Mod2 Facilitator
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A safer place to work – preventing and managing violent behaviour in the Health workplace
Module 2 AMT002 Aggression minimisation in high-risk environments Facilitator manual
NSW Health is a zero tolerance zone
NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel.
(02) 9391 9000
Fax.
(02) 9391 9101
TTY. (02) 9391 9900 www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the NSW Department of Health. © NSW Department of Health 2003 SHPN (CMH) 030136 ISBN 0 7347 3557 X July 2003 updated August 2004
MODULE 2 Aggression minimisation in high-risk environments
Contents Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Overview of the manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modular structure of the aggression minimisation program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How the manual is set out. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Facilitator preparation before training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sequence and timing of the modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 3 4 6 6 7 8
Introduction to Module 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 How Module 2 fits into the whole program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Assessment to Module 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NSW Health preventing and managing aggression in the Health workplace Assessment conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self assessment checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peer assessment checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Session plan for Module 2 . . . . . . . . Materials. . . . . . . . . . . . . . . . . . . . . . . Equipment required. . . . . . . . . . . . . . . Participant requirement . . . . . . . . . . . . Beginning the training session . . . . . . . 1. Welcome participants to the module 2. Housekeeping. . . . . . . . . . . . . . . . . 3. Outline principles of adult learning . .
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Background information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Part 1 Working in high-risk environments. . . . . . . . . . . . . . . . . . . What are high-risk environments? . . . . . . . . . . . . . . . . . . . . . . . . . . . Why are they high-risk? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zero tolerance approach to aggression . . . . . . . . . . . . . . . . . . . . . . . Some legal and ethical issues and scenarios in high-risk environments
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Part 2 Prevention in high-risk environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Keeping your area secure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Some principles for recognising and dealing with unauthorised visitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Working in the community and outreach environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Working in isolated areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 How to maintain safety when approaching a person with the potential for aggression. . . . . . . . . . . . . . . . . . . . . . . . 54 Ensuring the safety of self and others when interviewing patients or others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Part 3 Understanding aggression in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Triggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cycles of aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some possible responses at each stage of the aggression cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self-control plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part 4 Managing aggression in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Core values and skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Options when a person has been identified as being high-risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Short-term options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Long-term options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Strategies during hostage or armed hold-up situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high risk environments
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 2001.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 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
1
FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Introduction NSW Health: Preventing and managing aggression in the Health workplace What is it? A number of key projects have flowed from the work of the Violence Taskforce. One of these is the development of a statewide, appropriately accredited aggression minimisation training program. The focus of this training is to provide staff with the most up to date strategies, skills and techniques to prevent and minimise workplace aggression and violence. It is also based on relevant task force findings and incorporates key task force initiatives. The program includes a basic module for all staff identified as being at risk of workplace violence, a module for staff working in high-risk environments, a module designed specifically for managers and a refresher module.
What materials are provided? A CD-ROM is available and includes: ●
Facilitator manual: Modules 1 through to 4 (in Acrobat PDF format).
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Participant manual: Modules 1 through to 4 (in Acrobat PDF format).
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Powerpoint slides for Modules 1 through to 4.
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Recognition of prior learning forms and assessment of competency forms (as a separate Acrobat PDF format).
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Assessment scenarios and Question sheets for Module 1 (as a separate Acrobat PDF format).
All of the above are included on the CD.
Who will attend? Module 1 should be attended by all staff identified as being at risk of workplace violence, and generally speaking is a prerequisite for all other modules. More detailed advice on the application of this training is provided in the covering circular. Attendance at additional modules is recommended for staff determined by the Health Service to be at higher risk of workplace violence and includes, but is not limited to, security, mental health, Emergency Department, admissions, drug and alcohol, disability services, brain injury and aged care staff. All managers of staff identified as being at risk of workplace violence should attend the manager’s module and all relevant staff should attend the refresher module at least every two years. Health Services may determine that some groups need to attend the refresher more regularly.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 2 Aggression minimisation in high-risk environments
Overview of the manual This manual has been developed to provide educational resources for a facilitator to deliver a comprehensive education program in aggression minimisation. The manual is divided into four training manuals. Facilitators must have each of the following: 1.
Certificate IV in Assessment and Workplace Training.
2.
Experience in working in areas of significant violent risk.
3.
Experience in effectively managing violent incidents.
4.
An ability to relate to staff at all levels of the organisation.
Modular structure of the aggression minimisation program 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. The day is divided into four parts: 1.
Working in high-risk environments.
2.
Prevention in high-risk environments.
3.
Understanding aggression in high-risk environments.
4.
Managing aggression in high-risk environments.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Module 3 90405NSW – Course in aggression minimisation for managers This four-hour module is designed for managers of health units and facilities. It provides the participant with 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. The day is divided into three parts: 1.
The legal and policy framework for managing aggression.
2.
Promoting an aggression-free workplace.
3.
Assisting staff when aggression and violence occurs.
Module 4 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. The day is divided into four parts: 1.
The zero tolerance response.
2.
New developments in preventing and managing aggression and violence.
3.
The prevention of aggression and violence.
4.
Managing aggression and violence.
How the manual is set out The Facilitator manual is divided into the four modules. All facilitator notes throughout each module look like this. Basic course content in the Facilitator manual duplicates that found in the Participant manual. This course content forms the basic syllabus of the training and the trainer needs to know this material prior to conducting training. For each module, at the beginning of each section the relevant page number in the Participant manual is noted. Relevant slides that should be shown at each point are reproduced throughout this manual.
Layout icons The following symbols have been used throughout the Facilitator manual to assist in the presentation of material. In all cases, trainers should use their discretion in the presentation and timing of material depending on the mix of staff in the training group. Where possible, flexible delivery is encouraged and specific recommendations are made at the beginning of each module.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 2 Aggression minimisation in high-risk environments
Key points
Key points help you to summarise the major themes and information from the section. Explain and discuss
This icon suggests that you will need some verbal explanation and discussion of this concept or topic. Background reading
This icon appears when further background information and reading is supplied on a topic to assist the facilitator in understanding and delivering the training course. It should be read before the facilitator conducts any training. The background information may be verbally summarised by the trainer as the need arises. Ask the group
Whenever this icon appears in the manual a large group activity is suggested. Facilitators should ask the suggested question to the group as a whole and elicit answers or suggestions as appropriate. Participants may choose to write answers in the space in their manuals. Small group exercise
This icon represents small group activity. Whenever this icon appears in the manual a small group activity is suggested. Facilitators may get the group to break into smaller groups of two to five participants to discuss the question, before reporting back to the group as a whole. Participants may choose to write answers in the space in their manuals. Individual reflection exercise
This icon represents personal reflective activity. Whenever this icon appears in the manual personal reflection is suggested. Individual participants may complete this exercise alone. The facilitator may then choose to address the question to the group as a whole and collect responses from individuals. Participants may choose to write answers in the space in their manuals. Answers
Suggested answers to the individual, small and large group activities are provided. These amplify and reinforce the subject material covered in the Participant manual. Important training point
Important training points are highlighted with this symbol. You are on Participant manual page X
These icons assist you to keep the training program in sequence with the Participant manual. It is suggested that you regularly refer participants to the relevant page in their Participant manual for further information or to complete an activity.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Show overhead slide
Suggested place to present slide. Facilitator instruction
Specific training hints are given here. Write responses on board
Suggested place where the trainer may wish to reinforce points or collect responses from the group on a whiteboard/blackboard/butcher’s paper. Session time
Suggested times to conduct sessions are given and a session plan is provided for each module. These are to be used flexibly to meet the needs of trainers and participants. Session overview
An overview of the session is given here. Suggested break time
Suggested breaks are provided. These are flexible. Readings and resources
Additional readings and resources are highlighted here and should be read prior to commencing training.
Facilitator preparation before training Before running this training it is important to be familiar with: ●
All NSW Health documents and policies relating to aggression minimisation, prevention and management (see reference lists at the end of each module).
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All local policies relevant to aggression minimisation. These will include documentation and emergency responses relating to aggression minimisation, prevention and management, eg duress response, reporting protocols.
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It is helpful if you have an awareness of recent incidents in your area, where these have been a particular problem, and the outcome. This enables the training to be more relevant for participants.
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Facilitators need to familiarise themselves with the reference list at the end of the modules.
Sequence and timing of the modules The individual modules do not need to be taught together as a block. The space between teaching individual modules may be separated by weeks or months. It is important to consider the retention of information from previous training and be ready to reinforce previous training material, particularly from Module 1. Each module contains some common material from other modules to help reinforce basic concepts, eg zero tolerance. Module 1 forms the prerequisite for the other modules so needs to be made available to participants prior to offering the other modules.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 2 Aggression minimisation in high-risk environments
Assessment of competency Assessment activities accompany Modules 1-4 to facilitate demonstration of competency. Facilitators should ensure that training outcomes for each participant are appropriately documented. Recording forms accompany the Facilitator manual.
Flexible delivery The materials in this training program provide a core recommended syllabus for preventing and managing aggression in all NSW Health facilities. Each module has a set of learning outcomes and corresponding assessments. The training is designed in a modular format to allow ease of delivery, however it is possible that the training may be delivered using flexible delivery methods. Examples of how the training could be altered include (but are not limited to) the following: 1. Dividing a full day module into two parts, spread over two half days. 2. Emphasising some components of training over others for specific groups. For example, if the participant training group is non-clinical then the trainer may decide to focus more on communication strategies and bullying, harassment and discrimination than on some of the components that are more relevant for clinical staff. 3. Flexibly incorporating materials from other local training programs that overlap with the learning outcomes and provide additional training. 4. Shortening a module by providing advance reading materials and exercises to be reviewed in the participants’ own time and reinforced and assessed in the workshop. However, the trainer will need to determine that this approach is appropriate for the participant group. In considering flexible delivery options, it is important to ensure that the learning outcomes are met as set down in this program.
Recognition of prior learning Recognition of prior learning can be considered for this training. The relevant forms for recognition of prior learning accompany the Facilitator manual. Recognition of prior learning is based on the following: ●
Competence – a focus on the competencies an individual has acquired as a result of any formal or informal training and experience.
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Commitment – to recognise prior learning of individuals, therefore individuals will not have to duplicate their training unnecessarily.
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Access – every individual may have his or her prior learning recognised.
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Fairness – that the recognition of prior learning process is fair.
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Support – is provided for individuals in applying for recognition of prior learning. Certificate IV workplace trainers and assessors must provide support so that an efficient and effective service is maintained.
Portfolio documentation Appropriate documentation is to be filled in and evidence collected to be submitted with the application form. All documentation should be submitted as a portfolio. See below for types of evidence to be collected and included in a portfolio.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
7
FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Evidence guide The following is a guide for the evidence to be provided for recognition of prior learning. For each item of evidence you will need to indicate which part of the item is relevant to which learning outcomes. The following types of evidence may be collected: ●
Formal accredited certificates of previous training programs attended, or transcripts of courses of study.
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Authenticated reports on activities participated in, relevant to aggression minimisation.
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Certified evidence of discussions of case studies that shows evidence of having attained learning outcomes.
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Authenticated reports of work, skills and experience in responding to aggressive behaviour.
Other resources Participant manual A Participant manual is also available and should be used during the training. Participants are to use the manual during the training session, but also should take it away as a resource. There is additional information in the Participant manual, and it is not expected that every point can be covered during the training sessions. The training provides an orientation to the major issues in aggression minimisation and points the participant to further readings and resources in the area.
Lecture slides The CD-ROM contains the full set of Powerpoint slides. The Powerpoint slides can also be printed and transferred to overhead transparencies as needed.
Forms The CD-ROM contains the recognition of prior learning forms and the assessment of competency forms.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 2 Aggression minimisation in high-risk environments
Introduction to Module 2 How Module 2 fits into the whole program Module 2 is the second of four modules dealing with aggression prevention, minimisation and management. It builds upon Module 1. The material in Module 1 is assumed knowledge for this module, and recent completion of Module 1, or its equivalent, is a pre-requisite for completing Module 2. This module is focused on the needs of staff working in high-risk areas where there is often a higher prevalence of aggression. The module is designed to address more complex issues regarding responses required to minimise aggression. Other modules focus on managerial responsibilities and refresher training. Facilitators need to reinforce information from Module 1, such as prevention and the risk management approach.
Structure of Module 2 ●
Part 1 – Working in high-risk environments – the nature of high-risk and some legal and ethical issues governing work in these environments.
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Part 2 – Prevention in high-risk environments – including guidelines for improving safety and security.
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Part 3 – Understanding aggression in high-risk environments – including emotional and physical responses to escalating incidents.
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Part 4 – Managing aggression in high-risk environments – including detailed short and long-term response options.
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Part 5 – Assessment of competency and review.
Session times These times are flexible: Part 1 80 minutes Part 2 80 minutes Part 3 80 minutes Part 4 80 minutes Part 5 60 minutes NB. A session plan is provided at the beginning of Module 2.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Training room requirements The training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual. Equipment required: projection facilities for power point slides (or an overhead projector if the slides have been printed on overheads), a whiteboard and whiteboard pens (for writing up feedback from participant exercises). Participants will need pens or pencils for writing in their copy of the Participant manual.
Module overview This eight-hour program is designed for staff working in high-risk areas, eg emergency, security, mental health, 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.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 2 Aggression minimisation in high-risk environments
Assessment for Module 2 NSW Health preventing and managing aggression in the Health workplace Module 2 Aggression minimisation in high-risk environments – AMT002
Learning outcomes
Assessment questions
1. Identify the legal and ethical issues governing aggression.
Question 1
2. Identify safety strategies in responding to and managing aggression.
Question 4
3. Identify the triggers for aggression and stages in the cycle of aggression.
Question 2 and 3
4. Identify personal safety strategies when working in the community and outreach environments.
Question 8
5. Use communication skills to contain and reduce high tension situations.
Question 5
6. Identify short and long-term options for managing an aggressive person.
Question 6 and 7
Assessment method This assessment is designed to be a learning tool and the learning outcomes are to be assessed through peer and self assessment. Participants are to work in pairs and each is to choose a scenario that is different from their partner. Each participant then directs the questions to their partner and assesses their partner’s responses using the Peer assessment checklist. The partner is also given the opportunity to assess his or her own responses using the Self assessment checklist. When this is completed participants are to change roles and repeat the process for the other member of the pair. Participants may choose to jot down dot point answers in the column provided in the relevant checklist, though this is not mandatory. On completion of this task, participants are to discuss what difficulties they may have experienced in answering the questions relating to their scenario. Following this, the group of participants are to be debriefed and asked what areas they found difficult. Participants should subsequently be provided with possible strategies that could be used to overcome such difficulties. Participants who had problems answering a question should be given an opportunity to answer the question again.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
There are five critical aspects of the assessment relating to four of the assessment questions. The questions have been designed to align with the critical aspects of the assessment. Participants are deemed competent if they demonstrate the correct responses to these questions. The critical aspects of the assessment are identified in the marking guide (checklists).
Assessment conditions Participants will be provided with a case scenario and assessment questions at the completion of training. The facilitator is to inform the participants that they should put themselves in the place of the health worker in the scenario. Participants are to be informed about how the assessment should be carried out.
Assessment resources ●
Case scenarios
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Assessment questions
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Peer and self assessment checklists
NB. Assessment questions, Peer and Self assessment checklists and Case scenarios are shown below and can also be found as a separate Acrobat PDF document on the CD-ROM, in order that the assessment questions, checklists and scenarios may be printed out and handed to participants.
Assessment questions 1. What are the legal issues that need to be taken into account in this scenario? 2. What are the possible triggers for this aggressive incident? 3. At what stage in the cycle of aggression is the person in? What are the behaviours of the aggressive person that support your choice? 4. How would you ensure the safety of yourself and others in this situation? 5. What communication skills would you use in this situation to attempt to de-escalate the person’s aggressive behaviour? 6. What might be some short-term options for managing this aggressive incident? 7. What might be some long-term response options that may be used to manage this aggressive person in the future? NB. The following issue may not relate to the scenario, however all participants are required to respond to the question.
8. Identify several strategies to ensure your safety when visiting the community or housing settings for each of the following: ● Prior to leaving the office. ● During the visit. ● Working alone after hours.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Self assessment checklist Yes
No
Unsure
Brief description of response (optional)
Identified legal issues. Identified the triggers for aggression. Identified the stage of the assault cycle and supporting behaviours. Identified personal safety strategies when responding to and managing an aggressive person. Identified appropriate communication skills. Identified short-term response options. Identified long-term response options. Identified safety strategies: Prior to leaving the office. During the visit. When working alone after hours.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Peer assessment checklist Yes
No
Unsure
Brief description of response (optional)
Identified legal issues. Identified the triggers for aggression. Identified the stage of the assault cycle and supporting behaviours. Identified personal safety strategies when responding to and managing an aggressive person. Identified appropriate communication skills. Identified short-term response options. Identified long-term response options. Identified safety strategies: Prior to leaving the office. During the visit. When working alone after hours.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 2 Aggression minimisation in high-risk environments
Scenarios Scenario 1 – Leanne Smith, 34 years old and health worker Leanne has a diagnosis of personality disorder and has a history of self-harming behaviour. She lives with her abusive boyfriend. Over the past few weeks, Leanne’s mother has been concerned about her daughter’s behaviour and today Leanne told her mother she was going to harm herself because her boyfriend threatened her. Leanne’s mother rings you and explains her concerns to you. When you arrive, Leanne’s boyfriend lets you in. Leanne is in the bedroom and does not want to speak to you, but does so reluctantly. She shows you some minor cuts on her arm, stomach and legs. Leanne becomes increasingly agitated and angry and threatens to harm herself with a knife. You want Leanne to go into hospital, however Leanne tells you that she was not happy with the way she had been treated in the past when in hospital. As you try to convince Leanne to come to hospital with you she starts to yell and abuse you, making threats on your life if you try to make her go into hospital.
Scenario 2 – Brian Green, 49 years old and health worker Brian has been in and out of hospital over the last fifteen years. He has a history of schizophrenia and co-morbid alcohol abuse. Brian has a history of aggressive behaviour that seems to be getting worse as his cognitive functioning is deteriorating. He is currently in hospital again and cannot quite remember why. Since Brian has been in hospital for a long period of time he now thinks it must be time to go home. He starts to pack his things when a staff member tells him he cannot leave the hospital. Brian abuses the staff member and throws a book at the staff member as they leave the room. The incident is reported to you and you go to see Brian. Brian appears to have settled down so you decide to enter. Brian becomes very confused and angry when you come in because he knows that you will try to stop him from leaving. He starts shouting at you to get out and punches you on the side of the head. As Brian attempts to grab hold of you, you push him aside.
Scenario 3 – Tony Little, 60 years old and health worker Tony’s wife fell over in the kitchen and received a deep cut on her forehead. On arrival to hospital, Tony’s wife was taken away to see the doctor and he was asked to wait and fill in some forms. Tony is an alcoholic and is intoxicated. He smells of alcohol and is mumbling under his breath. You are concerned about Tony’s behaviour and recognise that he has previously been in the hospital and has been abusive to staff. You call security to watch over Tony. After an hour of waiting Tony has not received any news on his wife. Tony is angry and asks you what is taking so long. You tell Tony to wait while you go and find out. When you return you tell Tony that someone will be out shortly to talk to him. Tony becomes very angry and says he is going in to see his wife. He pushes you out of the way and starts walking into a restricted area. You attempt to stop him by grabbing him on the arm.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Scenario 4 – Peter Bond, 22 years old and health worker A friend takes Peter to hospital in the evening after he is involved in a fight. He had been bashed and has a head injury, as well as severe cuts and bruises on his face. He is taken to hospital and his friend waits in the waiting room. In the meantime, four youths walk into the hospital with a knife demanding to see Peter to ‘finish him off’. A staff member sees this and calls other staff and security. A youth approaches a staff member and grabs them by the arm and demands to see Peter. The staff member panics and screams. You and two other security officers arrive and all the youths run off except for the one holding onto the staff member’s arm. You and the other security officers restrain the youth.
Scenario 5 – Mary Smith, 33 years old and health worker Mary has been hanging around in the car park with her boyfriend late in the afternoon. They have been watching a clinic which is located as a separate building in the hospital grounds. Mary has been a patient of the clinic and has previously been aggressive towards the staff. They leave the car park and return later in the evening. When they return Mary and her boyfriend attempt to break into the building. A staff member walking to their car sees them. The staff member alerts security and you and another security officer arrive. Mary does not see you or the other security officer, but her boyfriend does and starts to run off. Mary’s boyfriend is being chased by the security officer while you attempt to apprehend Mary. You grab her bag to look what is in it. While doing this Mary bites you on the arm and kicks you in the shins.
Scenario 6 – Barbara Hartland, 80 years old and health worker Barbara is confused all the time. Sometimes she does not understand what people are saying to her, where she is or what is going on. When Barbara’s family visit, she becomes argumentative as she does not recognise them. Barbara is on an hourly toileting program and you have been instructed to take her to the toilet. Today you are very busy because of staff shortage and have to attend to many patients. You are also slightly irritable. You approach Barbara and tell her you are taking her to the toilet. Barbara does not hear you properly, and you take her by the arm to lead her to the toilet. Barbara thinks that someone is trying to attack her. She becomes frightened and starts screaming for help. She tries to get away from you by throwing her arms around and waving her walking stick around. You call for help and you and other staff attempt to restrain Barbara.
