Mod1 Participant

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

Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour Participant 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 2003 SHPN (CMH) 030207 ISBN 0 7347 3591 X July 2003 updated August 2004

MODULE 1 Respond effectively to difficult or challenging behaviour

Contents Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Modular structure of the aggression minimisation program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Assessment for Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Elements of competency and performance criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Assessment specification sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Learning outcomes for Module 1 – Responding to difficult or challenging behaviour . . . . . . . . . . . . . . . . . . 7 Aggression in the workplace – facts and figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Part 1 – Understanding difficult or challenging behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Defining aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Effects of aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 A zero tolerance response to aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Part 2 – Preventing aggression occurring. . . . . . . . . . . . What you need to know about keeping your workplace safe . Using a risk management approach to prevent aggression . . Eliminating or controlling risks . . . . . . . . . . . . . . . . . . . . . . . How the design of your workplace can prevent aggression . . More ways of keeping your workplace safe . . . . . . . . . . . . . Putting it all together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Caveats and background . . . . . . . . . . . . . . . . . . . . . . . . . . Individual risk highlighter . . . . . . . . . . . . . . . . . . . . . . . . . . . Violence risk awareness checklist. . . . . . . . . . . . . . . . . . . . . Violence minimisation checklist . . . . . . . . . . . . . . . . . . . . . . What workplace strategies do you have . . . . . . . . . . . . . . . .

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

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23 23 23 24 25 25 26 26 29 29 30 31 33 34

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

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35 35 36 36 37 38 38

Part 5 – Reporting and reviewing aggressive incidents . Reporting aggressive incidents . . . . . . . . . . . . . . . . . . . . . . What to expect from an aggressive incident investigation . . . Support mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self care following an aggressive incident . . . . . . . . . . . . . . . What support can you expect from your manager . . . . . . . .

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Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

NSW Health

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

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MODULE 1 Respond effectively to difficult or challenging behaviour

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 project contract steering committee who provided extensive guidance during the development of this project were Frances Waters (Violence Taskforce, Centre for Mental Health), Kathy Baker (Community & Extended Care 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 New Zealand 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 the members 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 Linda Sheahan. Consumer input was gratefully provided by Laraine Toms and Robyn Toohey. The NSW Health Learning and Development Managers forum and others affiliated with the reference group also provided helpful 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 2002. We also thank the fifteen educators from across the state who provided feedback during the two day trainer orientation at Western Sydney Area Health Service in November 2002. The developers would like to give special thanks to Professor Beverley Raphael and Professor Duncan Chappel from the Violence Taskforce for support, Dr Claire Mayhew for timely insights, Linda Graham for sharing her wisdom over the years through the development and implementation of the INTACT training program, Professor Kevin Gournay and Steve Wright from the Institute of Psychiatry, London, for helpful advice and resources, Dr Nadia Solowij and Jane Middleby-Clements for editorial assistance and to Professor Frank Deane from the Illawarra Institute for Mental Health for practical support. We also thank Shane 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 where appropriate and a list of these is given at the end of the relevant modules. Modules 1 and 2 of this program were 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.

NSW Health

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

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PA RT I C I PA N T M A N U A L NSW Health is a zero tolerance zone

Modular structure of the aggression minimisation program Module 1

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 is designed 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.

Module 2

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 risk assessment process, as being at significant risk of aggressive behaviour should also attend this module.

Module 3

90405NSW – Course in aggression minimisation for managers This nationally recognised qualification is a four hour module designed for managers. It provides the participant with detailed information, 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.

Module 4

2

AMT004 – Aggression minimisation refresher training This two-hour module is designed for all staff identified as being at risk of workplace violence, and should be repeated at a minimum of every two years after completion of Module 1. Depending on the level of risk, some staff may need to attend more frequently. It is designed to keep staff up to date with policies and practices, provide refresher training of skills, and workshop problems.

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

NSW Health

MODULE 1 Respond effectively to difficult or challenging behaviour

Assessment for Module 1 Health Training Package Competency: (HLTCSD6A) – Respond effectively to difficult or challenging behaviour. The learning outcomes and assessment align with the elements and performance criteria.

