Mod1 Facilitator

A safer place to work – preventing and managing violent behaviour in the Health workplace

Module 1

HLTCSD6A

Respond effectively to difficult or challenging behaviour

Facilitator manual

NSW Health is a zero tolerance zone

NSW DEPARTMENT OF HEALTH

73 Miller Street

NORTH SYDNEY NSW 2060

Tel. (02) 9391 9000

Fax. (02) 9391 9101

TTY. (02) 9391 9900

www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in part for study training purposes subject to

the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or

sale. Reproduction for purposes other than those indicated above, requires written permission from the

NSW Department of Health.

© NSW Department of Health 2004

SHPN (CMH) 030136

ISBN 0 7347 3557 X

July 2003

updated August 2004

M O D U L E 1Respond effectively to difficult or challenging behaviour

NSW Health A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6ARespond effectively to difficult or challenging behaviour (Version 1) © July 2003 – updated August 2004

i

ContentsAcknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Overview of the manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Modular structure of the aggression minimisation program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3How the manual is set out. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Facilitator preparation before training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Sequence and timing of the modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Other resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Introduction to Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9How Module 1 fits into the whole program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Assessment for Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Elements of competency and performance criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Assessor checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Assessment method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Assessment conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Assessment resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Session plan for Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Equipment required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Participant requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Beginning the training session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171. Welcome participants to the module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172. Housekeeping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173. Outline principles of adult learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174. How Module 1 fits into the whole program5. Structure of Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Aggression in the workplace – facts and figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Part 1 Understanding difficult or challenging behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Defining aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Effects of aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Zero tolerance response to aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Part 2 Preventing aggression occurring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29What you need to know about keeping your workplace safe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Using a risk management approach to prevent aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Eliminating or controlling risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36How the design of your workplace can prevent aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40More ways of keeping your workplace safe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Putting it all together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Caveats and background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Individual risk highlighter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Violence risk awareness checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Violence minimisation checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48What workplace strategies do you have . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Part 3 Preventing aggression escalating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Levels of aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Know your options for action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Deciding to stay or leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54When and who to call for back-up or help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Danger and safety zones when faced with an aggressive or violent person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Self help strategies to remain calm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Verbal and non-verbal de-escalation skills to prevent aggression and violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Attitudes are important . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Your attitudes towards people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Strategies for improving communication with people from a different culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64What governs your actions in responding to aggression? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Some more strategies when faced with a violent person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Response options for repeatedly aggressive people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Part 4 Bullying, harassment and discrimination at work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Scope of the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72You have a role to play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Some legal considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76How to confront a person who is bullying, harassing or discriminating against you . . . . . . . . . . . . . . . . . . . . . . . . . . 77How to formally make a complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Rights of the person making the complaint and the person who is complained against. . . . . . . . . . . . . . . . . . . . . . . 79

Part 5 Reporting and reviewing aggressive incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Reporting aggressive incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82What to expect from an aggressive incident investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Support mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86Self care following an aggressive incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90What support can you expect from your manager . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Related NSW Health policies and guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Module 1 assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Scenario 1: Support staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100Scenario 2: Mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Scenario 3: Enrolled nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102Scenario 4: Registered nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Scenario 5: Food services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104Scenario 6: Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105Scenario 7: Community – generalist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106Scenario 8: Community mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Scenario 9: Youth worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108Scenario 10: Bus driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Scenario 11: Drug and alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Scenario 12: Hospital security staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Scenario 13: Medical officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Scenario 1: Support staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Scenario 2: Mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Scenario 3: Enrolled nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119Scenario 4: Registered nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121Scenario 5: Food services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Scenario 6: Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Scenario 7: Community – generalist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127Scenario 8: Community mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129Scenario 9: Youth worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131Scenario 10: Bus driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133Scenario 11: Drug and alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Scenario 12: Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Scenario 13: Medical officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Marking guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Scenario 1: Support staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Scenario 2: Mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Scenario 3: Enrolled nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Scenario 4: Registered nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147Scenario 5: Food services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149Scenario 6: Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151Scenario 7: Community – generalist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153Scenario 8: Community mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155Scenario 9: Youth worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157Scenario 10: Bus driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159Scenario 11: Drug and alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161Scenario 12: Hospital security staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163Scenario 13: Medical officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6ARespond effectively to difficult or challenging behaviour (Version 1) © July 2003 – updated August 2004

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F A C I L I T A T O R M A N U A LNSW Health is a zero tolerance zone


Acknowledgments

This NSW Health violence prevention training program was developed by Brin FS Grenyer, Olga Ilkiw-Lavalle and Philip Biro from the Illawarra Institute for Mental Health. Mark Coleman provided assistance with the facilitator manuals and pilot workshops. The project was coordinated from the Violence Taskforce, Centre for Mental Health by Frances Waters. The members of the projectcontract steering committee who provided extensive guidance during the development of this project were Frances Waters (Violence Taskforce, Centre for Mental Health), Kathy Baker (Community & ExtendedCare Services and Nursing Services, Northern Sydney), Trish Butrej (Occupational Health and Safety, NSW Nurses’ Association), Maggie Christensen (Learning and Development, Central Coast), Nicole Ducat(Occupational Health and Safety, South Eastern Sydney), Louise Newman (Royal Australian and NewZealand College of Psychiatrists), Gemma Summers (Learning and Development, Northern Sydney) and Choong-Siew Yong (Australian Medical Association, NSW Branch).

A project content reference group also provided input during the development of the project, and themembers were Greg Hugh, Peter Bazzana, Greg Cole, Stephen Allnut, Distan Bach, Liz Cloughessy, Jim Delaney, Regina McDonald, David Gray, Rajni Chandran, Jennifer Bryant, Terry Tracey and LindaSheahan. Consumer input was gratefully provided by Laraine Toms and Robyn Toohey. The NSW HealthLearning and Development Managers forum and others affiliated with the reference group also providedhelpful comment and guidance during the developmental phases of this project, including Jenny Wright,Earle Durheim, Judy Saba, Brenda Bradbury, John Lain, Bill Wood, Aileen Ferguson, Simon Richards,Vaughan Bowie, Louise Fullerton, Mira Savich, lain Morriset, Lorraine Hyde, Glenda Hadley, Julie Reid,Natasha Mooney and Bill Tibben.

The developers would like to thank those staff of the South Western Sydney Area Health Service who provided useful feedback during the four days of piloting of each of the modules in October 2001. We also thank the fifteen educators from across the state who provided feedback during the two daytrainer orientation at Western Sydney Area Health Service in November 2002.

The developers would like to give special thanks to Professor Beverley Raphael and Professor DuncanChappel from the Violence Taskforce for support, Dr Claire Mayhew for timely insights, Linda Graham forsharing her wisdom over the years through the development and implementation of the INTACT trainingprogram, Professor Kevin Gournay and Steve Wright from the Institute of Psychiatry, London, for helpfuladvice and resources, Dr Nadia Solowij and Jane Middleby-Clements for editorial assistance and toProfessor Frank Deane from the Illawarra Institute for Mental Health for practical support. We also thankShane Pifferi, Marie Johnson, Vicky Biro, Tim Coombs, Ralph Stevenson, Dr Alexandra Cockram, Eugene McGarrell, Samantha Reis and Andrew Phipps for assistance with the project.

This program has incorporated and referred to relevant NSW Health policies and guidelines whereappropriate and a list of these is given at the end of the relevant modules. Modules 1 and 2 of this programwere adapted from a modular aggression minimisation program developed originally by Austraining (NSW)Pty Ltd for the Central Coast Area Health Service, which was revised by Jenelle Langham in 2000.Module 3 of this program is a revised version of that developed by Jenelle Langham for the Central Coast Area Health Service.


1


Introduction


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NSW Health: Preventing and managing aggression in the Health workplace

What is it?A number of key projects have flowed from the work of the Violence Taskforce. One of these is the development of a statewide, appropriately accredited aggression minimisation training program.

The focus of this training is to provide staff with the most up-to-date strategies, skills andtechniques to prevent and minimise workplace aggression and violence. It is also based onrelevant taskforce findings and incorporates key taskforce initiatives.

The program includes a basic module for all staff identified as being at risk of workplace violence,a module for staff working in high risk environments, a module designed specifically for managersand a refresher module.

What materials are provided?A CD-ROM is available and includes:

● Facilitator manual: Modules 1 through to 4 (in Acrobat PDF format).

● Participant manual: Modules 1 through to 4 (in Acrobat PDF format).

● Powerpoint slides for Modules 1 through to 4.

● Recognition of prior learning forms and assessment of competency forms (as a separateAcrobat PDF format).

● Assessment scenarios and Question sheets for Module 1 (as a separate Acrobat PDF format).

All of the above are included on the CD.

Who will attend?Module 1 should be attended by all staff identified as being at risk of workplace violence, and generally speaking is a prerequisite for all other modules. More detailed advice on theapplication of this training is provided in the covering circular. Attendance at additional modules is recommended for staff determined by the Health Service to be at higher risk of workplaceviolence and includes, but is not limited to, security, mental health, Emergency Department,admissions, drug and alcohol, disability services, brain injury and aged care staff.

All managers of staff identified as being at risk of workplace violence should attend the manager’smodule and all relevant staff should attend the refresher module at least every two years. HealthServices may determine that some groups need to attend the refresher more regularly.

his manual has been developed to provide educational resources for a facilitator to delivera comprehensive education program in aggression minimisation.

The manual is divided into four training manuals. Facilitators must have each of the following.

1. Certificate IV in Assessment and Workplace Training.

2. Experience in working in areas of significant violent risk.

3. Experience in effectively managing violent incidents.

4. An ability to relate to staff at all levels of the organisation.

Modular structure of the aggression minimisation program

HLTCSD6A – Respond effectively to difficult or challenging behaviour

This eight-hour program is designed for all staff identified as being at risk of workplace violence. It isdesigned to meet the Health Training Package competency HLTCSD6A – Respond Effectively to Difficult or Challenging Behaviour.

The day is divided into five parts:

1. Understanding difficult or challenging behaviour.

2. Preventing aggression occurring.

3. Preventing aggression escalating.

4. Bullying, harassment and discrimination at work.

5. Reporting and reviewing aggressive incidents.

AMT002 – Aggression minimisation in high-risk environments

This eight-hour program is designed for mental health and other staff working in high risk areas, eg emergency, security, community, aged care, disability, dental, midwifery and early childhood, methadone,brain injury, neurology, admissions and drug and alcohol services. Other staff members identified, via the riskassessment process, as being at significant risk of aggressive behaviour should also attend this module.

The day is divided into four parts:

1. Working in high-risk environments.

2. Prevention in high-risk environments.

3. Understanding aggression in high-risk environments.

4. Managing aggression in high-risk environments.



3

Overview of the manual

Module 1

Module 2

Module 3

Module 4

90405NSW – Course in aggression minimisation for managers

This four-hour module is designed for managers of health units and facilities. It provides the participant with detailedinformation, obligations and practical strategies for promoting a safe workplace environment free of aggression,assessing and managing risks and types of support to provide to staff, who have been victims of aggression.Completion of Module 1 is recommended prior to undertaking this module.

The day is divided into three parts:

1. The legal and policy framework for managing aggression.

2. Promoting an aggression-free workplace.

3. Assisting staff when aggression and violence occurs.

AMT004 – Aggression minimisation refresher training

This two-hour module is designed for all staff identified as being at risk of workplace violence, and should berepeated at a minimum of every two years after completion of Module 1. Depending on the level of risk, some staffmay need to attend more frequently. It is designed to keep staff up-to-date with policies and practices, providerefresher training of skills, and workshop problems.

The day is divided into four parts:

1. The zero tolerance response.

2. New developments in preventing and managing aggression and violence.

3. The prevention of aggression and violence.

4. Managing aggression and violence.

How the manual is set outThe Facilitator manual is divided into the four modules.

All facilitator notes throughout each module look like this.

Basic course content in the Facilitator manual duplicates that found in the Participant manual.This course content forms the basic syllabus of the training and the trainer needs to know this material prior to conducting training.

For each module, at the beginning of each section the relevant page number in the Participant manual is noted.

Relevant slides that should be shown at each point are reproduced throughout this manual.

Layout iconsThe following symbols have been used throughout the Facilitator manual to assist in the presentationof material. In all cases, trainers should use their discretion in the presentation and timing of materialdepending on the mix of staff in the training group. Where possible, flexible delivery is encouraged and specific recommendations are made at the beginning of each module.



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5


Key points

Key points help you to summarise the major themes and information from the section.

Explain and discuss

This icon suggests that you will need some verbal explanation and discussion of thisconcept or topic.

Background reading

This icon appears when further background information and reading is supplied on a topic to assist the facilitator in understanding and delivering the training course.It should be read before the facilitator conducts any training. The background informationmay be verbally summarised by the trainer as the need arises.

Ask the group

Whenever this icon appears in the manual a large group activity is suggested. Facilitators should ask the suggested question to the group as a whole and elicit answers or suggestions as appropriate. Participants may choose to write answersin the space in their manuals.

Small group exercise

This icon represents small group activity. Whenever this icon appears in the manual a small group activity is suggested. Facilitators may get the group to break into smallergroups of two to five participants to discuss the question, before reporting back to thegroup as a whole. Participants may choose to write answers in the space in theirmanuals.

Individual reflection exercise

This icon represents personal reflective activity. Whenever this icon appears in the manual personal reflection is suggested. Individual participants may complete this exercise alone. The facilitator may then choose to address the question to the group as a whole and collect responses from individuals. Participants may choose to write answers in the space in their manuals.

Answers

Suggested answers to the individual, small and large group activities are provided. These amplify and reinforce the subject material covered in the Participant manual.

Important training point

Important training points are highlighted with this symbol.

You are on Participant manual page X

These icons assist you to keep the training program in sequence with theParticipant manual. It is suggested that you regularly refer participants to the relevantpage in their Participant manual for further information or to complete an activity.

Show overhead slide

Suggested place to present slide.

Facilitator instruction

Specific training hints are given here.

Write responses on board

Suggested place where the trainer may wish to reinforce points or collect responses from the group on a whiteboard/blackboard/butcher’s paper.

Session time

Suggested times to conduct sessions are given and a session plan is provided for each module. These are to be used flexibly to meet the needs of trainers and participants.

Session overview

An overview of the session is given here.

Suggested break time

Suggested breaks are provided. These are flexible.

Readings and resources

Additional readings and resources are highlighted here and should be read prior tocommencing training.


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Facilitator preparation before trainingBefore running this training it is important to be familiar with:

● All NSW Health documents and policies relating to aggression minimisation, prevention andmanagement (see reference lists at the end of each module).

● All local policies relevant to aggression minimisation. These will include documentation and emergency responses relating to aggression minimisation, prevention and management, eg duress response, reporting protocols.

● It is helpful if you have an awareness of recent incidents in your area, where these have been a particular problem and the outcome. This enables the training to be more relevant for participants.

● Facilitators need to familiarise themselves with the reference list at the end of the modules.

Sequence and timing of the modulesThe individual modules do not need to be taught together as a block. The space betweenteaching individual modules may be separated by weeks or months. It is important to considerthe retention of information from previous training and be ready to reinforce previous trainingmaterial, particularly from Module 1. Each module contains some common material from othermodules to help reinforce basic concepts, eg zero tolerance. Module 1 forms the prerequisite for the other modules so needs to be made available to participants prior to offering the other modules.

Assessment of competencyAssessment activities accompany Modules 1-4 to facilitate demonstration of competency.Facilitators should ensure that training outcomes for each participant are appropriatelydocumented. Recording forms accompany the Facilitator manual.

Flexible deliveryThe materials in this training program provide a core recommended syllabus for preventing andmanaging aggression in all NSW Health facilities. Each module has a set of learning outcomesand corresponding assessments. The training is designed in a modular format to allow ease ofdelivery, however it is possible that the training may be delivered using flexible delivery methods.Examples of how the training could be altered include (but are not limited to) the following:

1. Dividing a full day module into two parts, spread over two half days.

2. Emphasising some components of training over others for specific groups. For example,if the participant training group is non-clinical then the trainer may decide to focus more on communication strategies and bullying, harassment and discrimination than on some of the components that are more relevant for clinical staff.

3. Flexibly incorporating materials from other local training programs that overlap with thelearning outcomes and provide additional training.

4. Shortening a module by providing advance reading materials and exercises to be reviewed in the participants’ own time and reinforced and assessed in the workshop. However, thetrainer will need to determine that this approach is appropriate for the participant group.

In considering flexible delivery options, it is important to ensure that the learning outcomes aremet as set down in this program.

Recognition of prior learningRecognition of prior learning can be considered for this training. The relevant forms for recognitionof prior learning accompany the Facilitator manual.

Recognition of prior learning is based on the following:

● Competence – a focus on the competencies an individual has acquired as a result of anyformal or informal training and experience.

● Commitment – to recognise prior learning of individuals, therefore individuals will not have toduplicate their training unnecessarily.

● Access – every individual may have his or her prior learning recognised.

● Fairness – that the recognition of prior learning process is fair.

● Support – is provided for individuals in applying for recognition of prior learning. Certificate IVworkplace trainers and assessors must provide support so that an efficient and effective serviceis maintained.

Portfolio documentationAppropriate documentation is to be filled in and evidence collected to be submitted with theapplication form. All documentation should be submitted as a portfolio. See below for types ofevidence to be collected and included in a portfolio.



7


Evidence guideThe following is a guide for the evidence to be provided for recognition of prior learning.

For each item of evidence you will need to indicate which part of the item is relevant to whichlearning outcomes.

The following types of evidence may be collected:

● Formal accredited certificates of previous training programs attended, or transcripts of courses of study.

● Authenticated reports on activities participated in, relevant to aggression minimisation.