Scenario 7 – George King, 79 years old and health worker George is seventy-nine years old and living alone since the death of his wife six months ago. He is very lonely and becomes quite confused at times. He has an ulcerated leg and is expecting you to call to do the dressing. You arrive at his house and start to set up the equipment. As you do so George dozes off. When you are ready to wake George you lean over to raise him in the chair. As you do this George thinks someone is trying to rob and hurt him. You try to reassure George and pull away from him. George does not hear what you said and tries to hit you. You move away telling George to ‘stop it’. George becomes frustrated, angry and waves his fist at you.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Scenario 8 – Sam King, 40 years old and health worker Sam is a patient in hospital and has suffered some neurological deficits as a result of a car accident. His memory is poor and he becomes easily frustrated and at times verbally aggressive towards the staff. You tell Sam that the doctor cannot come to see him now but will see him later. Sam forgets this and continues to repeatedly ask you when the doctor is coming. You tell Sam that you have already told him several times that the doctor would come later. Sam becomes abusive, insisting that you have not told him this. He thinks that no-one is interested in him and becomes frustrated and angry and punches a wall. He attempts to grab you but you push him aside causing him to stumble and fall.
Scenario 9 – Ken Jones, 36 years old and health worker Ken is thirty-six years old and has come for his appointment with you. He is late and is agitated. Earlier on in the day he had an argument with his ex-wife over access visits to his children, and was not happy with the legal advice he received on this issue. He eventually sees you for his appointment and presents as angry and irritable. During the session with you, he becomes concerned about what is written in his file. Ken demands to see his file immediately and becomes very angry when you do not comply. He becomes argumentative, is not listening to you, and clenches his fists. He gets up, leans over, and grabs his file. You attempt to grab his file back, and Ken with his force manages to push you over. He picks up the file and runs out of the building. You start to run after Ken.
Scenario 10 – Frank Wells, 32 years old and health worker Frank has been given some bad news about his young child. Both he and his wife are very upset. Frank has had some recent personal problems, being made redundant at work and his mother passed away last year. Frank also has an anger management problem and when angry and frustrated usually punches a wall. Frank feels that the staff are not doing enough for his child and is very angry, hurt and upset. He cannot believe all the bad news he has had recently. Frank is pacing around, tense and very stressed. His wife is worried about Frank and his reaction. You come up to Frank to discuss the situation. Frank is not listening, pacing and abusive toward you. He yells, “You don’t know how I feel”. He begins to demand that another doctor see his son and is about to punch the wall. You try to calm Frank down which only causes him to become even angrier, and he threatens to harm you if you do not organise a doctor immediately.
Scenario 11 – Carly Hall, 33 and health worker Carly has been out drinking with her friends in the afternoon. She is moderately drunk and decides that she wants to visit a friend. Carly wants to know what room her friend is in. You tell her that it is not visiting hours. Carly demands that she be told what room her friend is in. You again tell her that it is not visiting hours, so you will not give her this information. Carly indirectly threatens you, saying that she will be back with her friends. You pick up the phone to call security, but Carly grabs the phone out of your hands and slams it on the counter and leaves.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Session plan for Module 2 Training session: Module 2 Aggression minimisation in high-risk environments
Time
Topic
80 mins
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Introduction.
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Working in high-risk environments.
80 mins
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80 mins
Date: Time:
Learning outcomes
Content/activity
1
Small and large group discussions.
Prevention in high-risk environments.
2, 4 and 5
Small and large group discussions.
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Understanding aggression in high-risk environments.
3 and 5
Small and large group discussions.
80mins
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Managing aggression in high-risk environments.
6
Small and large group discussions.
60mins
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Assessment of competency and review.
All learning outcomes.
Small and large group discussions.
Materials The training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual.
Equipment required ●
Projection facilities for Powerpoint slides (or an overhead projector if the slides have been printed on overheads).
●
A whiteboard and whiteboard pens (for writing up feedback from participant exercises).
Participant requirement Pens or pencils for writing in their copy of the Participant manual.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Beginning the training session Session time 20 minutes
Facilitator instruction To begin teaching this module you will need to do the following:
1. Welcome participants to the module You may wish to facilitate an introductory activity (ice-breaker). Example – have participants pair off and: ●
introduce themselves and the area they work in
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discuss what they hope to gain from the training.
After a few minutes have passed re-assemble the group and ask each participant to introduce their partner.
Show overhead slide
2. Housekeeping Inform participants of the: ●
program times
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breaks and meals
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toilets
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mobile phones
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message board
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occupational health and safety (fire escapes).
3. Outline principles of adult learning ●
Everyone’s opinion will be respected.
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Participants’ work experience will be valued.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Show overhead slide
Explain and discuss Orient participants to how this module fits in with the whole program.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Background information Facilitator instruction The following is background information on the problem of aggression. Facilitators may wish to draw out some key points from this and refer to any local issues or data relevant to the problem of aggression and aggression management.
Aggression in the health service industry is a significant problem (Mayhew and Chapell, 2001a, 2001b, 2001c). This program aims to promote a working environment and practices which keep people safe from aggression. The goals of this training are to improve health care workers’ knowledge in relation to the major factors which contribute to safety and to gain knowledge and skills in responding to different instances of aggression.
Show overhead slide
Explain and discuss Overview the four parts of this module.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Part 1 Working in high-risk environments Show overhead slide
Session time 60 mins
Session overview This section looks at what high-risk environments are and why they are considered to be high-risk. It also examines the legal and ethical issues that need to be taken into account when responding to and managing aggression. These issues include duty of care, professional negligence, reasonable force, assault, arrest, restraint, false imprisonment, searching of patients and others, the Guardianship Tribunal, children and the NSW Mental Health Act 1990.
You are on Participant manual page 5.
Show overhead slide
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Ask the group What are high-risk environments? Explain and discuss Some examples of high-risk environments may include: ●
Emergency Departments and admissions units
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mental health treatment facilities
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a patient’s home
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community facilities
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aged care facilities
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corrections health facilities and prisons
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dental clinics
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disability facilities
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midwifery and early childhood facilities
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drug and alcohol treatment facilities
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rehabilitation, neurology and brain injury units.
Facilitator instruction Facilitator: Ask participants whether there are any other high-risk environments to add to the list and the reason for this. You may wish to comment that there are other kinds of environments that are high-risk in general eg poorly lit car parks, exits via dark or narrow lanes or underpasses, some areas used as shortcuts by the public and isolated areas.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Ask the group Why are they high-risk? Explain and discuss ●
The environment may be targeted by criminals because of money, drugs etc.
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Some environments may put the worker at higher risk of aggression because of the type of location and premises, the presence of others unknown to the worker and because immediate support may not be available.
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Some environments may be associated with visitors being under greater sources of stress which may be associated with a higher risk of aggression.
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Some environments such as waiting rooms may contribute to a higher risk of aggression when there is overcrowding, long waiting times and people in distress.
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Environments where workers are alone may contribute to a higher risk of aggression.
Certain medical problems that patients experience may be associated with a higher risk of aggression, such as: ●
confusion, eg delirium and acute organic brain syndromes, dementia, ie Alzheimer’s disease, multiple infarcts or brain dysfunction and trauma
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anxiety associated with their illness and treatment or psychosocial concerns
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mental illness and disorder
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pain
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substance abuse
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dual diagnosis (both mental illness and substance abuse)
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impulsive behaviours (such as those due to personality disorder)
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deafness, blindness and sensory impairment
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developmental disability
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brain impairment resulting from head injury, epilepsy, neurochemical disturbances, metabolic disturbance (such as hypoglycaemia and limbic system disorder), tumours, infection and other factors
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neurological disorder such as Huntington’s disease, Parkinson’s disease, Pick’s disease, Multiple Sclerosis or AIDS dementia.
Facilitator instruction Ask if anyone has been involved in any of the above. Emphasise how many of the high-risk environments are those that involve a high degree of stress and anxiety for patients, staff and visitors.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Show overhead slide
Zero tolerance approach 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. 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.
You are on Participant manual page 6.
Important training point Facilitator hint: Refer participants back to the zero tolerance overview in Module 1. It may be helpful to ask the group members to summarise their understanding of zero tolerance.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Explain and discuss 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).
Facilitator instruction The zero tolerance approach to aggression does not mean that aggression will never be encountered in the workplace. For example, in dementia and brain injury units aggressive and erratic behaviour can be a part of the condition encountered. The essential point is to ensure clinical care that is prompt and appropriate and that protects the safety of the patient, staff and others involved. The zero tolerance response means that in all instances of aggression, appropriate action must be taken to protect staff, patients and visitors from the effects of that aggression. In order for this to be successful, staff must recognise that aggression is not an acceptable part of the job.
Important training point Ensure you are familiar with the zero tolerance policy.
Show overhead slide
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Some legal and ethical issues and scenarios in high-risk environments Small group exercise Case study A person who is drunk has been brought into the hospital with a head wound and other cuts received in a fight. The person does not like the treatment being provided, and starts to become abusive. The individual feels no treatment is needed and wants to go home.
What should the worker do? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How might the principles governing ‘duty of care’ versus ‘professional negligence’ be relevant to a worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss
30
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How serious are the effects of the head injury?
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Is it life threatening?
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What would your level of experience and knowledge tell you about the effects of this type of injury and intoxication?
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If you felt reasonably sure that this person would suffer serious injury by letting them go home you may be liable for negligence, unless efforts to detain them constitute an unacceptable risk to your safety or the safety of others.
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If you kept the person against their will you would have to show that the person was unable to make an informed decision and the condition was an emergency.
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Remember you can only exercise duty of care within the limits of safety to yourself.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
How might the principles governing ‘reasonable force’ versus ‘assault’ be relevant to a worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Overview the principles of assault and reasonable force.
Background reading 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 need to be proven for a successful prosecution. Under NSW Criminal Law, the term aggravated assault covers the application of physical force. Such actions include pushing, stabbing, strangling a person, kicking, shooting and unlawful hitting. The attempted use of physical force that misses or fails to connect is nevertheless an assault. There must be a belief in the mind of the victim, created by the offender, that force is going to be used upon him/her. The law allows the individual the right to defend his/her life against all unlawful attacks. However: ●
no more force than is absolutely necessary to repel the attack can be used
●
the force must not be excessive and not out of reasonable proportion to the attack
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the individual must not use extra blows/strikes by way of revenge.
Any person who on reasonable grounds believes that he/she is likely to be the subject of an imminent attack can take reasonable measures to protect themselves. In both cases however, the measures taken in self-defence must be reasonable. The courts may take into account whether: ●
it was necessary for the defendant to stand their ground
●
the defendant could easily have used a means of escape
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it was necessary for the defendant to use a weapon.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Reasonable force
Reasonable force is the amount of force considered to be appropriate in proportion to the perceived danger posed. When a person considers that they or others are under attack or threat, and self-defence or the defence of others is required, the amount of force that is used must be considered to be consistent with the perceived threat faced. Each case is judged considering: ●
its unique circumstances
●
the threat that was posed
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level of training
●
support and options available.
You may wish to refer back to Section 3 of Module 1 relating to assault.
Ask the group Case study A fifteen year old boy was in hospital after he fell off his push bike. The boy went over to the drug trolley with his backpack, put something in his backpack, and ran out the door.
What should the worker do? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Facilitator: Ask the group to consider all the options. These may include doing nothing (letting him run away) through to seeking to stop the boy.
A suggestion is made that the security officer should run after the boy and restrain him.
What should the worker do? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
How might the principles governing ‘citizen’s arrest’ versus ‘restraint’, ‘false imprisonment’ and ‘assault’ be relevant to the worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Overview the principles governing arrest and restraint.
Background reading To arrest someone means to take that person’s liberty or freedom of movement away from them in order to deliver that person into legal custody, to be dealt with according to law. ●
Individuals are only able to arrest someone if the person is in the act of committing, or immediately after having committed an offence.
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If restraint is used, reasonable force only must be exercised.
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Security officers have no additional powers of arrest than those of the general public (unless they are a special constable).
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You have to consider the safety of yourself in making an arrest.
The role of a security officer is one of prevention and protection. They have only the same power as any other member of the community in relation to arrest. Restraint should only be used in an aggressive situation where all other measures and interventions have (if circumstances have allowed) been tried, and there is a foreseeable risk of harm to any persons. To be protected from prosecution for assault, when staff restrain a person they must use only reasonable force. This is the basis for self-defence in court. You may also wish to refer back to Section 3 of Module 1 regarding clinical and non-clinical restraint.
Explain and discuss Regarding the case study, it is unlikely that it is reasonable to arrest the person. A better option would be to report the event to the police, who have additional powers of arrest.
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Ask the group Consider the case where the boy does not run out of the hospital but after putting something in his backpack from the drug trolley he sits down on a nearby chair.
What should the worker do? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How might the principles governing ‘searching patients’ be relevant to the worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Discuss the issues surrounding searching patients.
Background reading The power to search clients is restricted to narrow circumstances allowed under criminal law which are strictly regulated, or when the client consents. Without clear lawful authority, any search initiated without consent would be a trespass upon the person and therefore unlawful. However, under the Inclosed Lands Protection Act 1901 hospitals are entitled to impose conditions of entry on persons who enter their premises. An example of these conditions, which would be considered lawful, are: ●
Prohibited weapons, fire arms or illegal drugs are not to be bought into the facility.
●
The hospital reserves the right to search persons if there is reasonable suspicion that a person has brought such weapons etc into the facility.
●
A person who refuses to be searched when requested will be escorted from the premises.
However the requirements of entry need to be displayed or communicated to those entering the premises, so that people are aware that such requirements exist.
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Facilitator instruction Facilitator suggestion: Another way of extending this discussion is to then suggest that after searching the boy’s bag only his wallet was found. A staff member had previously put the boy’s wallet on the trolley when he was being treated for his injury. Discuss with the group the issue of ‘reasonable suspicion’.
Background reading The situation is somewhat different in relation to persons involuntarily detained under the Mental Health Act, which provides for the involuntary detention of persons suffering from a mental illness that place themselves or others at risk of serious harm. The objects of the Act include facilitating treatment and care, and section 31 (2) specifically allows a detained person to be given such treatment as the medical superintendent ‘thinks fit’. This combination of provisions may authorise searching involuntary patients, where the search was directed towards care and/or treatment or prevention of harm to the patient or others. All of this information needs to be considered by health care facilities when developing policies and procedures in relation to searching.
Small group exercise Case study An involuntary patient decides she wants to leave the hospital and becomes excited and angry when told that she cannot leave the hospital. A staff member considers her ‘at risk’ and tells her she will give her something to calm her down. The drug injected has the effect of making the patient unconscious.
Could the patient claim false imprisonment? How might the principles governing the Mental Health Act be relevant to the worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Facilitator note: An example of a drug that may have this effect is Midazolam.
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Explain and discuss Overview the Mental Health Act and the issues of false imprisonment.
Background reading Mental Health Act 1990 ●
Under the NSW Mental Health Act, mentally ill persons are those who have a mental illness and as a result of the illness there are reasonable grounds for assuming that care, treatment or control is necessary to protect the person or others from serious harm.
●
Within the Act, mentally disordered persons are defined as those persons whose behaviour is so irrational that there are reasonable grounds for assuming that care, treatment or control is necessary to protect the person or others from serious physical harm.
Mentally Ill vs mentally disordered conditions
Mental illness is defined as a condition that impairs mental functioning as a result or one or more of the following: ●
Delusions.
●
Hallucinations.
●
Serious disorder of thought.
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Severe disturbance of mood.
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Sustained or repeated irrational behaviour indicating the presence of any one or more of the preceding symptoms.
The most common behaviours requiring containment for the protection of self or others include: ●
deliberate self harm
●
delirium
●
acute distress
●
confusion
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aggressive behaviour.
The most common underlying diagnosis is psychosis or bipolar disorder. Being detained under the Mental Health Act does not automatically mean that the patient may be sedated as treatment must be the least restrictive, allowing for effective care and treatment. The clinical situation must warrant the use of involuntary sedation.
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Ask the group Consider the scenario on page 35 (Participant’s manual, page 9) of the patient being administered a sedative. Instead of being an involuntary patient, the individual is elderly, repeatedly aggressive and under the Guardianship Tribunal.
How might the principles governing the Guardianship Tribunal be relevant to the worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Overview the role of the Guardianship Tribunal.
Background reading Guardianship Tribunal
A person may be under the Guardianship Tribunal for either financial or medical orders or both. If staff want to give additional or non-prescribed treatment to a patient whose order is for medical treatment they must contact the Tribunal first. However, in an emergency, the Tribunal should be contacted immediately after the person has been given their medical treatment. Guardianship Tribunal and mental health ●
The Guardianship Tribunal should be contacted about patients with behavioural disturbance who do not satisfy the criteria of the Mental Health Act 1990 for involuntary treatment, and who are incapable of giving consent, eg aggressive or self harming behaviour in a person with an intellectual disability.
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At times, patient management will require involuntary treatment, eg restraint/sedation or both. Any involuntary treatment must be justified legally.
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Staff need in each case to make an assessment of the patient’s mental state and capacity to consent.
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If a person is not admitted as an involuntary patient, or does not meet the criteria of a mentally ill or a mentally disordered person (who could therefore be ‘scheduled’), the only circumstance where involuntary sedation can occur is if the person lacks the mental capacity at the time to consent to treatment and the sedation is required as a matter of urgency.
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Explain and discuss Overview the issues in relation to children and adolescents.
Background reading General principles in relation to child and adolescent care ●
Parents have a general right to determine a child’s upbringing and education, including the right to discipline a child. Of course, this right is limited by laws concerning child abuse and neglect and by the fact that any punishment inflicted must be moderate and reasonable.
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Parents are entitled to ‘delegate’ this authority to other persons who stand in ‘loco parentis’ to the children.
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The right to decide on medical treatment arises independently of any right or control of a parent over a child. Thus, as a rule, medical treatment for a child under 14 can only occur with parent/guardian approval. Between 14-16 is the ‘grey’ area and when 16 and over the child can determine treatment independently. This point becomes relevant with regard to the issue of medication.
●
In NSW law, the only grounds to detain persons against their will outside of criminal law are found in the statutory provisions of the Mental Health Act and the Public Health Act. Recognition of parental or guardian authority is given with respect to voluntary admissions to psychiatric hospitals, but not with respect to involuntary admissions.
Basis of authority: voluntary admissions
38
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The only authority psychiatric services have over child and adolescent patients is based on the fact that the child is placed in a facility by the parents and that as part of that placement they also delegate staff of the facility to act in ‘loco parentis’.
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Therefore, with respect to the day to day care and control of the child, staff can do no more than would reasonably be done by the parent. The key document becomes the consent signed by the parents when the child was placed. The consent form should be carefully considered to ensure: – it includes all possible actions likely to be necessary – the language is clear and precise – parents are fully informed of all factors when giving consent.
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Once a consent form of sufficient detail is developed, a facility’s policy can act in conjunction with the consent, as a guideline to staff as to how they are to exercise the authority given to them.
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‘Grey areas’ ●
If any force is required, it should be minimum force only. Clearly, if a situation is escalating, evasion and seeking additional support is the best option. In this regard, if a matter of assault did come before a court, it would be unlikely to conclude that any parental authority would authorise the use of excessive force.
Further factors involving children under 16 ●
As noted above, the issue of consent to medical treatment, is complicated by the different scheme applying to juveniles between 14 and 16. In addition, questions arise as to the real ability to ensure a child over 16 stays with a parent against his or her will. It is understood that the parental rights of control in this regard are not always enforced.
Reference to the Mental Health Act: involuntary admissions ●
In relation to involuntary detention, the Mental Health Act makes no differentiation as to juveniles. Therefore technically an adolescent with a mental illness should be treated the same as an adult. In practice however, extra care needs to be taken when assessing juveniles before a decision is made to schedule them.
Small group exercise Case study In the evening two youths were noticed hanging around a health facility building. There is no one in the premises after hours. Staff working in another building noticed that the youths had driven their car and parked it outside the front door. One of the youths threw a rock at a window and no alarm was set off. They then proceeded to try to break into the building.
What is the role of staff when a crime is being committed? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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Facilitator instruction Facilitator: Reinforce the issues of: ●
safety first
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not approaching offenders
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notifying security or police
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taking note of the appearance of the youths and the car.
Facilitator instruction Facilitator: Add to the scenario by considering a case where two staff ran to stop the offenders. The staff were seriously assaulted by the youths. Issues to consider and discuss may include the following: ●
Whether the staff can charge for assault.
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Staff should not be knowingly placing themselves at unnecessary risk by approaching the youths.
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It is better to keep a distance, take down a description of the youths and car and call police.
