Perkins et al. Crime Sci (2017) 6:11 DOI 10.1186/s40163-017-0073-1 SYSTEMATIC REVIEW Open Access Personal security alarms for the prevention of assaults against healthcare staf Chloe Perkins1, Deirdre Beecher2, David Colas Aberg3, Phil Edwards1 and Nick Tilley3* Abstract Background: Personal security alarms have been used to try to reduce violence against healthcare staf, some of whose members face relatively high risks of assault. This systematic review focused on the efect of alarms in reducing the incidence and/or severity of assaults. Methods: Electronic databases, including Cochrane Library, Ovid MEDLINE(R); CINAHL Plus (EBSCO); PubMed; PsycINFO (OvidSP) PsycEXTRA; Applied Social Sciences Index and Abstracts (ProQuest) (1987 to current); Criminal Justice Abstracts (EBSCOhost); Psychology and Behavioural Science Collection (EBSCOhost); Social Policy and Practice (OvidSP) Sociological Abstracts; ProQuest theses and dissertations, were searched. Study designs eligible for inclusion were randomised controlled trials, interrupted time series and controlled before-after studies that assessed the impact of personal security alarms on assaults. Searches were undertaken for studies of healthcare staf in all settings (i.e. including staf working in confned spaces such as hospitals and also feld personnel such as community health work- ers). Workplace violence between colleagues (lateral violence and bullying) and other uses of personal alarms (e.g. fall alarms for the elderly, domestic violence prevention) were excluded. Search results were screened by title, abstracts and keywords for possible inclusion. Full text reports for all potentially relevant studies were obtained and indepen- dently assessed for fnal inclusion. The primary outcome was physical assaults (recorded or self-reported). Secondary outcomes included increased confdence or self-efcacy in violence prevention (recorded or self-reported). Main results: No studies were found that met all inclusion criteria. Four reported associations of personal alarms (and other variables) with risks of assault in healthcare settings. These were described narratively. Conclusions: Healthcare workers in emergency departments, psychiatric units and geriatric facilities face much higher risks of assault than those in other healthcare settings. Alarm systems vary widely. Alarm systems form one of a range of measures, which may interact with one another, that are used to reduce the risks of assault. Given this com- plexity and diversity, prior to feld trials EMMIE orientated efcacy trials are recommended to try to establish whether alarms can be introduced and operated in ways that can contribute to reducing assaults in specifc high-risk settings. In relation to fndings relating to any given intervention, EMMIE refers to efects produced, mechanisms activated to produce the efects, moderators or contexts relevant to the activation of mechanisms, implementation issues that arise, and economic costs and benefts. Keywords: Violence against healthcare workers, Alarms, EMMIE, Systematic review, Crime prevention, What Works Centre for Crime Reduction Background been assaulted and injured (Spector et al. 2014). In a 2010 Violence against healthcare staf is a major problem. An survey, between 5 and 8% of frontline National Health international review found that a third of nurses have Service (NHS) staf reported being physically assaulted by patients or other service users in the previous 12 months *Correspondence: [email protected] (Ipsos MORI 2010). Such assaults against NHS staf have 3 Department of Security and Crime Science, University College London, increased. According to NHS Protect fgures, a total of 35 Tavistock Square, London WC1H 9EZ, UK 70,555 physical assaults on NHS staf were reported in Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Perkins et al. Crime Sci (2017) 6:11 Page 2 of 19 the year 2015–2016 resulting in 1740 criminal sanctions; Te high risk of assaults for NHS staf is suggested to this represents an increase in total assaults of 4% from be due to factors including: inadequate security, staf 67,864 in the year 2014–2015 and an increase of 17% shortages, night-shift patterns, and the intensity of inter- from a total of 60,385 in the year 2004–2005 (NHS Pro- actions with patients (Oztunc 2006). Other contributory tect 2017a). Nurses are four times more likely to experi- factors reported include: patient mental health, patients ence assaults than any other NHS worker, with student under the infuence of alcohol or other drugs, waiting nurses