Safety at work: national survey of psychiatrists in basic training in Ireland

Notice ought to be taken of the discordance between staff and patients views (particularly in relation to consent and confidentiality) when attempting to detect and manage illicit drug use in psychiatric setting. This is particularly important when unconventional methods of detection (such as sniffer dogs) are being used. Moreover, clinicians and managers should be mindful that there currently exists very little (if any) data on the sensitivity and specificity of the use of sniffer dogs in situations such as this. Furthermore, there should be clear guidance on police involvement when illicit drug use is detected among in-patients. A balance needs to be struck between the patient’s dignity and the right to confidentiality, and the maintenance of a drug-free environment.


AIMS AND METHODS
To investigate the experiences of Irish psychiatric trainees in relation to safety at work and the related training issues.A questionnaire was posted to 243 psychiatric trainees throughout Ireland.

RESULTS
We obtained 113 responses (46.5%).Results indicated that tutors appear to consider safety at work as an important component of training.The availability of breakaway or similar training is much bigger than previously reported in Ireland.The standard of induction courses appears to be high.However, problems in working environments were revealed: 16% of trainees had been physically assaulted and 72% have felt threatened in the workplace.

Despite improvements in training in
Ireland, workplaces remain largely unsafe, putting staff and patients at risk.
The Trainee Section of the Irish College of Psychiatrists formed a working group on safety issues and training in 2004 to review the current status of safety at work, to explore the associated training issues for psychiatric trainees working in Ireland and to make recommendations regarding any deficiencies discovered in relation to the desired standards.The group was established following an increase in anecdotal reports of violence among trainees.
The working group prepared a report for the Irish College of Psychiatrists, which covered the following areas: a review of legislation and guidelines on safety for trainees, a literature review of the area, a review of professional organisations and their responses to violence

Method
The study was approved by the Irish College of Psychiatrists.A questionnaire with both quantitative and qualitative items was designed for the purposes of this survey.Because of the lack of a database of trainees, each of the 12 basic training schemes in Ireland were contacted for a list of their current trainees; 9 provided the information requested.We posted 243 questionnaires in two mail shots to the basic trainees identified.

Results
We received 113 replies giving a response rate of 46.5%.The main findings are summarised in Table 1 (complete results for overview of training and work environment, induction courses, experiences of non-physical threatening behaviour, experiences of physical assault and documentation of the assault are shown in online Tables DS1^DS5).Two questions dealt with recruitment issues, indicating that for 71 (68%) trainees safety concerns would be a factor when considering changing post and for 61 (60%) when choosing their specialty.

Discussion
This survey has revealed both the strengths and weaknesses of Irish psychiatric services in terms of safety at work and the associated training issues.
The response rate of 46.5% may raise concerns about response bias.However, we believe that this survey is valid owing to the large number of respondents (n=113) and the length of their experience (61% have been in psychiatry for longer than 2 years).
The survey took place in an era of change for the Irish health services.The management structures have changed dramatically over the last couple of years with the establishment of a national Health Services Executive and the appointment of a Chief Executive Officer.The organisation recently produced a corporate safety statement, stressing that the 'delivery of quality healthcare to our service users is intrinsically linked to the ability to provide a safe work environment for employees' (Health Service Executive, 2006).The working group strongly endorse this statement.
On the ground it appears that Irish psychiatric tutors have taken seriously the role that safety issues have for training and patient care.In terms of the importance placed on safety in the workplace, 81% of trainees in the study reported that this is stressed on beginning work in psychiatry.A further 85% reported that they received breakaway training or engaged in a similar course.This compares with a rate of less than a third of trainees as reported by O'Mahony & Corvin in 2001(O'Mahony & Corvin, 2001), which suggests that it is only in recent years that there has been a sea change in availability of such courses.
Broader issues of safety have also been addressed by trainers, as 78% of trainees had received training in the management of the environment (e.g.sitting next to the door, removing potential missiles from the room prior to conducting interview) in terms of safety and 88.5% of trainees had received an induction programme prior to the commencement of their job.This compares with a rate of availability of induction courses among senior registrars in the UK of 44% (Sipos, 2005).The working group noted that their quality appeared to be high, as a majority reached the standards of induction courses laid out in the Royal College of Psychiatrists' guidelines (Royal College of Psychiatrists, 1999).One area of weakness appeared to be the rarity of reference to the relevant College documents.
Despite initial high rates of uptake of breakaway courses, only half of the respondents are offered refresher courses and a third of those do not avail of this offer.The deficit in the use and/or the availability of alarms is still a live issue with just over a half of trainees stating that they have access to alarms and only a half of those with access reporting that they use them.
Moving beyond the training opportunities to the reality of work life revealed a less optimistic picture of the trainee experience.The working group were particularly concerned about the reported lack of available interview original papers rooms, with 68% of trainees saying that safe rooms are not available to them at all times.Unfortunately, Irish trainees are not alone in this and their experiences appear to be mirrored in the UK (Campbell & Fung, 2007).