Elements of competency and performance criteria National code

Element name

HLTCSD6A/01

Plan responses

1.1 Planned responses to instances of difficult or challenging behaviour; maximise 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/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 and diplomatically 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 of 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 offered as appropriate to area of responsibility. 3.3 Debriefing mechanisms and other activities are accessed and participated in. 3.4 Advice and assistance is sought as required.

NSW Health

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

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PA RT I C I PA N T M A N U A L NSW Health is a zero tolerance zone

Learning outcome

Elements of competency and performance criteria

Assessment question

1.

Identify and apply strategies for risk management to prevent aggression.

Question 9

2.

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

Element: Apply responses Performance criteria: 2.1, 2.3, 2.5

Question 1

3.

Give priority to the safety of self and others when confronted with aggressive behaviour.

Element: Plan responses Performance criteria: 1.2

Question 2

4.

Identify when, how and who to call for assistance.

Element: Plan responses Performance criteria: 1.1

Question 3

Element: Apply response Performance criteria: 2.2

4

5.

Use verbal and non-verbal communication strategies to manage aggressive behaviour.

Element: Apply response Performance criteria: 2.4

Question 4

6.

Identify appropriate reporting procedures.

Element: Report and review incidents Performance criteria: 3.1

Question 5

7.

Identify what can be expected from an incident investigation.

Element: Report and review incidents Performance criteria: 3.2

Question 6

8.

Identify available support services following an aggressive incident.

Element: Report and review incidents Performance criteria: 3.3

Question 7

9.

Identify how management can support you following an aggressive incident.

Element: Report and review incidents Performance criteria: 3.4

Question 8

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

NSW Health

MODULE 1 Respond effectively to difficult or challenging behaviour

Assessment specification sheet Candidate’s name Telephone (w)

Work location Units of competency to be assessed

Assessment methods

Assessment activities

HLTCSD6A Respond effectively to difficult and challenging behaviour

Multiple choice questionnaire

Completion of questionnaire based on a scenario appropriate to your workplace

Adequate completion of appropriate documentation

Completion of local incident form

Appropriate completion of risk assessment matrix

Completion of risk assessment matrix

Details of special requirements:

Assessor’s name

Signature Date of assessment

/

/

Time

Confirmation of assessment I confirm that: ●

the purpose of this assessment has been clearly explained to me

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the criteria (relevant competency standards) to be used in this assessment have been discussed with me and I am aware that I will be assessed against this criteria

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I have been given fair notice of the date, time and venue of this assessment

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I am aware of how the assessment will be done and the requirements relating to this assessment

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I am aware of my right to appeal an assessment decision with which I disagree, and the process for appealing that assessment.

Candidate’s signature Date of assessment

NSW Health

/

/

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

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MODULE 1 Respond effectively to difficult or challenging behaviour

Learning outcomes for Module 1 – Respond to difficult or challenging behaviour Module 1 is designed to meet competency HLTCSD6A – Respond effectively to difficult or challenging behaviour, a competency of the National (HLT02) Health Training Package. This competency relates to responding effectively to difficult or challenging behaviour of patients, clients and others. The learning outcomes of the module have been designed to align with the elements and performance criteria for the competency.

Learning outcomes At the conclusion of this module, participants should be able to: 1. identify and apply strategies for risk management to prevent aggression 2. identify and select appropriate response options when confronted with aggressive behaviour 3. give priority to the safety of the self and others when confronted with aggressive behaviour 4. identify when, how and who to call for assistance 5. use verbal and non-verbal communication strategies to manage aggressive behaviour 6. identify appropriate reporting procedures 7. identify what can be expected from an incident investigation 8. identify available support services following an aggressive incident 9. identify how management can be supportive following an aggressive incident.

NSW Health

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

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PA RT I C I PA N T M A N U A L NSW Health is a zero tolerance zone

Aggression in the workplace – facts and figures Aggression 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 involved the staff member being hit and being absent from work for more than five days. The estimated 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% experienced several episodes of physical aggression

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

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

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37.7% experienced verbal aggression; 59.3% experienced physical aggression between one and four times per year.