Facilitator instruction Consider what the organisation’s response might be to this incident. Organisation:
40
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Need to reinforce self protection and safety with regard to staff behaviour.
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Document incident.
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Perform a risk assessment.
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Instigate changes to improve security and surveillance.
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Key points • Some environments are at a higher risk, because they may be targets for crime. This may be due to money handling, design, type and location of premises, visitors being under a greater source of stress, staff working in isolation and the types of problems patients experience. • No staff member should knowingly place themselves at unnecessary risk of violence. • The zero tolerance response means that in all instances of aggression, appropriate action must be taken to protect staff, patients and visitors from the effects of that aggression. In order for this to be successful, staff must recognise that aggression is not an acceptable part of the job. • Always keep in mind the legal and ethical issues when responding to and managing aggression.
Suggested break time
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MODULE 2 Aggression minimisation in high-risk environments
Part 2 Prevention in high-risk environments Show overhead slide
Session time 80 minutes
Session overview This part looks at safety strategies in high-risk environments. It considers circumstances where unauthorised persons have entered restricted and unauthorised areas, safety when working in the community, how to approach an aggressive person and safety strategies when interviewing patients and others.
You are on Participant manual page 11
Show overhead slide
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Keeping your area secure Small group exercise Case study You notice a stranger is in the staff room with the door to a locker open and hanging on one hinge. The person is going through the locker of a staff member you know and you suspect this person is stealing.
What strategies could you use? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Basic principles are: 1. your safety 2. report the incident. Note the appearance of the person, note what they are doing and where they go afterwards. Ring security and report the incident formally. You might ask the group: ‘Should you approach the person?’ The safest strategy is not to approach the person, however, depending on the circumstances, saying something like, ‘can I help you?’ while maintaining a safe distance and not blocking the exit, may be appropriate.
Small group exercise Case study An elderly gentleman came to the receptionist’s desk. He was of non-English speaking background. He was speaking loudly, and abruptly said, “I want to see my wife, where is Ward 14”. Ward 14 is a high dependency unit with restricted admission. The staff member is worried that the gentleman is going to become aggressive and asks him in a quiet, polite manner what his wife’s name is. He answers loudly, “Where is Ward 14?” and puts his hand in his pocket as if he is about to take something out. At the same time he notices a sign with an arrow pointing toward Ward 14. He walks briskly toward the ward and pushes open the doors, entering the ward. The staff member panics, picks up the phone and calls security. Several security staff arrive and escort the gentleman, shouting and struggling, off the premises.
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Discuss the incident and the worker’s response. What strategies should be used when dealing with unauthorised access? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What might be the socio-cultural issues that might have contributed to this incident escalating? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Review principles of culturally diverse communication styles from Module 1. ●
Emphasise socio-cultural issues around miscommunication as a trigger for the escalation of aggression.
●
Review issue of hearing deficit as a possible trigger.
Ask the group Ask the participants: “should you call security?”
Facilitator instruction Recognise that de-escalation communication skills may no longer be appropriate because the person has moved into a restricted area.
Ask the group Ask participants: ‘What risk control measures can be put in place for restricted areas?’
Facilitator instruction Review issues to do with: ●
safety barriers around reception areas
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signage
●
locked doors to unit with video intercom for communication with staff.
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You are on Participant manual page 12.
Some principles for recognising and dealing with unauthorised visitors Explain and discuss ●
Where possible control access at the door.
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Call security, staff or police assistance if required (in-line with local procedures).
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If inside, ask them to leave (note details and call security if necessary).
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Complete an incident report.
Unauthorised access ●
Know your escape route.
●
Know your emergency numbers.
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Know your local emergency procedures.
●
Know location of duress alarms.
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Remain calm.
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Know that your safety is the first priority.
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Know how to contact security or police.
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Know your rights.
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Use non-confrontational methods.
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Use open hand gestures.
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Note clothing or distinguishing features.
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Complete an incident report.
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Seek counselling if appropriate.
Show overhead slide
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Working in the community and outreach environments Explain and discuss Staff working in the community face particular risks that need to be managed by the employer (Chaplin and Alison, 1998; Hunter, 1997).
Ask the group Discuss what risk assessment activities can be done prior to making community visits, in particular the first visit. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Facilitator: ●
Discuss if there are any local procedures, policies or risk assessment forms prior to the visit.
●
Highlight importance of recognising that there is a risk of aggression from those around the patient, eg family members, friends, flatmates, etc.
Discuss the following risk identification activities: ●
Assess for any prior history of aggression.
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Recognise that risks can change with different circumstances and that a low risk person or situation can change at any time.
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Obtain as much information as possible about the patient/client/business prior to the first visit.
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Collect relevant information about other members of the household and likely visitors when making home visits.
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Obtain information about the geographical location of the premises, eg is it in a high crime area, geographically isolated and/or have reduced accessibility to/availability of police.
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Gather specific information about the premises, eg security access, stairs, external lighting, hiding places, premises, age and condition, phone connection etc.
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Speak to other staff who may have provided the services or inspected the premises in the past.
●
Where possible speak to the patient/client by phone prior to the first appointment to confirm the meeting, as this can also provide insights: – Use a broad range of information resources, eg point of referral, relevant patient/client records, other staff, local GPs and local police.
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Important training point Facilitator note: Discuss local policies and procedures on risk assessment prior to the first visit.
Important training point SAFETY HINT: Recognise that the busier you are, the more at risk you may be. Being busy may lead you to: ●
being less likely to notice early warning signs of aggression
●
taking less time to clarify a person’s problem before acting
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being more vulnerable to taking unnecessary risks.
You are on Participant manual page 13. Small group exercise Facilitator note: For this exercise allocate a particular section to each group (see page 49 of this manual, page 14 of Participant’s manual) and then have each group give its response.
Case study Jane works in a small community health centre. She is leaving her office to visit a well known client, John, in his home. When Jane arrived at the house, John’s parents welcomed Jane in. When Jane walked in she realised she left her mobile phone in the car but did not go back outside to get it. John was in his bedroom with a friend Bill who Jane recognised and knew had a history of aggression. John closed the door behind Jane and when Jane started talking to John his friend Bill became abusive to Jane and started yelling and shouting at her. Jane immediately left the room and Bill started to follow her. Jane ran for the front door and tried to open it. John’s parents came to see what was going on but Bill pushed them aside. Jane eventually opened the door and ran to her car and was trying to find her keys in her bag. Meanwhile Bill grabbed Jane but let her go when John stopped him. Jane eventually got in her car and drove off.
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Consider the scenario. Discuss what you can do to ensure your safety in the community. Fill in the relevant issues to consider in the boxes provided. Prior to leaving the office
Travelling to and fro
On arrival
NSW Health
After the visit
Visiting alone
SAFETY IN THE COMMUNITY
During the visit
Visiting after hours
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Write responses on board Facilitator note: it is useful to write the answers to each section on a whiteboard.
Answers Prior to leaving the office ●
Ensure that your base knows where you are going and who you are going to see, and leave the following information: – The name, address and phone number of persons being visited. – Expected time of appointment. – Expected length of appointment. – Any changes to the schedule of visits. – The proposed route.
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Take any personal protective equipment that is provided.
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Ensure your mobile phone is working and 000 and your base number are keyed in.
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Do not make a home visit alone: – If you suspect or know a person has the potential for aggression (this includes other persons who may be in the home). – If you believe you are at risk. – If there is not enough information to establish a person’s potential for aggression.
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At times it may be appropriate for the police to go on the visit (consider using police if you are concerned about your own and/or another’s safety).
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Ring to see if the client is there.
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Perform a risk assessment.
Travelling to and from
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Keep your car locked while driving and windows up if practical; this prevents people entering when you stop at lights, etc.
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Ensure you have sufficient petrol.
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Do not walk in deserted places or take shortcuts through secluded alleys or vacant blocks.
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Always walk in the center of footpaths, away from buildings.
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Watch for any loiterers in doorways and windows.
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Walk around and not through groups of people.
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Never enter areas where there appears to be trouble in the neighbourhood.
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If you suspect you are being followed while walking, enter a business premises.
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If you suspect a car is following you, cross the street and walk in the opposite direction.
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If you think you are being followed while driving, drive to the nearest police, fire or petrol station.
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Park as close as possible to the premises being visited.
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Do not look lost (if you cannot see an address or building, drive down the street until you can find the building).
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If you are threatened by a thief at any time, do not resist, give them what they want immediately, then notify the police and your manager when safe to do so.
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Be aware of car safety procedures if the car breaks down.
On arrival ●
Park the car facing the way you will be exiting and make sure you cannot be blocked in (this stops you from being trapped or wasting time trying to turn).
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Do not attempt to enter premises if there are any potentially aggressive animals and they are not restrained.
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When entering buildings, check lighting and stairwells where no lift is available.
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If entering a lift, look first and do not enter if you are concerned about safety.
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Stay near the door and control panel in lifts, and be observant of others.
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Do not search for patients by unnecessarily knocking on doors.
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Do not remain in the parked car for long periods of time before and after visits.
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If you are concerned about location or access to premises, ask a family member to meet you and escort you to the patient.
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If no one is home and you are leaving a card, slip it under the door or put it in their letterbox if it is locked (so other people cannot find it).
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Always check the locking mechanism on the gate so you won’t be impeded if you need to leave quickly.
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Before knocking at the door and ringing the bell, listen for any arguments, unexpected voices or anything that may make the situation unsafe (these are reasons to reassess the situation).
During the visit ●
Be cautious when entering a person’s home.
●
If an unfamiliar person answers the door, make sure the client is home before entering.
●
Stand to one side with your work bag in front of you for protection.
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If at any time your professional instinct tells you something is wrong, leave immediately (even if you cannot work out what is wrong).
●
Leave immediately if you see any firearms or weapons (this must be noted in the patient’s file, police need to be informed and the incident reported to management).
●
Be aware of all exits.
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Do not sit in deep-seated lounges, as it is difficult to get out of some chairs in a hurry (ask for an upright chair).
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Always sit between the patient and the door but without blocking the patient’s way out.
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Keep your keys handy so that you do not waste time searching for them at the bottom of the bag.
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Only take in what you need.
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Leave immediately if you are verbally or physically threatened by anyone.
After hours visits ●
On any new referrals, two staff members should attend unless police are present.
●
Staff should have a mobile phone.
●
It is recommended that police attend with you if the patient has a history of violence, the patient is currently violent or the patient has access to a weapon.
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If the patient is intoxicated, suffering from withdrawal, agitated, disorientated or aggressive, it is preferable they be seen at a safe venue such as an Emergency Department.
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Staff should give the details of the patient’s address/location, their estimated time of departure and return and an assessment of the risk to a senior person in the facility.
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Patients and/or carers must be told to ensure that the lights surrounding the property are on for it to be easily identified, gates are open and any animals restrained.
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Staff should leave immediately if there is any evidence of a threat or anything that will affect staff safety.
Facilitator note: Discuss local procedures when mobile phones do not work in specific geographical areas.
After the visit ●
If you experienced any aggression or harassment (verbal or physical) report it to your manager, document the incident in the patient’s notes and complete an incident report form.
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Always report to base at regular intervals.
●
Always report ‘near misses’ – where aggression became a present risk but did not eventuate.
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Ensure your workplace has a policy and response if you do not return on time, eg activating a police response.
Important training point Facilitator: It is useful to raise the issue of local policies regarding high-risk patients. For example, it may be negotiated for high-risk patients to attend the centre.
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Show overhead slide
Explain and discuss Working in isolated areas If possible, staff should not work alone in isolated areas. However if this is unavoidable appropriate risk controls must be in place. Managers, and staff as appropriate, should: ●
be vigilant when entering, using or leaving isolated clinics
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have all emergency numbers programmed into the phone
●
have all essential phone numbers displayed
●
ensure that an effective contact network is established
●
ensure security doors are locked and all doors locked when working after hours in the clinic.
●
ensure all door and window locks are in good working order
●
ensure facility and approaches are well maintained
●
ensure all fixtures and fittings are in good working order
●
ensure there is adequate lighting during and after hours
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inform communication networks of all movements to and from the site and record in travel log times of arrival and departure, route taken and any foreseeable difficulties with travel
●
be aware of how to activate a duress alarm or security system.
Explain and discuss SAFETY TIPS in community work ●
Always ensure you have as much information as possible about the location and person being visited.
●
Ensure patients are aware of the visit and purpose.
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Under no circumstances should you knowingly place yourself or co-workers at risk. This also applies to those in an inspectorial role. Where the threat of violence presents itself, you should leave and/or seek further assistance, eg police. If you are unable to escape, evasive self-defence may be necessary.
●
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Always contact police if you are concerned about your own or another's security.
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Show overhead slide
Explain and discuss How to maintain safety when approaching a person with the potential for aggression When approaching or interviewing a person who has the potential for aggression, keep in mind some key points to ensure the safety of yourself, the person and others. By approaching the person in an appropriate way and being aware of simple safe practices, the likelihood of the person becoming aggressive is reduced.
Facilitator instruction It is useful to elicit other examples from the group.
SAFETY TIP Do
Don’t
●
●
Use any sudden or violent gestures.
●
Have prolonged eye contact.
●
Address the patient in a
Always remove any personal items that could be used by the patient to grab a hold of you, eg tie, necklace, earrings, stethoscope, etc, prior to approaching
confrontational manner.
the person and not in view of the person. ●
Be calm and confident.
●
Give the patient ample space.
●
Be empathic and emphasise your desire
●
Corner or tower over the patient.
●
Turn your back on the patient until you are well clear of the situation.
to help.
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MODULE 2 Aggression minimisation in high-risk environments
Show overhead slide
Explain and discuss Ensuring the safety of self and others when interviewing patients or others ●
Always be alert for the potential for aggressive behaviour.
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Always consider the safety of yourself, the patient, staff or others present.
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Let other staff know where you are in case assistance is required.
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Have other staff present (this can include security).
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Interview in environments where there are easy exits for you and the patient. This prevents any feelings of being trapped.
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Place yourself near the door and avoid putting yourself in a position where your exit may be blocked by the patient, or where you are blocking the patient’s exit.
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The furniture in the room should be heavy enough to make it difficult for the person to use it as a projectile.
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Wear a personal duress alarm and know how to use it.
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Remove any excessive items that could be used as weapons, eg heavy staplers, scissors, etc.
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Be alert to any potential hidden weapons.
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Do not assume that patients who have been in recent contact with the police have been searched and disarmed of weapons.
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Do not give ultimatums.
Facilitator instruction Facilitator: ●
Note the importance of having an exit strategy.
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Where possible, use rooms with two doors or exits.
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Do not situate yourself in a position where you cannot get to the door first.
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Don’t have things on your desk or in the room that can be used as a weapon (elicit examples from group).
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Emphasise the importance of always being polite (even if a person is disrespectful or abusive to you).
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Key points • Always know your local emergency response procedures; call security, staff or police if assistance is required with unauthorised visitors. • Know your emergency numbers and escape routes. • Always remain calm and non-confrontational. • Under no circumstances should you place yourself or co-workers at unnecessary risk. • Always use police if you are concerned about your safety when doing visits in the community. • Always use the safety strategies prior to approaching persons who are, or have the potential to be, aggressive. • Always use the safety strategies when interviewing patients or others.
Suggested break time
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MODULE 2 Aggression minimisation in high-risk environments
Part 3 Understanding aggression in high-risk environments Show overhead slide
Session time 80 minutes
Session overview This section aims to extend your knowledge of aggression through discussing common triggers for aggression in the health care industry and the cycle of aggression. The aggressive person’s and the recipient’s responses are both outlined and discussed. It is the recipient’s response that can give control back to the recipient in an aggressive situation.
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Explain and discuss Triggers A trigger is a specific occurrence that precipitates the escalation of a person’s aggressive behaviour. Triggers may be grouped under the following headings: • Environmental • Personal • Cultural • Workplace practices
Small group exercise Facilitator instruction Facilitator note: Divide participants into groups of four and allocate a trigger (environmental, personal, cultural or workplace practices) for each group to discuss. Have someone from each group share the responses with the larger group.
Name triggers you have witnessed or experienced under the following headings.
Write responses on board Environmental
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Facilitator – some issues might include:
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confined spaces and overcrowding
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environments that are too hot or too cold
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poorly designed rooms
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inadequate lighting
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uncomfortable spaces
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inadequate or poorly maintained facilities, eg no water dispensers, phone not working, inadequate toilet facilities.
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MODULE 2 Aggression minimisation in high-risk environments
Personal
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Facilitator – some issues might include: ●
attitudes
●
emotional state, eg anxiety, fear, stress
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physical health
●
expectations and beliefs.
Cultural
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Facilitator – some issues might include: ●
misunderstandings due to limited knowledge/understanding of English
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misinterpretation of body language, facial expression or speaking tone
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use of slang or forms of communication that are foreign
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differences in personal space, physical touching, gestures
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differences in religious practices.
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Workplace practices
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Facilitator – some issues might include: ●
excessive workloads
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problems with employee relationships
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restrictive policies and procedures
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inconsistent rule setting between staff
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long waiting lists and wait times
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lack of communication, eg not informing people of delays in treatment, waiting times etc.
Show overhead slide
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MODULE 2 Aggression minimisation in high-risk environments
Cycle of aggression Facilitator instruction Facilitator: Discuss each stage, how aggressive incidents may escalate rapidly and the post incident effects.
You are on Participant manual page 20. Facilitator instruction Facilitator: Use the next table as a discussion point. Consider each component of the cycle of aggression and discuss what the aggressive person and the recipient may be feeling at each stage. Then go through and review possible strategies to help minimise the aggression.
4 3
1 Baseline
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Some possible responses at each stage of the aggression cycle Cycle of aggression
Aggressive person
Recipient
Strategies
1 Baseline
●
●
●
Calm and relaxed.
Calm and relaxed.
Observe for verbal and non-verbal cues.
2 Trigger
3 Escalation
4 Crisis
5 Recovery
6 Post-crisis depression
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Increased muscle tension.
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Dry mouth.
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Tremor.
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Palpitations.
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Flushed.
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Anxious.
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Reflect feelings.
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Increased heart rate.
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Offer help.
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Worried.
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Problem solve.
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Be aware of your body language.
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Be aware of personal space.
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Be aware of your voice tone.
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Use open questions.
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Pacing.
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Dry mouth.
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Stay calm.
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Irregular, rapid, shallow breathing.
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Tense.
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Increased breathing.
Explain things are getting out of control.
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Tremor.
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Maintain safety.
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Reduced concentration.
Fight or flight impulses.
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Offer medication if appropriate.
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Fear and anxiety.
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Pale or ashen skin.
Keep dialogue simple and direct.
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Have back-up and an escape plan.
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Loss of control.
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In control.
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Maintain safety.
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Assault.
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Self-defence.
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Yours and others.
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Run or escape.
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Panic and attack.
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Call for back-up.
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Self harm.
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Increased heart rate.
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Run or escape.
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Freeze.
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Cry.
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Worn out.
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Quiet time.
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Tired.
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Frustrated.
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Talk with colleagues.
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Drained.
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Emotional.
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Reflect.
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Sad.
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Guilt.
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Remorse.
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Blame.
Seek formal support mechanisms.
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Apologetic.
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Questioning.
NB. Staff may call for back-up at any time. Back-up can include a more senior experienced member of staff.
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Explain and discuss Sometimes these responses can prevent you from responding in a way that you would desire. You may under or over react to a situation possibly: placing the aggressive person, others or yourself at greater risk of harm.
Show overhead slide
Explain and discuss Self-control plan You need to have a self-control plan in place so that when you are confronted with an aggressive incident, your response acts to calm the aggressive person and not to further escalate the individual. Your self-control plan should take only a couple of seconds.
Ask the group What self-control plan can you use when confronted with an aggressive incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
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Answers Facilitator: Elicit examples from the group. Some strategies might include: ●
deep breathing
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controlled breathing
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inner dialogues
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focus on empathy
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count to three.
This is the first step in a crisis. It slows you down and lets you think about responding in a controlled manner, rather than just reacting. It is a tool for putting on the brakes. ●
Deep breathing Focus on your breathing. Deep breathing is essential to preparing yourself physically to deal with an aggressive situation. There are a number of different breathing techniques which may be used.
●
Inner dialogues Inner dialogues are the conversations we have with ourselves which determine the way we approach a particular event, or the way we deal with a particular person. Inner dialogues influence our attitude and strongly influence the outcome. When we think things won’t go well, because of our negative inner dialogues, they probably won’t. Conversely, when we think things will go well, so long as it is not based on blind optimism, they usually do. Inner dialogues are also useful for monitoring the crises and your own reactions as you go along.
Ask the group When might these self-control plans be difficult to implement? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
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MODULE 2 Aggression minimisation in high-risk environments
Facilitator instruction Facilitator: Elicit examples from the group. Some strategies may not work when: ●
strategies do not suit the individual
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the person is being physically assaulted
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taken by surprise
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personal issues or triggers intrude
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you are physically unwell
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you feel helpless and hopeless about the situation
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your own family, children, or people that you know are involved.
Important training point Facilitator note: It is useful to point out that everyone may have a self-control plan but that it may not always be able to be drawn upon.
