62) ²⁶ focuses on unit size, staffing, staff training, security, and structure for new and existing acute in-patient units.

4. 4. Psychiatric Services to Accident and Emergency Departments (CR118) ²⁷ describes a number of safeguards and responses which may reduce or prevent the occurrence of violent incidents, including the recording of the incident and the subsequent dissemination of information.

A recent survey of College approval visits in the Republic of Ireland found that psychiatric trainees repeatedly expressed concern about interview facilities (particularly in accident and emergency departments), the use of personal alarms and the availability of breakaway training. Recommendations included the promotion of a safety awareness culture, the implementation of clear and auditable safety policies and incident reporting structures, and the representation of trainees on safety committees. ⁶

Employers’ responsibilities

The higher risk of violence towards psychiatric trainees compared with trainees in other medical specialties must be acknowledged by employers; for instance, specially designed interview rooms should be available for psychiatric assessments in accident and emergency departments.

The strategy for the development of mental health services in the Republic of Ireland, A Vision for Change, ²⁹ proposes significant growth in community psychiatry which may pose additional risks to clinicians. More importance needs to be placed on systems which decrease the risk of violence or which alert co-workers to acts of violence in the community, such as monitoring trainee absence from base, checking-in by telephone, CCTV, and enhancing safety in areas of low staffing, such as community out-patient clinics.

Trainee's responsibility for safety at work

Both the legislation and the College guidelines describe in some detail the responsibilities of the employer in providing a safe working environment. However, as mandated in the 2005 Act, the burden does not rest solely with the employer. There is an onus on the trainee to have due regard to their own safety and the safety of others in clinical practice. Psychiatric trainees therefore need to inform themselves of health and safety parameters, need to take responsibility for informing the relevant authorities when working conditions put themselves and their colleagues at unacceptable risk, and must report violent or near-misses incidents.