● Certified evidence of discussions of case studies that shows evidence of having attained learning outcomes.

● Authenticated reports of work, skills and experience in responding to aggressive behaviour.

Other Resources

Participant manualA Participant manual is also available and should be used during the training. Participants are to use the manual during the training session, but also should take it away as a resource. Thereis additional information in the Participant manual, and it is not expected that every point can becovered during the training sessions. The training provides an orientation to the major issues inaggression minimisation and points the participant to further readings and resources in the area.

Lecture slides The CD-ROM contains the full set of Powerpoint slides. The Powerpoint slides can also beprinted and transferred to overhead transparencies as needed.

FormsThe CD-ROM contains the recognition of prior learning forms and the assessment of competency forms.


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Introduction to Module 1



9

How Module 1 fits into the whole programModule 1 is the first of four modules dealing with aggression prevention, minimisation and management. This module is provided for all staff identified as being at risk ofworkplace violence, and for some will be all that is required for aggression minimisationtraining. Module 1 emphasises the workplace prevention of aggression, basic skillsrequired to de-escalate an aggressive situation and appropriate reporting procedures after the incident. Additional modules will address high-risk areas, managerialresponsibilities and refresher training.

Structure of Module 1HLTCSD6A Responding effectively to difficult or challenging behaviourThis eight-hour program is designed for all staff identified as being at risk of workplaceviolence. It is designed to meet the Health Training Package competency HLTCSD6ARespond effectively to difficult or challenging behaviour. The day is divided into six parts:






6. Assessment of competency.

The learning outcomes and assessment align with the national training guidelines and theHealth Training Package.

Session times 1. Introduction 10 mins

2. Understanding difficult or challenging behaviour 50 mins

3. Preventing aggression occurring 90 mins

4. Preventing aggression escalating 90 mins

5. Bullying, harassment and discrimination at work 60 mins

6. Reporting and reviewing aggressive incidents 60 mins

7. Assessment of competency 60 mins

Total training time: 7 hours

NB. A session plan is provided at the beginning of Module 1.

Training room requirementsThe training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual. Equipment required: projection facilities for Powerpoint slides (or an overhead projector if the slides have been printed on overheads), a whiteboard and whiteboard pens (for writing up feedback from participant exercises). Participants will need pens or pencils for writing in their copy of the Participant manual.


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Assessment for Module 1

Health Training Package Competency: (HLTCSD6A) – Respond Effectively to Difficult orChallenging Behaviour. The learning outcomes and assessment align with the elements and performance criteria.

Elements of competency and performance criteria


11

National code Element name

HLTCSD6A/01 Plan responses

1.1 Planned responses to instances of difficult or challenging behaviourmaximise the availability of other appropriate staff and resources.

1.2 Safety of self and others is given priority in responding to difficult or challenging behaviour.

HLTCSD6A/03 Report and review incidents

3.1 Incidents are reported according to organisational policies and procedures.

3.2 Incidents are reviewed with appropriate staff and suggestions offeredas appropriate to area of responsibility.

3.3 Debriefing mechanisms and other activities are accessed andparticipated in.

3.4 Advice and assistance is sought as required.

HLTCSD6A/02 Apply response

2.1 Responses reflect organisational policies and procedures.

2.2 Assistance is sought as required.

2.3 Difficult or challenging behaviour is dealt with promptly, firmly anddiplomatically in accordance with organisational policy and procedure.

2.4 Communication is used effectively to achieve the desired outcomes in responding to difficult or challenging behaviour.

2.5 Appropriate strategies are selected to suit particular instances ofdifficult or challenging behaviour.

Learning outcome


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Elements of competency andperformance criteria

Assessmentquestion

1. Identify and apply strategies for risk management to prevent aggression.

Question 9

9. Identify how management cansupport you following anaggressive incident.

Element: Report and review incidentsPerformance criteria: 3.4

2. Identify and select appropriate response options when confronted with aggressive behaviour.

Element: Apply responsePerformance criteria: 2.1, 2.3, 2.5

Question 1

Question 8

3. Give priority to the safety of selfand others when confronted withaggressive behaviour.

Element: Plan responsesPerformance criteria:1.2

Question 2

4. Identify when, how and who to call for assistance.

Element: Plan responsesPerformance criteria: 1.1

Element: Apply responsePerformance criteria: 2.2

Question 3

5. Use verbal and non-verbalcommunication strategies tomanage aggressive behaviour.

Element: Apply responsePerformance criteria: 2.4

Question 4

6. Identify appropriate reportingprocedures.


Question 5

7. Identify what can be expectedfrom an incident investigation.


Question 6

8. Identify available support servicesfollowing an aggressive incident.


Question 7

Yes No Unsure How

*Identified and selected appropriate response options.

*Ensured the safety of self and others.

*Identified when, how and who to call for help.

Identified appropriate verbal and non-verbal communication strategies.

*Identified appropriate reporting procedures.

Identified what can be expected from an incident investigation.

Identified available support services.

Identified support expected from management.

Identified and appliedstrategies for risk management.

Assessor checklist(optional to assist in determining competency)



13

* Denotes criteria for competence.


Assessment methodThe learning outcomes are to be assessed through case scenarios and responses to multiplechoice questions on an answer sheet. The questions have been designed to assess competencyin the learning outcomes of this program (see page 13). Participants are deemed competent if they provide the correct responses to these questions. The critical aspects of the assessment are identified in the marking guide. On the answer sheet all items need to be marked as on the marking guide, however, in the 1-3 range, variance may be accepted (ie 1-3 need not be in exactly that order). Only the options which appear in the marking guide for the scenario should be seen as acceptable responses. Question 9 does not link to any of the elements of competency so can be completed at another time if desired. With a group from oneemployment category this could be undertaken as a group exercise.

Assessment conditionsParticipants should be notified of the nature of the assessment (case scenarios and assessmentquestions) and should sign the standard NSW Health RTO Assessment specification (Participantmanual, page 5), to signify that they understand the assessment process at the commencementof the training. If the facilitator is unclear on how this should be managed, the facilitator shouldcontact the AHS Learning and Development Service. At the completion of the module thefacilitator should instruct the participants to complete the front sheet of the assessmentemphasising that it is important to identify the area of employment and to select the appropriatescenario. The facilitator should explain that, for some questions, answers need to be numberedin the order in which they should be done, while in others ticks are required in the appropriateboxes only. Questionnaires should be handed in for marking on completion and certificatesshould be issued within a reasonable period of time. Those who are deemed Not Yet Competentshould be given the opportunity to resubmit within a set time.

Flexibility is to be encouraged to meet any language and literacy needs.

Assessment resources● Case scenarios.

● Assessment question sheets – one set for each scenario.

● Marking guides.

● Sample incident form.

● Local risk management plan format.NB. Case scenarios, assessment question sheets and marking guides can be found at the end of the Facilitator manual.

Case scenarios and assessment question sheets can also be found as a separate Acrobat PDF document on the CD-ROM, in order that the scenarios and assessment question sheets may be printed out and handed to participants.

Each participant should be instructed to complete the scenario relevant to the participant’sposition with the organisation. It is important that the location and nature of the participant’s workis clearly identified on the question sheet. Participants will also be required to complete a sampleincident form on the scenario. Facilitators need to insert a copy of their local incident report form,and local risk management plan format (or similar) to allow for completion of the relevant sectionin the assessment. The coordinator within your organisation may wish to customise some of theoptions to meet local conditions.

It is anticipated that the scenarios will be available as trigger videos at a future date to cover alllanguage and literacy needs.


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Session plan for Module 1



15

Training session: Module 1Respond effectively to difficult or challenging behaviour

Date:

Time:

LearningTime Topic outcomes Content/activity

60 mins ● Introduction.

● Understanding difficult or challenging behaviour.

1 and 2 Small and large group discussions.

60 mins ● Assessment of competency. All learningoutcomes

Staff members respond toquestions in relation to thescenario they are given.

90 mins ● Preventing aggression occurring. 1, 2, 3 and 4 Small and large groupdiscussions.

90 mins ● Preventing aggression escalating. 2, 4 and 5 Small and large group discussions.

60 mins ● Bullying, harassment anddiscrimination at work.

4, 5 and 6 Small and large group discussions.

60 mins ● Reporting and reviewing aggressive incidents.

6, 7, 8 and 9 Small and large group discussions.

MaterialsThe training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual. `

Equipment required● Projection facilities for Powerpoint slides (or an overhead projector if the slides have been

printed on overheads).

● A whiteboard and whiteboard pens (for writing up feedback from participant exercises).

Participant requirementPens or pencils for writing in their copy of the Participant manual.

Beginning the training session



17

Session time 10 minutes

Facilitator instructionTo begin teaching this module you will need to do the following:

1. Welcome participants to the module

Inform participants of the:

● program times

● breaks and meals

● toilets

● mobile phones

● message board

● occupational health and safety (fire escapes).

You may wish to facilitate an introductory activity (ice-breaker).

Example – have participants pair off and:

● introduce themselves and the area they work in

● discuss what they hope to gain from the training.

After a few minutes have passed re-assemble the group and ask each participant to introduce their partner.

2. Housekeeping

3. Outline principles of adult learning

● Everyone’s opinion will be respected.

● Participants’ work experience will be valued.

Show overhead slide


4. How Module 1 fits into the whole program


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Module 1 is the first of four modules dealing with aggression prevention, minimisation and management. This module is for all staff identified as being at risk of workplace violence, and for some will be all that is required for aggressionminimisation training. Module 1 emphasises the workplace prevention ofaggression, basic skills required to de-escalate an aggressive situation andappropriate reporting procedures after the incident. Additional modules will address high-risk areas, managerial responsibilities and refresher training.

Show overhead slide

5. Structure of Module 1

HLTCSD6A – Respond effectively to difficult or challenging behaviour

This eight-hour program is designed for all staff. It is designed to meet theHealth Package competency HLTCSD6A – Respond Effectively to Difficult or Challenging Behaviour. The day is divided into six parts:






6. Assessment of competency.

Inform participants that the learning outcomes and assessment align with thenational training guidelines and the Health Training Package.

Show overhead slide

Aggression in the workplace –facts and figures



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The following is background information on the problem of aggression.Facilitators may wish to draw out some key points from this and refer to any local issues or data relevant to the problem of aggression and aggression management.

Explain and discuss

Background readingAggression in the health industry is a significant problem.1,2,3 In 1999/2000 there were 113 claims made to WorkCover from hospitals and nursing homes in NSW that involvedthe staff member being hit and being absent from work for more than five days. Theestimated cost of these claims was $1.3 million. This figure did not include the cost of violent incidents that did not result in a workers compensation claim or resulted in less than five days absence from work; this figure is likely to be significantly higher. It also does not include costs associated with administration of claims, fines, legal costs,absenteeism, staff turnover and recruitment, or the impact of violence against patients.a

In Australia little research has been conducted on the incidence of aggression. O’Connell,Young, Brooks, Hutchings and Lofthouse (2000)4 found over a 12 month period that:

● 95% of nurses experienced several episodes of verbal aggression; 80% experiencedseveral episodes of physical aggression

● 25% experienced verbal aggression; 6.7% encountered physical aggression on a weekly basis

● 32.4% experienced verbal aggression; 14.4% experienced physical aggression on a monthly basis

● 37.7% experienced verbal aggression; 59.3% experienced physical aggression between 1 and 4 times per year.

Show overhead slide


The types of injuries sustained by staff were a result of being grabbed, punched, pushed,pinched, scratched, kicked and hit with an object.

Barlow, Grenyer and Ilkiw-Lavalle (2000)5 report that during an 18 month study period, 13.7% of patients admitted to inpatient mental health units in the Illawarra Area Health Servicewere aggressive. There were on average five aggressive incidents per week in the inpatient units,and staff injuries accounted for 47.4% of the overall injuries incurred in the mental health units.53% of injuries occurred to patients and visitors.

Aggression is not just experienced from patients. Farrell (1999)6 reports that 30% of nursing staff experienced aggression from other staff over a six-week period. This included experiencingrudeness, being abused, being humiliated in front of others and peers, being denied access toopportunities, and having their work excessively scrutinised with threats of disciplinary action.

This program aims to promote a working environment and practice, which minimises and protectspeople from aggression. The goals of this training are to improve health care workers’ knowledgein relation to ways of preventing aggression and to gain knowledge and skills in responding todifferent instances of aggression.


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Part 1Understanding difficult or challenging behaviour


21

Session time 50 mins

Session overview This section looks at what aggression in the workplace is, what the effects ofaggression are and provides an understanding of the ‘zero tolerance’ response to aggression.

You are on Participant manual page 9


To teach this part you will need to have a copy of the NSW Health ZeroTolerance Policy and Framework Guidelines to show the participants, andenough copies of the zero tolerance brochure for all attendees. You will need to be familiar with the contents of both.

The purpose of the introductory questions are:

1. to begin a process where participants actively own the responsibility foraggression minimisation

2. to encourage a facilitative, active adult learning experience.

The aim of this part is to provide participants with an understanding of:

● the extent of aggression in the workplace

● the responsibility of all staff to manage aggression and its outcomes.

It is important to link the material in this module with local policies and proceduresat all times, and generate discussion of local issues relevant to the particularparticipant group attending the training on the day.



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Consider the number of interactions that occur between staff and patients, staff and staff, staff and visitors etc on any day in your area. Consider what proportion of interpersonal situations result in aggression.

Ask the group How many times are you exposed to aggression in your workplace?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

You would expect the answers to indicate that aggression is encountered on a frequent basis, particularly bullying and verbal abuse. For some people it can be encountered daily.

Answers

Whose problem is aggression in the workplace?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

It is expected that people acknowledge that aggression in the workplace iseveryone’s problem, including their own.

Answers

Show overhead slide

Show overhead slide


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Defining aggressionNSW Health defines aggression as:

‘Any incident in which employees are abused, threatened or assaulted in circumstances arising out

of, or in the course of, their employment including verbal, physical or psychological abuse, threats

or other intimidating behaviours, intentional physical attacks, aggravated assault, threats with an

offensive weapon, sexual harassment and sexual assault.’


Explain and discuss

Show overhead slide

Workplace aggression can beencountered from:

● patients

● relatives and friends of patients

● staff members

● members of the public

● intruders.

Targets of aggression include:

● you

● others

● property.

Explain and discuss

Show overhead slide



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The effects of aggression on the workplace10, 11,12 include:

● poor morale, erosion of worker loyalty and commitment

● reduced efficiency, productivity and public image

● costs associated with counselling, employee assistance, management time,rehabilitation, recruitment and training of new staff

● increased sick leave, absenteeism and staff turnover

● costs associated with compensation, prosecution and penalties imposed onthe organisation.

A zero tolerance response to aggression


The zero tolerance approach to aggression does not mean that aggression will never be encountered in the workplace. For example, in dementia and brain injury units, aggressive and erratic behaviour can be a part of the conditionencountered. The zero tolerance approach to aggression highlights that no amountof aggression in the workplace is acceptable, therefore all incidents of aggressionshould be reported and managed utilising the principles covered in this module.Facilitators need to be aware of the local zero tolerance policy and procedures.

Show overhead slide

Effects of aggressionThe effects of aggression4,7,8,9 on an individual can include:

● physical injury

● anxiety

● distress

● anger

● irritability

● self-blame

● apathy

● insomnia

● depression

● impaired decision making

● loss of self-confidence

● severe fatigue

● fear of patients

● difficulty returning to work.


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Explain and discuss

Background readingNSW Health is committed to the minimisation of violence in the public health system and the focus should always be on the prevention of violence. However, in the event thata violent incident does occur, NSW Health, as a result of a key recommendation from theTaskforce on the Prevention and Management of Violence in the Health Workplace, hasadopted a zero tolerance response to threatening, abusive or violent behaviour by anyperson towards any other person on health service premises, or towards NSW Health staff working in the community.

The zero tolerance response means that in all instances of aggression, appropriate actionwill be taken to protect staff, patients and visitors, and health service property from theeffects of such behaviour. It is about keeping staff, patients and visitors safe.

The zero tolerance response does not take the place of effective risk management, and at all times the focus must be on prevention. However, in the event of an aggressiveincident, consistent action must be taken to minimise the impact on all concerned.Options for action will be discussed in Part 3.

It should be noted that zero tolerance is NOT about taking punitive action against patients whose violent behaviour is a direct result of a medical condition. In thesecircumstances the emphasis is on prompt, effective clinical management andcompassionate care of the patient. At the same time the safety of the patient, staff and others who may be affected by the aggressive behaviour is paramount.

Readings and resourcesUnderpinning the zero tolerance response is the key message to staff that aggression is NOT an acceptable part of the job, and is not something simply to ‘be put up with’. For further information see the NSW Health Zero Tolerance Policy and FrameworkGuidelines and supporting brochure.

Outline the major components of zero tolerance.

Show overhead slide




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Zero tolerance attitudes and behaviours

Putting up with violence in the health workplace IS NOT an acceptable part of your job (if you don’t get the message, neither will patients and visitors).

Know your options when confronted with violent behaviour and exercise them consistently(the most effective way of protecting yourself AND getting the message to patients and visitors).

Management will support you in utilising these options (this is part of their responsibility).

Report all violent incidents (problems that don’t get reported don’t get fixed).

Be aware of violence as an occupational risk (it is just as real as other more recognised OHS risks eg manual handling, exposure to hazardous substances, etc).

Be vigilant of factors contributing to the risk of violence (prevention is better than cure).

Ask the group A key component of the zero tolerance response is to report all aggressive incidents.What might be some challenges to reporting all incidents in your workplace?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Answers

Show overhead slide

The zero tolerance approach is crucial to this training. Refer participants to the following table in their workbooks and explain and discuss each point.

It is expected that the answers here reflect the attitudes and behavioursoutlined on the previous page.

