Prioritising personal safety

All employers have a legal duty to protect the health and safety of employees under the Health and Safety at Work Act 1974/The Health and Safety at Work (Northern Ireland) Order 1978.

Furthermore, under the Management of Health and Safety at Work Regulations 1999/Management of Health and Safety at Work Regulations (Northern Ireland) 2000, they must assess the risk of harm to workers and take all reasonable steps to reduce the risk of harm to members of staff exposed to the risk.

Our guidance below outlines your employer's responsibilities to protect lone working community staff, as well as the steps you can take to raise and escalate your concerns. We have also included example scenarios where we would expect an employer to take action. The list is not exhaustive, and actions are illustrative. 

If unsustainable pressures at work mean that you have started working alone, or are working alone more frequently, this guidance may be helpful.

Please also see our Nursing Workforce Standards, in particular standard 10c.

What should my employer be doing to protect me when working?  

Any risks to workers must be included in organisational risk assessments. Measures, known as controls, can then be put in place to reduce the risk. These should include:

• training in: personal safety, escalation, carrying out a dynamic risk assessment, relevant organisational policies and procedures e.g. reporting incidents, dangerous animals, safeguarding and management of violence and aggression, and guidance on unacceptable behaviours
• means of raising the alarm e.g. effective lone working equipment 
• procedures for the supervision of lone working staff
• an organisation wide policy and process on unacceptable behaviours/situations and the withdrawal of care from patients who are violent and abusive.

Employers are also required to review risk assessments following any incidents or changes in work activity and/or the introduction of new procedures or equipment.

RCN safety representatives should be consulted on any measures that the employer is taking to reduce the risk to lone working staff.

Your safety is just as important as any other worker and you should not be put into dangerous situations. The NMC code states that you should take account of your own personal safety as well as those you care for.

The RCN expects all employers to have policies in place to manage violence and aggression, as well as other risks. Such policies must include steps to manage unacceptable behaviours encountered by nursing staff working in patient’s homes and outline when and how services will be managed (including withdrawing care) as a result of ongoing risks to staff. 

What should I do if I feel unsafe when working in a patient’s home?

• It is important to report all incidents and near misses in line with your employer's policies. The Health and Safety Executive describe a near miss as "an event not causing harm, but has the potential to cause injury or ill health or an undesired circumstance: a set of conditions or circumstances that have the potential to cause injury or ill health"
• Whenever you are doing a home visit, it is important to carry out a dynamic risk assessment (please see the relevant section below). This allows you to quickly assess a situation and take the necessary steps to remain safe. If it is a first-time visit, you must ensure that you have all the necessary information regarding the patient.
• If you have lone working apps or alarms always use them as instructed to log your location. Always ensure that someone from your organisation knows where you are at all times. Keep your work diary up to date and accessible to others.
• If you feel in serious or imminent danger do not enter the premises, withdraw to a place of safety, inform your manager and contact the police where appropriate.
• If you have entered a premises and it becomes apparent that you could be in serious or imminent danger make excuses e.g. that you have left equipment in the car, and immediately withdraw from the situation. Call your manager as soon as possible and contact the police where appropriate.
• The Employment Rights Act 1996 and the Employment Rights (Northern Ireland) Order 1996 provides you with protection against detriment or dismissal if you leave or refuse to return to a place of work because you reasonably believe there is serious and imminent danger that you could not reasonably be expected to avert.
• If you suspect that aggressive behaviour may be caused by a physiological condition (e.g. hypoglycaemia, hypoxia, hypovolaemia, acute stroke/ head injury or metabolic disturbance) that requires urgent life saving medical treatment, call emergency services for assistance.
• If an incident happens when you are in the home, follow your organisation's procedures, including how to activate your lone worker app or alarm.
• If you have carried out a dynamic risk assessment and concluded that it is unsafe to enter the premises, or have left it before delivering care, ensure you record this and give the reason for your decision. You must also report it using your organisation’s incident reporting procedures. If there is any doubt in your mind about your personal safety, err on the side of caution and do not enter the premises. You can always return later when you have discussed the issue with your line manager and the risks have been reviewed. The NMC code requires you to balance risks in relation to the people dependent on care services with your own safety. This means that you must consider other ways of delivering safe care and that you may need to refuse to provide care to an individual because it is not safe for you to do so.    
• Always report an incident in line with your organisation's incident reporting policy and procedure. It is important to do this as soon as possible to alert others who may be going to visit the patient  later in the day or on the next shift. Also, to comply with the NMC code, you must be able to justify your decision-making - your report and other notes will be an important record.
• Remember, if you have been threatened, physically or sexually assaulted, or abused because of your gender, disability, age, race, religion, pregnancy or maternity, sexual orientation or transgender identity you should report this to the police. Your employer should not deter you from reporting such incidents and should actively support you.

