Violence against patients and staff is widespread in mental health and learning disability inpatient units, research shows.
Substance abuse is a major factor
A national audit found one in three inpatient service users had experienced violent or threatening behaviour while in care.
For clinical staff the figure was 41%, and for nursing staff a massive 80%.
The study was carried out by the Healthcare Commission and the Royal College of Psychiatrists.
It also found that 18% of visitors to the units had experienced violent or threatening behaviour.
The researchers defined threatening behaviour as anything from raised voices to threat of attack with a weapon.
The Healthcare Commission has pledged to push for improvements in inpatient services.
The audit identified drug and alcohol abuse as a key factor behind many violent incidents. It says staff need more help dealing with this issue.
It also found that units are having to rely too heavily on temporary staff due to difficulties filling vacant posts. This was leading to problems creating cohesive and experienced teams.
It calls for the status of inpatient nursing to be raised to at least that of community nursing to help recruit and retain staff.
Other factors highlighted in the report include:
- Flaws in the design of many wards and units, which fail to meet basic safety standards
- Boredom among service users, who are not being offered structured and therapeutic care
The audit also highlights examples of good practice across the country, including the use of personal alarm in one trust to help make visitors feel safer.
No easy answer
Anna Walker, chief executive of the Healthcare Commission, said: "These figures are deeply worrying. No one is saying these issues are easy to deal with.
"But we must do more to protect the people who use and work in our mental health services.
"We will build on the findings of this report by refining the way we assess the performance of mental health units.
"There is plenty of good work going on. We've got to ensure best practice becomes standard practice."
Professor Paul Lelliott, of the Royal College of Psychiatrists, said: "The audit confirms just how challenging it is to work in mental health residential settings."
However, he said there was now a recognition in all parts of the NHS that action was needed.
Alex Nagle, director of NHS Security Management, said a dedicated team had been established to spread best practice, and to encourage a consistent approach to tackling the problem.
"Their aim is to create a safe, secure and therapeutic environment for staff and service users so that the highest standards of clinical care can be achieved."
A course in how deal with violence in a non-physical way was also to be offered throughout the NHS following a successful pilot.
"Its aim is to give staff the skills required to confidently and lawfully recognise, prevent, de-escalate and manage potentially violent situations."
Niall Dickson, chief executive of the independent King's Fund, called for a major overhaul of adult psychiatric inpatient wards.
He said: "This audit adds to the growing body of evidence of serious problems on many mental health wards up and down the country.
"There are still far too many patients, front-line health professionals and members of the public experiencing violent or threatening behaviour, which is unacceptable.
"It is not only distressing for the individuals involved, but reflects shortfalls in the way care is provided."
Around 6,500 questionnaires were submitted as part of the audit, including respondents from 265 units.