Key points • Look for any triggers. • Identify what stage of the cycle of aggression the person is in and use appropriate strategies to manage the person. • Be aware of your own bodily response and always use your own self-control plan.
Suggested break time
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MODULE 2 Aggression minimisation in high-risk environments
Part 4 Managing aggression in high-risk environments Show overhead slide
Session time 80 minutes
Session overview This part discusses the core values and skills required to manage aggressive people. Short and long-term strategies are discussed to both prevent and manage aggression in high-risk environments. Finally, the protective factors involved in an armed hold-up or hostage situation are identified.
Explain and discuss Core values and skills Paterson and Leadbetter16 suggest the following five core values and skills that staff need to possess when managing aggressive behaviour: ●
Consistency in showing respect for the values and dignity of the individual.
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Empathic, non-judgmental approach.
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Honesty.
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Self-awareness.
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Effective communication skills.
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Facilitator instruction Facilitator: Emphasise respect and politeness. Good social skills are highly effective in preventing and minimising aggression. De-escalation communication skills are really basic commonsense. ●
Be honest – don’t pretend you know what is going on if you do not. Tell the truth but do it in a way that is sensitive – be truthful but not brutal.
●
Communication depends on having your undivided attention. Listen to the person’s need. De-escalation does not necessarily mean you are talking – listening is a key communication strategy.
Explain and discuss To enhance relationships: ●
treat the person as an individual
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listen to others and make them feel comfortable about their problems
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enable others to have input into decisions
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spend time to help establish needs (patients and others)
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provide choices
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provide reasons for decisions
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assist with needs other than medical treatment.
Ask the group Ask the group: Identify three key factors that may be associated with an individual’s escalation toward frustration and aggression.
Answers Examples:
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Indifference of staff.
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Waiting times.
●
Not having issues adequately explained.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Show overhead slide
Explain and discuss Options when a person has been identified as being high-risk The outcome of your response options should be either to: ●
eliminate risk
or ●
reduce the risk to the lowest possible level.
It is important that all staff be aware that a range of options exist when faced with aggressive or violent individuals. 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 members involved. This may include calling for back-up, security or local police.
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Show overhead slide
Explain and discuss Short-term options Some short-term options for dealing with aggression may include the following. The order in which they are used or the appropriateness of the strategy depends on the specific situation. 1. Issue a verbal warning
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss In the face of verbally aggressive or abusive behaviour, it may be appropriate to issue a warning. If the staff member feels unable to do this, it is not appropriate to the situation, or that it will further inflame the situation, back-up should be sought. If the situation does warrant issuing a warning, this should be done in a calm, respectful, ‘informative’ manner.
2. Use communication skills
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Staff should remain calm, listen to the individual’s concerns in an empathic, non-confronting manner, emphasise their desire to help, try and make the individual more comfortable and utilise accompanying friends/relatives if appropriate.
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Important training point The key issue is trying to meet the needs of a person. Recognise that you cannot always meet their needs.
Explain and discuss Key crisis communication factors and techniques: Ask: ●
Who is in danger?
●
What has caused this?
●
What does the aggressive person want?
NEGOTIATION SKILLS: Try to provide as many choices as possible and help the person feel in control.
Explain and discuss Remember that the majority of people don’t reach crisis. If they are verbally abusing you, generally they are angry at the system. Stalking behaviour, intimidation and other anti-social behaviours should be immediately reported to the police. Usually this type of behaviour doesn’t respond well to advanced communication skills. Often there is a demand and a subtle or unsubtle threat. In this case, using minimal monotonic responses that do not engage with the person can be effective. Your statements need to reinforce acceptable behaviour and emphasise limit setting around inappropriate behaviour.
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3. Decide to stay or leave
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss If the individual fails to respond to verbal warnings or the situation escalates, staff should seek back-up and/or retreat if necessary. If staff feel unsafe at any time, they should call for back-up. You should always go and get help if you retreat. Remember that you still need to consider the safety of others.
4. Medication management
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss If the aggressive person is a patient and the aggression is deemed to be the result of a clinical condition, it may be considered appropriate to administer medication to this person. Oral medication should be initially offered if appropriate and if this is declined, then intramuscular or intravenous medication may be given.
5. Duress response options and calling for back-up
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Facilitator note: Ask participants about the duress alarm in their area. Explain that duress alarms do not reduce the incidence of aggression. However, they may reduce the likelihood or severity of injury when appropriately used.
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Explain and discuss Back-up
Depending on the level of perceived threat, imminence or actuality of violence, effects of the behaviour on others, availability of support and local protocols, back-up may include: ●
calling on a more senior staff member or clinician – in some circumstances, this may be enough to calm an aggressive patient and also allow for a clinical assessment if warranted
●
contacting security staff – the presence of security staff may act as a deterrent and/or assist in the protection of staff and visitors
●
using the duress alarm or initiating the duress response
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calling police or other external security services
●
withdrawing to a safer location.
6. Defending self
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Explain and discuss Staff are entitled by law to protect themselves or another from a threat of attack or injury. The protection afforded by the law is however limited to situations where there is an immediate or imminent threat or attack (see relevant section in Module 1 for background reading).
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Small group exercise Case study A seventy-eight year old patient is in intensive care after suffering a cardiac arrest. He has been in for two days and has improved only slightly. He begins to become agitated, and as the morning progresses he becomes louder, calling for the doctor and his wife, saying he wants to go home because he will be better off there. Attempts by the staff to calm him are not successful and he begins to lash out at staff as they approach him. He tries to climb out of bed saying that his taxi is out the front waiting for him. He is pulling at his IV line and repeats that he will miss his taxi if staff don’t get out of the way.
Which short term options would be useful in managing this patient? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Facilitator instruction It is useful to re-cap each of the short-term options and discuss how they may or may not apply to this case.
Show overhead slide
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MODULE 2 Aggression minimisation in high-risk environments
Explain and discuss Long-term options Important training point Facilitator: Emphasise that long-term response options are focused on the problem behaviours being displayed, not the illness. They will also vary depending on whether the source of aggression is a patient, visitor or intruder.
1. Written warnings
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss
Background reading Depending on the circumstances, it may be appropriate to issue a letter of warning to a patient or visitor who has exhibited repeated aggressive or violent behaviour and where verbal discussion with the patient has failed to resolve the situation. A number of factors will need to be considered in determining whether a letter is appropriate, or whether it is necessary to utilise other risk control strategies, eg a conditional treatment agreement. These factors may include: ●
frequency, nature and severity of the behaviour
●
circumstances surrounding the behaviour
●
extent of exposure of staff, visitors and others to the behaviour
●
level of threat or risk the behaviour presents to others
●
patient’s or visitor’s ability to comprehend the issues associated with their behaviour
●
patient’s or visitor’s capacity or ability to modify his/her behaviour
●
patient’s or visitor’s ability to read and understand English.
Document must have the signature of the unit manager, facility manager or area health service chief executive officer as most appropriate.
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2. Conditional treatment agreements
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss
Background reading In some circumstances it may be necessary to establish a conditional treatment agreement with the patient. Such circumstances may include where the patient has a history of repeatedly: ●
presenting for treatment under the influence of alcohol or other drugs, leading to aggressive, violent or disruptive behaviour
●
being accompanied by groups of friends/relatives significantly disrupting the treating environment
●
being accompanied by persons with a history of aggressive behaviour towards staff or others
●
presenting in an aggressive manner late at night or at change of shift times and disrupting the treating environment
●
regularly threatening, attempting or perpetrating violence against staff or other patients.
Depending on the individual circumstances, the following conditions may be considered for inclusion when developing conditional treatment agreements:
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Clearly articulated behavioural requirements (the patient and those accompanying him/her need to understand what behaviour is required).
●
Stated results of the patient’s failure to comply, eg treatment may need to be provided in different ways/times, visitors may not be permitted, etc.
●
Where the treatment will be provided, eg at what facility and at what location within that facility.
●
Specified time/s.
●
Who will accompany the patient, eg a friend/relative with a calming influence.
●
Who will not accompany the patient, eg friend/relative who is regularly threatening or aggressive towards staff, other patients.
●
The condition of the patient and those accompanying the patient, eg not under the influence of alcohol.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
The conditional treatment agreement should: ●
be developed in consultation with the patient and other relevant stakeholders, eg guardian, relatives, treating staff, security, etc
●
not be discriminatory, eg focuses on behaviour, not condition, race, etc
●
be regularly reviewed according to an agreed timetable (from both a clinical and practical perspective)
●
be reviewed when there are changes in the patient’s circumstances, eg moves to a different residential location, condition/behaviour improves, etc
●
focus on the ability to provide meaningful treatment in an appropriate facility and a safe environment
●
include an appeals mechanism.
Conditional treatment agreements should be negotiated with patients as far as possible. They should form part of broader risk control strategies aimed at protecting staff, patients and visitors from violence, while at the same time, as far as possible, allowing for appropriate treatment to be administered in a therapeutic environment.
3. Conditional visiting rights
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Facilitator instruction These usually apply to relatives or other visitors to a health facility and may be considered as a long-term option for repeated problem behaviours.
4. Exclusion from visits
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Facilitator instruction These usually apply to relatives or other visitors to a health facility and may be considered as a long-term option for repeated problem behaviours.
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5. Flagging and patient alerts
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss
Background reading File flagging ●
Used to identify patients who pose a risk to the health and safety of staff and other patients. Enables staff to be aware of the patient’s tendency to become violent.
●
The criteria to meet the need for a flag needs to be linked to violence and safety issues because of the person’s behaviour, not simply because of the person’s medical diagnosis.
●
The flagging of a file may result in the person being provided with service in a different manner than other patients. This may even, in extraordinary cases, include an inability to supply the service in certain circumstances.
Relevant legislation Anti-Discrimination Act 1977
The Anti-Discrimination Act provides for the making, conciliation and/or determining of complaints about ‘unlawful discrimination’. Under the Act, it is unlawful to discriminate on the grounds of race, sexual preference, transgender status, marital status or disability. Disability includes mental illness and infectious disease status. The Act states that it is unlawful for a person to refuse to provide goods and services to another person on the grounds of a disability, or to place terms on provision of those goods and services on the grounds of disability.
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Privacy and Personal Information Protection Act 1998 (PPIPA)
Since July 2000, the NSW public health system has been subject to privacy obligations under the above Act. It provides a comprehensive code designed to regulate the collection, use, storage and disclosure of information that can identify a person. It also includes the obligation to ensure that any information that is used is relevant, accurate, up to date, complete and not misleading. Under the Privacy and Personal Information Protection Act 1998 (PPIPA), disclosure of personal information is permissible provided it is necessary ‘to prevent or lessen a serious and imminent threat to the life or health of the individual to whom the information relates, or another person’. Any patient-alert system must therefore incorporate these criteria. Under both PPIPA and the Freedom of Information Act, patients have the right to know what is on their file and can request to view their file. There are exceptions to this, generally limited to circumstances where giving access to the information may have an adverse effect on the physical or mental health of the person concerned. Under section 15 of PPIPA, agencies have an obligation to ensure information used is ‘relevant, accurate, up to date, complete and not misleading’. This has two implications for local file flagging procedures. Firstly, it emphasises the need to ensure an accurate assessment of the patient that will support the flagging of the file. Secondly, it reflects the importance of ongoing review to ensure that any flag placed on a file is currently relevant. Patients also have the right to request that their file be amended and this would apply to a flag inserted into a file. If the request is refused, the patient can seek that a notation be placed on their file outlining their concern, without erasing the flag information completely. Retention of a flag that is no longer accurate will have implications under PPIPA and possibly the Anti-Discrimination Act. Thus, an active flag should not remain on a file once the risk is no longer current. A process to review and remove flags as appropriate is critical to any flagging system. Any file flagging system needs to be supported by related management plans. If a patient file has a flag for any reason, this needs to be supported by an up to date management plan that enables those managing the presenting patient to do so in a timely and appropriate manner.
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Facilitator instruction Discuss local policies and procedures on file flagging. In summary, the following issues need to be covered in local file flagging policies: ●
Clearly defined purpose for the flag, eg to protect the health and safety of treating staff and/or other patients.
●
Who is to be covered by the flag, eg patient only, family, regular visitors (as it is not only patients who may provide a significant threat).
●
Readily accessible patient management advice that supports the flag, eg how to manage the patient so that violence is prevented.
●
Clearly defined scope of who has access to the information, eg facility wide, AHS wide, other agencies.
●
Clear criteria for the particular flag, eg need to focus on staff and patient safety issues, be clearly related to violent or aggressive behaviours and avoid use of criteria based on impairment or condition. Avoidance of stigmatisation of particular individuals or classes of individuals, ie it needs to focus on behaviours and possible outcomes of those behaviours.
●
Review of flags for ongoing relevance, ie needs to be regular enough to ensure that the flag is still current.
●
Regular review of management plans for continued appropriateness, ie should be part of the flag review indicated above, though may need to be reviewed more regularly if they are not meeting the flag’s purpose or there is a change in the patient’s circumstances.
●
Clear responsibility for initiating, reviewing and removing flags.
●
Clear responsibility for reviewing and updating associated management plans.
6. Individual patient care plans
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss These will set out who is treating the patient, what the crisis care strategies are, identified goals and methods for achieving these goals. These plans are often used for suicidal or parasuicidal patients.
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7. Inability to treat
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Explain and discuss Background reading Despite the options available for managing violent patients, there may be, on rare occasions, and usually as a temporary measure, a situation where it is almost impossible to treat a patient without significant, unacceptable risks to those involved. Depending on the circumstances surrounding this situation, options may include: ●
deferring treatment where possible (if not life threatening) to a time when the risks are better able to be managed, eg when more suitably skilled and experienced staff are available, or when the patient is more settled
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arranging for treatment to be carried out in a different, more secure location
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the option not to treat (at that time or at that location) would only arise after all of the above mechanisms have been investigated to their full capacity, and should always be a last resort unless immediate escape from a violent event is necessary.
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8. Apprehended violence orders (AVO)
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Explain and discuss Background reading Where a staff member fears that there may be future violence, harassment or intimidation from someone they have been exposed to in the workplace or in the course of their work, regardless of whether charges of assault are being laid against the person, the staff member may seek to take out an Apprehended Violence Order (AVO). An AVO is an order made by the court to protect people from abuse, violence or threats of violence. They can also be applied for if someone is being stalked, intimidated or harassed, or has reason to fear that they may be in the future. The AVO is an agreement between the defendant and the court that the defendant will not engage in certain behaviours. It usually states that the defendant cannot assault, harass, threaten, stalk or intimidate the person seeking the order (the complainant), or go within a certain distance of their home or workplace. Other orders can be included if necessary. There are two types of AVO. An Apprehended Domestic Violence Order (ADVO) is made where those involved are related, have lived or are still living together or are in an intimate relationship. An Apprehended Personal Violence Order (APVO) is an AVO made where the people involved are not related and is the one most likely to apply in workplace violence situations.
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9. Laying charges
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Facilitator instruction It is helpful to reinforce this as an option. You may wish to elicit recent local examples of patients or visitors being charged.
Small group exercise Case study Jan, a community nurse, was on a routine visit to check up on a six-month-old baby. The baby’s father sells drugs and when Jan arrives on one of her visits a group of young, intoxicated males comes out of the kitchen, traps her and begins to threaten her. At this point, the baby’s mother comes out and intervenes and Jan runs out shaking and drives back to the community health centre.
What are the long-term response options for this incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Facilitator instruction It can be useful to review all the long-term options and consider which ones may be used in this case.
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Small group exercise Case study A person brought in her hurt five-year-old child with a head injury. She was very agitated and one of the staff noticed that an alert was flagged on her file with regard to a risk for aggression. The staff called security and the child was removed from the care of the person because they suspected the person caused the injury. The person then became very aggressive and assaulted security.
What are the short-term response options for this incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Facilitator instruction It can be useful to review all the short-term options and consider which ones may be used in this case.
Show overhead slide
Explain and discuss Strategies during hostage or armed hold-up situations When faced with a hostage or armed hold-up situation your priorities are:
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safety of self
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safety of others.
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Important training point Facilitator note: Hostage and armed hold-up are different situations. In a hostage situation, you are restrained for a period of time for the purpose of bargaining. In an armed hold up situation, you are usually involved for a shorter period of time. In both situations, the usual communication skills should not be used.
Explain and discuss The following principles apply: ●
If someone is pointing a gun in your direction, behave as if the gun is loaded and real, even if you have some doubts.
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Remain calm.
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Control your emotions, avoid eye contact, do not stare and avoid sudden movements.
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Do not attack the intruder or touch anything they have touched.
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Take note of intruder’s clothing and any other distinguishing features, but do not stare.
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If safe to do so, activate an alarm.
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Attempt to stay facing the person.
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Do not threaten the person in any way. This may mean that if you are a tall, large person, you may need to stay seated as long as possible so that you don’t present yourself as a threat.
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Comply with all demands that are not likely to cause harm, eg if the demand is for the key to the car – give them the key. If the demand is for the contents of the drug cupboard – give them the contents. Not meeting these demands will threaten your safety.
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Do not comply with unreasonable demands. Examples of unreasonable demands might include being ordered to jump out of a high window where the risk of death is high.
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Do not give them information about other people taken hostage.
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If taken hostage, do not draw attention to yourself, eg do not try to assert yourself. If someone is to be harmed, the people most often chosen are those of privilege or those who have been non-compliant or irritating.
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If involved in an armed hold-up, do not chase the person when they attempt to escape as this puts you at greater risk of harm.
Explain and discuss Generally speaking, Australian response units tend not to storm hostage or hold-up situations. The current strategy is to wait-out these situations. Hostage negotiators will typically not mention or refer to the people taken hostage in order not to raise their importance in the aggressor’s eyes.
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Key points • Always show respect and dignity for others. • Use effective communication skills. • Treat people as individuals, not as problems. • Know your short-term and long-term options.
Show overhead slide
Facilitator instruction Facilitator note: ●
Recap the importance of safety.
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Recap the impact of aggression on the individual.
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Recap self-care: monitor intake of caffeine, cigarettes, alcohol (remember their impact on the immune system).
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Reinforce mindfulness and stress reduction strategies.
Important training point Facilitator note: to conclude the session reinforce the zero tolerance attitudes and behaviours.
Assessment exercise is now facilitated Details of the assessment are at the front of the module.
Show overhead slide
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Related NSW Health policies and guidelines a.
Mental Health for Emergency Departments, May 2002 (red book).
b. Management of Adults with Severe Behavioural Disturbance, May 2002 (green book). c.
C2003/88 Reportable Incident Briefs to the NSW Department of Health.
d. C2001/22 Workplace Health and safety: A Better Practice Guide (currently under review). e.
C2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace.
f.
C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination.
g. NSW Health Security Manual. h. NSW Health Zero Tolerance Policy and Framework Guidelines. i.
IB94/4 Restraint of Children and Adolescents in Psychiatric Facilities.
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References 1. 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. 2. Bell DM, Espie CA (2002). A preliminary investigation into staff satisfaction, and staff emotions and attitudes in a unit for men with learning disabilities and serious challenging behaviours. British Journal of Learning Disabilities 30 (1), 19-27. 3. Chaplin E, Allison G (1998). The prevention and management of violence in the community. British Journal of Community Nursing 3 (6), 277-282. 4. Claravall L (1996). Health care violence: a nursing administration perspective. Journal of Nursing Administration (26) 2, 41-46. 5. Delaney J, Cleary M, Jordan R, Horsfall J (2000) An exploratory investigation into the nursing management of aggression in acute psychiatric settings. Journal of Psychiatric and Mental Health Nursing 8 (1), 77-84. 6. Fry AJ, O’Riordan, Turner M, Mills KL (2002). Survey of aggressive incidents experienced by community mental health staff. International Journal of Mental Health Nursing 11, 112-120. 7. Hunter E (1997). Violence prevention in the home health setting. Home Healthcare Nurse 15 (6), 403-409. 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. Jones J, Lyneham J (2000). Violence: part of the job for Australian nurses? Australian Journal of Advanced Nursing 18 (2), 27-32. 10. Martin E (1995) Nursing the psychiatric emergency. London, Butterworth, Heinmann. 11. 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. 12. 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. 13. 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. 14. Mental Health Council of Australia (2000) Enhancing relationships between health professionals and consumers and carers. Final Report. NSW Health
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15. NSW Interagency guidelines for child protection intervention, 2000. (online). Available www.kids.nsw.gov.au. 16. Paterson B, Leadbetter D (1999). De-escalation in the management of aggression and violence: towards evidence-based practice. In Turnbull J, Paterson B (eds) Aggression and violence: approaches to effective management (pp 95-123). Basingstoke: Macmillan. 17. Shah A (1999). Aggressive behaviour in the elderly. International Journal of Psychiatry in Clinical Practice 3, 85-103. 18. Zook R (2001). Developing a crisis response team. Journal for Nurses in Staff Development 17 (3), 125.
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Module 2 AMT002 Aggression minimisation in high-risk environments Facilitator manual
NSW Health is a zero tolerance zone
NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel.
