Don't delete the expletive /by Philip Davis

Don't delete the expletive

Mental Health Nursing, by Davis, Philip


We should all be nice to each other, right? Well, not quite, says Philip Davis. Sometimes you have to say it like it is

As someone who was a trained psychiatric nurse I have seen and experienced some abuse and violence at the hands of patients and visitors in the NHS. As someone who also used to be a trade union steward I have also had to deal with a managerial attitude that violence was part of the job. So I am pleased that the Department of Health and the NHS produced a national campaign designed to reduce the risk of violence to staff.

However, a difficulty with the NHS Zero Tolerance Campaign is that it tends to focus the minds of staff onto patients as potentially violent people. Of course the people responsible for this campaign are aware of this potential problem and much of the campaign is about trying to make staff aware of their prejudices and how their own attitudes and actions can actually provoke violence. Health minister John Mutton writes: 'All NHS employers ...should continue to work to create an environment in which all individuals feel valued and in which differences are recognised and fully utilised in delivering service goals.'

Unfortunately my experience of the acute adult inpatient services of my local hospital, and correspondence from the chief executive of that trust both suggest that this part of the campaign has been lost and it has become something used to foster the stereotype of the mentally ill as violent. Even worse, the campaign has been used to stifle legitimate complaint and, in doing, been brought into disrepute. Ultimately this will increase the risk of violence to the front line staff for whom the trust is responsible for providing a safe working environment. It will also increase the risk of these staff being violent to patients.

Whilst I was detained in hospital I saw a senior clinician who asked me how I was feeling. Since I was detained and prevented from looking after my elderly mother, as I usually do, I used strong language to express my strong feeling and quietly replied that 'I feel fucking awful'. The clinician's response to this expression of my distress was to tell me not to swear. Since the last time someone felt they could tell me what to say was when I was a child in school I felt this was a deeply patronising and uncaring response. Anyone who has done even a basic counselling course will know the importance of being non-judgmental.

I wrote to the chief executive, with the expectation that I would get a simple apology for the upset the staff member had caused me. Instead the chief executive replied: 'With regard to the use of bad language, I can only reiterate the Trust's stance that any language, which may be construed as harassment, will not be accepted and all people will be encouraged to articulate themselves without using expletives.' When I further questioned this, the chief executive wrote: The NHS zero tolerance zone campaign defines violence as: "Any incident where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health".

'It is in line with this national policy and having regard for the rights of service users, carers and staff that all people are encouraged to articulate their feelings without the use of expletives.'

I Since I don't believe any reasonable person could consider someone saying, in a quiet voice, that they felt 'fucking awful' as in any way harassing, abusive, threatening or an assault I was offended by this response.

My reply to the chief executive was: This response of quoting the NHS Zero tolerance policy at me is deeply offensive. It implies that by me saying " I feel fucking awful", in response to a question as to how I feel, that I am somehow threatening, abusing or assaulting someone. I consider that this implication that I abused, threatened or assaulted someone to be deeply offensive and defamatory.

'It is this way in which your staff member's use of their powerful position to impose cultural norms on me has been turned around, by you, into an implication that I abused him that has most led me to refusing to receive care from your Trust. It makes it clear that j your actual attitude is not one of partnership with clients but about the imposition of your beliefs as to what is in my "best interests".

'Additionally as someone with some experience of working in the NHS I can only say that a policy where people are "encouraged to articulate their feelings without the use of expletives" is, apart from being an imposition of limited cultural norms on to vulnerable people, an unworkable fantasy. If any staff member involved in therapeutic work tried to impose this it would ruin their therapeutic relationship, greatly decrease their ability to help patients and would probably increase their risk of being physically assaulted.'

I wrote to the Department of Health to find out if the chief executive was correct to suggest that 'all people are encouraged to articulate their feelings without the use of expletives' was in line with the Campaign. The Department replied that with regard to verbal abuse 'each incident should be treated and assessed on a case by case basis'. It is clear from this, that no blanket policy about what language people use, does fit in with the Campaign and that the chief executive's assertion was wrong.

I was also very concerned that the attitude expressed by the chief executive was discriminatory. In my letter to the Department of Health I wrote: 'I'm sure that you are aware that many people grow up and live in households where the use of the word "fuck" and other "vulgar" terms is common place and not, within that context, meant or seen as offensive. The musician Ozzy Osbourne certainly had this experience, and the television programme of his home life makes it clear that this is still his lifestyle. The chief executive's policy does not explain why anyone should have to change from their normal language because they are in hospital.'

Certainly I find it hard to see how Mr Osbourne, who used to live in my local area, could be encouraged to express himself without the use of expletives. The idea that someone from the background that Mr Osbourne had might be refused care because they used the language of their upbringing is very worrying.

Of course staff shouldn't be verbally abused but no person trained and paid to work with people in distress can possibly expect not to hear people use strong language to express strong feelings. Since my admission, I've had the opportunity to talk to some of the nursing staff employed in the trust all of whom had no idea that they were supposed to encourage people to express themselves without the use of expletives and all of whom thought the idea unreasonable.

My gut feeling about this incident, based on my experience of working in the NHS, is that when faced with a complaint from me about being patronised by a senior doctor, and knowing the adverse comments that have been made about the Trust's consultation with patients at every level, the chief executive responded in a defensive manner and grabbed j at the NHS Zero Tolerance Zone campaign as a way of diverting my complaint. In doing so, he brought this important campaign into disrepute and has thus shown not only a disregard for the rights of patients to be able to express themselves but has shown a disregard for the safety of his clinical staff.

After my last article, (Davis, 2004) where I considered some of the factors that put patients at risk from staff violence, (What's the count here? How many patients have been killed by staff restraint, physical and chemical, as compared to staff killed by patients?) this may seem to be a minor issue. However, if there was one thing I understood as a nurse, it was the development of a therapeutic milieu and the role that small but important symbolic issues had in that. An environment in which there is intolerance, and control, of language will foster the sense of powerlessness that leaves patients with only physical violence as a I method of expression. Of course, this physical violence will usually be directed at the patient themselves.



Copyright Community Psychiatric Nurses Association