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 Service were 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. Fifty-three percent 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 experiencing rudeness, being abused, being humiliated in front of others and peers, being denied access to opportunities, and having their work excessively scrutinised with threats of disciplinary action. This program aims to promote a working environment and practice, which minimises and protects people from aggression. The goals of this training are to improve health care workers’ knowledge in relation to ways of preventing aggression and to gain knowledge and skills in responding to different instances of aggression.

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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

NSW Health

MODULE 1 Respond effectively to difficult or challenging behaviour

Part 1 Understanding difficult or challenging behaviour This section looks at what aggression in the workplace is, what the effects of aggression are and provides an understanding of the ‘zero tolerance’ response to aggression. 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. How many times are you exposed to aggression in your workplace? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Whose problem is aggression in the workplace? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Defining aggression NSW 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.’

Workplace aggression can be encountered from: ●

patients

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relatives and friends of patients

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staff members

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members of the public

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intruders.

NSW Health

Targets of aggression include: ●

you

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others

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property.

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

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PA RT I C I PA N T M A N U A L NSW Health is a zero tolerance zone

Effects of aggression The effects of aggression can include:

4,7,8,9

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physical injury

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anxiety

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distress

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anger

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irritability

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self-blame

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apathy

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insomnia

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depression

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impaired decision making

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loss of self-confidence

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severe fatigue

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fear of patients

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difficulty returning to work.

on an individual

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

poor morale, erosion of worker loyalty and commitment

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reduced efficiency, productivity and public image

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

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increased sick leave, absenteeism and staff turnover

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costs associated with compensation, prosecution and penalties imposed on the organisation.

A zero tolerance response to aggression NSW 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 that a violent incident does occur, NSW Health, as a result of a key recommendation from the Taskforce on the Prevention and Management of Violence in the Health Workplace, has adopted a zero tolerance response to threatening, abusive or violent behaviour by any person 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 action will be taken to protect staff, patients and visitors, and health service property from the effects 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 aggressive incident, 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 these circumstances the emphasis is on prompt, effective clinical management and compassionate 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. Underpinning 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 Framework Guidelines and supporting brochure.

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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

NSW Health

MODULE 1 Respond effectively to difficult or challenging behaviour

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).

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? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Key points ●

Aggression may be encountered in the workplace.

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Anyone can be a target.

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It affects both the individual and the organisation.

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NSW Health is committed to a ZERO TOLERANCE response to aggression in the workplace.

NSW Health

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 updated August 2004

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MODULE 1 Respond effectively to difficult or challenging behaviour

Part 2 Preventing aggression occurring 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 of aggression and how buildings and workplaces can be designed and redesigned to prevent or reduce the risk of aggression occurring.

What you need to know about keeping your workplace safe Under 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 and without 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 and safety of their employees.

This 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 responsibility to ensure the health and safety of any persons who are at their place of work, and who may be affected by their acts or omissions at work. Employees have a responsibility to take reasonable care regarding the health and safety of any persons who are at their place 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 cover for prosecution or fines.

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Using a risk management approach to prevent aggression Risk 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 the steps outlined staff members can assist their managers to make better decisions on how best to eliminate or control a risk by reducing it to its lowest possible level.16

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 reported then they cannot be responded to via the risk management process.

Assessing risk involves estimating the extent of the risk to assist with prioritising and developing control strategies. The following factors need to be considered when assessing risks in the workplace. For each factor what aspects would you consider to be associated with aggression in the workplace? Factors relating to a specific individual that may be associated with aggression in the workplace? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Physical environment associated with aggression in the workplace? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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Work systems and practices associated with aggression in the workplace? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Staff factors associated with aggression in the workplace? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Community work associated with aggression in the workplace? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ How would you prioritise risks? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Eliminating or controlling risks Eliminating 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 to eliminate 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. Prior to any implementation 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.

Regulatory hierarchy for controlling risk 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 or providing appropriate training, instruction or information).

5.

Using personal protective equipment.

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

Case study Jim, 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 is not receiving the help that others get from the team. He is not invited to a work picnic and people have put nasty stickers and food scraps into his locker. This culminates early one day when a patient becomes argumentative and physically violent 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 the tea-room after this episode all the other staff are smiling.