(02) 9391 9000
Fax.
(02) 9391 9101
TTY. (02) 9391 9900 www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the NSW Department of Health. © NSW Department of Health 2003 SHPN (CMH) 030136 ISBN 0 7347 3557 X July 2003 updated August 2004
MODULE 2 Aggression minimisation in high-risk environments
Contents Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Overview of the manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modular structure of the aggression minimisation program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How the manual is set out. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Facilitator preparation before training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sequence and timing of the modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 3 4 6 6 7 8
Introduction to Module 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 How Module 2 fits into the whole program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Assessment to Module 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NSW Health preventing and managing aggression in the Health workplace Assessment conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self assessment checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peer assessment checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Session plan for Module 2 . . . . . . . . Materials. . . . . . . . . . . . . . . . . . . . . . . Equipment required. . . . . . . . . . . . . . . Participant requirement . . . . . . . . . . . . Beginning the training session . . . . . . . 1. Welcome participants to the module 2. Housekeeping. . . . . . . . . . . . . . . . . 3. Outline principles of adult learning . .
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Background information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Part 1 Working in high-risk environments. . . . . . . . . . . . . . . . . . . What are high-risk environments? . . . . . . . . . . . . . . . . . . . . . . . . . . . Why are they high-risk? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zero tolerance approach to aggression . . . . . . . . . . . . . . . . . . . . . . . Some legal and ethical issues and scenarios in high-risk environments
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Part 2 Prevention in high-risk environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Keeping your area secure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Some principles for recognising and dealing with unauthorised visitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Working in the community and outreach environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Working in isolated areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 How to maintain safety when approaching a person with the potential for aggression. . . . . . . . . . . . . . . . . . . . . . . . 54 Ensuring the safety of self and others when interviewing patients or others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Part 3 Understanding aggression in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Triggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cycles of aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some possible responses at each stage of the aggression cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self-control plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part 4 Managing aggression in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Core values and skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Options when a person has been identified as being high-risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Short-term options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Long-term options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Strategies during hostage or armed hold-up situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 NSW Health
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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 2001.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.
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Introduction NSW Health: Preventing and managing aggression in the Health workplace What is it? A number of key projects have flowed from the work of the Violence Taskforce. One of these is the development of a statewide, appropriately accredited aggression minimisation training program. The focus of this training is to provide staff with the most up to date strategies, skills and techniques to prevent and minimise workplace aggression and violence. It is also based on relevant task force findings and incorporates key task force initiatives. The program includes a basic module for all staff identified as being at risk of workplace violence, a module for staff working in high-risk environments, a module designed specifically for managers and a refresher module.
What materials are provided? A CD-ROM is available and includes: ●
Facilitator manual: Modules 1 through to 4 (in Acrobat PDF format).
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Participant manual: Modules 1 through to 4 (in Acrobat PDF format).
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Powerpoint slides for Modules 1 through to 4.
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Recognition of prior learning forms and assessment of competency forms (as a separate Acrobat PDF format).
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Assessment scenarios and Question sheets for Module 1 (as a separate Acrobat PDF format).
All of the above are included on the CD.
Who will attend? Module 1 should be attended by all staff identified as being at risk of workplace violence, and generally speaking is a prerequisite for all other modules. More detailed advice on the application of this training is provided in the covering circular. Attendance at additional modules is recommended for staff determined by the Health Service to be at higher risk of workplace violence and includes, but is not limited to, security, mental health, Emergency Department, admissions, drug and alcohol, disability services, brain injury and aged care staff. All managers of staff identified as being at risk of workplace violence should attend the manager’s module and all relevant staff should attend the refresher module at least every two years. Health Services may determine that some groups need to attend the refresher more regularly.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Overview of the manual This manual has been developed to provide educational resources for a facilitator to deliver a comprehensive education program in aggression minimisation. The manual is divided into four training manuals. Facilitators must have each of the following: 1.
Certificate IV in Assessment and Workplace Training.
2.
Experience in working in areas of significant violent risk.
3.
Experience in effectively managing violent incidents.
4.
An ability to relate to staff at all levels of the organisation.
Modular structure of the aggression minimisation program 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. The day is divided into four parts: 1.
Working in high-risk environments.
2.
Prevention in high-risk environments.
3.
Understanding aggression in high-risk environments.
4.
Managing aggression in high-risk environments.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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Module 3 90405NSW – Course in aggression minimisation for managers This four-hour module is designed for managers of health units and facilities. It provides the participant with 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. The day is divided into three parts: 1.
The legal and policy framework for managing aggression.
2.
Promoting an aggression-free workplace.
3.
Assisting staff when aggression and violence occurs.
Module 4 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. The day is divided into four parts: 1.
The zero tolerance response.
2.
New developments in preventing and managing aggression and violence.
3.
The prevention of aggression and violence.
4.
Managing aggression and violence.
How the manual is set out The Facilitator manual is divided into the four modules. All facilitator notes throughout each module look like this. Basic course content in the Facilitator manual duplicates that found in the Participant manual. This course content forms the basic syllabus of the training and the trainer needs to know this material prior to conducting training. For each module, at the beginning of each section the relevant page number in the Participant manual is noted. Relevant slides that should be shown at each point are reproduced throughout this manual.
Layout icons The following symbols have been used throughout the Facilitator manual to assist in the presentation of material. In all cases, trainers should use their discretion in the presentation and timing of material depending on the mix of staff in the training group. Where possible, flexible delivery is encouraged and specific recommendations are made at the beginning of each module.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 2 Aggression minimisation in high-risk environments
Key points
Key points help you to summarise the major themes and information from the section. Explain and discuss
This icon suggests that you will need some verbal explanation and discussion of this concept or topic. Background reading
This icon appears when further background information and reading is supplied on a topic to assist the facilitator in understanding and delivering the training course. It should be read before the facilitator conducts any training. The background information may be verbally summarised by the trainer as the need arises. Ask the group
Whenever this icon appears in the manual a large group activity is suggested. Facilitators should ask the suggested question to the group as a whole and elicit answers or suggestions as appropriate. Participants may choose to write answers in the space in their manuals. Small group exercise
This icon represents small group activity. Whenever this icon appears in the manual a small group activity is suggested. Facilitators may get the group to break into smaller groups of two to five participants to discuss the question, before reporting back to the group as a whole. Participants may choose to write answers in the space in their manuals. Individual reflection exercise
This icon represents personal reflective activity. Whenever this icon appears in the manual personal reflection is suggested. Individual participants may complete this exercise alone. The facilitator may then choose to address the question to the group as a whole and collect responses from individuals. Participants may choose to write answers in the space in their manuals. Answers
Suggested answers to the individual, small and large group activities are provided. These amplify and reinforce the subject material covered in the Participant manual. Important training point
Important training points are highlighted with this symbol. You are on Participant manual page X
These icons assist you to keep the training program in sequence with the Participant manual. It is suggested that you regularly refer participants to the relevant page in their Participant manual for further information or to complete an activity.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Show overhead slide
Suggested place to present slide. Facilitator instruction
Specific training hints are given here. Write responses on board
Suggested place where the trainer may wish to reinforce points or collect responses from the group on a whiteboard/blackboard/butcher’s paper. Session time
Suggested times to conduct sessions are given and a session plan is provided for each module. These are to be used flexibly to meet the needs of trainers and participants. Session overview
An overview of the session is given here. Suggested break time
Suggested breaks are provided. These are flexible. Readings and resources
Additional readings and resources are highlighted here and should be read prior to commencing training.
Facilitator preparation before training Before running this training it is important to be familiar with: ●
All NSW Health documents and policies relating to aggression minimisation, prevention and management (see reference lists at the end of each module).
●
All local policies relevant to aggression minimisation. These will include documentation and emergency responses relating to aggression minimisation, prevention and management, eg duress response, reporting protocols.
●
It is helpful if you have an awareness of recent incidents in your area, where these have been a particular problem, and the outcome. This enables the training to be more relevant for participants.
●
Facilitators need to familiarise themselves with the reference list at the end of the modules.
Sequence and timing of the modules The individual modules do not need to be taught together as a block. The space between teaching individual modules may be separated by weeks or months. It is important to consider the retention of information from previous training and be ready to reinforce previous training material, particularly from Module 1. Each module contains some common material from other modules to help reinforce basic concepts, eg zero tolerance. Module 1 forms the prerequisite for the other modules so needs to be made available to participants prior to offering the other modules.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Assessment of competency Assessment activities accompany Modules 1-4 to facilitate demonstration of competency. Facilitators should ensure that training outcomes for each participant are appropriately documented. Recording forms accompany the Facilitator manual.
Flexible delivery The materials in this training program provide a core recommended syllabus for preventing and managing aggression in all NSW Health facilities. Each module has a set of learning outcomes and corresponding assessments. The training is designed in a modular format to allow ease of delivery, however it is possible that the training may be delivered using flexible delivery methods. Examples of how the training could be altered include (but are not limited to) the following: 1. Dividing a full day module into two parts, spread over two half days. 2. Emphasising some components of training over others for specific groups. For example, if the participant training group is non-clinical then the trainer may decide to focus more on communication strategies and bullying, harassment and discrimination than on some of the components that are more relevant for clinical staff. 3. Flexibly incorporating materials from other local training programs that overlap with the learning outcomes and provide additional training. 4. Shortening a module by providing advance reading materials and exercises to be reviewed in the participants’ own time and reinforced and assessed in the workshop. However, the trainer will need to determine that this approach is appropriate for the participant group. In considering flexible delivery options, it is important to ensure that the learning outcomes are met as set down in this program.
Recognition of prior learning Recognition of prior learning can be considered for this training. The relevant forms for recognition of prior learning accompany the Facilitator manual. Recognition of prior learning is based on the following: ●
Competence – a focus on the competencies an individual has acquired as a result of any formal or informal training and experience.
●
Commitment – to recognise prior learning of individuals, therefore individuals will not have to duplicate their training unnecessarily.
●
Access – every individual may have his or her prior learning recognised.
●
Fairness – that the recognition of prior learning process is fair.
●
Support – is provided for individuals in applying for recognition of prior learning. Certificate IV workplace trainers and assessors must provide support so that an efficient and effective service is maintained.
Portfolio documentation Appropriate documentation is to be filled in and evidence collected to be submitted with the application form. All documentation should be submitted as a portfolio. See below for types of evidence to be collected and included in a portfolio.
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Evidence guide The following is a guide for the evidence to be provided for recognition of prior learning. For each item of evidence you will need to indicate which part of the item is relevant to which learning outcomes. The following types of evidence may be collected: ●
Formal accredited certificates of previous training programs attended, or transcripts of courses of study.
●
Authenticated reports on activities participated in, relevant to aggression minimisation.
●
Certified evidence of discussions of case studies that shows evidence of having attained learning outcomes.
●
Authenticated reports of work, skills and experience in responding to aggressive behaviour.
Other resources Participant manual A Participant manual is also available and should be used during the training. Participants are to use the manual during the training session, but also should take it away as a resource. There is additional information in the Participant manual, and it is not expected that every point can be covered during the training sessions. The training provides an orientation to the major issues in aggression minimisation and points the participant to further readings and resources in the area.
Lecture slides The CD-ROM contains the full set of Powerpoint slides. The Powerpoint slides can also be printed and transferred to overhead transparencies as needed.
Forms The CD-ROM contains the recognition of prior learning forms and the assessment of competency forms.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 2 Aggression minimisation in high-risk environments
Introduction to Module 2 How Module 2 fits into the whole program Module 2 is the second of four modules dealing with aggression prevention, minimisation and management. It builds upon Module 1. The material in Module 1 is assumed knowledge for this module, and recent completion of Module 1, or its equivalent, is a pre-requisite for completing Module 2. This module is focused on the needs of staff working in high-risk areas where there is often a higher prevalence of aggression. The module is designed to address more complex issues regarding responses required to minimise aggression. Other modules focus on managerial responsibilities and refresher training. Facilitators need to reinforce information from Module 1, such as prevention and the risk management approach.
Structure of Module 2 ●
Part 1 – Working in high-risk environments – the nature of high-risk and some legal and ethical issues governing work in these environments.
●
Part 2 – Prevention in high-risk environments – including guidelines for improving safety and security.
●
Part 3 – Understanding aggression in high-risk environments – including emotional and physical responses to escalating incidents.
●
Part 4 – Managing aggression in high-risk environments – including detailed short and long-term response options.
●
Part 5 – Assessment of competency and review.
Session times These times are flexible: Part 1 80 minutes Part 2 80 minutes Part 3 80 minutes Part 4 80 minutes Part 5 60 minutes NB. A session plan is provided at the beginning of Module 2.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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Training room requirements The training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual. Equipment required: projection facilities for power point slides (or an overhead projector if the slides have been printed on overheads), a whiteboard and whiteboard pens (for writing up feedback from participant exercises). Participants will need pens or pencils for writing in their copy of the Participant manual.
Module overview This eight-hour program is designed for staff working in high-risk areas, eg emergency, security, mental health, 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.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Assessment for Module 2 NSW Health preventing and managing aggression in the Health workplace Module 2 Aggression minimisation in high-risk environments – AMT002
Learning outcomes
Assessment questions
1. Identify the legal and ethical issues governing aggression.
Question 1
2. Identify safety strategies in responding to and managing aggression.
Question 4
3. Identify the triggers for aggression and stages in the cycle of aggression.
Question 2 and 3
4. Identify personal safety strategies when working in the community and outreach environments.
Question 8
5. Use communication skills to contain and reduce high tension situations.
Question 5
6. Identify short and long-term options for managing an aggressive person.
Question 6 and 7
Assessment method This assessment is designed to be a learning tool and the learning outcomes are to be assessed through peer and self assessment. Participants are to work in pairs and each is to choose a scenario that is different from their partner. Each participant then directs the questions to their partner and assesses their partner’s responses using the Peer assessment checklist. The partner is also given the opportunity to assess his or her own responses using the Self assessment checklist. When this is completed participants are to change roles and repeat the process for the other member of the pair. Participants may choose to jot down dot point answers in the column provided in the relevant checklist, though this is not mandatory. On completion of this task, participants are to discuss what difficulties they may have experienced in answering the questions relating to their scenario. Following this, the group of participants are to be debriefed and asked what areas they found difficult. Participants should subsequently be provided with possible strategies that could be used to overcome such difficulties. Participants who had problems answering a question should be given an opportunity to answer the question again.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
There are five critical aspects of the assessment relating to four of the assessment questions. The questions have been designed to align with the critical aspects of the assessment. Participants are deemed competent if they demonstrate the correct responses to these questions. The critical aspects of the assessment are identified in the marking guide (checklists).
Assessment conditions Participants will be provided with a case scenario and assessment questions at the completion of training. The facilitator is to inform the participants that they should put themselves in the place of the health worker in the scenario. Participants are to be informed about how the assessment should be carried out.
Assessment resources ●
Case scenarios
●
Assessment questions
●
Peer and self assessment checklists
NB. Assessment questions, Peer and Self assessment checklists and Case scenarios are shown below and can also be found as a separate Acrobat PDF document on the CD-ROM, in order that the assessment questions, checklists and scenarios may be printed out and handed to participants.
Assessment questions 1. What are the legal issues that need to be taken into account in this scenario? 2. What are the possible triggers for this aggressive incident? 3. At what stage in the cycle of aggression is the person in? What are the behaviours of the aggressive person that support your choice? 4. How would you ensure the safety of yourself and others in this situation? 5. What communication skills would you use in this situation to attempt to de-escalate the person’s aggressive behaviour? 6. What might be some short-term options for managing this aggressive incident? 7. What might be some long-term response options that may be used to manage this aggressive person in the future? NB. The following issue may not relate to the scenario, however all participants are required to respond to the question.
8. Identify several strategies to ensure your safety when visiting the community or housing settings for each of the following: ● Prior to leaving the office. ● During the visit. ● Working alone after hours.
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MODULE 2 Aggression minimisation in high-risk environments
Self assessment checklist Yes
No
Unsure
Brief description of response (optional)
Identified legal issues. Identified the triggers for aggression. Identified the stage of the assault cycle and supporting behaviours. Identified personal safety strategies when responding to and managing an aggressive person. Identified appropriate communication skills. Identified short-term response options. Identified long-term response options. Identified safety strategies: Prior to leaving the office. During the visit. When working alone after hours.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Peer assessment checklist Yes
No
Unsure
Brief description of response (optional)
Identified legal issues. Identified the triggers for aggression. Identified the stage of the assault cycle and supporting behaviours. Identified personal safety strategies when responding to and managing an aggressive person. Identified appropriate communication skills. Identified short-term response options. Identified long-term response options. Identified safety strategies: Prior to leaving the office. During the visit. When working alone after hours.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Scenarios Scenario 1 – Leanne Smith, 34 years old and health worker Leanne has a diagnosis of personality disorder and has a history of self-harming behaviour. She lives with her abusive boyfriend. Over the past few weeks, Leanne’s mother has been concerned about her daughter’s behaviour and today Leanne told her mother she was going to harm herself because her boyfriend threatened her. Leanne’s mother rings you and explains her concerns to you. When you arrive, Leanne’s boyfriend lets you in. Leanne is in the bedroom and does not want to speak to you, but does so reluctantly. She shows you some minor cuts on her arm, stomach and legs. Leanne becomes increasingly agitated and angry and threatens to harm herself with a knife. You want Leanne to go into hospital, however Leanne tells you that she was not happy with the way she had been treated in the past when in hospital. As you try to convince Leanne to come to hospital with you she starts to yell and abuse you, making threats on your life if you try to make her go into hospital.
Scenario 2 – Brian Green, 49 years old and health worker Brian has been in and out of hospital over the last fifteen years. He has a history of schizophrenia and co-morbid alcohol abuse. Brian has a history of aggressive behaviour that seems to be getting worse as his cognitive functioning is deteriorating. He is currently in hospital again and cannot quite remember why. Since Brian has been in hospital for a long period of time he now thinks it must be time to go home. He starts to pack his things when a staff member tells him he cannot leave the hospital. Brian abuses the staff member and throws a book at the staff member as they leave the room. The incident is reported to you and you go to see Brian. Brian appears to have settled down so you decide to enter. Brian becomes very confused and angry when you come in because he knows that you will try to stop him from leaving. He starts shouting at you to get out and punches you on the side of the head. As Brian attempts to grab hold of you, you push him aside.
Scenario 3 – Tony Little, 60 years old and health worker Tony’s wife fell over in the kitchen and received a deep cut on her forehead. On arrival to hospital, Tony’s wife was taken away to see the doctor and he was asked to wait and fill in some forms. Tony is an alcoholic and is intoxicated. He smells of alcohol and is mumbling under his breath. You are concerned about Tony’s behaviour and recognise that he has previously been in the hospital and has been abusive to staff. You call security to watch over Tony. After an hour of waiting Tony has not received any news on his wife. Tony is angry and asks you what is taking so long. You tell Tony to wait while you go and find out. When you return you tell Tony that someone will be out shortly to talk to him. Tony becomes very angry and says he is going in to see his wife. He pushes you out of the way and starts walking into a restricted area. You attempt to stop him by grabbing him on the arm.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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Scenario 4 – Peter Bond, 22 years old and health worker A friend takes Peter to hospital in the evening after he is involved in a fight. He had been bashed and has a head injury, as well as severe cuts and bruises on his face. He is taken to hospital and his friend waits in the waiting room. In the meantime, four youths walk into the hospital with a knife demanding to see Peter to ‘finish him off’. A staff member sees this and calls other staff and security. A youth approaches a staff member and grabs them by the arm and demands to see Peter. The staff member panics and screams. You and two other security officers arrive and all the youths run off except for the one holding onto the staff member’s arm. You and the other security officers restrain the youth.
Scenario 5 – Mary Smith, 33 years old and health worker Mary has been hanging around in the car park with her boyfriend late in the afternoon. They have been watching a clinic which is located as a separate building in the hospital grounds. Mary has been a patient of the clinic and has previously been aggressive towards the staff. They leave the car park and return later in the evening. When they return Mary and her boyfriend attempt to break into the building. A staff member walking to their car sees them. The staff member alerts security and you and another security officer arrive. Mary does not see you or the other security officer, but her boyfriend does and starts to run off. Mary’s boyfriend is being chased by the security officer while you attempt to apprehend Mary. You grab her bag to look what is in it. While doing this Mary bites you on the arm and kicks you in the shins.
Scenario 6 – Barbara Hartland, 80 years old and health worker Barbara is confused all the time. Sometimes she does not understand what people are saying to her, where she is or what is going on. When Barbara’s family visit, she becomes argumentative as she does not recognise them. Barbara is on an hourly toileting program and you have been instructed to take her to the toilet. Today you are very busy because of staff shortage and have to attend to many patients. You are also slightly irritable. You approach Barbara and tell her you are taking her to the toilet. Barbara does not hear you properly, and you take her by the arm to lead her to the toilet. Barbara thinks that someone is trying to attack her. She becomes frightened and starts screaming for help. She tries to get away from you by throwing her arms around and waving her walking stick around. You call for help and you and other staff attempt to restrain Barbara.
