In 1998 and 1999, the NHS Executive carried out a survey of sickness absence, accidents and violence in all National Health Service (NHS) Trusts in England, and found that there were approximately 65 000 violent incidents against NHS Trust staff each year. The average number of incidents in mental health/learning disability trusts was over three times the average for all trusts, and the NHS Zero-Tolerance Zone Campaign was launched in response to these findings in October 1999 (Department of Health, 2000).

Violence in the workplace is of increasing concern to junior doctors in general and trainee psychiatrists in particular (Reference Bhugra, Smith and JunaidBhugra et al, 1990). Assaults on psychiatrists have been recognised as an important occupational hazard (Reference O'Sullivan and MeagherO’Sullivan & Meagher, 1998) and there is some evidence that violence on psychiatric wards might be increasing (Reference Shah, Fineberg and JamesShah et al, 1991; Reference Owen, Tarantello and JonesOwen et al, 1998). The Collegiate Trainees’ Committee has repeatedly addressed issues around trainees’ safety and has issued a number of clear recommendations regarding safety training, induction courses, local policies and procedures, and safety standards for interview rooms (Reference Cormac, Crean and MotrejaCormac et al, 1999).

Issues of safety also rated highly on the improvement ‘wish list’ for trainees in a survey of active problems and issues recently undertaken by the Collegiate Trainees’ Committee (Reference Wilson, Corby and AtkinsWilson et al, 2000). However, a survey of safety awareness and provisions for safety in the workplace among junior psychiatrists in Wales revealed gaps in the provision of safety training and facilities (Reference ChubbChubb, 1997).

We therefore decided to survey specialist registrars’ awareness of safety training and actual safety provisions within the largest psychiatric specialist registrar rotation scheme in the South West (the Avon & Wiltshire Mental Health Partnership NHS Trust currently serves a population of ca. 1.6 million).

Method

Based on recommendations made in recent reports by Royal College of Psychiatrists Working Parties and the Collegiate Trainees’ Committee (Reference Cormac, Crean and MotrejaCormac et al, 1999; Royal College of Psychiatrists Working Party, 1998; 2000) and a similar survey among junior psychiatrists in Wales (Reference ChubbChubb, 1997), we designed an anonymous, confidential questionnaire to survey safety awareness and provision for safety. We sent it to all specialist registrars (SpRs) within the Avon & Wiltshire Mental Health Partnership NHS Trust who had a National Training Number in general adult psychiatry (n=33). This included SpRs in dual training in old age and general adult psychiatry, but excluded those training in the specialities of forensic, child & adolescent or learning disability psychiatry. The questionnaire was sent out in August 2001, when most SpRs had been in their current post for about 10 months. To optimise the response rate, the questionnaire was sent out for a second time a few weeks later.

The questionnaire consisted of a series of statements, and respondents were asked to indicate the ones reflecting their own experiences or opinions. Each SpR could rate the safety profile of up to five interview rooms used by them at their present post by ticking which of a given list of desirable safety features (Reference Cormac, Crean and MotrejaCormac et al, 1999) were present in each room.

Results

Twenty-seven out of 33 questionnaires were completed and returned, giving an overall response rate of 82%. We have summarised responses to each question in Table 1.

Table 1. Summary of responses

Safety training	n	% of total (n=27)	% of SpRs with training (n=24)
At any time during your psychiatric training so far (i.e. as SHO or SpR), have you ever participated in any safety training?	24	89%
Any theoretical safety training?	13	48%	54%
Any practical safety training (e.g. breakaway techniques)?	23	85%	96%
Any other form of safety training?	2	7%	8%
Who paid for your safety training?
My employer	22	82%	92%
I had to pay for it myself	0	0%	0%
It was funded in some other way	2	7%	8%
Have you attended any further training sessions since then?
Yes, one further session	4	15%	17%
Yes, several sessions	1	4%	4%
How much time has passed since you last participated in any safety training?
>24 months	15	55.6%	63%
Induction	n	% of total (n=27)	% of SpRs with induction (n=12)
In your present SpR post, did you have any induction at the beginning of your placement?	12	44%
Tour of the site and relevant buildings	7	26%	59%
Written information about relevant local safety policies	5	17%	42%
Guidance about maintaining personal safety and privacy	3	11%	25%
Any other written material regarding safety or management of violence	3	11%	25%
Protected time for induction (e.g. first clinics cancelled)	7	26%	59%
Teaching or training sessions	4	15%	33%
Any other form of induction	5	19%	42%
Local policies and procedures	n	% of total (n=27)	% of relevant subgroup (n=17)
Are you aware of any local safety policies or procedures actually being in place in any of the teams you work with (e.g. alarm systems, active monitoring of absence from community base etc.)?	17	63%
If your team has local safety procedures, have you been included into any of these?	10	37%	59%
Have you ever been expected to make emergency assessments alone in the community?	9	33%
Experience of violence or assault	n	% of total (n=27)
Do you ever feel vulnerable or fearful for your personal safety at work?
No, I don't	10	37%
Yes, sometimes I do	16	59%
Yes, I do most of the time	1	4%
Have you ever been assaulted or been involved in a violent incident at work?
Yes, during present job	0	0%
Yes, during previous psychiatric SpR job	0	0%
Yes, during previous psychiatric SHO job	18	67%
Yes, during other jobs	4	15%
No, never	7	26%