Key points

● Aggression may be encountered in the workplace.

● Anyone can be a target.

● It affects both the individual and the organisation.

● NSW Health is committed to a ZERO TOLERANCE response to aggression inthe workplace.


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Emphasise the following:

● Being aware of your local zero tolerance policy.

● Reinforcing attitudes and behaviours which indicate that violence is not anacceptable part of the job.

● Actively contributing to aggression and violence risk management discussionsat meetings.

● Making sure that the zero tolerance approach is communicated to patients andvisitors, ie by making sure they have access to pamphlets that outline their rightsand what behaviour is expected when they are in the facility.

● Making sure that all related materials are provided for patients in their bedsidelockers and patient information kit.

● Keeping supplies in waiting areas, etc.

● Making sure key phone numbers and response codes are clearly displayed inhigh-risk areas eg reception areas, nurse stations, in consulting rooms, etc.




Reinforce the key points.

Show overhead slide

Part 2Preventing aggression occurring



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Session overview This section focuses on preventing aggression. It will look at the legal obligations for preventing aggression; how risk management can prevent or reduce the risk ofaggression; how buildings and workplaces can be designed and redesigned toprevent or reduce the risk of aggression occurring.



The most important aspect of this part is to emphasise that preventing aggression is a far more effective strategy than focusing on management of an aggressive incident. Prevention is the cornerstone of aggression minimisation.

To lead this part the facilitator will need to be familiar with:

● NSW Occupational Health & Safety Act, 2000

● NSW Occupational Health & Safety Regulation, 2001

● WorkCover NSW Risk Management at Work Guide, 2001

● Crime Prevention through Environmental Design (CPTED) principles

● WorkCover Risk Assessment Code of Practice, 2001

● NSW Health Security ManualNB. The NSW Health Design Series publication Health Facility Guideline – Security and Safety, released in

February 2003 provides useful information on CPTED principles.


There is a need to emphasise that everyone has a role in risk management andaggression prevention.



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Explain and discuss

What you need to know about keeping your workplace safeUnder the NSW Occupational Health and Safety Act 2000 employers have a duty of care for the health and safety of all people in the work place.b This requires employers to:

● ensure that premises controlled by the employer where people work are safe andwithout risk to health

● ensure that systems of work and the working environment are safe and without risk to health

● ensure that any equipment or substance provided for use by the employees at work, is safe and without risk to health when properly used

● provide necessary information, instruction, training and supervision for the health andsafety of their employees.

Show overhead slide

Show overhead slide

Show overhead slide


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Background readingThis Act is supported by the Occupational Health and Safety Regulation 2001.

Employers under this regulation are required to:

● identify workplace hazards, including violence

● assess the risks associated with the hazards

● eliminate risks where possible

● implement risk control measures

● consult with employees, and their representatives throughout the process

● provide training.

Under the NSW Occupational Health and Safety Act 2000 employers have a responsibilityto ensure the health and safety of any persons who are at their place of work, and whomay be affected by their acts or omissions at work. Employees have a responsibility totake reasonable care regarding the health and safety of any persons who are at theirplace of work, and who may be affected by their acts or omissions at work.

Employers are required to comply with NSW occupational health and safety legislation.There are various offences and penalties for non-compliance with the Act and Regulation, even if no-one has been injured. Penalties can be issued to employers and employees.Individuals may be personally liable for fines, and insurance protection does not coverfor prosecution or fines.


Explain and discuss

Outline the major responsibilities of the act and regulation.

Outline the major points in risk management.

Explain and discuss

Show overhead slide




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The risk management process

Step 1. Identifying the problem (hazard identification) eg workplace aggression.

Step 2. Assessing the risk (determining how serious the aggression problem is).

Step 3. Eliminating or controlling the risk of workplace aggression by deciding what needs to be done to solve the problem and in what order (risk control measures need to be ranked from the most effective to the least effective).

Step 4. Monitoring, reviewing and improving the system.

SAFETY HINT – Report all instances of aggression. If instances are not reportedthen they cannot be responded to via the risk management process.

Explain and discuss

Show overhead slide

Background reading

Using a risk management approach to prevent aggressionRisk management is the process of identifying situations that are likely to cause harm to people or property. The aim is to avert or diminish the chances of harm by being proactive in seeking to prevent, or reduce, injury to people or property.15

The individual staff member has a good perception of the risk of aggression associated with their workplace. Therefore the individual plays an important role when being consulted about the risks of aggression, and ways to prevent or control risks. As such it is important that staff actively contribute when being consulted.

Risk management is an interactive process of clearly designed steps.15 By following thesteps outlined staff members can assist their managers to make better decisions on howbest to eliminate or control a risk by reducing it to its lowest possible level.16

Ask the group

Write responses on boardAssessing risk involves estimating the extent of the risk to assist with prioritising and developing control strategies. The following factors need to be considered whenassessing risks in the workplace. For each factor what aspects would you consider to be associated with aggression in the workplace?

Individual factors relating to an individual that may be associated with aggression in the workplace.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


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Answers

Facilitator: Participant responses should include:

● clinical (patient factors)

● substance abuse/intoxication

● history of violence

● medical illness (eg dementia, delirium, psychosis)

● history of poor impulse control

● confusion

● anxiety/fear

● pain/grief

● head injury

● rejection and humiliation

● concerns or requests being ignored.

Physical environment associated with aggression in the workplace.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


Work systems and practices associated with aggression in the workplace.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


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• working alone or in isolation

• having long waiting times

• working late at night

• patients not being given explanations regarding the reasons for long waiting times.

Answers

Answers


● facility/unit location – is it near a hotel or club, in or near a high crime area orused by locals as a short cut

● facility design and layout – location and layout of Emergency Departments,reception and waiting areas, treatment and interview rooms, location of access,public telephones, lighting, access to refreshments and toilets, air conditioning

● alarm systems and general security

● high-risk activities undertaken in the workplace, eg on-site storage of drugs

● parking areas – away from the workplace, poorly lit, dark spots and hiding places

● entries and exits – multiple public access, lack of staff escape routes, doorspropped open for fresh air, exit doors that provide easy access to staff andclinical areas

● Emergency Departments – poor separation of public and treatment or staff areas,easy access to staff areas

● reception/waiting areas – poor staff view, easy access to staff areas, reducedpersonal space, inadequate seating, lack of public facilities eg phones, toilets,lack of privacy

● treatment/interview rooms – single access/egress point, inability to separatepatients from distraught, intoxicated or noisy family or friends.


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Staff factors associated with aggression in the workplace.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


Answers


● staff shortages

● lack of trained and experienced staff

● busy workloads

● personal issues (tiredness, stress, illness)

● ignoring patients

● not being polite.

Community work associated with aggression in the workplace.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


● obtaining as much information as possible about the patient/client/business prior to the first visit

● obtaining relevant information about other members of the household andlikely visitors when making home visits

● gathering information about the geographical location of the premises, eg is it in a high crime area, geographically isolated, does it have reducedaccessibility to/availability of police

● acquiring specific information about the premises, eg is there security access,stairs, external lighting, hiding places, are the premises modern, in good repair, is phone connected, etc

● speaking to other staff who may have provided the services or inspected thepremises in the past

● where possible, speaking to the patient/client by phone prior to the first visit to confirm the appointment, as this can also provide insights

● using as broad a range possible of information/resources eg point of referral,relevant patient/client records, other staff, local GPs, local police.

Answers


Explain and discuss

Eliminating or controlling risksEliminating or controlling risks involves deciding what needs to be done to eliminate or control the problem of aggression and lessen the risk to the lowest possible level. Under the Occupational Health and Safety Regulation 2001 employers are required toeliminate any ‘reasonably foreseeable’ risks to the health and safety of their employees.However this is not possible in all circumstances, therefore risk control measures need to be implemented according to the hierarchy set out in the legislation.16 Prior to anyimplementation of controls, the controls need to be ranked from the most effective to the least effective. In most cases several control measures will be needed.

How would you prioritise risks?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


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Answers

Facilitator: Inform participants that to identify and put in place effective riskcontrol strategies it is necessary to identify the level of threat posed by thevarious risks and hazards. This provides information about those risks that most urgently need action and helps prioritise others for future management.

Factors to consider when prioritising risks for remedial action include:

● the nature of the risk or hazard, eg physical, psychological, chemical

● the degree or severity of harm that the hazard/risk may cause

● how likely it is that harm will occur as a result of the exposure

● how often staff are exposed to the risk or hazard

● how long the periods of exposure are

● how many staff are exposed to the risk or hazard?

Show overhead slide


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Facilitator: Inform participants that not all risks can be eliminated, eg to eliminate the risk of aggression in Emergency Departments very few patients would be accepted. In this situation, controlling the risk rather than eliminating the risk is the appropriate course of action. Other examples of controlling the risk include:

● providing comfortable waiting areas with well maintained facilities

● providing regular updates to patients and visitors on waiting times and causesfor delay etc

● the use of duress alarms (personal and fixed)

● closed circuit television systems

● access controls

● security personnel

● effective triage systems

● aggression prevention and minimisation training for staff.

It needs to be ensured that risk control measures do not introduce new hazards to the workplace. For example a post-operative patient not fully recovered, may in a very busy ward get out of bed and therefore be at risk of sustaining an injury.An example of a measure that could possibly be used to control this risk is theintroduction of bed rails. However, even with this safety measure there is thepotential for a confused post-operative patient to try and climb over the bed rails and consequently be at risk of injury. Therefore, when selecting controlstrategies, it is important to be mindful of not introducing new or more seriousrisks. The above is an example only and other examples may be used.

Explain and discuss

Regulatory hierarchy for controlling risk16

1. Substituting a hazard giving rise to the risk with a hazard that gives rise to a lesser risk.

2. Isolating the hazard from the person put at risk.

3. Minimising the risk by engineering means.

4. Minimising the risk by administrative means (eg by adopting safe working practices orproviding appropriate training, instruction or information).

5. Using personal protective equipment.




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Facilitator: For hierarchy of risk controls (examples the facilitator can mention)

Examples of engineering controls

● Designing out the risk or hazard when planning new premises, equipment and work systems.

● Redesigning existing work environments, equipment and work systems toeliminate the risks.

● Isolating the risk or hazard from staff.

Examples of administrative controls

● Rotating staff to reduce frequency and duration of exposure to the risk.

● Maintenance programs and housekeeping.

● Providing information and training.

● Developing procedures and protocols for hazardous activities.

The process of monitoring, reviewing and improving policies, procedures and theenvironment is a continuous one for all staff. This process enables the identification ofareas of further risk, gaps in systems that could lead to potentially aggressive incidents,failures in any previously identified preventative measures and the reassessment andmonitoring of controls implemented.

Case studyJim, a new person in your work area, is having trouble adjusting to his new work environment. You notice Jim increasingly is being isolated at work and isnot receiving the help that others get from the team. He is not invited to a workpicnic and people have put nasty stickers and food scraps into his locker. Thisculminates early one day when a patient becomes argumentative and physicallyviolent with him, and staff are slow to respond to his calls for assistance. Jim is at significant risk of injury, but he manages to escape. When he walks into thetea-room after this episode all the other staff are smiling.


Facilitator needs to emphasise that this process is an active and ongoing onewith an emphasis on consultation between managers and staff.



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Apply the four steps of risk management to this scenario.

1. Identify the hazard.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

2. Assess the risk (how serious the problem is).

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

3. Eliminate or control the risk (decide what needs to be done).

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

4. Monitor, review and improve the system.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Answers

Facilitator: These four steps are from the previous two pages and participantsshould be able to break down the process – the hazard is bullying, the risk isserious, steps need to be put in place to report, investigate and manage thebullying with management, and this needs to be monitored. Staff may needadditional training. Jim may need counselling and assistance.

Show overhead slide


2. Natural surveillance.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


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How the design of your workplace can prevent aggression

Explain and discussCrime prevention through environmental design (CPTED)2,17 and situational crimeprevention2,17 are approaches that can be applied to enhance building design. These approaches decrease the possibility of crime occurring in the workplace by:

● increasing the risk for offenders

● making it harder for offenders to make up an excuse for the trespass

● reducing the likely rewards for criminal behaviour.

Ask the group


What is involved?

1. Territorial reinforcement.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Facilitator: Inform participants that ‘territorial reinforcement’ includes the ideathat people can be encouraged to view the health care setting as somethingthat is theirs. A sense of protectiveness of the facility by staff is an importantaspect of safety. In areas where staff only are permitted, staff are more likelyto pay attention to the area. Strategies include:

● being responsible for the facility and its use

● ensuring facilities have clear transitions and boundaries between the healthfacility and the general community, and between staff only areas and other areas

● establishing clear visible signs on who is to use a space and its purpose.

Answers


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Facilitator: Inform participants that the surveillance principle refers to the way in which work facilities are designed so that high risk sections can beoverlooked and watched by other staff going about in their normal day to daytasks. Therefore good surveillance means that people within the health settingcan see what others are doing. Facilities designed with good surveillanceopportunities are less likely to be targeted by criminals as an area to commit an offence. Strategies include:

● having clear sight lines between public and staff places

● good lighting for visibility

● ensuring that the areas that are landscaped are not places where offenders have an opportunity to hide or entrap victims

● designing pathways to car-parks to be in full view of all passers-by and overlooked by windows.

Answers


Improve surveillance

Facilitator: Inform participants that increasing visibility in the workplacediscourages offenders as it improves the chance of others witnessing andreporting the offenders. Examples of strategies are in the list below:

● Adequate lighting in car parks, corridors and storage areas.

● Safety glass windows in interview rooms so patient/staff interactions can be seen by outsiders while at the same time providing reasonable privacy for patients and others.

● Closed circuit television.

● Large signs indicating that the workplace is being monitored continuously.

3. Space management.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________



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Facilitator: Inform participants that space management refers to ensuringthat surrounding spaces around buildings are well maintained and cared for and used appropriately. These include:

● keeping sites clean

● attending quickly to the repair of vandalism and graffiti

● replacing any burned out lighting

● removing or refurbishing decayed physical surroundings.

Answers


Improve fittings and furniture

Facilitator: Inform participants that the types of fittings and furniture used in the workplace can reduce the risk of aggression by making it more difficult forperpetrators to commit the crime and injure others. Examples of strategies arein the list below:

● Ensure comfortable waiting areas.

● Have clear signage and give explanations for any delays.

● To ensure protection enquiry desks may be fitted with well designed, clear screens with appropriately placed slits for communications and passage of documents.

● Have duress alarms in discreet places.

● Ensure where possible that interview rooms have two doors.

● Ensure that furniture is comfortable but kept to a minimum.

● Provide easy access to food and drinks in waiting areas.

Explain and discussKeep your high-risk areas safe by using the following strategies:

● Deadlock drug storage areas.

● Designate safe escape routes.

● Have key or card access to staff working areas.

● Use metal detection systems.

● Install duress alarms.

● Minimise public entry points.

● Install barriers at reception desks.

Readings and resourcesNSW Health has developed the Health Facility Guideline: Safety and Security as part ofthe Health Building Design Series, to assist facility planners and designers to reduce risksthrough the design of workplaces and the internal physical environment incorporatingCPTED principles. These Guidelines will also assist user groups and staff involved in theconsultation process for the design of new and refurbished health buildings or facilities.See also the NSW Health Security Manual.


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More ways of keeping your workplace safe


Facilitator: Inform participants that controlling access to specific high risk areas in the work environment through architectural or engineering designs or redesigns is known as ‘target hardening’. Examples of strategies are inthe list below.

Show overhead slide


Putting it all together

Explain and discussUse the Individual risk highlighter to help you identify the warning signs of potential patient aggression. It may help you identify immediate triggers for aggression in individual patients.

Use the Violence risk awareness checklist to help identify all the different risks in yourworkplace and encourage problem solving.

Use the Violence minimisation checklist for a comprehensive list of strategies to reduce risk.

Caveats and background



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It is also important to recognise that staff or visitors may also be aggressive.Although the following risk highlighter, risk awareness and risk reductionchecklists focus mainly on patient-initiated aggression, many of the sameprinciples apply to other sources of aggression.

1. Accurate risk prediction for an individual patient at a particular time is very difficult.

2. The ‘Individual risk highlighter’ is to be used in considering the risk of immediatetriggers for aggression in individual patients.

3. The ‘Individual risk highlighter’ does not provide a statistical likelihood of aggression. It serves only to remind staff of factors that increase the likelihood of aggression.

4. The ‘Individual risk highlighter’ is not intended to be used for all patients – only for thatsubset for which there are some preliminary indications that the patient has a potentialto be violent.

5. Risk is a dynamic concept – it can change rapidly, and requires frequent reassessment.


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Overview the following highlighter and checklists with participants. It isrecommended that the facilitator go through each one, discussing each point and illustrating how the different factors identified can be associated with increased risk of aggression. You may choose to invite participants tovolunteer relevant examples from their workplace to illustrate the points.

The ‘Individual risk highlighter’ should be applied when:

1. staff feel afraid (trust the instinct)

2. person looks angry

3. person appears intoxicated

4. hunger and fatigue are present

5. person appears to be irrational or to have lost touch with reality

6. person seems to feel trapped and terrified

7. person is enraged or bizarre

8. there is a history of violence

9. person is accompanied by a crowd of others

10. person appears agitated and twitchy

11. person is demanding

12. person is very distressed.

Explain and discuss



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Historical

1. History of previous violence.

2. History of impulsiveness/risk taking behaviour.

3. History of substance abuse.

4. History of childhood abuse.

5. History of significant head injury.

6. History of criminal behaviour, arrest or imprisonment.

7. Poor compliance to medication.

8. Anti-social personality disorder.

9. Few friends or family.

10. Young men.

Current

1. ‘Gut feeling’ of staff that person may be violent.