Scenario 7 – George King, 79 years old and health worker George is seventy-nine years old and living alone since the death of his wife six months ago. He is very lonely and becomes quite confused at times. He has an ulcerated leg and is expecting you to call to do the dressing. You arrive at his house and start to set up the equipment. As you do so George dozes off. When you are ready to wake George you lean over to raise him in the chair. As you do this George thinks someone is trying to rob and hurt him. You try to reassure George and pull away from him. George does not hear what you said and tries to hit you. You move away telling George to ‘stop it’. George becomes frustrated, angry and waves his fist at you.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Scenario 8 – Sam King, 40 years old and health worker Sam is a patient in hospital and has suffered some neurological deficits as a result of a car accident. His memory is poor and he becomes easily frustrated and at times verbally aggressive towards the staff. You tell Sam that the doctor cannot come to see him now but will see him later. Sam forgets this and continues to repeatedly ask you when the doctor is coming. You tell Sam that you have already told him several times that the doctor would come later. Sam becomes abusive, insisting that you have not told him this. He thinks that no-one is interested in him and becomes frustrated and angry and punches a wall. He attempts to grab you but you push him aside causing him to stumble and fall.
Scenario 9 – Ken Jones, 36 years old and health worker Ken is thirty-six years old and has come for his appointment with you. He is late and is agitated. Earlier on in the day he had an argument with his ex-wife over access visits to his children, and was not happy with the legal advice he received on this issue. He eventually sees you for his appointment and presents as angry and irritable. During the session with you, he becomes concerned about what is written in his file. Ken demands to see his file immediately and becomes very angry when you do not comply. He becomes argumentative, is not listening to you, and clenches his fists. He gets up, leans over, and grabs his file. You attempt to grab his file back, and Ken with his force manages to push you over. He picks up the file and runs out of the building. You start to run after Ken.
Scenario 10 – Frank Wells, 32 years old and health worker Frank has been given some bad news about his young child. Both he and his wife are very upset. Frank has had some recent personal problems, being made redundant at work and his mother passed away last year. Frank also has an anger management problem and when angry and frustrated usually punches a wall. Frank feels that the staff are not doing enough for his child and is very angry, hurt and upset. He cannot believe all the bad news he has had recently. Frank is pacing around, tense and very stressed. His wife is worried about Frank and his reaction. You come up to Frank to discuss the situation. Frank is not listening, pacing and abusive toward you. He yells, “You don’t know how I feel”. He begins to demand that another doctor see his son and is about to punch the wall. You try to calm Frank down which only causes him to become even angrier, and he threatens to harm you if you do not organise a doctor immediately.
Scenario 11 – Carly Hall, 33 and health worker Carly has been out drinking with her friends in the afternoon. She is moderately drunk and decides that she wants to visit a friend. Carly wants to know what room her friend is in. You tell her that it is not visiting hours. Carly demands that she be told what room her friend is in. You again tell her that it is not visiting hours, so you will not give her this information. Carly indirectly threatens you, saying that she will be back with her friends. You pick up the phone to call security, but Carly grabs the phone out of your hands and slams it on the counter and leaves.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Session plan for Module 2 Training session: Module 2 Aggression minimisation in high-risk environments
Time
Topic
80 mins
●
Introduction.
●
Working in high-risk environments.
80 mins
●
80 mins
Date: Time:
Learning outcomes
Content/activity
1
Small and large group discussions.
Prevention in high-risk environments.
2, 4 and 5
Small and large group discussions.
●
Understanding aggression in high-risk environments.
3 and 5
Small and large group discussions.
80mins
●
Managing aggression in high-risk environments.
6
Small and large group discussions.
60mins
●
Assessment of competency and review.
All learning outcomes.
Small and large group discussions.
Materials The training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual.
Equipment required ●
Projection facilities for Powerpoint slides (or an overhead projector if the slides have been printed on overheads).
●
A whiteboard and whiteboard pens (for writing up feedback from participant exercises).
Participant requirement Pens or pencils for writing in their copy of the Participant manual.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Beginning the training session Session time 20 minutes
Facilitator instruction To begin teaching this module you will need to do the following:
1. Welcome participants to the module You may wish to facilitate an introductory activity (ice-breaker). Example – have participants pair off and: ●
introduce themselves and the area they work in
●
discuss what they hope to gain from the training.
After a few minutes have passed re-assemble the group and ask each participant to introduce their partner.
Show overhead slide
2. Housekeeping Inform participants of the: ●
program times
●
breaks and meals
●
toilets
●
mobile phones
●
message board
●
occupational health and safety (fire escapes).
3. Outline principles of adult learning ●
Everyone’s opinion will be respected.
●
Participants’ work experience will be valued.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Show overhead slide
Explain and discuss Orient participants to how this module fits in with the whole program.
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MODULE 2 Aggression minimisation in high-risk environments
Background information Facilitator instruction The following is background information on the problem of aggression. Facilitators may wish to draw out some key points from this and refer to any local issues or data relevant to the problem of aggression and aggression management.
Aggression in the health service industry is a significant problem (Mayhew and Chapell, 2001a, 2001b, 2001c). This program aims to promote a working environment and practices which keep people safe from aggression. The goals of this training are to improve health care workers’ knowledge in relation to the major factors which contribute to safety and to gain knowledge and skills in responding to different instances of aggression.
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Explain and discuss Overview the four parts of this module.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Part 1 Working in high-risk environments Show overhead slide
Session time 60 mins
Session overview This section looks at what high-risk environments are and why they are considered to be high-risk. It also examines the legal and ethical issues that need to be taken into account when responding to and managing aggression. These issues include duty of care, professional negligence, reasonable force, assault, arrest, restraint, false imprisonment, searching of patients and others, the Guardianship Tribunal, children and the NSW Mental Health Act 1990.
You are on Participant manual page 5.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Ask the group What are high-risk environments? Explain and discuss Some examples of high-risk environments may include: ●
Emergency Departments and admissions units
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mental health treatment facilities
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a patient’s home
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community facilities
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aged care facilities
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corrections health facilities and prisons
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dental clinics
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disability facilities
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midwifery and early childhood facilities
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drug and alcohol treatment facilities
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rehabilitation, neurology and brain injury units.
Facilitator instruction Facilitator: Ask participants whether there are any other high-risk environments to add to the list and the reason for this. You may wish to comment that there are other kinds of environments that are high-risk in general eg poorly lit car parks, exits via dark or narrow lanes or underpasses, some areas used as shortcuts by the public and isolated areas.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Ask the group Why are they high-risk? Explain and discuss ●
The environment may be targeted by criminals because of money, drugs etc.
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Some environments may put the worker at higher risk of aggression because of the type of location and premises, the presence of others unknown to the worker and because immediate support may not be available.
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Some environments may be associated with visitors being under greater sources of stress which may be associated with a higher risk of aggression.
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Some environments such as waiting rooms may contribute to a higher risk of aggression when there is overcrowding, long waiting times and people in distress.
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Environments where workers are alone may contribute to a higher risk of aggression.
Certain medical problems that patients experience may be associated with a higher risk of aggression, such as: ●
confusion, eg delirium and acute organic brain syndromes, dementia, ie Alzheimer’s disease, multiple infarcts or brain dysfunction and trauma
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anxiety associated with their illness and treatment or psychosocial concerns
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mental illness and disorder
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pain
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substance abuse
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dual diagnosis (both mental illness and substance abuse)
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impulsive behaviours (such as those due to personality disorder)
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deafness, blindness and sensory impairment
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developmental disability
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brain impairment resulting from head injury, epilepsy, neurochemical disturbances, metabolic disturbance (such as hypoglycaemia and limbic system disorder), tumours, infection and other factors
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neurological disorder such as Huntington’s disease, Parkinson’s disease, Pick’s disease, Multiple Sclerosis or AIDS dementia.
Facilitator instruction Ask if anyone has been involved in any of the above. Emphasise how many of the high-risk environments are those that involve a high degree of stress and anxiety for patients, staff and visitors.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
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Zero tolerance approach 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. 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.
You are on Participant manual page 6.
Important training point Facilitator hint: Refer participants back to the zero tolerance overview in Module 1. It may be helpful to ask the group members to summarise their understanding of zero tolerance.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Explain and discuss 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).
Facilitator instruction The zero tolerance approach to aggression does not mean that aggression will never be encountered in the workplace. For example, in dementia and brain injury units aggressive and erratic behaviour can be a part of the condition encountered. The essential point is to ensure clinical care that is prompt and appropriate and that protects the safety of the patient, staff and others involved. The zero tolerance response means that in all instances of aggression, appropriate action must be taken to protect staff, patients and visitors from the effects of that aggression. In order for this to be successful, staff must recognise that aggression is not an acceptable part of the job.
Important training point Ensure you are familiar with the zero tolerance policy.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Some legal and ethical issues and scenarios in high-risk environments Small group exercise Case study A person who is drunk has been brought into the hospital with a head wound and other cuts received in a fight. The person does not like the treatment being provided, and starts to become abusive. The individual feels no treatment is needed and wants to go home.
What should the worker do? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How might the principles governing ‘duty of care’ versus ‘professional negligence’ be relevant to a worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss
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How serious are the effects of the head injury?
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Is it life threatening?
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What would your level of experience and knowledge tell you about the effects of this type of injury and intoxication?
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If you felt reasonably sure that this person would suffer serious injury by letting them go home you may be liable for negligence, unless efforts to detain them constitute an unacceptable risk to your safety or the safety of others.
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If you kept the person against their will you would have to show that the person was unable to make an informed decision and the condition was an emergency.
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Remember you can only exercise duty of care within the limits of safety to yourself.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
How might the principles governing ‘reasonable force’ versus ‘assault’ be relevant to a worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Overview the principles of assault and reasonable force.
Background reading 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 need to be proven for a successful prosecution. Under NSW Criminal Law, the term aggravated assault covers the application of physical force. Such actions include pushing, stabbing, strangling a person, kicking, shooting and unlawful hitting. The attempted use of physical force that misses or fails to connect is nevertheless an assault. There must be a belief in the mind of the victim, created by the offender, that force is going to be used upon him/her. The law allows the individual the right to defend his/her life against all unlawful attacks. However: ●
no more force than is absolutely necessary to repel the attack can be used
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the force must not be excessive and not out of reasonable proportion to the attack
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the individual must not use extra blows/strikes by way of revenge.
Any person who on reasonable grounds believes that he/she is likely to be the subject of an imminent attack can take reasonable measures to protect themselves. In both cases however, the measures taken in self-defence must be reasonable. The courts may take into account whether: ●
it was necessary for the defendant to stand their ground
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the defendant could easily have used a means of escape
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it was necessary for the defendant to use a weapon.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Reasonable force
Reasonable force is the amount of force considered to be appropriate in proportion to the perceived danger posed. When a person considers that they or others are under attack or threat, and self-defence or the defence of others is required, the amount of force that is used must be considered to be consistent with the perceived threat faced. Each case is judged considering: ●
its unique circumstances
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the threat that was posed
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level of training
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support and options available.
You may wish to refer back to Section 3 of Module 1 relating to assault.
Ask the group Case study A fifteen year old boy was in hospital after he fell off his push bike. The boy went over to the drug trolley with his backpack, put something in his backpack, and ran out the door.
What should the worker do? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Facilitator: Ask the group to consider all the options. These may include doing nothing (letting him run away) through to seeking to stop the boy.
A suggestion is made that the security officer should run after the boy and restrain him.
What should the worker do? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
How might the principles governing ‘citizen’s arrest’ versus ‘restraint’, ‘false imprisonment’ and ‘assault’ be relevant to the worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Overview the principles governing arrest and restraint.
Background reading To arrest someone means to take that person’s liberty or freedom of movement away from them in order to deliver that person into legal custody, to be dealt with according to law. ●
Individuals are only able to arrest someone if the person is in the act of committing, or immediately after having committed an offence.
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If restraint is used, reasonable force only must be exercised.
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Security officers have no additional powers of arrest than those of the general public (unless they are a special constable).
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You have to consider the safety of yourself in making an arrest.
The role of a security officer is one of prevention and protection. They have only the same power as any other member of the community in relation to arrest. Restraint should only be used in an aggressive situation where all other measures and interventions have (if circumstances have allowed) been tried, and there is a foreseeable risk of harm to any persons. To be protected from prosecution for assault, when staff restrain a person they must use only reasonable force. This is the basis for self-defence in court. You may also wish to refer back to Section 3 of Module 1 regarding clinical and non-clinical restraint.
Explain and discuss Regarding the case study, it is unlikely that it is reasonable to arrest the person. A better option would be to report the event to the police, who have additional powers of arrest.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Ask the group Consider the case where the boy does not run out of the hospital but after putting something in his backpack from the drug trolley he sits down on a nearby chair.
What should the worker do? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How might the principles governing ‘searching patients’ be relevant to the worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Discuss the issues surrounding searching patients.
Background reading The power to search clients is restricted to narrow circumstances allowed under criminal law which are strictly regulated, or when the client consents. Without clear lawful authority, any search initiated without consent would be a trespass upon the person and therefore unlawful. However, under the Inclosed Lands Protection Act 1901 hospitals are entitled to impose conditions of entry on persons who enter their premises. An example of these conditions, which would be considered lawful, are: ●
Prohibited weapons, fire arms or illegal drugs are not to be bought into the facility.
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The hospital reserves the right to search persons if there is reasonable suspicion that a person has brought such weapons etc into the facility.
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A person who refuses to be searched when requested will be escorted from the premises.
However the requirements of entry need to be displayed or communicated to those entering the premises, so that people are aware that such requirements exist.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Facilitator instruction Facilitator suggestion: Another way of extending this discussion is to then suggest that after searching the boy’s bag only his wallet was found. A staff member had previously put the boy’s wallet on the trolley when he was being treated for his injury. Discuss with the group the issue of ‘reasonable suspicion’.
Background reading The situation is somewhat different in relation to persons involuntarily detained under the Mental Health Act, which provides for the involuntary detention of persons suffering from a mental illness that place themselves or others at risk of serious harm. The objects of the Act include facilitating treatment and care, and section 31 (2) specifically allows a detained person to be given such treatment as the medical superintendent ‘thinks fit’. This combination of provisions may authorise searching involuntary patients, where the search was directed towards care and/or treatment or prevention of harm to the patient or others. All of this information needs to be considered by health care facilities when developing policies and procedures in relation to searching.
Small group exercise Case study An involuntary patient decides she wants to leave the hospital and becomes excited and angry when told that she cannot leave the hospital. A staff member considers her ‘at risk’ and tells her she will give her something to calm her down. The drug injected has the effect of making the patient unconscious.
Could the patient claim false imprisonment? How might the principles governing the Mental Health Act be relevant to the worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Facilitator note: An example of a drug that may have this effect is Midazolam.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Explain and discuss Overview the Mental Health Act and the issues of false imprisonment.
Background reading Mental Health Act 1990 ●
Under the NSW Mental Health Act, mentally ill persons are those who have a mental illness and as a result of the illness there are reasonable grounds for assuming that care, treatment or control is necessary to protect the person or others from serious harm.
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Within the Act, mentally disordered persons are defined as those persons whose behaviour is so irrational that there are reasonable grounds for assuming that care, treatment or control is necessary to protect the person or others from serious physical harm.
Mentally Ill vs mentally disordered conditions
Mental illness is defined as a condition that impairs mental functioning as a result or one or more of the following: ●
Delusions.
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Hallucinations.
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Serious disorder of thought.
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Severe disturbance of mood.
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Sustained or repeated irrational behaviour indicating the presence of any one or more of the preceding symptoms.
The most common behaviours requiring containment for the protection of self or others include: ●
deliberate self harm
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delirium
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acute distress
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confusion
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aggressive behaviour.
The most common underlying diagnosis is psychosis or bipolar disorder. Being detained under the Mental Health Act does not automatically mean that the patient may be sedated as treatment must be the least restrictive, allowing for effective care and treatment. The clinical situation must warrant the use of involuntary sedation.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Ask the group Consider the scenario on page 35 (Participant’s manual, page 9) of the patient being administered a sedative. Instead of being an involuntary patient, the individual is elderly, repeatedly aggressive and under the Guardianship Tribunal.
How might the principles governing the Guardianship Tribunal be relevant to the worker’s response to the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Overview the role of the Guardianship Tribunal.
Background reading Guardianship Tribunal
A person may be under the Guardianship Tribunal for either financial or medical orders or both. If staff want to give additional or non-prescribed treatment to a patient whose order is for medical treatment they must contact the Tribunal first. However, in an emergency, the Tribunal should be contacted immediately after the person has been given their medical treatment. Guardianship Tribunal and mental health ●
The Guardianship Tribunal should be contacted about patients with behavioural disturbance who do not satisfy the criteria of the Mental Health Act 1990 for involuntary treatment, and who are incapable of giving consent, eg aggressive or self harming behaviour in a person with an intellectual disability.
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At times, patient management will require involuntary treatment, eg restraint/sedation or both. Any involuntary treatment must be justified legally.
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Staff need in each case to make an assessment of the patient’s mental state and capacity to consent.
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If a person is not admitted as an involuntary patient, or does not meet the criteria of a mentally ill or a mentally disordered person (who could therefore be ‘scheduled’), the only circumstance where involuntary sedation can occur is if the person lacks the mental capacity at the time to consent to treatment and the sedation is required as a matter of urgency.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Explain and discuss Overview the issues in relation to children and adolescents.
Background reading General principles in relation to child and adolescent care ●
Parents have a general right to determine a child’s upbringing and education, including the right to discipline a child. Of course, this right is limited by laws concerning child abuse and neglect and by the fact that any punishment inflicted must be moderate and reasonable.
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Parents are entitled to ‘delegate’ this authority to other persons who stand in ‘loco parentis’ to the children.
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The right to decide on medical treatment arises independently of any right or control of a parent over a child. Thus, as a rule, medical treatment for a child under 14 can only occur with parent/guardian approval. Between 14-16 is the ‘grey’ area and when 16 and over the child can determine treatment independently. This point becomes relevant with regard to the issue of medication.
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In NSW law, the only grounds to detain persons against their will outside of criminal law are found in the statutory provisions of the Mental Health Act and the Public Health Act. Recognition of parental or guardian authority is given with respect to voluntary admissions to psychiatric hospitals, but not with respect to involuntary admissions.
Basis of authority: voluntary admissions
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The only authority psychiatric services have over child and adolescent patients is based on the fact that the child is placed in a facility by the parents and that as part of that placement they also delegate staff of the facility to act in ‘loco parentis’.
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Therefore, with respect to the day to day care and control of the child, staff can do no more than would reasonably be done by the parent. The key document becomes the consent signed by the parents when the child was placed. The consent form should be carefully considered to ensure: – it includes all possible actions likely to be necessary – the language is clear and precise – parents are fully informed of all factors when giving consent.
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Once a consent form of sufficient detail is developed, a facility’s policy can act in conjunction with the consent, as a guideline to staff as to how they are to exercise the authority given to them.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
‘Grey areas’ ●
If any force is required, it should be minimum force only. Clearly, if a situation is escalating, evasion and seeking additional support is the best option. In this regard, if a matter of assault did come before a court, it would be unlikely to conclude that any parental authority would authorise the use of excessive force.
Further factors involving children under 16 ●
As noted above, the issue of consent to medical treatment, is complicated by the different scheme applying to juveniles between 14 and 16. In addition, questions arise as to the real ability to ensure a child over 16 stays with a parent against his or her will. It is understood that the parental rights of control in this regard are not always enforced.
Reference to the Mental Health Act: involuntary admissions ●
In relation to involuntary detention, the Mental Health Act makes no differentiation as to juveniles. Therefore technically an adolescent with a mental illness should be treated the same as an adult. In practice however, extra care needs to be taken when assessing juveniles before a decision is made to schedule them.
Small group exercise Case study In the evening two youths were noticed hanging around a health facility building. There is no one in the premises after hours. Staff working in another building noticed that the youths had driven their car and parked it outside the front door. One of the youths threw a rock at a window and no alarm was set off. They then proceeded to try to break into the building.
What is the role of staff when a crime is being committed? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Facilitator instruction Facilitator: Reinforce the issues of: ●
safety first
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not approaching offenders
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notifying security or police
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taking note of the appearance of the youths and the car.
Facilitator instruction Facilitator: Add to the scenario by considering a case where two staff ran to stop the offenders. The staff were seriously assaulted by the youths. Issues to consider and discuss may include the following: ●
Whether the staff can charge for assault.
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Staff should not be knowingly placing themselves at unnecessary risk by approaching the youths.
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It is better to keep a distance, take down a description of the youths and car and call police.
Facilitator instruction Consider what the organisation’s response might be to this incident. Organisation:
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Need to reinforce self protection and safety with regard to staff behaviour.
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Document incident.
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Perform a risk assessment.