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. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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How the design of your workplace can prevent aggression Crime prevention through environmental design (CPTED)2,17 and situational crime prevention2,17 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.

What is involved? 1. Territorial reinforcement. ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Natural surveillance. ____________________________________________________________________________________ ____________________________________________________________________________________ 3. Space management. ____________________________________________________________________________________ ____________________________________________________________________________________ NSW Health has developed a Health Facility Guideline: Safety and Security as part of the Health Building Design Series, to assist facility planners and designers to reduce risks through the design of workplaces and the internal physical environment incorporating CPTED principles. These guidelines will also assist user groups and staff involved in the consultation process for the design of new and refurbished health buildings or facilities.

More ways of keeping your workplace safe Keep your high-risk areas safe by using the following strategies: ●

Deadlock drug storage areas.

●

Designate safe escape routes.

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Have key or card access to staff working areas.

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Use metal detection systems.

●

Install duress alarms.

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Minimise public entry points.

●

Install barriers at reception desks.

For further information see the Security Manual.

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Putting it all together Use 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 your workplace and encourage problem solving. Use the Violence minimisation checklist for a comprehensive list of strategies to reduce risk.

Caveats and background It is also important to recognise that staff or visitors may also be aggressive. Although the following risk highlighter, risk awareness and risk reduction checklists focus mainly on patient-initiated aggression, many of the same principles 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 immediate triggers 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 that subset for which there are some preliminary indications that the patient has a potential to be violent. 5. Risk is a dynamic concept – it can change rapidly, and requires frequent reassessment.

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.

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Individual risk highlighter To be used for considering factors that increase the risk of violence in individuals. Historical 1.

History of previous violence.

Behaviours that may indicate impending aggression

2.

History of impulsiveness/risk taking behaviour.

1.

Loud clipped or angry speech.

3.

History of substance abuse.

2.

Pacing.

4.

History of childhood abuse.

3.

Angry facial expression.

5.

History of significant head injury.

4.

Intense staring.

6.

History of criminal behaviour, arrest or imprisonment.

5.

Refusal to communicate.

6.

Threats or gestures.

7.

Poor compliance to medication.

7.

Physical agitation, eg clenching of fists.

8.

Anti-social personality disorder.

8.

Restlessness or fidgeting.

9.

Few friends or family.

9.

Delusions or hallucinations with violent content.

10. Young men.

10. Patient themselves reporting violent feelings. 11. Intoxication.

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 or stimulants 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.

12. The absence of a calming support person can exacerbate the situation. 13. Aggressive to the environment, eg kicking walls, banging doors. 14. Isolative behaviour. 15. Frequent demands.

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.

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Violence risk awareness checklist Individual factors (client/visitors)

Context • 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.

• 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.

Risk

Physical environment

Individual factors

• 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.

• 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.

What to do • Take precautions. • Alert others. • Follow hospital procedure. • Have clear patient management plans. • Apply ‘Individual risk highlighter’.

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Violence minimisation checklist Individual factors (client/visitors)

Context

• 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.

Risk reduction

• 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.

Physical environment

Individual factors (staff)

• 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.

• 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.

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What to do • 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.

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What workplace strategies do you have? What policies and procedures are in your workplace to manage an aggressive incident? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ What are your responsibilities in relation to workplace policies and procedures? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ How does your employer ensure that you have read and are up to date with current policies and procedures on managing aggression? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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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Part 3 Preventing aggression escalating 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 physically aggressive 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 aggression escalating are practised.

Levels of aggression If an aggressive person confronts you, it can help to identify what level of aggression they are displaying: 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 what level the person is displaying will help you decide the best way to try and prevent the aggression escalating.

Know your options for action There are always options available when confronted with an aggressive person and it is important that staff know the appropriate response options. These responses will depend on a number of factors including the nature and severity of the event, whether it is a patient, visitor or intruder, and the skills, experience and confidence of the staff member/s involved. This may include going straight to calling for backup, security or local police. When considering your options you always need to keep in mind the following: ●

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

●

Always remain calm and assess the level of threat and the different levels of aggression displayed 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 the situation 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 injury to 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.

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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.

Deciding to stay or leave An 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: ●

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

●

you endanger yourself or others by staying

●

when you are alone with an aggressive person.