2. Recent stress (documented in notes or history).

3. Recent trouble with the law or arrest(documented in notes or history).

4. Poor problem solving ability.

5. Substance abuse especially alcohol orstimulants such as speed or cocaine.

6. Specific plan involving violence.

7. Potential victim is available.

8. Access to means – guns, knives, explosives etc (documented in notes or history).

9. Agitated behaviour.

10. Current disturbed mental state, eg head injury, intoxication, dementia:

– intoxication – anger – impulsivity– depression– mania– hallucinations – particularly ones involving

violence or commands– delusions – especially of infidelity, being

threatened, hypochondriacal, of violent acts, or of a litigious or hyper-religious nature

– confusion/delirium/dementia.

Behaviours that may indicate impending aggression

1. Loud clipped or angry speech.

2. Pacing.

3. Angry facial expression.

4. Intense staring.

5. Refusal to communicate.

6. Threats or gestures.

7. Physical agitation, eg clenching of fists.

8. Restlessness or fidgeting.

9. Delusions or hallucinations with violent content.

10. Patient themselves reporting violent feelings.

11. Intoxication.

12. The absence of a calming support person canexacerbate the situation.

13. Aggressive to the environment, eg kickingwalls, banging doors.

14. Isolative behaviour.

15. Frequent demands.

Individual risk highlighterTo be used for considering factors that increase the risk of violence in individuals.


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Violence risk awareness checklist

• Intoxification or confusion.• Hunger and fatigue.• Head injury/psychosis.• Humiliation.• Being ignored, rejected.• Concerns or requests dismissed.• Frustration/helplessness.• Pain/grief.• Anxiety/fear.• Poor impulse control.• Anti-social personality.• Narcissistic entitlement.• History of aggression.

Individual factors (client/visitors)

Risk

• Long waiting times.• Competing demands on staff.• High workload/busy.• Staff shortages.• Unpreparedness.• Unclear management plans.• Lack of timely information to

patients, visitors or staff.• Telephone ringing often.• Cultural variation.• Presence of rival gang members.• Late at night.

Context

• Crowded or noisy area.• Inadequate space.• Small examination rooms.• Small, unclean waiting areas.• Dirty, poorly maintained areas.• Isolated or dimly lit areas.• Dangerous objects, eg scalpels,

small oxygen cylinders, boxes, breakable objects.

Physical environment• Anxiety/fear.• Personal issues – tiredness,

stress, illness.• Inexperience.• Irritability.• Discourteousness.• Attitudes to different groups and

types of people.• Ignoring patients, visitors,

other staff.• Whispering about or openly

discussing confidential information related to workplace.

Individual factors

• Take precautions.• Alert others.• Follow hospital procedure.• Have clear patient

management plans.• Apply ‘Individual risk highlighter’.

What to do



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Violence minimisation checklist

• Be calm, don't confront.• Be aware of impact of

environmental context and staff behaviours on patients, visitors and other staff.

• Anticipate effect of patient state of mind.

• Speak to people courteously using their name.

• Try to understand main concerns, provide information.

• Emphasise a desire to help.• Allow ample personal space.

Individual factors (client/visitors)

Riskreduction

• Update person about waiting times.

• Regularly provide person with relevant information.

• Rotate visiting support/family/ other groups to reduce congestion.

• Limit numbers of visitors.• Call for security or request Police

presence if rival gang members are present.

• Manage staff distribution/ placement to minimise the impact of staff shortages.

• Set alert reminders to reduce unpreparedness.

• Clear management plans are available.

Context

• Well designed and maintained areas.

• Reduce noise where possible.• Good visibility.• Provide well lit, warm and tidy

areas.• Provide distractions, eg reading

materials, toys, TV, good seating.• Allow separation of patients,

visitors and staff.• Limit the presence of dangerous

objects, eg scalpels, small oxygen cylinders, boxes, breakable objects.

Physical environment• Be attentive to patient/relatives

concerns/needs.• Present a professional manner

at all times to each other.• Remain calm and courteous.• Buddy inexperienced staff.• Provide timely information to

patients, visitors and staff.• Initiate staff wellbeing program.• Identify and provide suitable

interventions in high workload situations.

• Participate in aggression management training.

• Be aware of patient's perceptions of staff, ie don't stand and gossip in view of the public.

Individual factors (staff)

• Take precautions/ be vigilant.

• Alert others.• Follow hospital procedure.• Familiarise yourself with

specific management plans.• Alert others to your

presence in isolated areas.• Move patients or others

away from the disturbance.• Allocate staff to provide

reassurance to patients and their families in the vicinity of the disturbance.

What to do


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Ask the group What policies and procedures are in your workplace to manage an aggressive incident?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________



Show overhead slide

Facilitator: Familiarise yourself with local policies relating to the prevention and management of aggressive incidents. Present them here. You may chooseto write these on the whiteboard.

What are your responsibilities in relation to workplace policies and procedures?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Facilitator: Participants should emphasise that it is everyone’s responsibility to be involved in policy formation and carrying out procedures consistent withthese policies. It is also everyone’s responsibility to ensure their awareness ofthe content of these policies.

Answers

How does your employer ensure that you have read and are up-to-date with current policiesand procedures on managing aggression?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

What workplace strategies do you have?


Key points to remember

● You have a key role to play in keeping your workplace safe.

● The risk management process involves identifying, assessing, eliminating or controlling risks, and monitoring, reviewing and improving the system.

● The design of your workplace plays an important role in preventing aggression.

● Regularly monitor your workplace and the people around you.


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Facilitator: Ascertain from participants what processes are in place to ensurethese policies have been read.

Answers

Show overhead slide


Part 3Preventing aggression escalating



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Session time 90 mins

Session overview This section reviews the levels of aggression, what options you have in responding to aggressive behaviour and the legal issues you need to be aware of when choosing your options. It reviews options when faced with a physicallyaggressive or violent person and strategies to remain calm. Understanding the role of attitudes and cultural diversity in minimising aggression are reviewed.Effective verbal and non-verbal de-escalation skills to prevent aggressionescalating are practised.


Facilitator: Part 3 outlines the response options available for staff when aperson’s aggressive behaviour has begun to escalate. These response optionsare then discussed outlining the appropriate timing for each, and the verbal andnon-verbal skills required for these options. The impact of cultural diversity isalso highlighted. Before leading this part, gain an awareness of the main ethnicgroups residing in the facility’s locality and catchment area and their differingcommunication styles. You should also be aware of the relevant legal issues.

Show overhead slide



Levels of aggression

Explain and discussIf an aggressive person confronts you, it can help to identify what level of aggression theyare displaying:


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Show overhead slide

Level Examples of behaviour

Low Agitated, frowning, irritable.

Moderate Clenched fists, making direct verbal threats.

High Pushing, throwing, doing physical harm.

You have many options when confronted with an aggressive person. Knowing whatlevel the person is displaying will help you decide the best way to try and prevent theaggression escalating.

Show overhead slide

Know your options for actionThere are always options available when confronted with an aggressive person and it is important that staff know the appropriate response options. These responses willdepend on a number of factors including the nature and severity of the event, whetherit is a patient, visitor or intruder, and the skills, experience and confidence of the staffmember/s involved. This may include going straight to calling for back-up, security or local police.


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Explain and discussWhen considering your options you always need to keep in mind the following:

● Whether the person has an underlying physical or mental condition that is contributingto the person’s aggressive or violent behaviour.

● Always remain calm and assess the level of threat and the different levels of aggressiondisplayed as this will help you to make a decision on the appropriate response to take.

● Regardless of the response option you choose, de-escalating and containing thesituation should be considered where possible.

● If at any time you feel unsafe you need to call for support and/or leave.

● At all times your priority is for the safety of yourself and others including preventing injuryto yourself and others around you.

● Be aware of the potential for violence, look for contributing factors or warning signs.

● You can use more than one option.

Refer to Participant manual


Response options...

● Issue a verbal warning.

● Seek support from other staff.

● Request that the person behaving aggressively leave.

● Request that the patient be reviewed by a clinician.

● Negotiate treatment.

● Use verbal de-escalation and distraction techniques.

● Stay and call for help.

● Leave and seek help.

● Utilise the duress alarm or unit emergency response as relevant.

● Initiate team restraint response.

● Initiate external emergency response, eg security, police.

● Charging of the perpetrator with assault.

Explain the following response options, emphasising that they are in noparticular order and that the circumstances referred to on the previous page will affect which options are utilised. Also emphasise that at any time the staffmember feels it necessary, back-up should be called. The response optionsbelow are a key component of the training.

Draw the participants’ attention to the following table on page 24.



Explain and discuss

Deciding to stay or leaveAn important decision to be made in a situation of potential aggression: ‘Do I stay or do I go’. When do you leave?

You should leave the situation when:

a. you feel you cannot control the situation or the situation is getting out of control

b. you endanger yourself or others by staying

c. when you are alone with an aggressive person.

If possible, a person’s potential for aggression should be identified early. Potential factorsto be aware of include the person having a past history of aggression, the presence ofany current threats of harm and the likely availability of weapons. This also assists inmaking the decision regarding whether to stay or leave.



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Show overhead slide

SAFETY HINT – In all situations that are getting out of control you shouldimmediately seek help, regardless of whether you decide to stay or leave.

Ask the group Consider some instances where you were confronted with an aggressive person. What factors influenced your decision to stay or leave?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Facilitator: You should expect participants to outline some of the reasons whythey came to this decision. These may be quite varied. Acknowledge all of themand explain that the preceding list given is not exhaustive.

Answers


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When and who to call for back-up or help

Ask the group


Show overhead slide

Write responses on boardIf you feel unsafe at any time you need to call for back-up or help. Who can you call for backup or help?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Facilitator: Answers may include security staff, peers, wards people and police.

Answers

Ask the group Consider all of the above response options. Which would be suitable for the differing levels of aggression?

Low ________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


Answers

Moderate ____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


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Facilitator: Participant answers should include:

● negotiating treatment

● issuing verbal warning

● using verbal de-escalation and distraction techniques

● seeking support from other staff.

Answers


● requesting that the person behaving aggressively leave

● negotiating treatment

● issuing verbal warning

● seeking support from other staff.

High ________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


● initiating unit emergency response

● initiating external emergency response

● leaving and seeking help.

Answers

Show overhead slide


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Danger and safety zones when faced with an aggressive or violent person

Background readingWith a physically aggressive or violent person, the ‘danger zone’ is being in physicalproximity to the person so that you could be reached by a punch or kick. By keeping asafe distance from the person, you will be in a ‘safer zone’. It is easier for an aggressiveperson to lunge or move straight ahead than for them to move to the side or backwards.Therefore, the ideal position to stand is out of the danger zone and slightly to one side of the aggressive person.

Explain and discussHere is a suggested ideal stance:

● Stand in the safer zone not the danger zone.

● Stand slightly to the side of the person so they cannot lunge straight at you.

● Shift your weight to your toes so you can move quickly if needed.

● Place your hands in front of you in an open position.

● Ensure you face them so you observe them clearly.



Facilitator: You may choose to demonstrate these zones in front of the group ina role-play with a volunteer.

Show overhead slide

Self help strategies to remain calm

Background readingIn order to manage or control a situation of impending aggression, it is important to keep calm and in control. This involves acknowledging and managing our own feelingsand responses.

Controlling feelings of fear, anxiety and apprehension can be done by pausing, breathing(deep breaths), positive self-talk (thinking) and/or counting to three. While interacting withan aggressive person be aware of your breathing rate and keep it slow and deep. This isone of the most effective tools for maintaining a state of calm.


Verbal and non-verbal de-escalation skills to preventaggression and violenceVerbal and non-verbal de-escalation skills are an important strategy for reducing andpreventing aggression and violence. These skills will de-escalate aggressive behaviour inmost, but not all aggressive people. It is important to recognise that de-escalation skillsinclude both verbal and non-verbal skills.

Explain and discuss


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Show overhead slide

Background reading

Non-verbal skills

Presenting yourself as being calm and in control is a powerful de-escalation skill. Your behaviour will calm the person as much, if not more, than the words you say.

Here are some important points to consider when endeavouring to display a calm,controlled disposition.

● Do not mirror (copy) the aggressive behaviour or postures back to the person.

● If possible, give the person more rather than less personal space. Do not invadetheir personal space. Avoid touching the person.

● Do not hide your hands or move them too much. Have them in a non-threateningrelaxed position that reveals your open palms if possible. Avoid folding your arms across your chest, having your hands on your hips or in your pockets.

● Maintain eye contact, however do not be threatening ie do not stare, instead use broken eye contact.

● Be attentive to the individual rather than concerned with something else that ishappening in the area.

Explain and discuss


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Verbal skills

Using the following verbal skills can help de-escalate aggression. Many instances ofaggression occur because a person’s needs are not being met. Understanding theperson’s expectations, and trying to ‘put yourself in their shoes’, can help you understandwhat is troubling them. Communicating back to them that you understand somethingabout their expectations and feelings can be a powerful de-escalation tool. Helping tonegotiate a solution will in most cases reduce their aggression.

Tone of voice

When speaking to an aggressive person your tone of voice should be calm and low,though loud enough for them to hear if they are shouting over the top of you. Endeavourto speak slowly and clearly so that you will be easily understood. Remember that you are modelling appropriate behaviour. You are also encouraging the other person to thinkabout and re-focus on the situation rather than to act out their anger. Remember thatraised voices are likely to escalate aggression.

Briefly acknowledge feelings

It can be helpful to briefly acknowledge the person’s emotional state first, beforeaddressing their need. Often just communicating to the person your awareness of theiremotional state can immediately calm them. An example might be to say, ‘I understandthat you are angry and frustrated by this situation’. Once you have acknowledged theiremotions, you can then seek more information or provide possible solutions to their need.

Explanations

A person who is emotionally aroused cannot absorb as much information as a calmperson. It is therefore helpful to:

● keep sentences short

● keep words simple.

Humour

Be very careful with the use of humour. If you believe the use of humour may help to de-escalate the person, ensure:

● you use mainstream humour

● the aggressive person is not the butt of the joke.


Background reading

Show overhead slide


Help the individual to have their needs met

It is important to realise that most aggressive people simply want their needs met. Let them know you will support them in this as much as you can, without makingpromises that cannot be kept.

Setting limits

Sometimes you need to set limits on a person’s behaviour for the safety of themselves or others, and to enforce unit rules. Examples can include: not allowing smoking; notallowing access to patients during certain hours or when undergoing medical procedures;or preventing a person from entering or leaving a restricted area.

Using assertion skills may help you in such situations. An assertive response would be to set the limit and then explain to the person the reason for the limit. Being assertive can help ensure that the needs of both parties are satisfied with thesettlement negotiated. Whilst it is important to be firm when setting limits, a person who becomes very aggressive may not accept these limits. Remember the first rule is to maintain your safety. Therefore, if the situation deteriorates you may need to backdown and seek assistance.


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Summary of verbal and non-verbal de-escalation skills

Do

● Introduce yourself (first name only).

● Be calm and in control.

● Give the person more personal space.

● Maintain eye contact in a non-threatening way.

● Be attentive and listen actively.

● Communicate back that you understand.

● Acknowledge the person’s emotions.

● Help to negotiate a solution.

● Model appropriate behaviour.

● Speak slowly and clearly.

● Keep sentences short and simple.

● Help the person as much as possible to havetheir needs met.

● Set limits where appropriate.

Don’t

● Mirror (copy) the aggressive person’s behaviour.

● Touch the person.

● Hide or move your hands too much.

● Fold your arms across your chest.

● Raise your voice.

Point out that the workbook has a summary of the skills.

Explain and discuss

Refer to Participant manual page 28


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Consider one of the stressful situations listed previously.

Work in pairs to create a situation where one person acts out aggressively (both verbally and non-verbally). The other person is to play the role of a staff member aiming to de-escalate the situation, and should practice using both verbal and non-verbal de-escalation responses. Remember the staff member should practise keeping calm and in control.

Following the role-play discuss the de-escalation strategies used and the effect this hadon the aggressive person and the staff member. Then change roles and repeat.




Case study1. When told of the waiting list for elective surgery, a patient became irate

about the public health system. The patient yelled loudly and cursed thegovernment and said something should be done about it.

2. A patient in pain and suffering from the effects of alcohol, swore violently at a staff member and threatened to punch the staff member if help wasn’timmediately provided.

Walk around the groups and offer assistance where required.

Show overhead slide

Explain and discuss

Attitudes are importantPeople have different ways of communicating. Misinterpreting a person’s behaviour can lead to aggression being unnecessarily escalated. This misinterpretation can have two sources:

● Your attitudes and expectations about certain people.

● Misunderstanding communication styles of people from different cultures.


Background reading

Your attitudes towards peopleAttitudes influence behaviour.18 Therefore the beliefs, values, ideas and knowledge held by an organisation’s employees and management is reflected in the workplace culture.Certain attitudes in staff19,20,21,22 have been found to be associated with aggressivebehaviour in patients, staff and others including family members or visitors.

Attitudes that increase the risk of aggressive behaviour include:

● not liking the person and projecting this onto them

● not treating the person with respect

● making assumptions about a person without finding out their needs or concerns

● interacting with the person as if you are a parent

● being authoritarian

● being inflexible

● being controlling

● using a threatening tone or behaviour

● being coercive

● being argumentative

● stigmatisation of others.


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Show overhead slide

Misinterpreting diverse communication styles


Facilitator: As examples, discuss the main ethnic groups residing in the facility’s locality and catchment area and their differing communication styles.Inform participants that it is important that they obtain as much information as possible on the diverse cultures within the area.


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Explain and discussPeople from a different background may have different characteristic behaviours to your own. Some examples can include different rules and conventions about:

a. eye contact

b. stance

c. tone of voice

d. listening style

e. gestures

f. language

g. personal space

h. gender of person providing advice/care.