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Instigate changes to improve security and surveillance.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 2 Aggression minimisation in high-risk environments
Key points • Some environments are at a higher risk, because they may be targets for crime. This may be due to money handling, design, type and location of premises, visitors being under a greater source of stress, staff working in isolation and the types of problems patients experience. • No staff member should knowingly place themselves at unnecessary risk of violence. • The zero tolerance response means that in all instances of aggression, appropriate action must be taken to protect staff, patients and visitors from the effects of that aggression. In order for this to be successful, staff must recognise that aggression is not an acceptable part of the job. • Always keep in mind the legal and ethical issues when responding to and managing aggression.
Suggested break time
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Part 2 Prevention in high-risk environments Show overhead slide
Session time 80 minutes
Session overview This part looks at safety strategies in high-risk environments. It considers circumstances where unauthorised persons have entered restricted and unauthorised areas, safety when working in the community, how to approach an aggressive person and safety strategies when interviewing patients and others.
You are on Participant manual page 11
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Keeping your area secure Small group exercise Case study You notice a stranger is in the staff room with the door to a locker open and hanging on one hinge. The person is going through the locker of a staff member you know and you suspect this person is stealing.
What strategies could you use? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Basic principles are: 1. your safety 2. report the incident. Note the appearance of the person, note what they are doing and where they go afterwards. Ring security and report the incident formally. You might ask the group: ‘Should you approach the person?’ The safest strategy is not to approach the person, however, depending on the circumstances, saying something like, ‘can I help you?’ while maintaining a safe distance and not blocking the exit, may be appropriate.
Small group exercise Case study An elderly gentleman came to the receptionist’s desk. He was of non-English speaking background. He was speaking loudly, and abruptly said, “I want to see my wife, where is Ward 14”. Ward 14 is a high dependency unit with restricted admission. The staff member is worried that the gentleman is going to become aggressive and asks him in a quiet, polite manner what his wife’s name is. He answers loudly, “Where is Ward 14?” and puts his hand in his pocket as if he is about to take something out. At the same time he notices a sign with an arrow pointing toward Ward 14. He walks briskly toward the ward and pushes open the doors, entering the ward. The staff member panics, picks up the phone and calls security. Several security staff arrive and escort the gentleman, shouting and struggling, off the premises.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Discuss the incident and the worker’s response. What strategies should be used when dealing with unauthorised access? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What might be the socio-cultural issues that might have contributed to this incident escalating? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Review principles of culturally diverse communication styles from Module 1. ●
Emphasise socio-cultural issues around miscommunication as a trigger for the escalation of aggression.
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Review issue of hearing deficit as a possible trigger.
Ask the group Ask the participants: “should you call security?”
Facilitator instruction Recognise that de-escalation communication skills may no longer be appropriate because the person has moved into a restricted area.
Ask the group Ask participants: ‘What risk control measures can be put in place for restricted areas?’
Facilitator instruction Review issues to do with: ●
safety barriers around reception areas
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signage
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locked doors to unit with video intercom for communication with staff.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
You are on Participant manual page 12.
Some principles for recognising and dealing with unauthorised visitors Explain and discuss ●
Where possible control access at the door.
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Call security, staff or police assistance if required (in-line with local procedures).
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If inside, ask them to leave (note details and call security if necessary).
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Complete an incident report.
Unauthorised access ●
Know your escape route.
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Know your emergency numbers.
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Know your local emergency procedures.
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Know location of duress alarms.
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Remain calm.
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Know that your safety is the first priority.
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Know how to contact security or police.
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Know your rights.
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Use non-confrontational methods.
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Use open hand gestures.
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Note clothing or distinguishing features.
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Complete an incident report.
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Seek counselling if appropriate.
Show overhead slide
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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MODULE 2 Aggression minimisation in high-risk environments
Working in the community and outreach environments Explain and discuss Staff working in the community face particular risks that need to be managed by the employer (Chaplin and Alison, 1998; Hunter, 1997).
Ask the group Discuss what risk assessment activities can be done prior to making community visits, in particular the first visit. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Facilitator: ●
Discuss if there are any local procedures, policies or risk assessment forms prior to the visit.
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Highlight importance of recognising that there is a risk of aggression from those around the patient, eg family members, friends, flatmates, etc.
Discuss the following risk identification activities: ●
Assess for any prior history of aggression.
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Recognise that risks can change with different circumstances and that a low risk person or situation can change at any time.
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Obtain as much information as possible about the patient/client/business prior to the first visit.
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Collect relevant information about other members of the household and likely visitors when making home visits.
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Obtain information about the geographical location of the premises, eg is it in a high crime area, geographically isolated and/or have reduced accessibility to/availability of police.
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Gather specific information about the premises, eg security access, stairs, external lighting, hiding places, premises, age and condition, phone connection etc.
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Speak to other staff who may have provided the services or inspected the premises in the past.
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Where possible speak to the patient/client by phone prior to the first appointment to confirm the meeting, as this can also provide insights: – Use a broad range of information resources, eg point of referral, relevant patient/client records, other staff, local GPs and local police.
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Important training point Facilitator note: Discuss local policies and procedures on risk assessment prior to the first visit.
Important training point SAFETY HINT: Recognise that the busier you are, the more at risk you may be. Being busy may lead you to: ●
being less likely to notice early warning signs of aggression
●
taking less time to clarify a person’s problem before acting
●
being more vulnerable to taking unnecessary risks.
You are on Participant manual page 13. Small group exercise Facilitator note: For this exercise allocate a particular section to each group (see page 49 of this manual, page 14 of Participant’s manual) and then have each group give its response.
Case study Jane works in a small community health centre. She is leaving her office to visit a well known client, John, in his home. When Jane arrived at the house, John’s parents welcomed Jane in. When Jane walked in she realised she left her mobile phone in the car but did not go back outside to get it. John was in his bedroom with a friend Bill who Jane recognised and knew had a history of aggression. John closed the door behind Jane and when Jane started talking to John his friend Bill became abusive to Jane and started yelling and shouting at her. Jane immediately left the room and Bill started to follow her. Jane ran for the front door and tried to open it. John’s parents came to see what was going on but Bill pushed them aside. Jane eventually opened the door and ran to her car and was trying to find her keys in her bag. Meanwhile Bill grabbed Jane but let her go when John stopped him. Jane eventually got in her car and drove off.
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Consider the scenario. Discuss what you can do to ensure your safety in the community. Fill in the relevant issues to consider in the boxes provided. Prior to leaving the office
Travelling to and fro
On arrival
NSW Health
After the visit
Visiting alone
SAFETY IN THE COMMUNITY
During the visit
Visiting after hours
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Write responses on board Facilitator note: it is useful to write the answers to each section on a whiteboard.
Answers Prior to leaving the office ●
Ensure that your base knows where you are going and who you are going to see, and leave the following information: – The name, address and phone number of persons being visited. – Expected time of appointment. – Expected length of appointment. – Any changes to the schedule of visits. – The proposed route.
●
Take any personal protective equipment that is provided.
●
Ensure your mobile phone is working and 000 and your base number are keyed in.
●
Do not make a home visit alone: – If you suspect or know a person has the potential for aggression (this includes other persons who may be in the home). – If you believe you are at risk. – If there is not enough information to establish a person’s potential for aggression.
●
At times it may be appropriate for the police to go on the visit (consider using police if you are concerned about your own and/or another’s safety).
●
Ring to see if the client is there.
●
Perform a risk assessment.
Travelling to and from
50
●
Keep your car locked while driving and windows up if practical; this prevents people entering when you stop at lights, etc.
●
Ensure you have sufficient petrol.
●
Do not walk in deserted places or take shortcuts through secluded alleys or vacant blocks.
●
Always walk in the center of footpaths, away from buildings.
●
Watch for any loiterers in doorways and windows.
●
Walk around and not through groups of people.
●
Never enter areas where there appears to be trouble in the neighbourhood.
●
If you suspect you are being followed while walking, enter a business premises.
●
If you suspect a car is following you, cross the street and walk in the opposite direction.
●
If you think you are being followed while driving, drive to the nearest police, fire or petrol station.
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Park as close as possible to the premises being visited.
●
Do not look lost (if you cannot see an address or building, drive down the street until you can find the building).
●
If you are threatened by a thief at any time, do not resist, give them what they want immediately, then notify the police and your manager when safe to do so.
●
Be aware of car safety procedures if the car breaks down.
On arrival ●
Park the car facing the way you will be exiting and make sure you cannot be blocked in (this stops you from being trapped or wasting time trying to turn).
●
Do not attempt to enter premises if there are any potentially aggressive animals and they are not restrained.
●
When entering buildings, check lighting and stairwells where no lift is available.
●
If entering a lift, look first and do not enter if you are concerned about safety.
●
Stay near the door and control panel in lifts, and be observant of others.
●
Do not search for patients by unnecessarily knocking on doors.
●
Do not remain in the parked car for long periods of time before and after visits.
●
If you are concerned about location or access to premises, ask a family member to meet you and escort you to the patient.
●
If no one is home and you are leaving a card, slip it under the door or put it in their letterbox if it is locked (so other people cannot find it).
●
Always check the locking mechanism on the gate so you won’t be impeded if you need to leave quickly.
●
Before knocking at the door and ringing the bell, listen for any arguments, unexpected voices or anything that may make the situation unsafe (these are reasons to reassess the situation).
During the visit ●
Be cautious when entering a person’s home.
●
If an unfamiliar person answers the door, make sure the client is home before entering.
●
Stand to one side with your work bag in front of you for protection.
●
If at any time your professional instinct tells you something is wrong, leave immediately (even if you cannot work out what is wrong).
●
Leave immediately if you see any firearms or weapons (this must be noted in the patient’s file, police need to be informed and the incident reported to management).
●
Be aware of all exits.
●
Do not sit in deep-seated lounges, as it is difficult to get out of some chairs in a hurry (ask for an upright chair).
●
Always sit between the patient and the door but without blocking the patient’s way out.
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Keep your keys handy so that you do not waste time searching for them at the bottom of the bag.
●
Only take in what you need.
●
Leave immediately if you are verbally or physically threatened by anyone.
After hours visits ●
On any new referrals, two staff members should attend unless police are present.
●
Staff should have a mobile phone.
●
It is recommended that police attend with you if the patient has a history of violence, the patient is currently violent or the patient has access to a weapon.
●
If the patient is intoxicated, suffering from withdrawal, agitated, disorientated or aggressive, it is preferable they be seen at a safe venue such as an Emergency Department.
●
Staff should give the details of the patient’s address/location, their estimated time of departure and return and an assessment of the risk to a senior person in the facility.
●
Patients and/or carers must be told to ensure that the lights surrounding the property are on for it to be easily identified, gates are open and any animals restrained.
●
Staff should leave immediately if there is any evidence of a threat or anything that will affect staff safety.
Facilitator note: Discuss local procedures when mobile phones do not work in specific geographical areas.
After the visit ●
If you experienced any aggression or harassment (verbal or physical) report it to your manager, document the incident in the patient’s notes and complete an incident report form.
●
Always report to base at regular intervals.
●
Always report ‘near misses’ – where aggression became a present risk but did not eventuate.
●
Ensure your workplace has a policy and response if you do not return on time, eg activating a police response.
Important training point Facilitator: It is useful to raise the issue of local policies regarding high-risk patients. For example, it may be negotiated for high-risk patients to attend the centre.
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Show overhead slide
Explain and discuss Working in isolated areas If possible, staff should not work alone in isolated areas. However if this is unavoidable appropriate risk controls must be in place. Managers, and staff as appropriate, should: ●
be vigilant when entering, using or leaving isolated clinics
●
have all emergency numbers programmed into the phone
●
have all essential phone numbers displayed
●
ensure that an effective contact network is established
●
ensure security doors are locked and all doors locked when working after hours in the clinic.
●
ensure all door and window locks are in good working order
●
ensure facility and approaches are well maintained
●
ensure all fixtures and fittings are in good working order
●
ensure there is adequate lighting during and after hours
●
inform communication networks of all movements to and from the site and record in travel log times of arrival and departure, route taken and any foreseeable difficulties with travel
●
be aware of how to activate a duress alarm or security system.
Explain and discuss SAFETY TIPS in community work ●
Always ensure you have as much information as possible about the location and person being visited.
●
Ensure patients are aware of the visit and purpose.
●
Under no circumstances should you knowingly place yourself or co-workers at risk. This also applies to those in an inspectorial role. Where the threat of violence presents itself, you should leave and/or seek further assistance, eg police. If you are unable to escape, evasive self-defence may be necessary.
●
NSW Health
Always contact police if you are concerned about your own or another's security.
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Show overhead slide
Explain and discuss How to maintain safety when approaching a person with the potential for aggression When approaching or interviewing a person who has the potential for aggression, keep in mind some key points to ensure the safety of yourself, the person and others. By approaching the person in an appropriate way and being aware of simple safe practices, the likelihood of the person becoming aggressive is reduced.
Facilitator instruction It is useful to elicit other examples from the group.
SAFETY TIP Do
Don’t
●
●
Use any sudden or violent gestures.
●
Have prolonged eye contact.
●
Address the patient in a
Always remove any personal items that could be used by the patient to grab a hold of you, eg tie, necklace, earrings, stethoscope, etc, prior to approaching
confrontational manner.
the person and not in view of the person. ●
Be calm and confident.
●
Give the patient ample space.
●
Be empathic and emphasise your desire
●
Corner or tower over the patient.
●
Turn your back on the patient until you are well clear of the situation.
to help.
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Show overhead slide
Explain and discuss Ensuring the safety of self and others when interviewing patients or others ●
Always be alert for the potential for aggressive behaviour.
●
Always consider the safety of yourself, the patient, staff or others present.
●
Let other staff know where you are in case assistance is required.
●
Have other staff present (this can include security).
●
Interview in environments where there are easy exits for you and the patient. This prevents any feelings of being trapped.
●
Place yourself near the door and avoid putting yourself in a position where your exit may be blocked by the patient, or where you are blocking the patient’s exit.
●
The furniture in the room should be heavy enough to make it difficult for the person to use it as a projectile.
●
Wear a personal duress alarm and know how to use it.
●
Remove any excessive items that could be used as weapons, eg heavy staplers, scissors, etc.
●
Be alert to any potential hidden weapons.
●
Do not assume that patients who have been in recent contact with the police have been searched and disarmed of weapons.
●
Do not give ultimatums.
Facilitator instruction Facilitator: ●
Note the importance of having an exit strategy.
●
Where possible, use rooms with two doors or exits.
●
Do not situate yourself in a position where you cannot get to the door first.
●
Don’t have things on your desk or in the room that can be used as a weapon (elicit examples from group).
●
Emphasise the importance of always being polite (even if a person is disrespectful or abusive to you).
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Key points • Always know your local emergency response procedures; call security, staff or police if assistance is required with unauthorised visitors. • Know your emergency numbers and escape routes. • Always remain calm and non-confrontational. • Under no circumstances should you place yourself or co-workers at unnecessary risk. • Always use police if you are concerned about your safety when doing visits in the community. • Always use the safety strategies prior to approaching persons who are, or have the potential to be, aggressive. • Always use the safety strategies when interviewing patients or others.
Suggested break time
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Part 3 Understanding aggression in high-risk environments Show overhead slide
Session time 80 minutes
Session overview This section aims to extend your knowledge of aggression through discussing common triggers for aggression in the health care industry and the cycle of aggression. The aggressive person’s and the recipient’s responses are both outlined and discussed. It is the recipient’s response that can give control back to the recipient in an aggressive situation.
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Explain and discuss Triggers A trigger is a specific occurrence that precipitates the escalation of a person’s aggressive behaviour. Triggers may be grouped under the following headings: • Environmental • Personal • Cultural • Workplace practices
Small group exercise Facilitator instruction Facilitator note: Divide participants into groups of four and allocate a trigger (environmental, personal, cultural or workplace practices) for each group to discuss. Have someone from each group share the responses with the larger group.
Name triggers you have witnessed or experienced under the following headings.
Write responses on board Environmental
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Facilitator – some issues might include:
58
●
confined spaces and overcrowding
●
environments that are too hot or too cold
●
poorly designed rooms
●
inadequate lighting
●
uncomfortable spaces
●
inadequate or poorly maintained facilities, eg no water dispensers, phone not working, inadequate toilet facilities.
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MODULE 2 Aggression minimisation in high-risk environments
Personal
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Facilitator – some issues might include: ●
attitudes
●
emotional state, eg anxiety, fear, stress
●
physical health
●
expectations and beliefs.
Cultural
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Facilitator – some issues might include: ●
misunderstandings due to limited knowledge/understanding of English
●
misinterpretation of body language, facial expression or speaking tone
●
use of slang or forms of communication that are foreign
●
differences in personal space, physical touching, gestures
●
differences in religious practices.
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Workplace practices
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Facilitator – some issues might include: ●
excessive workloads
●
problems with employee relationships
●
restrictive policies and procedures
●
inconsistent rule setting between staff
●
long waiting lists and wait times
●
lack of communication, eg not informing people of delays in treatment, waiting times etc.
Show overhead slide
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MODULE 2 Aggression minimisation in high-risk environments
Cycle of aggression Facilitator instruction Facilitator: Discuss each stage, how aggressive incidents may escalate rapidly and the post incident effects.
You are on Participant manual page 20. Facilitator instruction Facilitator: Use the next table as a discussion point. Consider each component of the cycle of aggression and discuss what the aggressive person and the recipient may be feeling at each stage. Then go through and review possible strategies to help minimise the aggression.
4 3
1 Baseline
NSW Health
5
2 6
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Some possible responses at each stage of the aggression cycle Cycle of aggression
Aggressive person
Recipient
Strategies
1 Baseline
●
●
●
Calm and relaxed.
Calm and relaxed.
Observe for verbal and non-verbal cues.
2 Trigger
3 Escalation
4 Crisis
5 Recovery
6 Post-crisis depression
●
Increased muscle tension.
●
Dry mouth.
●
Tremor.
●
Palpitations.
●
Flushed.
●
Anxious.
●
Reflect feelings.
●
Increased heart rate.
●
Offer help.
●
Worried.
●
Problem solve.
●
Be aware of your body language.
●
Be aware of personal space.
●
Be aware of your voice tone.
●
Use open questions.
●
Pacing.
●
Dry mouth.
●
Stay calm.
●
Irregular, rapid, shallow breathing.
●
Tense.
●
●
Increased breathing.
Explain things are getting out of control.
●
Tremor.
●
●
Maintain safety.
●
Reduced concentration.
Fight or flight impulses.
●
Offer medication if appropriate.
●
Fear and anxiety.
●
●
Pale or ashen skin.
Keep dialogue simple and direct.
●
Have back-up and an escape plan.
●
Loss of control.
●
In control.
●
Maintain safety.
●
Assault.
●
Self-defence.
●
Yours and others.
●
Run or escape.
●
Panic and attack.
●
Call for back-up.
●
Self harm.
●
Increased heart rate.
●
Run or escape.
●
Freeze.
●
Cry.
●
Worn out.
●
Quiet time.
●
Tired.
●
Frustrated.
●
Talk with colleagues.
●
Drained.
●
Emotional.
●
Reflect.
●
Sad.
●
Guilt.
●
●
Remorse.
●
Blame.
Seek formal support mechanisms.
●
Apologetic.
●
Questioning.
NB. Staff may call for back-up at any time. Back-up can include a more senior experienced member of staff.
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Explain and discuss Sometimes these responses can prevent you from responding in a way that you would desire. You may under or over react to a situation possibly: placing the aggressive person, others or yourself at greater risk of harm.
Show overhead slide
Explain and discuss Self-control plan You need to have a self-control plan in place so that when you are confronted with an aggressive incident, your response acts to calm the aggressive person and not to further escalate the individual. Your self-control plan should take only a couple of seconds.
Ask the group What self-control plan can you use when confronted with an aggressive incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
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Answers Facilitator: Elicit examples from the group. Some strategies might include: ●
deep breathing
●
controlled breathing
●
inner dialogues
●
focus on empathy
●
count to three.
This is the first step in a crisis. It slows you down and lets you think about responding in a controlled manner, rather than just reacting. It is a tool for putting on the brakes. ●
Deep breathing Focus on your breathing. Deep breathing is essential to preparing yourself physically to deal with an aggressive situation. There are a number of different breathing techniques which may be used.
●
Inner dialogues Inner dialogues are the conversations we have with ourselves which determine the way we approach a particular event, or the way we deal with a particular person. Inner dialogues influence our attitude and strongly influence the outcome. When we think things won’t go well, because of our negative inner dialogues, they probably won’t. Conversely, when we think things will go well, so long as it is not based on blind optimism, they usually do. Inner dialogues are also useful for monitoring the crises and your own reactions as you go along.
Ask the group When might these self-control plans be difficult to implement? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
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MODULE 2 Aggression minimisation in high-risk environments
Facilitator instruction Facilitator: Elicit examples from the group. Some strategies may not work when: ●
strategies do not suit the individual
●
the person is being physically assaulted
●
taken by surprise
●
personal issues or triggers intrude
●
you are physically unwell
●
you feel helpless and hopeless about the situation
●
your own family, children, or people that you know are involved.
Important training point Facilitator note: It is useful to point out that everyone may have a self-control plan but that it may not always be able to be drawn upon.