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

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

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

When and who to call for back-up or help If you feel unsafe at any time you need to call for back-up or help. Who can you call for back-up or help? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Consider all of the above response options. Which would be suitable for the differing levels of aggression? Low

______________________________________________________________________________

____________________________________________________________________________________ Moderate __________________________________________________________________________ ____________________________________________________________________________________ High

______________________________________________________________________________

____________________________________________________________________________________

Danger and safety zones when faced with an aggressive or violent person With a physically aggressive or violent person, the ‘danger zone’ is being in physical proximity to the person so that you could be reached by a punch or kick. By keeping a safe distance from the person, you will be in a ‘safer zone’. It is easier for an aggressive person 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. Here 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.

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Self help strategies to remain calm In 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 feelings and 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 with an aggressive person be aware of your breathing rate and keep it slow and deep. This is one of the most effective tools for maintaining a state of calm.

Verbal and non-verbal de-escalation skills to prevent aggression and violence Verbal and non-verbal de-escalation skills are an important strategy for reducing and preventing aggression and violence. These skills will de-escalate aggressive behaviour in most, but not all aggressive people. It is important to recognise that de-escalation skills include both verbal and non-verbal skills.

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 invade their personal space. Avoid touching the person.

●

Do not hide your hands or move them too much. Have them in a non-threatening relaxed 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 is happening in the area.

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

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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. Endeavour to 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 think about and re-focus on the situation rather than to act out their anger. Remember that raised voices are likely to escalate aggression.

Briefly acknowledge feelings It can be helpful to briefly acknowledge the person’s emotional state first, before addressing their need. Often just communicating to the person your awareness of their emotional state can immediately calm them. An example might be to say, ‘I understand that you are angry and frustrated by this situation’. Once you have acknowledged their emotions, 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 calm person. 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.

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 making promises 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; not allowing access to patients during certain hours or when undergoing medical procedures; 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 the settlement 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 back down and seek assistance.

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Summary of verbal and non-verbal de-escalation skills Do

Don’t

●

Introduce yourself (first name only).

●

Mirror (copy) the aggressive person’s behaviour.

●

Be calm and in control.

●

Touch the person.

●

Give the person more personal space.

●

Hide or move your hands too much.

●

Maintain eye contact in a non-threatening way.

●

Fold your arms across your chest.

●

Be attentive and listen actively.

●

Raise your voice.

●

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 have their needs met.

●

Set limits where appropriate.

Case study 1. When told of the waiting list for elective surgery, a patient became irate about the public health system. The patient yelled loudly and cursed the government 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’t immediately provided.

Consider one of the stressful situations listed above. 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 practise 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 had on the aggressive person and the staff member. Then change roles and repeat.

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Attitudes are important People 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.

Your attitudes towards people Attitudes 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 aggressive behaviour 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.

Misinterpreting diverse communication styles People 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. Do 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 has intellectual deficits.

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Some verbal and non-verbal ways of communication used by people can be misinterpreted 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 to English. For example, when a person ‘sounds’ angry it may be that they are angry, or it may be that the tone of their first language applied to English causes the listener to assume that they are angry. Do not raise your voice to someone with an accent, unless you know they are deaf. The same words 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 in their culture.

●

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

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

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

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Apologise for any mistakes.

Strategies for improving communication with people from a different culture To improve communication with people from different cultural backgrounds the following strategies are recommended:23 ●

Always accept and respect differences between and among people.

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If required use interpreters.

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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.

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

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Promote a feeling of acceptance.

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Show respect and dignity for the person.

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

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

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

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

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Avoid any unnecessary or unfamiliar words.

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Restate the problem in more specific ways.

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

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Avoid giving mixed messages.

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Do not speak too quickly.

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

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Check that you have been understood.

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

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

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

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What are the client’s expectations?

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What are the culturally bound behaviours?