Background readingDo not assume that because someone speaks with an accent they have poor English skills. In addition, do not assume a person with limited grammar skills hasintellectual deficits.

Some verbal and non-verbal ways of communication used by people can bemisinterpreted as the person being angry or aggressive. Consider the role of tone and pitch in communication. Often what is difficult to master is the translation of tone.Many languages use tone in ways distinctly different from English. For example, when a person ‘sounds’ angry it may be that they are angry, or it may be that the tone of theirfirst language applied to English causes the listener to assume that they are angry. Do notraise your voice to someone with an accent, unless you know they are deaf. The samewords said in a number of different tones can evoke totally different meanings. To understand these you can use the following strategies:

● If others from a similar cultural background are around ask them for help.

● Acknowledge your unfamiliarity with their culture. The person will value your interest intheir culture.

● Clarify communication styles you are not sure about with the person. For example,if someone is talking loudly say ‘I have the impression that you might be angry becauseyou are speaking loudly’. This will allow the person to explain themselves. It may be thatthey have hearing difficulties.

● Ask questions when necessary to help assess the person’s coping strategies duringstressful situations. For example, ‘How do you handle...’ or ‘Some people find thatwhen this happens it is best to... what would be better for you?’

● Clarify, interpret and re-label the person’s behaviour.

● Apologise for any mistakes.



Explain and discuss

Strategies for improving communication with people froma different cultureTo improve communication with people from different cultural backgrounds the followingstrategies are recommended.23

● Always accept and respect differences between and among people.

● If required use interpreters.

● If working in areas where the population or person is of a specific cultural background,learn as much as possible about the culture and the way they communicate.

● Be aware that mistakes can happen and you can misinterpret the person.

● Promote a feeling of acceptance.

● Show respect and dignity for the person.

● Do not stereotype by age, sex, ethnicity, socioeconomic status, style of dress and othersocial categories.

● Do not assume you know where a person has come from, let them tell you.

● Clarify as accurately as possible how the person is thinking and feeling.

● Reflect the person’s feelings verbally but do not be critical.

● Avoid any unnecessary or unfamiliar words.

● Restate the problem in more specific ways.

● Use the same time perspective as the person, eg if they are using past or future tense,use the same.

● Avoid giving mixed messages.

● Do not speak too quickly.

● Do not raise your voice to speak more clearly unless the person is hard of hearing.

● Check that you have been understood.

Remember communication is also affected by context. The context in which an interactionoccurs will impact on the outcomes of the interaction.

● Is the person familiar with the ‘rules’, eg do they know that the waiting time is threehours, as the sign is in English and they may not be able to read it?

● Has the client had previous experience in this context, eg the health setting?

● What are the client’s expectations?

● What are the culturally bound behaviours?

● How do I check these things out with the client in context?


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Explain and discuss


Show overhead slide

Background reading

What governs your actions in responding to aggression?Both the perpetrator of aggression and the victims of aggression have rights that areprotected by legislative frameworks such as the Crimes Act and the Mental Health Act. In addition, people have a common law right not to be harmed by the acts or omissionsof another person or organisation. It is important that when you consider and implementyour options, the rights of the perpetrator as well as your rights are considered. Legalissues to be considered here include:

Mental Health Act 1990

This NSW Act governs the care, treatment and control of people with mental illness and disorder. Its underlying premise is that people should be treated using the leastrestrictive care. The Mental Health Act defines a mentally ill person as someone sufferingfrom a mental illness and owing to that illness there are reasonable grounds for believingthat care, treatment or control of that person is necessary for the person’s own protectionor for the protection of others from serious harm. This Act sets out the circumstances inwhich this can happen, provides a framework of checks and balances and ensures thatinterference with a person’s rights, dignity and self-respect is kept to the minimumnecessary to keep the patient and others safe.


Facilitator: Inform participants of the following points:

● The patient may not be able to leave the unit due to involuntary admission.

● The patient may not be able to refuse treatment due to involuntary admission.

● The patient has the right to receive treatment.

● The patient has the right to be in the least restrictive environment.

● The patient has the right to be treated with dignity and respect.


Crimes Act 1900

Under the Crimes Act 1900, people who commit assaults and other acts of violence inNSW Health can be charged with criminal offences under the Act. The Act also allows forapprehended personal violence orders to be taken out where a person has reasonablegrounds to fear personal violence, harassment or molestation.

Explain and discuss

Assault

The criminal offence of assault consists of:

i. force applied to another without their consent, or

ii. the actual intent to cause harm to the person, or

iii. a very high degree of reckless indifference to the probability of harm occurring.

These are the conditions that must be proved if there is to be a successful assaultprosecution on behalf of a staff member or any member of the public.

Explain and discuss

The principle of reasonable force

Section 418 of the Crimes Act 1900 states that a person may use self-defence if and only if the person believes the conduct is necessary:

● to defend himself or herself or another person, or

● to prevent or terminate the unlawful deprivation of his or her liberty or the liberty ofanother person, or

● to protect property from unlawful taking, destruction, damage or interference, and theconduct is a reasonable response in the circumstances as he or she perceives them.These provisions were introduced in February 2002.

This means that a person who assaults another person in self-defence is not criminallyresponsible if acting in lawful self-defence. As stated above self-defence is not limited tothe defence of one’s own person, and can be used as a defence for assaults that occurwhen protecting property or other people.

In the past the test was whether the perception of a threat was reasonable in thecircumstances, and whether a ‘reasonable’ person in the same circumstances would alsohave been able to come to the same conclusion. The defence is now broader and statesthat as long as the accused believed that they were under threat, it does not matter that a ‘reasonable’ person may not have perceived such a threat in the same circumstances.

However, a reasonable response is still required for the law of self-defence to operate. The law states that there must be some reasonable proportion between the threatperceived by the accused and his or her response to it. So the key issue is that theperson threatened must be able to persuade a court that they felt threatened, that the threat was real to them and that their response was appropriate.


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Facilitator: Reinforce that when using self-defence techniques, the force usedmust be consistent with the threat perceived by the individual.

Explain and discuss

Restraint

Restraint may be necessary in emergency situations involving aggressive patients, where there is a foreseeable risk of harm to themselves or others. At all times NSW Healthpolicy requirements relating to clinical restraint should be adhered to. See NSW Healthdocuments: Management of Adults with Severe Behavioural Disturbance, May 2002;Mental Health for Emergency Departments, May 2002; Policies on Seclusion Practices:the Use of Restraint and the Use of IV Sedation in Psychiatric In-Patient Facilities,December 1994.

When staff restrain a patient they must use only reasonable force in order to be protected from prosecution for assault. With regard to the restraint of others in the act of committing a crime, the first consideration for staff is their own safety and the safety of others. Attempting to restrain in these circumstances may expose staff to unnecessaryrisks, and unless there is an immediate and significant threat to the safety of others staffshould retreat and observe from a safe distance, and police should be called.

Explain and discuss

Duty of care

Duty of care requires that a staff member act in the best interests of the patient. However, it is essential to note that a duty of care does not suggest that staff shouldremain in dangerous situations or place themselves at unacceptable risk. At times a staffmember’s duty of care to a patient may justify the use of detainment, restraint or sedationfor the patient’s own safety or the safety of others. In these situations having exercised a duty of care may be a defence for staff members against claims of false imprisonmentor assault. Not exercising a duty of care may result in a claim of negligence depending on the circumstances.


Background readingIn some situations, despite all your efforts to prevent aggression escalating, you mayfind yourself having to manage an aggressive or violent situation. You should be preparedto respond in an appropriate way. In responding to the person who is aggressive, yourbehaviour should be calm and show that you are in control, with no more forcefulnessthan the situation requires. Always remember that safety of yourself and others is givenpriority. Here are some more strategies and tips for dealing with these situations.e

● Never attempt to deal with a physically violent situation alone.

● Only one staff member should speak to the person, do not allow other staff to interrupt as this may cause the physically aggressive person to become confused.

● Evasive self-defence may be required if you are attacked, followed by leaving the situation if required. The principle of reasonable force should be taken into consideration.

● Initiate your duress alarm or local emergency response. If necessary, dial (0) 000 andask for the police. The following information needs to be reported to the police duringthe call:

– that an assault is in progress or has just taken place

– the name of the facility, address, your name and telephone number

– the exact location of the assault and number of people involved

– what the person(s) looked like (if a vehicle was used to get away – the type of vehicle it was)

– whether any weapons were used.

● Have all witnesses wait for the police, or obtain their name, address and telephonenumber if they insist on leaving.

● Have a staff member at the entrance of the facility to direct police to the scene of the assault.

● Utilise post-aggressive incident management strategies.

Some more strategies when faced with a violent person


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Show overhead slide


69

Explain and discussResponse options for repeatedly aggressive people.



Show overhead slides in sequence with discussion

Show overhead slide

These long-term response options are an important component of the training.Go through each and discuss.

Response options for repeatedly aggressive peopleThe following options could be considered for dealing with repeated aggressive behaviour:

● Formal patient management plans.

● Written warnings.

● Conditional treatment agreements.

● Exclusion from visits.

● Conditional visiting rights.

● Patient alerts in conjunction with support management plans.

● Formal recognition of inability to treat in certain circumstances.

● Taking out an AVO to protect staff.

● Having charges laid.

Readings and resourcesFor further information, consult the following document: NSW Health Zero TolerancePolicy and Framework Guidelines.


Key points



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● Know your options when confronted with an aggressive situation.

● If you feel unsafe at any time call for back up.

● All times your priority is for the safety of yourself and others.

● Stay calm.

● Remember the danger and safer zones.

● Use appropriate verbal and non-verbal de-escalation techniques.

● Be aware of your own attitudes that may contribute to aggression.

● Always accept and respect differences between and among people.

● Keep in mind the legal issues surrounding your response options.

Part 4Bullying, harassment and discrimination at work



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Session overview This section looks at the behaviours, effects and legal issues surrounding bullying,discrimination and harassment, making a formal complaint, and how to confront aperson who is bullying, harassing or discriminating against you.


Show overhead slide


This section aims to introduce participants to the issue of bullying, harassmentand discrimination in the workplace. Facilitators will need to know the localpolicies and procedures relating to bullying, harassment and discriminationin the workplace.



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Scope of the problem

Ask the group

Write responses on boardWhat is bullying, harassment and discrimination?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Answers


Facilitator: Inform participants that bullying may involve the bully havinga position of power over the person/people being bullied.

In the workplace this can be organisational power, however bullying in theworkplace is not restricted to this. Frequently in the workplace, the bully can be in a junior position or a work colleague. In this case the power for the bully is social or personal.

There are some analogies that can be made between bullying at school andbullying in the workplace. An example at school is the bigger boys beating up the smaller ones; likewise in the workplace an example is the supervisor bullyingtheir staff. An example of personal or social power in the school grounds is a morepopular younger pupil bullying one of the older less popular pupils. This personhas obvious social power and can mobilise other members of the class to excludethe person from their games and call them names. Likewise in the workplace ajunior member of staff, that has been there for many years and has extensivesocial networks, may bully a senior but more recent staff member. This can result in social isolation.


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Ask the group

Write responses on boardWhat behaviours are associated with bullying, harassment and discrimination?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Answers

Facilitator: This is not an exclusive list and there are many behavioursassociated with bullying, harassment and discrimination.

● Consistent non-granting of reasonable requests.

● Sarcasm, put-downs.

● Consistently giving the worst jobs.

● Unreasonable criticism.

● Abuse (physical, verbal and/or psychological).

Facilitator: If criticism has not been raised by participants, raise this issue and point out that when criticism is personal and not performance based, itis bullying. Explain that not all criticism can be labelled as bullying. A distinctionneeds to be made between reasonable and unreasonable criticism. Give theexample of a staff member displaying poor work performance. Explain thisneeds to be addressed using the appropriate processes so that it cannot be justified as bullying.

In addition, not all refusal of leave, transfer of applications or roster requestscan be labelled as bullying; only a certain number of staff can have annual leave at certain times or days or on a certain day. The issue for bullying is that there is a pattern of behaviour where there is a consistent non-granting of reasonable requests. For example, if a staff member applies for annual leaveat Christmas, but enough people have already applied for Christmas leave, then the non-granting of this request cannot be labelled as bullying.




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Facilitator: Refer and talk about the local policies and procedures whendiscussing the answers given.

Show overhead slide

Explain and discussThe effects of bullying25,26, harassment and discrimination on the individual can include:

● distress

● poor work performance

● perceived poor career prospects

● lack of trust between staff

● emotional reactions and stress including loss of self-confidence and self-esteem

● poor concentration

● poor relationships with family and friends

● unwanted transfer, resignation, early retirement or even dismissal therefore resulting in loss of income

● development of anxiety disorders and/or depression.

Ask the group

Write responses on boardWhat are the local policies for dealing with this?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


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The effects on an organisation25 include:

● increased absenteeism

● high staff turnover

● lower efficiency among staff experiencing bullying, harassment and discrimination

● more mistakes and accidents

● lower staff morale

● legal and tribunal costs

● compensation pay outs

● increased workers compensation premiums.


Show overhead slide

Show overhead slide

Explain and discuss

You have a role to playYou are able to promote a workplace that is free of bullying, harassment anddiscrimination by 25:

● always treating others with respect

● when speaking to others, not condoning bullying, harassment and discrimination

● ensuring that personal behaviour does not support bullying, harassment and discrimination

● reporting any incidents of bullying, harassment and discrimination immediately uponwitnessing them

● promoting anti-bullying, anti-harassment and anti-discriminatory behaviour.


Readings and resourcesFor further information, consult the Joint Management and Employee Association PolicyStatement on Bullying Harassment and Discrimination.



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Show overhead slide

Facilitator: Explain that in some circumstances there may be a case for initiatinglegal action against a person who is bullying.

Explain and discuss

Some legal considerationsDefamation is the publishing (written or verbal) of material that will damage the reputationof a person. It may lead to the ridicule, hatred or contempt of the person.

There are some circumstances that may not be considered defamation,

such as:

● statements that would lead to the conviction of a crime

● statements of disease process, eg medical notes

● statements that would lead to a person being judged to be unfit for a profession.

Defenses against defamation

● Absolute privilege where the right for free speech is more important than the rights ofthe individual.

● Qualified privilege where privilege exists, however malice would destroy this privilege.

● Public interest, ie where it is in the public interest to know.

Explain and discuss

Background reading


Overview the key points here.


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How to confront a person who is bullying, harassing or discriminating against youNot everyone lacks assertiveness to confront persons who are bullying, harassing ordiscriminating, however, there are skills you can use so that you do not lose your temperand embarrass or humiliate yourself.26

1. You need to understand why confrontation can work

Persons who bully, harass or discriminate usually lack appropriate social self-controllingbehaviours. By confronting the person this means that you are putting controls onthem. For example, an opening statement could be, “I’m sorry you feel you have to demean and degrade me and I have no idea why you do this, but I will not put up with this sort of behaviour. There is no place for this kind of behaviour in thisdepartment/facility unit”.

2. When confronting the person, it might be helpful in some situations

to do this in private

This is so that the person is unprepared and has no witnesses. If there are witnessesthen these people should be your allies who support you and who may have been insimilar situations, and not people who support the bully.

3. Specify the specific behaviours and don’t use labels

Refrain from using statements such as, ‘I don’t like the way you bully me’ or ‘Stop putting me down in front of my colleagues’.

Try to use statements such as, ‘I find it unacceptable that you publicly criticise mywork. If there is a need for you to do that, could you please do it in private’.

4. Keep things simple

People who bully, discriminate or harass may have deep-seated motivations. However it is best not to try and delve into or analyse what is motivating them tobehave in the way they do.

5. Describe to the individual the consequences of their behaviour on others

If you know that the person is doing the same to others it is reasonable to let themknow about this.

For example, ‘Several of us have noticed how Jane seems to be depressed and upset recently. One of the reasons for that may be that you ridicule her work. Like me,she would rather that if you had concerns with her work that you discuss them with her privately’.

6. Reinforce the message

No matter what the person is trying to say in a confrontation keep the message clearon what type of reputation they are making for themselves.

For example, ‘You know how you embarrass me when you ridicule me in public, but you are not aware that you are also humiliating yourself. People see this behaviour as a weakness and not a strength’.



Explain and discuss

How to formally make a complaint● Report the incident.

● Name any witnesses.

● Provide details in the complaint about:

– who was involved

– when it happened

– what happened

– consequences for you.

● Seek support in this process.

It is strongly suggested that you gain the services of an advocate in this process. The most obvious would be a representative from your industrial or professionalorganisation. Ensure you are familiar with local bullying reporting procedures.

7. Give positive alternatives

Try to think of some positive alternatives.

For example, ‘You were not always like this. I remember when you had a really good effect on others, when you praised their work’. This type of statement makes it clear that the person can behave in a positive and acceptable way and it is also a good ending for the confrontation.

8. Keep a diary of events

Keep a diary of each incident.

For each incident include what circumstances led to the incident, who was present,what type of behaviour was displayed and how you felt. These records may need to be used in subsequent interviews with senior managers.


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Show overhead slide


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Rights of the person making the complaint and the person who is complained againstThe person making the complaint and the person who is being complained againsthave rights that need to be considered and observed. These rights are consistent with the principles of:

● natural justice

● equal opportunity

● workplace awards and conditions.

Explain and discuss

Rights of the person making the complaint

The person who believes they are a victim of bullying, harassment or discrimination at work has the right to:

● make a complaint

● be free from victimisation from having made this complaint

● have access, advice and support from either the Human Resources Unit or a professionalor industrial body

● have themselves and the complaint kept confidential.

Rights of the person that is being complained against

The person who is being complained against has the rights to:

● be informed of the complaint

● be able to respond to the complaint

● have the opportunity for representation in their response

● have themselves and the complaint kept confidential.