What should I do if I have concerns about the safety of others in the home?

Please see our safeguarding guidance for further information. 

Assess your surroundings

Is there anything around which is cause for alarm? For example, a potential weapon or dangerous animal. Think about how you will get out if things get difficult.

Assess the client/s:

Is their behaviour or the behaviour of someone with them cause for alarm? Are they acting in a strange manner?

Act:

You are not expected to put your own personal safety at risk. If you feel unsafe withdraw from the situation to a place of safety and inform your manager. Where it is safe to do so use de-escalation techniques. If you feel the situation is escalating use strategies to remove yourself, such as “I just have to pop back to the car to get some notes” or “to the other room to get some equipment”. Use your lone worker alarm systems as per employer’s policy/ procedure.

Further information from the RCN:

Personal safety when working alone: guidance for members working in health and social care
Violence in the workplace
Third party sexual harassment guidance

What should my employer do in cases where I have reported feeling unsafe or have been abused/assaulted?

Your manager should immediately investigate the incident, review risk assessments, and take necessary additional steps to protect you and others who could be affected by the situation. Staff must not be asked to enter a potentially unsafe situation until all risk assessments and controls are in place. 

Measures that could be taken include reviewing the patient’s treatment plan especially where the behaviour may be due to an underlying health condition or disability. This could include relocating the care to a health care building, or training family members to deliver routine care.  

The RCN also expects employers to have a policy on the management of violence and aggression, which would include actions to tackle unacceptable behaviours or unsafe environments. Depending on the severity of the incident, steps will include your manager having a conversation with the individuals to highlight unacceptable behaviours or conditions, a formal letter outlining what the expectations of the organisation are in terms of behaviours and sanctions that will be taken if behaviours continue, and finally the withdrawal of all but emergency care.     

Where a physical assault has resulted in more than seven days off work, or you are unable to do normal duties, they should report the incident to the Health and Safety Executive or the Health and Safety Executive Northern Ireland  the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). 

Your employer should also provide you with psychological support and, where necessary, support you in reporting the incident to the police. 

Please also see our guidance on violence in the workplace. 

What should I do if I am unhappy with the action my employer has taken and I continue to feel unsafe?

Although employers should take all incident reports concerning lone working community staff seriously, we know that some nursing staff are put under extreme pressure to return to unsafe working environments. The RCN can support you to raise concerns.

First, ensure that you have documented all of your concerns and followed the organisation’s incident reporting and raising concerns procedures. You can also contact us for advice or speak to your local RCN safety representative about escalating the issue. 

You can also use our model letter to highlight your concerns. Either use it alone or, ideally, get it signed by a group of colleagues and give to your manager. 

Model letter for staff in England, Scotland and Wales
Model letter for staff in Northern Ireland

If you have an RCN workplace representative let them know what action you have taken and give them a copy of the letter. As a registrant, by reporting issues and raising concerns you are acting within the NMC code and your employer should never discourage or victimise you for doing so. 

Family members ignore requests to socially distance when delivering care to a resident, nor open windows to ventilate home

Action by nursing staff:

• reinforce the need to maintain social distancing and ventilate the home using leaflets/materials to highlight risks
• report as an incident using organisational incident reporting procedures.

Action by manager/employer:

• support nursing staff to highlight concerns with householder e.g. by phoning or writing and exploring/discussing their concerns
• escalate as per behavioural agreement policy
• review risks and consider use of higher grade personal protective equipment
• relocating care where behaviours continue.