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

What governs your actions in responding to aggression? Both the perpetrator of aggression and the victims of aggression have rights that are protected 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 omissions of another person or organisation. It is important that when you consider and implement your options, the rights of the perpetrator as well as your rights are considered. Legal issues to be considered here include:

Mental Health Act 1990 This NSW Mental Health Act 1990 governs the care, treatment and control of people with mental illness and disorder. Its underlying premise is that people should be treated using the least restrictive care. The Act defines a mentally ill person as someone suffering from a mental illness. Owing to that illness there are reasonable grounds for believing that care, treatment or control of that person is necessary for the person’s own protection or for the protection of others from serious harm. This Act sets out the circumstances in which this can happen, provides a framework of checks and balances and ensures that interference with a person’s rights, dignity and self-respect is kept to the minimum necessary to keep the patient and others safe.

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

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 assault prosecution on behalf of a staff member or any member of the public. NSW Health

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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

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prevent or terminate the unlawful deprivation of his or her liberty or the liberty of another person, or

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protect property from unlawful taking, destruction, damage or interference, and the conduct 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 criminally responsible if acting in lawful self-defence. As stated above self-defence is not limited to the defence of one’s own person, and can be used as a defence for assaults that occur when protecting property or other people. In the past the test was whether the perception of a threat was reasonable in the circumstances, and whether a ‘reasonable’ person in the same circumstances would also have been able to come to the same conclusion. The defence is now broader and states that 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 threat perceived by the accused and his or her response to it. So the key issue is that the person 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.

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 Health policy requirements relating to clinical restraint should be adhered to. See NSW Health documents: 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 unnecessary risks, and unless there is an immediate and significant threat to the safety of others staff should retreat and observe from a safe distance, and police should be called.

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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 should remain in dangerous situations or place themselves at unacceptable risk. At times a staff member’s duty of care to a patient may justify the use of detainment, restraint or sedation for 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 imprisonment or assault. Not exercising a duty of care may result in a claim of negligence depending on the circumstances.

Some more strategies when faced with a violent person In some situations, despite all your efforts to prevent aggression escalating, you may find yourself having to manage an aggressive or violent situation. You should be prepared to respond in an appropriate way. In responding to the person who is aggressive, your behaviour should be calm and show that you are in control, with no more forcefulness than the situation requires. Always remember that safety of yourself and others is given priority. 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 to allow escape. The principle of reasonable force should always be adhered to.

●

Initiate your duress alarm or local emergency response. If necessary, dial (0) 000 and ask for the police. The following information needs to be reported to the police during the 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 telephone number if they insist on leaving.

●

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

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Utilise post-aggressive incident management strategies.

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Response options for repeatedly aggressive people The following options could be considered for dealing with repeated aggressive behaviour: ●

Formal patient management plans.

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Written warnings.

●

Conditional treatment agreements.

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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.

For further information, consult the following document: NSW Health Zero Tolerance Policy and Framework Guidelines.

Key points ●

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.

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Part 4 Bullying, harassment and discrimination at work This section looks at the behaviours, effects and legal issues surrounding bullying, discrimination and harassment, making a formal complaint, and how to confront a person who is bullying, harassing or discriminating against you.

Scope of the problem What is bullying, harassment and discrimination? ____________________________________________________________________________________ ____________________________________________________________________________________ What behaviours are associated with bullying, harassment and discrimination? ____________________________________________________________________________________ ____________________________________________________________________________________ What are the local policies for dealing with this? ____________________________________________________________________________________ ____________________________________________________________________________________ The effects of bullying,25,26 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.

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The effects on an organisationf,25 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.

You have a role to play You are able to promote a workplace that is free of bullying, harassment and discrimination 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 upon witnessing them

●

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

For further information, consult the Joint Management and Employee Association Policy Statement on Bullying Harassment and Discrimination.

Some legal considerations Defamation is the publishing (written or verbal) of material that will damage the reputation of 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 of the individual.

●

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

●

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

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How to confront a person who is bullying, harassing or discriminating against you Not everyone lacks assertiveness to confront persons who are bullying, harassing or discriminating, however there are skills you can use so that you do not lose your temper and 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-controlling behaviours. By confronting the person this means that you are putting controls on them. 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 this department/facility unit’. 2. When confronting the person, it might be helpful in some situations to do this in private. This is so the person is unprepared and has no witnesses. If there are witnesses then these people should be your allies who support you and who may have been in similar situations; 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 my work. 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 to behave 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 them know about this. For example, ‘Several of us have noticed how Jane seems to be depressed and upset recently. One of the reasons 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 clear on 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’. 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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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.