Small group exercise Discuss the obstacles to overcoming bullying, harassment and discrimination in your ownworkplace and some possible solutions.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________



This is a useful activity in small groups as it gives participants an opportunity todiscuss workplace bullying in a smaller and safer environment. Ask participantsat the end to share some reflections on the problems and solutions discussed.


Key points

● Bullying, harassment and discrimination affects the individual and organisation.

● You have a role in promoting a workplace free of bullying, harassment and discrimination.

● Report all incidents of bullying, harassment and discrimination.


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Show overhead slide

Part 5Reporting and reviewing aggressive incidents



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Session overview This section reviews the processes and procedures of reporting and reviewingaggressive incidents, including the kind of support you should expect if you are involved in an incident. A key resource is NSW Health circular 2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace.


Show overhead slide


The focus of Part 5 is to provide an understanding to all staff of the necessityfor and process of:

● reporting an incident

● the requirements of an investigation

● seeking support after an incident

● self care after an incident

● facilitators will require knowledge of local policies and documentation regardingreporting an aggressive incident, the investigatory process and the care of staff after aggressive incidents.

NB. Employers also have duties with regard to the above.


Background reading

Reporting aggressive incidentsAll aggressive incidents need to be reported and documented on the appropriateforms1,13,28 and, where relevant in the patient’s clinical notes. This includes verbal threats,bullying, ‘near miss’ events, workers compensation claims, property damage insuranceclaims, and security incidents. Depending on the nature of the aggressive incident, someincidents will be reported by managers to the Health Executive, the NSW Department ofHealth or other external agencies, eg WorkCover NSW, NSW Police, Department ofCommunity Services or the Treasury Managed Fund.a

Ask the group Consider your local policies and procedures for reporting and documenting aggressive incidents.

Discuss the requirements for writing incident reports following an aggressive incident?(How much time do you have? Who is responsible for writing the report? Who is thereport given to? Who signs the report?)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________



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Facilitator: It is useful to consider common objections to writing incidentreports. These can include:

● the incident was not seen as serious enough

● perception that nothing would be gained

● fear of being blamed for the incident

● feeling that management would not be supportive

● the incident may reflect badly on the victim

● in areas where many incidents involve low levels of aggression, staff feel otherduties are unable to be completed if they are continually completing incidentforms for less serious incidents

● fear of victimisation

● avoidance and denial of aggression

● bullying is less likely to be reported unless it is repeated and has escalatedin intensity.

Tips for writing incident reports


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Reporting incidents is a key strategy of a zero tolerance response.

Show overhead slide


Refer to list of tips.

Key points

● Make sure it can be easily read and understood.

● Incident reports and notes have the potential to be a legal document.

● Do not use ‘white-out’ (correction fluid).

● Focus on the facts of the event and what was witnessed without interpretation.

● Keep your reports emotionally neutral.

Emphasise the following key points below.




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Show overhead slide

Explain to participants that all significant reported incidents shouldbe investigated.

What to expect from an investigation of an aggressive incident

Ask the group Why do you think it is important that aggressive incidents are investigated?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Answers

Facilitator: Answers should include:

● staff have access to information necessary to the risk management process

● incidents can be investigated, their causes and contributing factors identified,and their recurrence prevented

● facilities are able to meet OHS legislative requirements and departmental reporting requirements

● information can be assessed to determine such things as severity of the event, task type and location, perpetrator characteristics, day/time eg Saturdaynight and possible causes/contributing factors. This information will assist inidentifying high risk circumstances, times, locations, tasks and employee groupswhich in turn provides a good starting point for identifying risk control measures.

Readings and resourcesFor further information on aggressive incident investigations, consult Effective IncidentResponse: A Framework for Prevention and Management in the Health Workplace.


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Small group exercise Think of an aggressive incident that you have been involved in or know occurred.

Discuss what happened during the investigation of the incident. How was it conducted?What did you or others think would happen during the investigation? How did you feel during and after the investigation?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Answers


Facilitator: After participants have informed the larger group of their answers, inform participants that staff can expect that the incident be promptly investigated and that the investigation is:

● conducted in a supportive and non-judgmental way

● focused on identifying the underlying root cause/s and contributing factors

● conducted without apportioning blame

● focused on system breakdowns and identifying control measures to preventa recurrence.





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Type of stress reactions that can be experienced

● Positive reactions – feeling strong, concerned for others in an unselfish way, increased sense ofpersonal worth and achievement.

● Physical – fatigue, sleep disturbance, hyperarousal, eg hypervigilance, somatic complaints(psychological disorders with physical symptoms).

● Emotional – shock, anger, irritability, helplessness, loss of control, numbness, being fearful and helpless.

● Cognitive – poor concentration and memory, worry, intrusive thoughts, flashbacks.

● Interpersonal – social withdrawal, relationship difficulties.

● Substance abuse.

● Acute or Post-traumatic Stress Disorder.

Explain and discuss

Support mechanismsAll people react to stress differently, therefore your reactions after an aggressive incidentare a normal response to an abnormal event. Even if you are a witness to an aggressiveincident you can also experience similar emotional reactions.29 For many people,depending on the type of aggressive incident, the emotional reactions will decrease over a period of a few weeks.

Facilitator: If staff members do not know the difference between Acute StressDisorder and Post-traumatic Stress Disorder explain the difference.

Post-traumatic Stress Disorder – may result from exposure to a very severe or life threatening incident. Symptoms range across three clusters comprising of:

1. re-experiencing, eg flashbacks, intrusive recollections, nightmares

2. avoidance and numbing, eg avoidance of reminders of the trauma, emotional detachment, withdrawal and dissociation

3. hyperarousal symptoms, eg hypervigilance, concentration and memory problems.

Symptoms must be present at least one month post-incident and symptoms mustbe severe enough to impair normal functioning.

Acute Stress Disorder – is an acute (short-term) form of Post-traumatic Stress Disorder. The person experiences dissociation, re-experiencing, avoidance and hyperarousal.


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Show overhead slide

Participants may wish to write down the following in their workbooks.

Depending on your reactions the following types of support should be available to youb:

Psychological first aid – Immediate social and practical help


Facilitator: Inform participants that psychological first aid is an initialintervention following an incident. It focuses on the establishment of safety,providing basic human needs and physical care, ie comfort, support, safety and communication. The focus is on providing practical help.

Employee assistance programs


Facilitator: Inform participants about the local Employee Assistance program.

Peer support programs


Facilitator: Inform participants that peer support programs use volunteers that are trained in appropriate methods for assisting colleagues in theirworkplace. This is not counselling or therapy. Identified peer support personsshould not have been directly involved in the incident and such assistance is only implemented if the affected person has agreed.


Supportive or specialised counselling



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Facilitator: Explain to participants the difference between supportive andspecialised counselling.

Supportive counselling is carried out by a trained counsellor for an acutelydistressed person. It involves comforting and reassurance, practical advice,allowing the person to discuss their experience (only if they feel they need to do so) linking them to support networks, and identifying those at risk who mayneed follow-up and specialised services.

Specialised counselling is for people experiencing severe or prolonged distress or disturbance following an incident, or for those determined to be at significantrisk of adverse outcomes and is provided after appropriate clinical assessment. A specialist clinical professional (usually with mental health training) provides thiscounselling and it may be linked to a range of other interventions. The specialisedcounselling should be provided by a clinician with whom the distressed staffmember has no working relationship.

Supportive group discussion


Facilitator: Inform participants that supportive group discussion involves groups of people who have been affected by an incident coming togethernaturally in the aftermath to talk through or discuss their experience. This isoften seen as helpful and people may consider it an opportunity to ‘debrief’about their experience.

Formal critical incident debriefing is no longer recommended by NSW Health as a structured intervention post-incident.


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Mental health care



Operational debriefing

Facilitator Instruction

Facilitator: Inform participants that operational review and debriefing is theprocess of analysing the effectiveness of the response to, and management of,the specific incident. It allows for any necessary improvements to be made tothe duress response procedure and incident management plans. Operationalprocedures should include:

● involving staff who experienced the incident

● with others who may have been involved, eg police

● identifying the positive and negative aspects of the response

● identifying ways of improving future response

● producing a brief, documented summary of findings, recommendations and outcomes

● allocating responsibility for implementing improvements.

Facilitator: Inform participants that specialised mental health care may involvepsychiatric treatment, which may include counselling and possibly medicationfor those who have developed psychiatric problems.

Other practical help


Facilitator: Inform participants that other practical help may be offered, such as transport home after an incident, and help if children need to be picked up.

Show overhead slide


Explain and discuss

Self care following an aggressive incidentHow you react to an aggressive incident may interfere with the way you function at workand in your personal life for a period of time.

The following strategies can help you to deal with these reactions.h



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You might like to write down some suggestions from participants for each of the following.

Use your own distress tolerance skills.

______________________________________________________________________________

______________________________________________________________________________


Facilitator: Inform participants that dealing with the distress includes:

● accepting that you are distressed and expressing your feelings

● using controlled breathing techniques, meditation or relaxation techniques that work for you

● going slow, doing one thing at a time (set small realistic goals and use smalltasks to achieve these goals)

● looking after yourself (make time for physical exercise, keep a healthy balanceddiet, avoid excessive caffeine, alcohol, sedatives and nicotine).

Take time out.

______________________________________________________________________________

______________________________________________________________________________


Facilitator: Inform participants that taking time out includes:

● having lunch, morning and afternoon tea breaks and chats with colleagues and peers

● taking time out to do hobbies or other meaningful activities for yourself

● making time for stress management activities.


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Use time management strategies.

______________________________________________________________________________

______________________________________________________________________________



Facilitator: Inform participants that some time management strategies includes:

● scheduling, planning and prioritising tasks

● setting goals for what you want to achieve

● giving yourself a reward for completing tasks.

Don’t always be alone.

______________________________________________________________________________

______________________________________________________________________________


Facilitator: Inform participants that engaging family, social and work supportis important.

Develop self-awareness and mindfulness.

______________________________________________________________________________

______________________________________________________________________________


Facilitator: Inform participants that self-awareness and mindfulness includes:

● engaging in activities and tasks for the intrinsic value of doing so

● focusing on the process rather than the outcome. Look at what you’re doing and how you’re doing things – take note and be aware of this. Look at whatworks and doesn’t work

● focusing on what you’re doing at the time rather than dwelling on the past or present.


______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

What I do now What I would like to try

Use techniques for starting and finishing each day.

______________________________________________________________________________

______________________________________________________________________________



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Facilitator: Inform participants that transition techniques for starting and finishing each day includes:

● reviewing each day and looking at what you have done well today

● keeping to your normal routine

● winding down at night time

● preparing for each new day.

Individual reflection exerciseWork on your own and fill in the spaces below for things that you do for yourself, andwhat you would like to try to do for yourself to manage stress.


Facilitator: Give participants time to complete this by themselves in class, or you may suggest they do it after the workshop.


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Explain and discuss

What support can you expect from your managerYou can expect your manager to support you with the following:

● Assistance with appropriate support mechanisms.

● Not forcing you to provide care for a patient who has injured you.

● Support when you return to work.

● Providing access to injury management programs, eg return to work programs,rehabilitation, retraining.

● Help with compensation issues.

● When a request has been made for police to take out an AVO on behalf of you.

● When a request has been made for police to press charges.

● During any court hearings.

● If you need to attend the police station to make a statement.

● Support at any other times during the legal process.


Show overhead slide

Key points

1. Report and document all aggressive incidents.

2. Intense emotions and stress reactions can be experienced followingaggressive incidents.

3. Support mechanisms in the workplace are available.

4. Self-care is important.

5. You can expect your manager to support you.



Assessment



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You are now to conduct the assessment for this module. The assessmentexercise is described at the beginning of this module. Case scenarios,assessment question sheets and the marking guide can be found at theback of the Facilitator manual. The CD-ROM contains a separate documentincluding the case scenarios and assessment question sheets, for the purpose of printing copies to hand to participants.

At the conclusion of the assessment the module has been completed. Reinforce the message that participants should read and review their participant manuals from time to time.

Show overhead slide

Related NSW Health policies and guidelines



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a. NSW Health Zero Tolerance Policy and Framework Guidelines.

b. C2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace.

c. C2001/22 Workplace Health and Safety: A Better Practice Guide (currently under review).

d. Design Series (DS) Health Facility Guideline – Security and Safety 2003.

e. NSW Health Security Manual.

f. C2002/50 Joint Management and Employee Association Policy Statement on Bullying,Harassment and Discrimination.

g. Mental Health for Emergency Departments, May 2002 (red book).

h. Management of Adults with Severe Behavioural Disturbance, May 2002 (green book).

i. C2003/88 Reportable Incident Briefs to the NSW Department of Health.

j. C94/127 Policies on Seclusion Practices, the Use of Restraint and the Use of IV Sedation inPsychiatric In-Patient Facilities (currently under review).



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References

1. Mayhew C, Chappell D (2001a). Occupational violence: types, reporting patterns, and variations between health sectors. Working Paper Series no. 139, School of IndustrialRelations and Organisational Behaviour and the Industrial Relations Research Centre, paperwritten for the Taskforce on the Prevention and Management of Violence in the HealthWorkplace, University of NSW, Sydney.

2. Mayhew C, Chappell D (2001b). Prevention of occupational violence in the health workplace.Working Paper Series no. 140, School of Industrial Relations and Organisational Behaviourand the Industrial Relations Research Centre, paper written for the Taskforce on thePrevention and Management of Violence in the Health Workplace, University of NSW, Sydney.

3. Mayhew C, Chappell D (2001c). Internal violence (or bullying) and the health workforce.Working Paper Series no. 141, School of Industrial Relations and Organisational Behaviourand the Industrial Relations Research Centre, paper written for the Taskforce on thePrevention and Management of Violence in the Health Workplace, University of NSW, Sydney.

4. O’Connell B, Young J, Brooks J, Hutchings J, Lofthouse J (2000). Nurses’ perceptions of thenature and frequency of aggression in general ward settings and high dependency areas.Journal of Clinical Nursing, 9 (4), 602-610.

5. Barlow K, Grenyer B, Ilkiw-Lavalle O (2000). Prevalence and precipitants of aggression inpsychiatric inpatient units. Australian and New Zealand Journal of Psychiatry, 34, 967-974.

6. Farrell GA (1999). Aggression in clinical settings: nurses’ views – a follow-up study. Journal of Advanced Nursing, 29 (3), 532-541.

7. Everley GS, Lasting JM (1995). Psychotraumatology: key papers and care concepts in posttraumatic stress. New York: Plenum Press.

8. Ilkiw-Lavalle O, Grenyer B (2003). Differences between patient and staff perceptions ofaggression in mental health units. Psychiatric Services, 54, 389-393.

9. Perrone S (1999). Violence in the workplace. Research and Public Policy Series no. 22,Australian Institute of Criminology, Canberra.

10. Baron SA (1996). Organizational factors in workplace violence: developing effective programs to reduce workplace violence. Occupational Medicine: State of the Art Reviews, 11 (2), 335-348.

11. Fletcher TA, Brakel SM, Cavanaugh JL (2000). Violence in the workplace: new perspectives inforensic mental health services in the USA. British Journal of Psychiatry, 176, 339-344.

12. Smith-Pittman MH, McKoy D (1999). Workplace violence in healthcare environments. Nursing Forum, 34 (3), 5-13.

13. Jones J, Lyneham J (2000). Violence: part of the job for Australian nurses? Australian Journalof Advanced Nursing, 18 (2), 27-32.


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14. Erickson L, Williams-Evans SA (2000). Attitudes of emergency nurses regarding patientassaults. Journal of Emergency Nursing, 26 (3), 210-215.

15. WorkCover NSW (2001). Risk management at work guide [On-line]. Available www.workcover.nsw.gov.au/

16. Illawarra Health. (2001). Risk management in occupational health and safety. DevelopmentVersion for OHS Task Force Review. Risk management Unit, Human Resources Department.

17. Bowie V (2000). Preventing and managing violence by intruders in the workplace: situational,organisational and societal response. Journal of Occupational Health and Safety:Australia and New Zealand, 16, 5, 443-448.

18. Poster EC, Ryan JA (1989). Nurses’ attitudes toward physical assaults by patients. Archives of Psychiatric Nursing, 3 (6), 315-332.

19. Beech P, Norman IJ (1995). Patients’ perceptions of the quality of psychiatric nursing care:finding from a small-scale descriptive study. Journal of Clinical Nursing, 4, 117-123.

20. Lowe T (1992). Characteristics of effective nursing interventions in the management ofchallenging behaviour. Journal of Advanced Nursing, 17, 1226-1232.

21. Quintal SA (2002). Violence against psychiatric nurses: an untreated epidemic?Journal of Psychosocial Nursing, 40 (1), 46-53.

22. Mental Health Council of Australia. (2000). Enhancing relationships between healthprofessionals and consumers and carers – Final Report.

23. Kavanagh KH, Kennedy PH (1992). Promoting cultural diversity: strategies for health careprofessionals. California: Sage Publications.

24. Field T (1996). Bully in sight. Oxfordshire: Success Unlimited.

25. McCarthy P. Henderson M, Sheehan M, Barker M (2001). Bullying. Module 7 – The CCHEqual Opportunity Training Manual. Commercial Clearing House (CCH), North Ryde, 50,001-50,453.

26. McMillan I (1995). Loosing control. Nursing Times, 91 (15), 40.

27. Randall P (1997). Adult bullying: perpetrators and victims. London: Routledge.

28. Macdonald G, Sirotich F (2001). Reporting client violence. Social Work, 46 (2), 107-114.

29. Rees C, Lehane P (1996). Witnessing violence to staff: a study of nurses’ experiences.Nursing Standard, 11 (13-15), 45-47.


Module 1 assessment


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Aggression minimisation scenarios1. Support staff.