Key points • Look for any triggers. • Identify what stage of the cycle of aggression the person is in and use appropriate strategies to manage the person. • Be aware of your own bodily response and always use your own self-control plan.
Suggested break time
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MODULE 2 Aggression minimisation in high-risk environments
Part 4 Managing aggression in high-risk environments Show overhead slide
Session time 80 minutes
Session overview This part discusses the core values and skills required to manage aggressive people. Short and long-term strategies are discussed to both prevent and manage aggression in high-risk environments. Finally, the protective factors involved in an armed hold-up or hostage situation are identified.
Explain and discuss Core values and skills Paterson and Leadbetter16 suggest the following five core values and skills that staff need to possess when managing aggressive behaviour: ●
Consistency in showing respect for the values and dignity of the individual.
●
Empathic, non-judgmental approach.
●
Honesty.
●
Self-awareness.
●
Effective communication skills.
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Facilitator instruction Facilitator: Emphasise respect and politeness. Good social skills are highly effective in preventing and minimising aggression. De-escalation communication skills are really basic commonsense. ●
Be honest – don’t pretend you know what is going on if you do not. Tell the truth but do it in a way that is sensitive – be truthful but not brutal.
●
Communication depends on having your undivided attention. Listen to the person’s need. De-escalation does not necessarily mean you are talking – listening is a key communication strategy.
Explain and discuss To enhance relationships: ●
treat the person as an individual
●
listen to others and make them feel comfortable about their problems
●
enable others to have input into decisions
●
spend time to help establish needs (patients and others)
●
provide choices
●
provide reasons for decisions
●
assist with needs other than medical treatment.
Ask the group Ask the group: Identify three key factors that may be associated with an individual’s escalation toward frustration and aggression.
Answers Examples:
68
●
Indifference of staff.
●
Waiting times.
●
Not having issues adequately explained.
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MODULE 2 Aggression minimisation in high-risk environments
Show overhead slide
Explain and discuss Options when a person has been identified as being high-risk The outcome of your response options should be either to: ●
eliminate risk
or ●
reduce the risk to the lowest possible level.
It is important that all staff be aware that a range of options exist when faced with aggressive or violent individuals. 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 members involved. This may include calling for back-up, security or local police.
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Show overhead slide
Explain and discuss Short-term options Some short-term options for dealing with aggression may include the following. The order in which they are used or the appropriateness of the strategy depends on the specific situation. 1. Issue a verbal warning
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss In the face of verbally aggressive or abusive behaviour, it may be appropriate to issue a warning. If the staff member feels unable to do this, it is not appropriate to the situation, or that it will further inflame the situation, back-up should be sought. If the situation does warrant issuing a warning, this should be done in a calm, respectful, ‘informative’ manner.
2. Use communication skills
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Staff should remain calm, listen to the individual’s concerns in an empathic, non-confronting manner, emphasise their desire to help, try and make the individual more comfortable and utilise accompanying friends/relatives if appropriate.
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Important training point The key issue is trying to meet the needs of a person. Recognise that you cannot always meet their needs.
Explain and discuss Key crisis communication factors and techniques: Ask: ●
Who is in danger?
●
What has caused this?
●
What does the aggressive person want?
NEGOTIATION SKILLS: Try to provide as many choices as possible and help the person feel in control.
Explain and discuss Remember that the majority of people don’t reach crisis. If they are verbally abusing you, generally they are angry at the system. Stalking behaviour, intimidation and other anti-social behaviours should be immediately reported to the police. Usually this type of behaviour doesn’t respond well to advanced communication skills. Often there is a demand and a subtle or unsubtle threat. In this case, using minimal monotonic responses that do not engage with the person can be effective. Your statements need to reinforce acceptable behaviour and emphasise limit setting around inappropriate behaviour.
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3. Decide to stay or leave
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss If the individual fails to respond to verbal warnings or the situation escalates, staff should seek back-up and/or retreat if necessary. If staff feel unsafe at any time, they should call for back-up. You should always go and get help if you retreat. Remember that you still need to consider the safety of others.
4. Medication management
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss If the aggressive person is a patient and the aggression is deemed to be the result of a clinical condition, it may be considered appropriate to administer medication to this person. Oral medication should be initially offered if appropriate and if this is declined, then intramuscular or intravenous medication may be given.
5. Duress response options and calling for back-up
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction Facilitator note: Ask participants about the duress alarm in their area. Explain that duress alarms do not reduce the incidence of aggression. However, they may reduce the likelihood or severity of injury when appropriately used.
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Explain and discuss Back-up
Depending on the level of perceived threat, imminence or actuality of violence, effects of the behaviour on others, availability of support and local protocols, back-up may include: ●
calling on a more senior staff member or clinician – in some circumstances, this may be enough to calm an aggressive patient and also allow for a clinical assessment if warranted
●
contacting security staff – the presence of security staff may act as a deterrent and/or assist in the protection of staff and visitors
●
using the duress alarm or initiating the duress response
●
calling police or other external security services
●
withdrawing to a safer location.
6. Defending self
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Explain and discuss Staff are entitled by law to protect themselves or another from a threat of attack or injury. The protection afforded by the law is however limited to situations where there is an immediate or imminent threat or attack (see relevant section in Module 1 for background reading).
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Small group exercise Case study A seventy-eight year old patient is in intensive care after suffering a cardiac arrest. He has been in for two days and has improved only slightly. He begins to become agitated, and as the morning progresses he becomes louder, calling for the doctor and his wife, saying he wants to go home because he will be better off there. Attempts by the staff to calm him are not successful and he begins to lash out at staff as they approach him. He tries to climb out of bed saying that his taxi is out the front waiting for him. He is pulling at his IV line and repeats that he will miss his taxi if staff don’t get out of the way.
Which short term options would be useful in managing this patient? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Facilitator instruction It is useful to re-cap each of the short-term options and discuss how they may or may not apply to this case.
Show overhead slide
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Explain and discuss Long-term options Important training point Facilitator: Emphasise that long-term response options are focused on the problem behaviours being displayed, not the illness. They will also vary depending on whether the source of aggression is a patient, visitor or intruder.
1. Written warnings
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss
Background reading Depending on the circumstances, it may be appropriate to issue a letter of warning to a patient or visitor who has exhibited repeated aggressive or violent behaviour and where verbal discussion with the patient has failed to resolve the situation. A number of factors will need to be considered in determining whether a letter is appropriate, or whether it is necessary to utilise other risk control strategies, eg a conditional treatment agreement. These factors may include: ●
frequency, nature and severity of the behaviour
●
circumstances surrounding the behaviour
●
extent of exposure of staff, visitors and others to the behaviour
●
level of threat or risk the behaviour presents to others
●
patient’s or visitor’s ability to comprehend the issues associated with their behaviour
●
patient’s or visitor’s capacity or ability to modify his/her behaviour
●
patient’s or visitor’s ability to read and understand English.
Document must have the signature of the unit manager, facility manager or area health service chief executive officer as most appropriate.
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2. Conditional treatment agreements
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss
Background reading In some circumstances it may be necessary to establish a conditional treatment agreement with the patient. Such circumstances may include where the patient has a history of repeatedly: ●
presenting for treatment under the influence of alcohol or other drugs, leading to aggressive, violent or disruptive behaviour
●
being accompanied by groups of friends/relatives significantly disrupting the treating environment
●
being accompanied by persons with a history of aggressive behaviour towards staff or others
●
presenting in an aggressive manner late at night or at change of shift times and disrupting the treating environment
●
regularly threatening, attempting or perpetrating violence against staff or other patients.
Depending on the individual circumstances, the following conditions may be considered for inclusion when developing conditional treatment agreements:
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Clearly articulated behavioural requirements (the patient and those accompanying him/her need to understand what behaviour is required).
●
Stated results of the patient’s failure to comply, eg treatment may need to be provided in different ways/times, visitors may not be permitted, etc.
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Where the treatment will be provided, eg at what facility and at what location within that facility.
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Specified time/s.
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Who will accompany the patient, eg a friend/relative with a calming influence.
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Who will not accompany the patient, eg friend/relative who is regularly threatening or aggressive towards staff, other patients.
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The condition of the patient and those accompanying the patient, eg not under the influence of alcohol.
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The conditional treatment agreement should: ●
be developed in consultation with the patient and other relevant stakeholders, eg guardian, relatives, treating staff, security, etc
●
not be discriminatory, eg focuses on behaviour, not condition, race, etc
●
be regularly reviewed according to an agreed timetable (from both a clinical and practical perspective)
●
be reviewed when there are changes in the patient’s circumstances, eg moves to a different residential location, condition/behaviour improves, etc
●
focus on the ability to provide meaningful treatment in an appropriate facility and a safe environment
●
include an appeals mechanism.
Conditional treatment agreements should be negotiated with patients as far as possible. They should form part of broader risk control strategies aimed at protecting staff, patients and visitors from violence, while at the same time, as far as possible, allowing for appropriate treatment to be administered in a therapeutic environment.
3. Conditional visiting rights
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Facilitator instruction These usually apply to relatives or other visitors to a health facility and may be considered as a long-term option for repeated problem behaviours.
4. Exclusion from visits
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Facilitator instruction These usually apply to relatives or other visitors to a health facility and may be considered as a long-term option for repeated problem behaviours.
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5. Flagging and patient alerts
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss
Background reading File flagging ●
Used to identify patients who pose a risk to the health and safety of staff and other patients. Enables staff to be aware of the patient’s tendency to become violent.
●
The criteria to meet the need for a flag needs to be linked to violence and safety issues because of the person’s behaviour, not simply because of the person’s medical diagnosis.
●
The flagging of a file may result in the person being provided with service in a different manner than other patients. This may even, in extraordinary cases, include an inability to supply the service in certain circumstances.
Relevant legislation Anti-Discrimination Act 1977
The Anti-Discrimination Act provides for the making, conciliation and/or determining of complaints about ‘unlawful discrimination’. Under the Act, it is unlawful to discriminate on the grounds of race, sexual preference, transgender status, marital status or disability. Disability includes mental illness and infectious disease status. The Act states that it is unlawful for a person to refuse to provide goods and services to another person on the grounds of a disability, or to place terms on provision of those goods and services on the grounds of disability.
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Privacy and Personal Information Protection Act 1998 (PPIPA)
Since July 2000, the NSW public health system has been subject to privacy obligations under the above Act. It provides a comprehensive code designed to regulate the collection, use, storage and disclosure of information that can identify a person. It also includes the obligation to ensure that any information that is used is relevant, accurate, up to date, complete and not misleading. Under the Privacy and Personal Information Protection Act 1998 (PPIPA), disclosure of personal information is permissible provided it is necessary ‘to prevent or lessen a serious and imminent threat to the life or health of the individual to whom the information relates, or another person’. Any patient-alert system must therefore incorporate these criteria. Under both PPIPA and the Freedom of Information Act, patients have the right to know what is on their file and can request to view their file. There are exceptions to this, generally limited to circumstances where giving access to the information may have an adverse effect on the physical or mental health of the person concerned. Under section 15 of PPIPA, agencies have an obligation to ensure information used is ‘relevant, accurate, up to date, complete and not misleading’. This has two implications for local file flagging procedures. Firstly, it emphasises the need to ensure an accurate assessment of the patient that will support the flagging of the file. Secondly, it reflects the importance of ongoing review to ensure that any flag placed on a file is currently relevant. Patients also have the right to request that their file be amended and this would apply to a flag inserted into a file. If the request is refused, the patient can seek that a notation be placed on their file outlining their concern, without erasing the flag information completely. Retention of a flag that is no longer accurate will have implications under PPIPA and possibly the Anti-Discrimination Act. Thus, an active flag should not remain on a file once the risk is no longer current. A process to review and remove flags as appropriate is critical to any flagging system. Any file flagging system needs to be supported by related management plans. If a patient file has a flag for any reason, this needs to be supported by an up to date management plan that enables those managing the presenting patient to do so in a timely and appropriate manner.
NSW Health
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Facilitator instruction Discuss local policies and procedures on file flagging. In summary, the following issues need to be covered in local file flagging policies: ●
Clearly defined purpose for the flag, eg to protect the health and safety of treating staff and/or other patients.
●
Who is to be covered by the flag, eg patient only, family, regular visitors (as it is not only patients who may provide a significant threat).
●
Readily accessible patient management advice that supports the flag, eg how to manage the patient so that violence is prevented.
●
Clearly defined scope of who has access to the information, eg facility wide, AHS wide, other agencies.
●
Clear criteria for the particular flag, eg need to focus on staff and patient safety issues, be clearly related to violent or aggressive behaviours and avoid use of criteria based on impairment or condition. Avoidance of stigmatisation of particular individuals or classes of individuals, ie it needs to focus on behaviours and possible outcomes of those behaviours.
●
Review of flags for ongoing relevance, ie needs to be regular enough to ensure that the flag is still current.
●
Regular review of management plans for continued appropriateness, ie should be part of the flag review indicated above, though may need to be reviewed more regularly if they are not meeting the flag’s purpose or there is a change in the patient’s circumstances.
●
Clear responsibility for initiating, reviewing and removing flags.
●
Clear responsibility for reviewing and updating associated management plans.
6. Individual patient care plans
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss These will set out who is treating the patient, what the crisis care strategies are, identified goals and methods for achieving these goals. These plans are often used for suicidal or parasuicidal patients.
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7. Inability to treat
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Explain and discuss Background reading Despite the options available for managing violent patients, there may be, on rare occasions, and usually as a temporary measure, a situation where it is almost impossible to treat a patient without significant, unacceptable risks to those involved. Depending on the circumstances surrounding this situation, options may include: ●
deferring treatment where possible (if not life threatening) to a time when the risks are better able to be managed, eg when more suitably skilled and experienced staff are available, or when the patient is more settled
●
arranging for treatment to be carried out in a different, more secure location
●
the option not to treat (at that time or at that location) would only arise after all of the above mechanisms have been investigated to their full capacity, and should always be a last resort unless immediate escape from a violent event is necessary.
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8. Apprehended violence orders (AVO)
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Explain and discuss Background reading Where a staff member fears that there may be future violence, harassment or intimidation from someone they have been exposed to in the workplace or in the course of their work, regardless of whether charges of assault are being laid against the person, the staff member may seek to take out an Apprehended Violence Order (AVO). An AVO is an order made by the court to protect people from abuse, violence or threats of violence. They can also be applied for if someone is being stalked, intimidated or harassed, or has reason to fear that they may be in the future. The AVO is an agreement between the defendant and the court that the defendant will not engage in certain behaviours. It usually states that the defendant cannot assault, harass, threaten, stalk or intimidate the person seeking the order (the complainant), or go within a certain distance of their home or workplace. Other orders can be included if necessary. There are two types of AVO. An Apprehended Domestic Violence Order (ADVO) is made where those involved are related, have lived or are still living together or are in an intimate relationship. An Apprehended Personal Violence Order (APVO) is an AVO made where the people involved are not related and is the one most likely to apply in workplace violence situations.
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9. Laying charges
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Facilitator instruction It is helpful to reinforce this as an option. You may wish to elicit recent local examples of patients or visitors being charged.
Small group exercise Case study Jan, a community nurse, was on a routine visit to check up on a six-month-old baby. The baby’s father sells drugs and when Jan arrives on one of her visits a group of young, intoxicated males comes out of the kitchen, traps her and begins to threaten her. At this point, the baby’s mother comes out and intervenes and Jan runs out shaking and drives back to the community health centre.
What are the long-term response options for this incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Facilitator instruction It can be useful to review all the long-term options and consider which ones may be used in this case.
NSW Health
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Small group exercise Case study A person brought in her hurt five-year-old child with a head injury. She was very agitated and one of the staff noticed that an alert was flagged on her file with regard to a risk for aggression. The staff called security and the child was removed from the care of the person because they suspected the person caused the injury. The person then became very aggressive and assaulted security.
What are the short-term response options for this incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Facilitator instruction It can be useful to review all the short-term options and consider which ones may be used in this case.
Show overhead slide
Explain and discuss Strategies during hostage or armed hold-up situations When faced with a hostage or armed hold-up situation your priorities are:
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●
safety of self
●
safety of others.
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Important training point Facilitator note: Hostage and armed hold-up are different situations. In a hostage situation, you are restrained for a period of time for the purpose of bargaining. In an armed hold up situation, you are usually involved for a shorter period of time. In both situations, the usual communication skills should not be used.
Explain and discuss The following principles apply: ●
If someone is pointing a gun in your direction, behave as if the gun is loaded and real, even if you have some doubts.
●
Remain calm.
●
Control your emotions, avoid eye contact, do not stare and avoid sudden movements.
●
Do not attack the intruder or touch anything they have touched.
●
Take note of intruder’s clothing and any other distinguishing features, but do not stare.
●
If safe to do so, activate an alarm.
●
Attempt to stay facing the person.
●
Do not threaten the person in any way. This may mean that if you are a tall, large person, you may need to stay seated as long as possible so that you don’t present yourself as a threat.
●
Comply with all demands that are not likely to cause harm, eg if the demand is for the key to the car – give them the key. If the demand is for the contents of the drug cupboard – give them the contents. Not meeting these demands will threaten your safety.
●
Do not comply with unreasonable demands. Examples of unreasonable demands might include being ordered to jump out of a high window where the risk of death is high.
●
Do not give them information about other people taken hostage.
●
If taken hostage, do not draw attention to yourself, eg do not try to assert yourself. If someone is to be harmed, the people most often chosen are those of privilege or those who have been non-compliant or irritating.
●
If involved in an armed hold-up, do not chase the person when they attempt to escape as this puts you at greater risk of harm.
Explain and discuss Generally speaking, Australian response units tend not to storm hostage or hold-up situations. The current strategy is to wait-out these situations. Hostage negotiators will typically not mention or refer to the people taken hostage in order not to raise their importance in the aggressor’s eyes.
NSW Health
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Key points • Always show respect and dignity for others. • Use effective communication skills. • Treat people as individuals, not as problems. • Know your short-term and long-term options.
Show overhead slide
Facilitator instruction Facilitator note: ●
Recap the importance of safety.
●
Recap the impact of aggression on the individual.
●
Recap self-care: monitor intake of caffeine, cigarettes, alcohol (remember their impact on the immune system).
●
Reinforce mindfulness and stress reduction strategies.
Important training point Facilitator note: to conclude the session reinforce the zero tolerance attitudes and behaviours.
Assessment exercise is now facilitated Details of the assessment are at the front of the module.
Show overhead slide
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Related NSW Health policies and guidelines a.
Mental Health for Emergency Departments, May 2002 (red book).
b. Management of Adults with Severe Behavioural Disturbance, May 2002 (green book). c.
C2003/88 Reportable Incident Briefs to the NSW Department of Health.
d. C2001/22 Workplace Health and safety: A Better Practice Guide (currently under review). e.
C2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace.
f.
C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination.
g. NSW Health Security Manual. h. NSW Health Zero Tolerance Policy and Framework Guidelines. i.
IB94/4 Restraint of Children and Adolescents in Psychiatric Facilities.
NSW Health
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References 1. 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. 2. Bell DM, Espie CA (2002). A preliminary investigation into staff satisfaction, and staff emotions and attitudes in a unit for men with learning disabilities and serious challenging behaviours. British Journal of Learning Disabilities 30 (1), 19-27. 3. Chaplin E, Allison G (1998). The prevention and management of violence in the community. British Journal of Community Nursing 3 (6), 277-282. 4. Claravall L (1996). Health care violence: a nursing administration perspective. Journal of Nursing Administration (26) 2, 41-46. 5. Delaney J, Cleary M, Jordan R, Horsfall J (2000) An exploratory investigation into the nursing management of aggression in acute psychiatric settings. Journal of Psychiatric and Mental Health Nursing 8 (1), 77-84. 6. Fry AJ, O’Riordan, Turner M, Mills KL (2002). Survey of aggressive incidents experienced by community mental health staff. International Journal of Mental Health Nursing 11, 112-120. 7. Hunter E (1997). Violence prevention in the home health setting. Home Healthcare Nurse 15 (6), 403-409. 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. Jones J, Lyneham J (2000). Violence: part of the job for Australian nurses? Australian Journal of Advanced Nursing 18 (2), 27-32. 10. Martin E (1995) Nursing the psychiatric emergency. London, Butterworth, Heinmann. 11. 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. 12. 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. 13. 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. 14. Mental Health Council of Australia (2000) Enhancing relationships between health professionals and consumers and carers. Final Report. NSW Health
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15. NSW Interagency guidelines for child protection intervention, 2000. (online). Available www.kids.nsw.gov.au. 16. Paterson B, Leadbetter D (1999). De-escalation in the management of aggression and violence: towards evidence-based practice. In Turnbull J, Paterson B (eds) Aggression and violence: approaches to effective management (pp 95-123). Basingstoke: Macmillan. 17. Shah A (1999). Aggressive behaviour in the elderly. International Journal of Psychiatry in Clinical Practice 3, 85-103. 18. Zook R (2001). Developing a crisis response team. Journal for Nurses in Staff Development 17 (3), 125.
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