Psychiatric training - a dangerous pursuit

We performed a review of the international literature, Royal College of 
Psychiatrists guidelines and Irish legislation concerning psychiatric trainees 
and their experience of violence. Physical violence in the workplace was 
reported by 16% of traineesin Ireland and 67% of specialist registrars in the 
UK; 72% of trainees in Belgium reported verbal violence. Personal 
characteristics of trainees which increase the risk of experiencing violence 
are underresearched, although it is observed that the duration of clinical 
experience seems to be somewhat protective. The advent of community psychiatry 
brings new risks to trainees. The Royal College of Psychiatrists issued 
guidelines and reports that are useful in developing facilities and promoting 
trainee safety. Although legislation provides some protection to trainees, it 
also places responsibility on them as employees.

Psychiatric training -a dangerous pursuit SUMMARY We performed a review of the international literature, Royal College of Psychiatrists guidelines and Irish legislation concerning psychiatric trainees and their experience of violence. Physical violence in the workplace was reported by 16% of trainees in Ireland and 67% of specialist registrars in the UK; 72% of trainees in Belgium reported verbal violence. Personal characteristics of trainees which increase the risk of experiencing violence are underresearched, although it is observed that the duration of clinical experience seems to be somewhat protective. The advent of community psychiatry brings new risks to trainees. The Royal College of Psychiatrists issued guidelines and reports that are useful in developing facilities and promoting trainee safety. Although legislation provides some protection to trainees, it also places responsibility on them as employees.
Health professionals are at increased risk of violence at work. In the UK, National Health Service staff have a 1 in 200 risk of major injury through wounding at work, compared with the general public's risk of 1 in 5300 for men and 1 in 25 000 for women. 1 The risk of experiencing aggression at work is even greater in psychiatry and psychiatric trainees are most at risk. 2 The definition of violent behaviour in the literature varies widely, reflecting the many ways in which violence may affect health workers. In this article we have classified violence into either physical or verbal aggression. Physical aggression refers to any behaviour that relates to injury to person or destruction of property, whereas verbal aggression refers to spoken threats, including physical gestures that evoke fear. We review important research concerning violence and safeguards regarding psychiatric trainees and include a brief summary of the legislative and policy framework in which psychiatry trainees in the Republic of Ireland operate.

Irish studies
There are few published studies concerning the safety of psychiatric trainees in Ireland. Meagher et al 3 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. 4 Younger psychiatrists were at an increased risk of assault compared with older psychiatrists. 5 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, 4 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 Prevalence Following a study by members of the Collegiate Training Committee of the Royal College of Psychiatrists, which indicated that trainee psychiatrists believed that violence to staff was a problem, 7 the British Medical Association (BMA) survey of psychiatric trainees found that 60% reported that their work had put them at risk of violence. 8 Although the BMA study was limited owing to a poor response rate and did not include overall figures for actual violence, it did include narrative accounts from trainees who admitted feeling at risk due to unsafe and seemingly uncaring systems in the workplace. A 2003 survey of specialist registrars in psychiatry in the southwest of England revealed that 67% had been assaulted in psychiatric posts. 9 The risk of violence in the UK is similar to that reported in a recent study in Belgium, which found that as many as 56% of the psychiatric trainee respondents had been confronted with at least one physical assault by a patient during their residency and that only a small minority had received any training related to patient violence. 10 Similarly, studies from North America consistently report that 40% of psychiatric trainees have experienced a physical assault at work. [11][12][13][14] Violence with weapons and verbal assault Although reports of assault with weapons are infrequent, one US study reported psychiatric trainees frequently discovering weapons on patients in the emergency room. 11 Conversely, verbal assault of trainee psychiatrists is widely reported -just over 70% of trainees had been threatened by a patient. 10,14 This figure is much lower for psychiatrists of all grades (32%). 15 Possible factors increasing risk of violence to psychiatric trainees

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. 16 Despite these recommendations, a third of specialist registrars had been asked to do emergency assessments in the community on their own. 9 Trainees'gender -a factor?
Most studies report no difference between male and female trainee psychiatrists in the risk of experiencing violence. 5,12,14 However, Milstein 17 found that female psychiatric trainees were more likely to be assaulted than their male colleagues (45 v. 35%), whereas Davies 15 reported that male psychiatric trainees were more likely to experience both verbal and physical violence.

Trainees v. consultant psychiatrists
In a study by Davies,15 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 2 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; 18 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. 9 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. 12 However, vulnerability to violence may not be influenced by courses on management and prevention of violence. 19 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. 20 Of concern is the finding that the process of audit did not lead to an improvement in the safety of interview rooms. 21 Underreporting In a study of assaults on staff in a state hospital, five times as many assaults occurred as were formally reported. 22 Similarly, 82.2% of assaults on psychiatric junior doctors were not reported to consultants or managers. 18 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%. 5

Legislation, policies and guidelines
Safety for doctors working in psychiatry in Ireland is governed by the Health and Safety at Work Act 2005 and a number of agencies, including: . the Health and SafetyAuthority . the Health Service Executive . the Royal College of Psychiatrists.

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. Safety forTrainees 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. 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. 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.

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

Discussion
The high levels of physical and verbal violence suffered by psychiatric trainees are a cause for concern. However, the available research may be limited by the inherent biases of retrospective questionnaires. Selection and recall bias may result in an overrepresentation of incidents of physical violence and an underreporting of verbal aggression. The variation in the definition of violence may also affect the prevalence reported and make comparisons difficult. Near-misses (incidents which could have resulted in physical assault) may be underrecorded in questionnaires. Robust research and development in this area will require systems to comprehensively and prospectively record incidents of physical and verbal abuse.
It is interesting that Ireland has a lower prevalence of physical violence among psychiatric trainees than the UK, Belgium and the USA, particularly so since Ireland has the highest rate of victim-reported violent assault in the general community in the European Union. 28 The reasons for this discrepancy have not been investigated and remain unclear.
It is of concern that despite the increased availability of induction courses, and training in breakaway techniques and other aspects of personal safety, there has been no demonstrable decrease in the prevalence of violence. This may be because violence is sporadic and relatively infrequent or may be due to the difficulty of removing all risk of violence from clinical situations. It may also be because the physical protections as recommended in the College guidelines, such as purposebuilt interview rooms and chaperones, are still frequently unavailable. 6 Research is needed to evaluate such measures.

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.

Conclusions
Despite legislation and state bodies giving legal protection, and representative bodies issuing guidelines, psychiatric trainees still suffer violence at a higher rate than their non-psychiatric peers. Psychiatric trainees may be reluctant to report incidents and have described feeling unsupported by their employers. In addition to taking more responsibility for personal safety, trainees need to have the courage and motivation to report unsafe work conditions and practices to the relevant bodies. Developments in community psychiatry pose additional challenges, and services need to be planned with safety in mind. Both employers and trainees need to appreciate the new risks raised by the development of community psychiatry, and need to act now to reduce the risk of serious injury or death.

Declaration of interest
None.