and those in psychiatric and learning disability time and delays, problems understanding information, areas at highest risk (Wells and Bowers 2002). One quar- anxiety caused by practical issues (e.g. transport and ter of assaults are reported in acute wards and 69% in parking), and an increase in expectations of standards of those for mental health problems and learning disability. service which may not be met (Ipsos MORI 2010; Rew Globally, nurses working in some departments face much and Ferns 2005). higher levels of violence than those in others. Te pro- portions experiencing violence in geriatric wards (45.9%), Interventions emergency departments (49.5%), and psychiatric depart- Scoping literature searches revealed many studies that ments are substantially higher than those in a general identifed the problem of assaults against staf in the sample of nurses (23.4%) (Spector et al. 2014). Te source healthcare setting, and many studies that estimated the of these physical assaults against nurses have been found prevalence of such attacks and the exposure of healthcare to be predominantly patients, accounting for 64%, with a staf to violence. However, there is a paucity of primary further 30% being carried out by the family or friends of research into interventions to prevent violence. Interven- patients and the remaining 11% is lateral violence from tions to prevent violence against healthcare staf may be nurses, physicians or staf (Spector et al. 2014). broadly classifed as: Te Crime Survey of England and Wales identifes occupational groups at most risk of violence. Te 2014– • Environmental (e.g. stafng numbers; CCTV; fxed 2015 Survey estimated that 1.3% of employed adults of emergency alarms; personal security alarms; secu- working age had experienced one or more incident of rity guards; police ofcers in A&E; making building violence at work over 12 months. It found workers in access more secure for staf; ambient environments, protective service occupations (e.g. police ofcers) to proper lighting and calming décor; facilities for chil- be at greatest risk with 9.2% experiencing one or more dren, e.g. play area); incident. Next came health and social care associate • Practices and policies (e.g. legislation such as the professionals, such as most nurses, of whom 6.1% suf- Criminal Justice and Immigration Act 2008; ‘zero tol- fered one or more incident—over four times the overall erance’ approach policies); rate (Health and Safety Executive 2017b). Tose work- • Staf skills (e.g. NHS confict resolution training; ver- ing in protective services and health have consistently bal techniques; prevention and recognition strate- been reported, over a number of years as being at high gies; staf attitudes, knowledge and skills) (Anderson risk. et al. 2010). In 2000, the Home Ofce estimated the total average cost of each common assault at £540, which includes the Key measures identifed by NHS Protect to tackle vio- physical and emotional impact, victim services, lost out- lence in healthcare settings include (Business plan 2014): put and the police court and prison costs (the average establishment of NHS Serious Incident Reporting System for more serious incidents of violence against the per- (SIRS) and Physical Assault Reporting System (PARS); son, excluding homicide, rising to £19,000) (Ofce 2017). confict resolution training (NHS Protect 2013); use of Impacts of violence on staf include pain, time away from the powers under the Criminal Justice and Immigra- work, depression and low self-esteem; impacts on the tion Act 2008 (CJIA) to tackle nuisance or disturbance NHS include loss of personnel for signifcant amounts of behaviour (sections 119–120 make an ofence of causing time and resignations (NHS 2003). Violence and abuse a nuisance or disturbance on NHS premises, and provide against staf present substantial costs to the NHS through power of removal); and guidance on the prevention and additional staf training, security, staf absenteeism, poor management of challenging behaviours in NHS settings. staf retention, and legal fees. Direct fnancial costs of A 2003 report from the National Audit Ofce identifed £69 million per annum have been attributed to physical a variety of security measures in place across NHS trusts; and non-physical violence and aggression in the NHS panic alarm systems (in 85% of trusts); closed-circuit (National Audit Ofce 2003). Te cost of physical assaults television (CCTV) (in 92% trusts); security staf (40%); during 2007–2008 was estimated at £60 million (NHS police presence (20%) and