2. Mental health.

3. Enrolled nurse.

4. Registered nurse.

5. Food services.

6. Administration.

7. Community – generalist.

8. Community mental health.

9. Youth worker.

10. Bus driver.

11. Drug and alcohol.

12. Security.

13. Medical officers.


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Scenario 1: Support staff

Aggressor

Pat Wild – 50 years old

Pat is a homeless person walking along a poorly lit highway, when he was struck by a car. He doesn’t remember this very clearly.

The car did not stop, but a passing motorist called an ambulance, and in a semi-conscious statePat was taken into the Accident and Emergency Department.

He awoke to find you trying to take off his trousers.

He is extremely alarmed and frightened.

He begins to raise his voice and yell:

“What the bloody hell do you think you are doing?”

Defuser

Sid Barrat – (Personal services assistant) PSA

You are a PSA working on evening shift in the Accident and Emergency Department.

A fifty year old homeless person who was struck by a car is brought in.

He is in a dirty, dishevelled state. He appears to be in a semi-conscious state.

You begin to undress him, in readiness for examination by a doctor.


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Scenario 2: Mental health

Aggressor

Bob Jones – 59 years old

Bob has been put in the mental hospital again for a break, and to make sure he takes hismedication. He thinks it is not too bad, except they take his cigarettes, and hassle him to have showers all the time when he believes there’s nothing wrong with him.

He has just gone back to bed after breakfast for a rest when you come in and tell him to have a shower and get dressed. You want to take his dressing gown away and place a shirt and pants out for him to wear. He doesn’t mind the shirt, but feels very uncomfortable about the pants. He has told hospital staff over and over again that he is half man, half woman. They must be either liars or idiots.

When you come back a second time, and approach him, he tells you to:

“Bugger off, you silly bitch.”

Defuser

Jenny White – Registered nurse

You are working in psychiatric unit and have an older chronic schizophrenic man on your client load today. This man lives with his elderly brother who has done his best to take care of his sibling through his many acute psychotic episodes, and his wandering ways.

Bob often disappears for days on end and always has a personal hygiene problem. He is rarelyfunctional enough to think of showering, shaving, or even changing his clothes. This is usuallysupervised by his community nurse when he is out of hospital. He has the delusion that he is ‘half man’, ‘half woman’ among others, and appears to have continual auditory hallucinations.Though physically he is a big man, he is usually a gentle soul, so it shocks you when you go to his room for the second time that morning to prompt him to have a shower and get out of his old, smelly, cigarette and food-stained dressing gown and he sits suddenly upright in bed, glares at you and yells:

“Bugger off, you silly bitch.”


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Scenario 3: Enrolled nurse

Aggressor

Mr Sainsbury – Lawyer

Mr Sainsbury is visiting his child in the paediatric unit of Sandtown Hospital. He was at a friend’swedding when he received a call to say his six year-old child was knocked over by a car.

He has a younger child, and since his wife died twelve months ago, he has been strugglingto maintain his legal practice and to be a father and mother to both of his children.

He is extremely worried about his son as he has multiple injuries and is barely conscious.

He is dying for a cigarette, but he does not wish to go too far from his child’s bedside. He decides to step into the hall and have a quick smoke while they are taking his observations.

Suddenly you come up beside him, and start telling him to put out his cigarette. He at firsttries to explain he is only going to have a few puffs, when you call him inconsiderate.

He sees red, and is determined not to let this bitch push him around!

Defuser

Nurse Moore – Enrolled nurse

You are working in a paediatric unit on a Saturday afternoon. You can smell cigarette smoke. You follow the smell out into the corridor to investigate.

You see a tall, thin man, who is slightly dishevelled, but well dressed. He is smoking and swaying slightly.

You tell him that he is not able to smoke here, and that he will have to go outside, explainingthat he is being inconsiderate by smoking in a hospital.


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Scenario 4: Registered nurse

Aggressor

Mrs Steele

Mrs Steele has just come to visit her beloved elderly mother in the nursing home to which shewas admitted three weeks ago. Mrs Steele had cared for her as long as she possibly could athome, but with a family of teenagers, husband, dog and a part-time job, she found that lookingafter her mother adequately was beyond her.

It was upsetting enough to have to put her in a home, but to make it worse, each time Mrs Steelevisits she has found her with:

● dried bits of food on her face

● a wet bed and nightdress

● the wrong clothes – even though she have supplied a dozen outfits and sets of nightclothes.

Mrs Steele is so angry she asks to see the nurse in charge, and demands to know why hermother is not being cared for.

She has had enough, and feels like reporting the nursing home to the authorities.

Defuser

Nurse Andrews – 35 year old registered nurse

You work in a nursing home on Friday, Saturday and Sundays as you are also studying part-time.

In the past couple of weeks you have heard comments in passing about the relative of an elderlywoman who was admitted recently. Apparently this person is very critical and always complainsabout something at every visit. The staff have been known to say:

“Stay out of the way when the relative visits.”

You are in the clinic room preparing for the evening medication round when this relative appearsat the door, red-faced and yells at you:

“I can’t believe what goes on in this place... I thought you were supposed to care for peoplehere... It is an absolute disgrace! I intend to report you to the authorities.”


NSW Health104


Scenario 5: Food Services

Aggressor

Jack Gleeson – 52 year old farmer

Jack Gleeson is in a surgical ward recovering from an abdominal operation he had four days ago.He is a farmer with a normally healthy appetite. Because of his surgery and tests in the previousweek, he has not had a decent meal for some time.

Since surgery, he has gradually been introduced to solid food. However, in the past two days:

● his menu was lost, and he only received a meal after he had to make several inquiries

● he has had his meal preferences changed without anyone consulting him

● his meals are usually luke-warm and bland

● his evening meal, which he has been looking forward to all day, has just arrived – it is cold and it is a very small helping

● he has HAD ENOUGH! He rings for the nurse, and yells:

– “How the hell do you people expect us to get well when you feed us such tripe!?”

– “I want to see the Matron of the hospital, so that I can give her a piece of my mind!”

Defuser

Mavis Davis – Food services

You are doing an evening shift on a Saturday after returning from three weeks leave.

It is a busy surgical ward, and you are just starting to get to know the patients.

Suddenly, just after the evening meals are delivered, there is a buzzer and a large middle-agedmale patient starts bellowing at you about the food, and demanding to see the ‘Matron’.


105


Scenario 6: Administration

Aggressor

Harold Johnston – 22 years old

Harold Johnson is a twenty-two year old from a non-English speaking background. He lives in the local area, with his aunt, uncle, father and four brothers. There is a group of teenagers in the area who regularly gang up on him and assault him physically and verbally. Tonight he has been attacked again just outside the hotel where he was having a quiet drink with his friends. His friends have taken him to the Emergency Department at the hospital as he has a lacerationover his right eye which may need stitching. As he enters he notices that the Accident andEmergency Department is not very busy, there is only one other person in the waiting room. He comes to the desk and asks you how long he will have to wait. You are busy shuffling papers and tell him, “We will get to you when we can.” He feels upset, he is injured and in pain and he wants to be treated immediately. He swears at you in a loud voice and tells you, “If I am not seen immediately I will put a cut over your eye and see how you feel!”

Defuser

Kim Jackson – Receptionist

You are working in the Accident and Emergency Department at 11 o’clock at night. You attendto a person at the desk who has been brought in to have a laceration over their right eye stitched.You vaguely recognise them as young person who lives near your family. As you come closer you smell alcohol on their breath. The casualty waiting room is quiet, but all the beds are full andnursing staff are busy with car accident victims brought in the last half hour. You tell the patient,“we will get to you when we can”. He swears loudly at you and threatens to physically hurt you.


NSW Health106


Scenario 7: Community – generalist

Aggressor

Trevor White – 70 years old

Trevor White returned home four days ago from hospital following an operation for abdominalcancer. In hospital he developed a number of complications due to:

i. infection of his wound site

ii. an allergic reaction to drugs which were given, and

iii. an ulcer on his left shin which developed following a fall in the hospital bathroom.

He has been told that a nurse will visit twice each day to change his dressings. Until then,he cannot be showered. He wants to maintain his personal standards despite this damn disease, and it angers him that the nurse comes at a different time each day, sometimeseven after 12 noon.

His lifelong companion, Rex, died six months earlier and now he has been hit with this trouble.

When you finally arrive, Trevor tells you that he intends to complain to your manager, and to write a letter to the newspapers telling how incompetent our public health service is.

He is in pain and furious.

Defuser

Justin Brown – Registered nurse

You are visiting your sixth patient for the morning, and have two more to go before you returnto the office. You have only seen this elderly man three times before, and he was generally a bitirritable, possibly due to his terminal illness.

As you go inside to attend to his care, he begins shouting at you:

“Can’t you do better than this? I might as well be living in a third world country, or dead, for all people care in this world!”


107


Scenario 8: Community mental health

Aggressor

Edna Goffman – 60 year old with a mental illness

Edna Goffman is on a clinical ‘holiday’ camp that she has paid for out of her pension, with agroup of nursing students and some mental health teachers.

One morning a student nurse comes in to tell her it is time to get up. Edna tells her to bugger off and let her sleep in; she is on holidays. But the student nurse is persistent, and says if Ednadoesn’t get out of bed, have her shower and breakfast in the next half an hour, everyone will bewaiting for her if they want to go out.

Edna has had enough of her whining voice, and tells her if she doesn’t shut up and mind her own business she’ll smash her face in.

Defuser

Mr/s Trainer – Mental health nurse

You are a clinical teacher with a group of student nurses and clients on a clinical teaching camp.

The clients have all been diagnosed at some time with a mental illness. Some are living in thecommunity, while some are long stay patients at a large psychiatric facility in the area.

A student nurse has just come into the dining area and asked you to speak to the client, becauseher client will not get out of bed, and had threatened her with violence. What will you do?


NSW Health108


Scenario 9: Youth worker

Aggressor

Jack White – 70 years old

Jack White is the grandfather of a fifteen year old boy called Jason. Jason has had a bit oftrouble at school and with the police for wagging and shoplifting. Jack has just learnt that thegovernment social workers have got involved in the family’s business because of this. Jack isirate, as this is totally unnecessary, in his opinion. In his day, families sorted these things outthemselves. Jack also doesn’t want his mates at the RSL Club to find out that this is happening.

Jack phones you at your office and tells you they should: ‘Drop the case’. When you say thatisn’t possible, he is outraged at this ‘Big brother watching you’ tactics. He begins to tell you, in no uncertain terms, what he thinks.

Defuser

Jacky Lee

You are a youth worker who has recently taken a fifteen year-old male referred to the service bya school counsellor.

The boy has a number of personal issues to resolve. He has been truanting school, allegedlyselling drugs with a number of others from his school and is in trouble with the police. His parentshave a relationship pattern: separate then come together for a short while, argue, then separateagain. Both parents drink heavily.

You have reason to suspect there may be issues of sexual abuse involving a male uncle or parental grandfather. You are called to the phone to answer inquiries by a male relative of the youth.

The male tells you to ‘Drop the case’. When you try to find out to whom you are speaking, and to explain your professional obligations, the caller begins calling you ‘A bloody fascist’, and making angry threats.


109


Scenario 10: Bus driver

Aggressor

Jack White – 70 years old

Jack White has worked hard all his life, only to be struck with a number of illnesses from heartdisease to kidney problems since the year after he retired. He also has shortness of breath fromsixty years of smoking.

He doesn’t know how much longer he is going to be on God’s earth, but he wants it to last aslong as he can.

Jack has to regularly visit the local hospital, and takes the train as he no longer drives a car.However, the courtesy bus provided by the hospital to save him the walk up a long hill, alwaysseems to be longer than the maximum wait of 15 minutes they state on the timetable. This usuallymeans that he is late for your appointment in the clinic, and often he is pushed to the end of thequeue, and has to wait even` longer because of it.

It is a hot day, and sure enough, he has been waiting twenty-one minutes for the bus to comesince getting off his train. HE HAS HAD ENOUGH!

When the bus finally arrives, Jack struggles in, then YELLS at you:

“How the hell do you expect us to get well when you don’t meet us when you should?!”

“I want to see the person in charge so that I can make a complaint!”

Defuser

John/Jean – Courtesy bus driver

Your name is John/Jean and you are one of the staff of Health Service who drives the courtesybus around the hospital campus and the train station.

You are making your first trip to the train station after morning tea, when a skinny looking old manbegins abusing you as soon as you stop.


NSW Health110


Scenario 11: Drug and alcohol

Aggressor

Robert White – Methadone clinic client

Robert White is a client at a methadone clinic in the drug and alcohol unit. He has had a‘take-away’ dose for the next day stolen by someone who came into his flat.

Robert explains this to you and asks for another dose, but is told that he can’t have anotherone until tomorrow.

This pisses him off and he becomes very angry, as it seems that the staff never exhibit trustin him, and he is scared that he will have to ‘hang-out’ until he gets another dose.

He bloody thought this would happen, as soon as he realised the dose had been pinched.

He begins to raise his voice and yells at you.

Defuser

Bob Brown – Nurse

You are a nurse working at a methadone clinic in the drug and alcohol unit.

A client comes in who has already been given a ‘take-away’ dose for the day and he is asking for a second dose.

You tell him that he cannot have another dose, and he becomes angry and begins to raise hisvoice and yell at you.


111


Scenario 12: Security

Aggressor

Byron Bay – 45 years old

Byron Bay was at work this morning when he received a phone call from a neighbour informinghim that there had been an accident at home and his wife and child had been taken to hospital.When he contacts the hospital to obtain information he is transferred to a number of people whodo not seem to know what is going on and nobody will answer his questions about the conditionof his wife and child. This makes him very angry and he goes to the hospital to sort this mess out.

Defuser

Alice/Alan Springs – Hospital security

You are working a day shift when you receive a duress call to the patient inquiry area. The information you receive is a large male person has become hostile and threatening towards the staff in this area. The staff are having a great deal of difficulty with this person as he will not cooperate with their attempts to deal with his inquiries; he is now threatening to pull the place apart unless something is done.


NSW Health112


Scenario 13: Medical officer

Aggressor

Mark Peterson – 22 years old

Mark Peterson is at a friend’s party, the night is going well until a group of people arrive who are not invited. When they asked him to leave, a physical struggle occurs and he receives a cut to his head. He feels that the injury is only minor but his friends want to take him to hospitalas they want to ensure that he is not seriously injured. This irritates him as he feels this isunnecessary but he agrees to go to the Hospital.

When he arrives he notices that the Emergency Department is crowded and there is a long wait.This irritates him further.

Defuser

Kim Black – Medical officer

You are on duty in a busy Emergency Department on a Saturday night. You have been informed by the nursing staff that a young man has come to the department with a head wound after being in a fight at a party. The information you receive is that he has become more agitated since he has arrived and is now stating that if he does not get attentionimmediately he is going to leave. Previously, when the triage nurse had suggested that the wound may need stitches, the client stated if anybody hurt him they will pay for it.

Assessment



113

Support staff

Mental health registered nurse

Enrolled nurse

Registered nurse

Food services

Administration

Community – generalist

Community mental health

Youth worker

Bus driver

Drug and alcohol

Hospital security staff

Medical officer

NSW Health Aggression Minimisation Training Program

Module 1 – HLTCSD6A Respond effectively to difficult or challenging behaviour

Name: ____________________________________________________________________________

Position: __________________________________________________________________________

Location: __________________________________________________________________________

Department/unit: __________________________________________________________________

You are to answer each question, based on the scenario you have selected. Please readthe scenario carefully and write your response to the following questions. Please indicate whichscenario you are responding to.


115

S U P P O R T S T A F F S C E N A R I O 1

1. What are your options in responding to this aggressive incident keeping in mind yourduty of care. Number the most appropriate option/s for this scenario in priority order. (1 = do first)

Use of reasonable force

Obtain clinical assessment/review of current physical and mental health

Obtain assistance

Deal with situation alone

2. How would you ensure the safety of yourself and others in this situation? Number each appropriate option/s for this scenario in priority order. (1 = do first)

Obtain assistance to do task according to policy and procedure manual

Universal precautions/infection/age

Use of appropriate body language

Speak in a calm friendly manner

Defusing techniques

Physical self defence

3. Where would you get assistance? Number each appropriate option/s for this scenario in priority order. (1 = do first)

Duress response team if available

Visitors


Police

Fellow staff/considering gender issues

4. What communication skills might you use? Tick each appropriate option/s for this scenario. (Not in priority order)

Listening to/giving information

Using assertiveness verbal/non-verbal

Speaking to client at their level, being sensitive to cultural background and education level using simple, easy-to-understand language

Speaking in a slowed controlled fashion

Limiting setting where appropriate

M O D U L E 1Responding effectively to difficult or challenging behaviour


NSW Health116


S C E N A R I O 1 S U P P O R T S T A F F

5. You are now required to complete the attached incident form in relation to this incident.Please submit the incident form and these pages to the assessor.

6. Why is it important this incident is investigated? Tick each appropriate option/s for this scenario. (Not in priority order)

To identify the contributing factors to prevent or reduce the likelihood of a recurrence

To identify patterns of severity within location, type of work tasks being performed

To find somebody to blame

7. What assistance is available to you after an aggressive incident? Tick each appropriate option/s for this scenario. (Not in priority order)

Peer debriefing

Change jobs

Counselling/group/one-on-one

8. If you feel affected by the incident, how can you access assistance? Tick each appropriate option/s for this scenario. (Not in priority order)

Support from fellow workers

Staff counsellors (if available)

Employee assistance (if available)

Approach manager

Private counselling

9. Complete a risk management plan for this incident.


117


MENTAL HEALTH S C E N A R I O 2


Takes clothes when they are unattended

Attain assistance

Consider clinical assessment

Insist they obey your instructions


Determine if this is a critical procedure and needs to occur

Obtain assistance

Separate from others in case aggression escalates

Ensure self defence




Visitors

Fellow ward staff

Police


Communicate slowly and clearly

Limit setting where appropriate

Use negotiation skills

Use communication strategies that are appropriate to client’s present mental state

Use authoritative tone

5. You are now required to complete the attached incident form in relation tothis incident. Please submit the incident form and these pages to the assessor.