Safety of interview rooms

More than half of all the respondents (n=15; 56%) felt that they had to interview patients in unsuitable rooms. Fifty-nine rooms were rated for the presence of safety features based on College recommendations (Reference Cormac, Crean and MotrejaCormac et al, 1999) and the results have been summarised in Table 2.

Table 2. Safety of interview rooms

Safety of interview rooms	Yes (n=59)	%
Is the room situated close to main staff areas, i.e. not isolated?	45	77%
Does the room have a readily-accessible panic button?	23	40%
If there is a panic button, are you aware of any explicit policies, which tell staff how to respond when an alarm is raised?	6	10%
Does the room have unimpeded exit?	33	56%
Does the exit door open outward?	8	14%
Can the door be opened without a key to exit?	54	92%
Is the room suitably furnished and free of clutter?	40	68%
Does the room have an internal inspection window to permit viewing when the room is occupied?	15	25%

Conclusion

This survey, with a high response rate of 82%, provides representative and valuable information about safety awareness and actual safety provisions for SpRs in the largest Mental Health Trust in the South West region of the UK.

There are some encouraging findings, especially the high proportion of SpRs (89%) who had participated in some form of safety training. However, less than half of all respondents had received any safety training within the past 2 years, indicating problems regarding the necessary continuity of such training. Less than half of the respondents had been given a period of formal induction at the beginning of their post and, even more worryingly, only 37% were aware of having been actively included in local safety policies and procedures. Clear induction procedures could help to improve this situation by introducing and including SpRs to local safety arrangements.

Interview room safety was another area that suggested the persistence of significant gaps, disregarding official College recommendations (Reference Cormac, Crean and MotrejaCormac et al, 1999): again, more than half of all the respondents reported that they had to interview patients in unsuitable rooms. Out of 59 rated interview rooms, only 23 had readily-accessible panic buttons and for only six out of these 23 rooms were SpRs aware of any explicit policies on how to react if an alarm was raised. Lillywhite et al (Reference Lillywhite, Morgan and Walter1995) had surveyed interview room safety in parts of the area covered currently by the Avon & Wiltshire Mental Health Partnership NHS Trust, and made recommendations for improvements and regular audits. Our survey suggests that there is still scope for further work in this area.

We were encouraged to find that despite the above-mentioned gaps and problems with safety provisions, none of the SpRs surveyed reported any personal involvement in an assault or violent incident during any of their SpR jobs. However, two-thirds reported such personal involvement during previous psychiatric SHO jobs. This unexpected finding clearly underlines the importance of monitoring and raising safety standards for all trainees. The majority of SpRs (60%) felt at times vulnerable or fearful for their personal safety at work. Improvements in areas such as regular provision of safety training, formal induction and inclusion in safety procedures, as well as further improvements in interview room safety, could help to increase their overall job safety and satisfaction.

This audit was carried out prior to a General and Old Age Psychiatry Specialist Advisory Sub-Committee accreditation visit by the Royal College of Psychiatrists, and we have presented our findings to the SpR Programme Director and the Training Committee of Avon & Wiltshire Mental Health Partnership NHS Trust. Although we did not include SpRs from other psychiatric specialities (e.g. forensic, child & adolescent or learning disability) nor SHOs in this audit, we recommend monitoring the effectiveness of any potential improvements through further regular surveys of all psychiatric trainees.

Declaration of interest

None.