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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 professional organisation. Ensure you are familiar with local bullying reporting procedures.

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

natural justice

●

equal opportunity

●

workplace awards and conditions.

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 professional or 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 right 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.

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Discuss the obstacles to overcoming bullying, harassment and discrimination in your own workplace and some possible solutions. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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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Part 5 Reporting and reviewing aggressive incidents This section reviews the processes and procedures of reporting and reviewing aggressive 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.

Reporting aggressive incidents All aggressive incidents need to be reported and documented on the appropriate forms1,13,28 and, where relevant in the patient’s clinical notes. This includes verbal threats, bullying, ‘near miss’ events, workers compensation claims, property damage insurance claims, and security incidents. Depending on the nature of the aggressive incident, some incidents will be reported by managers to the Health executive, the NSW Department of Health or other external agencies, eg WorkCover NSW, NSW Police, Department of Community Services or the Treasury Managed Fund.a 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 the report given to? Who signs the report?)

Tips for writing incident reports ●

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.

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What to expect from an investigation of an aggressive incident Why do you think it is important that aggressive incidents are investigated? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ For further information on aggressive incident investigations, consult Effective Incident Response: A Framework for Prevention and Management in the Health Workplace. 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? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Support mechanisms All people react to stress differently, therefore your reactions after an aggressive incident are a normal response to an abnormal event. Even if you are a witness to an aggressive incident 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.

Type of stress reactions that can be experienced ●

Positive reactions – feeling strong, concerned for others in an unselfish way, increased sense of personal 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.

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Depending on your reactions the following types of support should be available to you:b ●

Psychological first aid – immediate social and practical help.

●

Employee assistance programs.

●

Peer support programs.

●

Supportive or specialised counselling.

●

Supportive group discussion.

●

Operational debriefing.

●

Mental health care.

●

Other practical help.

Self care following an aggressive incident How you react to an aggressive incident may interfere with the way you function at work and in your personal life for a period of time. The following strategies can help you to deal with these reactions:h Use your own distress tolerance skills. ____________________________________________________________________________________ ____________________________________________________________________________________ Take time out. ____________________________________________________________________________________ ____________________________________________________________________________________ Use time management strategies. ____________________________________________________________________________________ ____________________________________________________________________________________ Don’t always be alone. ____________________________________________________________________________________ ____________________________________________________________________________________ Develop self-awareness and mindfulness. ____________________________________________________________________________________ ____________________________________________________________________________________ Use techniques for starting and finishing each day. ____________________________________________________________________________________ ____________________________________________________________________________________

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Work on your own and fill in the spaces below for things that you do for yourself, and what you would like to try to do for yourself to manage stress.

What I do now

What I would like to try

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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What support can you expect from your manager You 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.

Key points 1. Report and document all aggressive incidents. 2. Intense emotions and stress reactions can be experienced following aggressive incidents. 3. Support mechanisms in the workplace are available. 4. Self-care is important. 5. You can expect your manager to support you.

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Related NSW Health policies and guidelines 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 in Psychiatric 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 Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, 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 Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention 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 Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention 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 the nature 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 in psychiatric 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 post traumatic stress. New York: Plenum Press. 8. Ilkiw-Lavalle O, Grenyer B (2003). Differences between patient and staff perceptions of aggression 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 in forensic 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. and Lyneham, J. (2000). Violence: part of the job for Australian nurses? Australian Journal of Advanced Nursing, 18 (2), 27-32.

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14. Erickson L, Williams-Evans SA (2000). Attitudes of emergency nurses regarding patient assaults. Journal of Emergency Nursing, 26 (3), 210-215. 15. WorkCover NSW Health and Safety Guide. (2001). Risk management at work (online). Available www.workcover.nsw.gov.au/ 16. Illawarra Health. (2001). Risk management in occupational health and safety. Development Version 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 of challenging 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 health professionals and consumers and carers – Final Report. 23. Kavanagh KH, Kennedy PH (1992). Promoting cultural diversity: strategies for health care professionals. 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 CCH Equal 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.

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