NSW Health118


S C E N A R I O 2 MENTAL HEALTH


Ongoing clinical management of client

Identify contributing factor

Develop strategies to improve ward safety

Find someone to blame


Peer debriefing


Change jobs





Approach manager

Private counselling



119


ENROLLED NURSE S C E N A R I O 3


Inform of hospital policy and explain if required

Ensure your own safety

Escort the person from the hospital grounds

Attempt to keep other people out of area


Inform security of situation

Remove cigarettes

Leave area safely and calmly

Attempt to gauge level of intoxication

Use communication skills to effectively defuse situation




Visitors


Police


Listening/giving information


Speaking to client at their level using simple, easy-to-understand language

Speaking in a slowed contracted fashion


Using communication appropriate to level of intoxication


NSW Health120


S C E N A R I O 3 ENROLLED NURSE



For hospital environment safety

For hospital statistics

To review policy in relation to staff intervention rules




Peer debriefing

Change jobs



Approach manager



Private counselling



121


REGISTERED NURSE S C E N A R I O 4


Ignore complaints as the family is over involved

Review personal care procedures

Awareness of family issues about long-term care for mother

Acknowledgment of relative’s concerns

Attend to client immediately


Use defusing communication techniques

Move to a more appropriate environment

Make staff aware of possible difficulties that may occur at visiting times

Inform the relative of the nurses’ busy workloads



Relatives

Police

Fellow staff

Other patients

4. What communication skills might you use? Tick each appropriate option/s for this scenario (Not in priority order)

Setting limits

Providing information

Speaking slowly and calmly

Communicating to gain empathy

Validating the families concerns

5. You are now required to complete the attached incident form in relation to this incident. Please submit the incident form and these pages to the assessor.


NSW Health122


S C E N A R I O 4 REGISTERED NURSE


To keep OH&S unit busy

To ensure best practice guidelines are followed


To review policy and procedures


Group/personal counselling

Peer debriefing

Change jobs



Private counselling



Approach manager



123


FOOD SERVICES S C E N A R I O 5


Speak in an abrupt manner

Inform clinical staff of behaviour

Assessment of environmental safety issues/food trays and other hazards

Determine what level of threat is displayed


Pull curtain around to isolate

Inform clinical staff

Remove of environment hazards

Blame the hospital chefs



Police

Other patients to alert other staff

Ward staff

Visitors


Argue back

Attempt to negotiate a solution

Remain calm and in control

Set limits where appropriate

Keep sentences short and words simple

5. You are now required to complete the attached incident form in relation to thisincident. Please submit the incident form and these pages to the assessor.


NSW Health124


S C E N A R I O 5 FOOD SERVICES


To develop strategies to improve services


To identify contributing factors


Peer debriefing

Change jobs






Private counselling

Approach manager



125


ADMINISTRATION S C E N A R I O 6



Obtain clinical assistance to assess urgency of medical condition


Consider safety of others in the reception area


Assess level of threat



Obtain assistance

Use physical self defence

Use of defusing communication techniques



Visitors


Police





Speaking to client at their level being sensitive to cultural background and education levelusing simple, easy-to-understand language





NSW Health126


S C E N A R I O 6 ADMINISTRATION






Peer debriefing

Change jobs




Approach manager

Private counselling





127


COMMUNITY – GENERALIST S C E N A R I O 7


Explain limitation and constraints in home care

Compliance with the organisation policy on home visits

Refuse home visit due to danger

Empathy towards patients emotional state/bereavement/deteriorating health

Refer to mental health because of aggression



Use of home visit safety policy

Transfer of information to appropriate staff

Ensure client is aware of changes of routine


Police


Others at the house


4. What communication skills might you use? Tick each appropriate option/s for this scenario (Not in priority order).





Using communication techniques to defuse the situation



NSW Health128


S C E N A R I O 7 COMMUNITY – GENERALIST


To identify the contributing factors and so prevent or reduce the likelihood of a recurrence




Private counselling

Peer debriefing

From friends and family

Group counselling



Private counselling



Approach manager



129

COMMUNITY MENTAL HEALTH S C E N A R I O 8


Determine if clinical review required for patient


Tell student not to bother you

Ensure student is aware of safety issues


Gauge level of threat

Inform other staff of situation

Intervene with appropriate techniques to educate student

Call police

3. Where would you get assistance? Number each appropriate option/s for thisscenario in priority order. (1 = do first)

Fellow staff

Local farmer

Police








M O D U L E 1Responding effectively to difficult or challenging behaviour


NSW Health130


S C E N A R I O 8 COMMUNITY MENTAL HEALTH


To identify safety issues related to aggression displayed outside of usual clinical settings

To determine if the aggression is a behaviour as a result of deteriorating mental state

To blame somebody

For best practice guidelines


Change jobs

Peer debriefing

Counselling/group/individual



Approach manager



Private counselling



131


YOUTH WORKER S C E N A R I O 9


Offer an appointment to discuss the callers concerns further

Use strong language to show the caller they cannot push you around

Use of telephone aggression minimisation policy (if available)

Explain your professional/legal responsibilities

2. How would you ensure the safety of yourself and others in this situation?Number each appropriate option/s for this scenario in priority order. (1 = do first)

Ignore the episode to stop any further difficulties

Note caller’s hostile attitude and record this in the appropriate place

Place a ban on any further contact with the family

Appropriate safety/security issues used if appointment accepted


Just hang up the phone

Use of hospital/Area Health Service phone policy

Police

Use of verbal defusing techniques









NSW Health132


S C E N A R I O 9 YOUTH WORKER


Possible legal implications

Possible escalation to higher level of aggression eg physical

To follow mandatory procedures



Peer debriefing

Change jobs



Private counselling

Approach manager





133


BUS DRIVER S C E N A R I O 1 0


Ignoring the client’s protests

Assessing the level of threat posed to other users of the service

Refusing the client access to the bus

Attempting to defuse the situation ie giving information


Refuse access to the bus

Monitor client’s behaviour during the trip

Use mechanical restraints on the client

The other passengers need to lookout for themselves

Assess the level of threat to other passengers

Ignore the behaviour and it will go away


Ward staff

Duress team

Police


Passers by



Give relevant information


Use communication skills to effectively defuse the situation

Ignore client’s concerns



NSW Health134


S C E N A R I O 1 0 BUS DRIVER


To keep people in employment

To identify the causes and contributing factors so as to prevent or reduce the likelihoodof a recurrence


To identify patterns of severity, location and type of work performed



Peer debriefing

Change jobs




Approach manager


Private counselling



135


DRUG AND ALCOHOL S C E N A R I O 1 1


Attempt to gauge level of aggression




Discuss other options to assist the client

Explain policy in relation to methadone administration


Obtain assistance

Physical self-defence







Police



Visitors



Speak to client at their level being sensitive to cultural background and education levelusing, simple-easy-to-understand language





NSW Health136


S C E N A R I O 1 1 DRUG AND ALCOHOL




To identify the contributing factors so as to prevent or reduce the likelihood of arecurrence



Change jobs

Peer debriefing


8. If you feel affected by the incident, how can you access assistance?Tick each appropriate option/s for this scenario. (Not in priority order)




Approach manager

Private counselling



137


HOSPITAL SECURITY STAFF S C E N A R I O 1 2


Obtain assistance



Use defusing techniques to calm the situation

Remove other people from the area







Defusing techniques



Visitors



Police




Speak to client at their level being sensitive to cultural background and education levelusing, simple easy-to-understand language




NSW Health138





To identify the contributing factors so as to prevent or reduce the likelihood of a recurrence




Peer debriefing


Change jobs





Approach manager

Private counselling



139


MEDICAL OFFICER S C E N A R I O 1 3






Engage client to enable an adequate investigation of their physical condition

Examine need to be detained against their wishes for medical reasons

Allow client to leave because of their aggressive behaviour


Obtain assistance





Defusing techniques

Explain and inform client of reasons for your concern



Police


Visitors



NSW Health140


S C E N A R I O 1 3 MEDICAL OFFICER



Speak to client at their level being sensitive to cultural background and education levelusing simple, easy-to-understand language




Demanding that they stop what they are doing immediately







Change jobs

Peer debriefing






Private counselling

Approach manager



141

M A R K I N G G U I D E


S U P P O R T S T A F F S C E N A R I O 1



Obtain clinical assessment/review of current physical and mental health

Obtain assistance







Defusing techniques




Visitors


Police



Listening to/giving information


Speaking to client at their level, being sensitive to cultural background and education level, using simple-easy-to understand language



1

4

2

5

3

5

2

3

4

6

1

4

2

1

3


NSW Health142



S C E N A R I O 1 S U P P O R T S T A F F







Peer debriefing

Change jobs






Approach manager

Private counselling


✓

✓

✓

✓

✓

✓

✓

✓

✓


143



MENTAL HEALTH S C E N A R I O 2


Takes clothes when they are unattended

Attain assistance

Consider clinical assessment

Insist they obey your instructions


Determine if this is a critical procedure and needs to occur

Obtain assistance

Separate from others in case aggression escalates

Ensure self-defence




Visitors

Fellow ward staff

Police


Communicate slowly and clearly


Use negotiation skills

Use communication strategies that are appropriate to client’s present mental state

Use authoritative tone

5. You are now required to complete the attached incident form in relation tothis incident. Please submit the incident form and these pages to the assessor.

✓

✓

✓

✓

4

1

5

2

3

4

2

1

3

4

1

2

3


NSW Health144



S C E N A R I O 2 MENTAL HEALTH


Ongoing clinical management of client

Identify contributing factor

Develop strategies to improve ward safety

Find someone to blame


Peer debriefing


Change jobs





Approach manager

Private counselling


✓

✓

✓

✓

✓

✓

✓

✓

✓

✓


145



ENROLLED NURSE S C E N A R I O 3


Inform of hospital policy and explain if required

Ensure your own safety

Escort the person from the hospital grounds

Attempt to keep other people out of area


Inform security of situation

Remove cigarettes

Leave area safely and calmly

Attempt to gauge level of intoxication

Use communication skills to effectively defuse situation




Visitors


Police







Using communication appropriate to level of intoxication✓

✓

✓

✓

✓

✓

4

1

5

2

3

1

4

2

5

3

3

4

1

2


NSW Health146



S C E N A R I O 3 ENROLLED NURSE



For hospital environment safety

For hospital statistics

To review policy in relation to staff intervention rules




Peer debriefing

Change jobs



Approach manager



Private counselling


✓

✓

✓

✓

✓

✓

✓

✓

✓

✓


147



REGISTERED NURSE S C E N A R I O 4


Ignore complaints as the family is over involved

Review personal care procedures

Awareness of family issues about long-term care for mother

Acknowledgment of relative’s concerns

Attend to client immediately


Use defusing communication techniques

Move to a more appropriate environment

Make staff aware of possible difficulties that may occur at visiting times

Inform the relative of the nurses’ busy workloads



Relatives

Police

Fellow staff

Other patients


Setting limits

Providing information

Speaking slowly and calmly

Communicating to gain empathy

Validating the families concerns

5. You are now required to complete the attached incident form in relation to this incident. Please submit the incident form and these pages to the assessor.

✓

✓

✓

✓

✓

5

1

3

4

2

4

2

1

3

4

1

3

2

5


NSW Health148



S C E N A R I O 4 REGISTERED NURSE


To keep OH&S unit busy

To ensure best practice guidelines are followed


To review policy and procedures


Group/personal counselling

Peer debriefing

Change jobs



Private counselling



Approach manager


✓

✓

✓

✓

✓

✓

✓

✓

✓

✓


149



FOOD SERVICES S C E N A R I O 5


Speak in an abrupt manner

Inform clinical staff of behaviour

Assessment of environmental safety issues/food trays and other hazards

Determine what level of threat is displayed


Pull curtain around to isolate

Inform clinical staff

Remove environment hazards

Blame the hospital chefs



Police

Other patients to alert other staff

Ward staff

Visitors


Argue back

Attempt to negotiate a solution

Remain calm and in control



5. You are now required to complete the attached incident form in relation to thisincident. Please submit the incident form and these pages to the assessor.

✓

✓

✓

✓

5

1

3

4

2

4

1

2

3

2

1

3

4


NSW Health150



S C E N A R I O 5 FOOD SERVICES


To develop strategies to improve services


To identify contributing factors


Peer debriefing

Change jobs






Private counselling

Approach manager


✓

✓

✓

✓

✓

✓

✓

✓

✓


151



ADMINISTRATION S C E N A R I O 6



Obtain clinical assistance to assess urgency of medical condition







Obtain assistance

Use physical self-defence




Visitors


Police





Speaking to client at their level being sensitive to cultural background and education levelusing simple, easy-to-understand language




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NSW Health152



S C E N A R I O 6 ADMINISTRATION






Peer debriefing

Change jobs




Approach manager

Private counselling




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153



COMMUNITY – GENERALIST S C E N A R I O 7


Explain limitation and constraints in home care

Compliance with the organisation policy on home visits

Refuse home visit due to danger

Empathy towards patients emotional state/bereavement/deteriorating health

Refer to mental health because of aggression



Use of home visit safety policy

Transfer of information to appropriate staff

Ensure client is aware of changes of routine


Police


Others at the house







Using communication techniques to defuse the situation


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NSW Health154



S C E N A R I O 7 COMMUNITY – GENERALIST

6. Why is it important this incident is investigated? Tick each appropriate option/s for this scenario. (Not in priority order).

To identify the contributing factors and so prevent or reduce the likelihood of a recurrence




Private counselling

Peer debriefing

From friends and family

Group counselling



Private counselling



Approach manager


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155



COMMUNITY MENTAL HEALTH S C E N A R I O 8


Determine if clinical review required for patient


Tell student not to bother you

Ensure student is aware of safety issues


Gauge level of threat

Inform other staff of situation

Intervene with appropriate techniques to educate student

Call police

3. Where would you get assistance? Number each appropriate option/s for thisscenario in priority order. (1 = do first)

Fellow staff

Local farmer

Police








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NSW Health156



S C E N A R I O 8 COMMUNITY MENTAL HEALTH


To identify safety issues related to aggression displayed outside of usual clinical settings

To determine if the aggression is a behaviour as a result of deteriorating mental state

To blame somebody

For best practice guidelines


Change jobs

Peer debriefing




Approach manager



Private counselling


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157



YOUTH WORKER S C E N A R I O 9


Offer an appointment to discuss the callers concerns further

Use strong language to show the caller they cannot push you around

Use of telephone aggression minimisation policy (if available)

Explain your professional/legal responsibilities

2. How would you ensure the safety of yourself and others in this situation?Number each appropriate option/s for this scenario in priority order. (1 = do first)

Ignore the episode to stop any further difficulties

Note caller’s hostile attitude and record this in the appropriate place

Place a ban on any further contact with the family

Appropriate safety/security issues used if appointment accepted


Just hang up the phone

Use of hospital/Area Health Service phone policy

Police

Use of verbal defusing techniques








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NSW Health158



S C E N A R I O 9 YOUTH WORKER


Possible legal implications

Possible escalation to higher level of aggression eg physical

To follow mandatory procedures



Peer debriefing

Change jobs



Private counselling

Approach manager




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159



BUS DRIVER S C E N A R I O 1 0


Ignoring the client’s protests

Assessing the level of threat posed to other users of the service

Refusing the client access to the bus

Attempting to defuse the situation ie giving information


Refuse access to the bus

Monitor client’s behaviour during the trip

Use mechanical restraints on the client

The other passengers need to lookout for themselves

Assess the level of threat to other passengers

Ignore the behaviour and it will go away


Ward staff

Duress team

Police


Passers by



Give relevant information


Use communication skills to effectively defuse the situation

Ignore client’s concerns


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NSW Health160



S C E N A R I O 1 0 BUS DRIVER


To keep people in employment

To identify the causes and contributing factors so as to prevent or reduce the likelihood ofa recurrence


To identify patterns of severity, location and type of work performed



Peer debriefing

Change jobs




Approach manager


Private counselling

9. Complete a risk management plan for this incident

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161



DRUG AND ALCOHOL S C E N A R I O 1 1






Discuss other options to assist the client

Explain policy in relation to methadone administration


Obtain assistance








Police

Duress response team (if available)


Visitors






Limit setting where appropriate✓

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NSW Health162



S C E N A R I O 1 1 DRUG AND ALCOHOL







Change jobs

Peer debriefing


8. If you feel affected by the incident, how can you access assistance?Tick each appropriate option/s for this scenario. (Not in priority order)




Approach manager

Private counselling


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163





Obtain assistance



Use defusing techniques to calm the situation

Remove other people from the area







Defusing techniques



Visitors



Police






Limit setting where appropriate✓

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NSW Health164










Peer debriefing


Change jobs





Approach manager

Private counselling


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165



MEDICAL OFFICER S C E N A R I O 1 3






Engage client to enable an adequate investigation of their physical condition

Examine the need to be detained against their wishes for medical reasons

Allow client to leave because of their aggressive behaviour


Obtain assistance





Defusing techniques

Explain and inform client of reasons for your concern



Police


Visitors

Duress response team (if available)2

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NSW Health166



S C E N A R I O 1 3 MEDICAL OFFICER







Demanding that they stop what they are doing immediately


6. Why is it important this incident is investigated? Tick each appropriate option/s for thisscenario. (Not in priority order)





Change jobs

Peer debriefing






Private counselling

Approach manager


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Documents

Mod1 Facilitator