Where patients or visitors refuse to wear face coverings or masks 

Action by Nursing staff should:

• reinforce the need to wear face coverings as a tool to help limit the transmission of infection where this is appropriate for patients to do so
• remind people of the guidance
  • England: NHS England NHS Improvement: NHS Patients, staff and visitors must continue to wear face coverings in healthcare settings
  • Northern Ireland: Coronavirus (COVID-19): face coverings
  • Scotland: Coronavirus (COVID-19): face coverings guidance
  • Wales: Face coverings to continue to help keep Wales safe

Action by managers/employer:

• support nursing staff to highlight concerns with patients and visitors
• escalate as per behavioural agreement policy
• review risks and consider use of higher grade personal protective equipment, relocating care where behaviours continue.

The RCN believes if a member of health care staff contracts COVID-19 while working in clinical practice where they have been exposed to patients with COVID-19, employers should submit a RIDDOR report in line with HSE guidance.

A patient’s dog is out of control and despite repeated requests to keep it locked in another room. the patient refuses to do so.  The dog bites a member of nursing staff when delivering care.

Action by nursing staff:

• seek medical care / advice for animal bite
• report incident as per organisation's reporting procedures
• follow safeguarding procedures as necessary e.g. where dog presents a risk to children in the house.

Action by employer/manager:

• draw up a formal behaviour agreement with the patient outlining what is expected when the nurse visits i.e. lock dog in another room
• if the behaviour agreement is not followed, and the dog is loose, support the nurse not to enter the house and to report to manager immediately
• escalate the behavioural agreement in line with the management of violence and aggression policy
• support nursing staff who have been bitten with first aid needs and to report to the police and offer psychological support.

A nurse enters a new patient’s home and the patient is clearly agitated, they notice a large machete type knife on the dining room table. As a result of the behaviour and weapon, the nurse assesses themselves to be at risk of serious or imminent danger.

Action by nursing staff:

• use strategies to withdraw from the home e.g. I have left notes in the car
• immediately call line manager to report and document as soon as possible using organisational reporting procedures.
• document dynamic risk assessment and why decision was made
• refer to safeguarding policy where others may be at harm.

Action by manager/employer:

• inform patient why care was not delivered 
• follow safeguarding policy and escalate to police as appropriate
• review risk assessments and care requirements
• take steps to mitigate the risk to staff but ensure that care is delivered e.g. relocating care to a site with security presence.

A patient’s husband puts his hand up a nurse’s uniform, sexually assaulting them. Apparently, he is known to have done this on several occasions along with the use of lewd overtly sexual language, but no action has been taken apart from nurses visiting in pairs. Nursing staff have stopped reporting as they don’t believe anything will be done.

Action by nursing staff:

• report every incident, including sexual harassment using the organisation’s incident reporting procedures - please also see the RCN third party sexual harassment guidance
• report to the police as a sexual assault.

Action by manager/employer:

• review risk assessment and take steps to immediately mitigate risks of sexual assault to nursing staff e.g. relocating care to a healthcare building, training family members to deliver care and consider the temporary deployment of a male nurse or chaperone
• support nursing staff to report a sexual assault to the police and offer psychological support
• if incident is not being followed up by the police or no charges brought, contact patient’s husband to discuss that his behaviour is unacceptable and agree steps he will take e.g. be out of the room when care is being delivered
• escalate formally to a behavioural agreement if no improvements are made.

Whilst the patient may not be abusive or violent there may be situations where the environment is unsafe e.g. hoarding of papers making it difficult to access the patient to deliver care or an infestation.  These may not present a serious and imminent risk but they are situations which can lead to harm to the nursing staff and the patient

Action by nursing staff:

• report the situation to your manager following the organisation's reporting policy
• escalate via your safeguarding policy and where necessary ensure social services are aware.

Action by manager/employer:

• support nursing staff to follow up action with social services
• review risk assessments and explore with nursing staff means of mitigating the risk e.g. relocating care or training a family member to deliver care while the situation is being addressed
• manager to visit to support assessment of risk and discuss concerns with patient/patient’s family
• look at providing additional equipment eg. coveralls, torches or safety shoes for staff
• if the situation does not improve following social service intervention, escalate via your employer’s management of violence and aggression policy on acceptable behaviours/withdrawal of service.