Rush et al Safety at work: national survey in Ireland
During work, chaperones are not available to trainees in the areas where they are needed most such as accident and emergency departments.The Royal College of Psychiatrists highlights the need for interpreters in helping to reduce the risk of a violent incident and this is increasingly relevant to the Irish psychiatric services because of the novel experience of high inward immigration over the past few years.Unfortunately, 43.5% of trainees are having difficulty accessing these vital services.
The British Medical Association revealed that 60% of psychiatric trainees in the UK reported that they felt at risk of violence in their workplace (British Medical Association, 2005).This is somewhat lower than our figure of 72% who have felt threatened/unsafe at work but similar to the figures reported from Belgium (Guido et al, 2005).
In our survey of 113 trainees, 16% admitted that they were physically assaulted.Meagher et al (1997) reported that as much as 27% of trainees in Ireland had experienced violence at work, but our findings are more in keeping with the study of O' Mahony & Corvin (2001) which also found 16% trainees to be affected.O 'Sullivan & Meagher (1998) found that 39% of all psychiatrists had been physically assaulted, with trainees at higher risk.This is clearly more than our data suggests.We speculate that addressing safety issues as evidenced by the expansion of training courses may be contributing to the lower levels of violent assault, even in an environment which has not been designed in either structure or practice with safety as a high priority.Other factors, such as differences in the definition of violence used, may also complicate comparisons between studies.
The reporting rates indicated a considerable variability in the person approached in the workplace after a verbal or physical assault.We were concerned that this might indicate a lack of clarity as to the appropriate 'port of call'.There may be a great diversity in terms of local protocol but we thought that this is unlikely and that local policies should be audited to ensure services are responding appropriately to incidents.Given the person most likely to be approached for support is the trainee's consultant, opportunities should exist for all consultants to receive training on safety at work.In terms of the response to episodes of threat or assault, 75.5% and 77% respectively were at least satisfied with the response.
It is of concern that all trainees who were physically assaulted declined any psychological support, possibly reflecting a lack of regard for their own well-being.This is a professional competency which must be supported to prevent burnout and an appropriate culture should be fostered to encourage this skill.In addition, there was a reduced rate of reporting of incidents if they did not involve actual violence as only 67.5% of trainees reported non-physical threatening episodes to their consultant.Again this may reflect trainees' lack of personal safety awareness, but it also has negative implications for the ongoing monitoring of 'near-miss' events, preventing an appropriate system response.
The involvement of the Gardai, the Irish police, in tackling violence at work may be a contentious issue in psychiatric services.However, we would argue that any perception of aggressive behaviours as 'acceptable' in psychiatric services is inappropriate for patient care and risks a dereliction of duty to trainees.Garda were notified about only 3 of the 17 assaults reported.Of note, the College report 78 recommends that consideration should be given to pressing charges in the event of a violent incident.We have called for psychiatric services to review their policies in relation to this area.

Conclusions
This study provides an ongoing reminder that violence is not an uncommon event in the lives of trainee psychiatrists.We are pleased to report positive developments in meeting training needs but further issues remain to be addressed, most importantly the introduction of safe working practices and a safe environment.Tutors appear to have taken their responsibilities in this matter seriously by providing professional training on safety but as a group they have not been as successful in engaging the management to provide work environments and practices with safety as a top priority.If we are to meet the highest standards of patient care, safety in the workplace cannot be ignored or seen as peripheral.

Declaration of interest
None.
Khalifa et al Police and sniffer dogs in psychiatric settings original papers BAYNEY, R. & IKKOS, G. (2003) Managing criminal acts on the psychiatric ward: understanding the police view.Advances in Psychiatric Treatment, 9, 359-367.DEPARTMENT OF HEALTH (1999) The Code of Practice to the Mental Health Act1983 (revised).TSO (The Stationery Office).DOLAN, M. & KIRWAN, H. (2001) Survey of staff perceptions of illicit drug use among patients in a medium secure unit.Psychiatric Bulletin, 25,14-17.
R v. Broadmoor Special Hospital Authority and the Secretary of State for the Department of Health Ex parte S, H & D [1998] COD199.at work, the current status of training schemes in the country as assessed by the Royal College of Psychiatrists Accreditation Visits, a national survey of trainees in relation to safety and training and conclusions and recommendations.This paper reports on the findings of the national survey.

Table 1 .
Summary of results