Mod3 Facilitator
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A safer place to work – preventing and managing violent behaviour in the Health workplace
Module 3 90405NSW Course in aggression minimisation for managers 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 3 Course in aggression minimisation for managers
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 . . . . . . . . . . . . . . . . Recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . Other resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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3 3 4 6 7 8
Introduction to Module 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 How Module 3 fits into the whole program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Assessment for Module 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Competency standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 General competencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Learning outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Assessment criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Assessment method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Assessment conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Assessment resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Guidelines for course assessment assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 A strategic plan for aggression minimisation in the workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Marking key – Assessor checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Session plan for Module 3 . Materials. . . . . . . . . . . . . . . . Equipment required. . . . . . . . Participant requirement . . . . .
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Beginning the training session . . . . . . . . . 1. Welcome participants to the module . . . . . 2. House keeping . . . . . . . . . . . . . . . . . . . . . 3. Principles of adult learning . . . . . . . . . . . . . 4. How Module 3 fits into the whole program . 5. Overview of the program . . . . . . . . . . . . . . Assessment . . . . . . . . . . . . . . . . . . . . . . . . .
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17 17 17 17
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Background information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Part 1 The legal and policy framework for managing aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 A zero tolerance response to aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Legal principles of civil and criminal actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Part 2 Promoting an aggression-free workplace . . . . . . Promoting a culture of safety . . . . . . . . . . . . . . . . . . . . . . . . Occupational health and safety legislation. . . . . . . . . . . . . . . Occupational health and safety responsibilities for managers . Risk management and the consulting process . . . . . . . . . . . Designing a safer workplace . . . . . . . . . . . . . . . . . . . . . . . . Regular monitoring, reviewing and evaluating . . . . . . . . . . . .
NSW Health
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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43 44 45 48 50 53 58
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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
Part 3 Assisting staff when aggression and violence occurs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dealing with bullying, harassment and discrimination in the workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Response options when confronted with aggression or violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What is required for the effective management of aggression?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The duress response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reporting aggressive incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Investigating aggressive and violent incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Responding to staff stress after an incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of managers in supporting staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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63 63 68 71 72 75 76 79 84
Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Appendices Appendix A Bullying, harassment and discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Appendix B Incident management plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Appendix C Managers’ roles and responsibilities to reduce the incidence and severity of aggression and violence . . 97 Appendix D Duress response planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Appendix E Assessment assignment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Hypothetical exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
NSW Health
MODULE 3 Course in aggression minimisation for managers
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 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
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 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
NSW Health
MODULE 3 Course in aggression minimisation for managers
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 related 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 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
NSW Health
MODULE 3 Course in aggression minimisation for managers
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 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
NSW Health
MODULE 3 Course in aggression minimisation for managers
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.
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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
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.
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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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MODULE 3 Course in aggression minimisation for managers
Introduction to Module 3 How Module 3 fits into the whole program Module 3 is the third 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 recommended for completing Module 3. 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, aggression free working environment and for assessing and managing aggression risks. It also suggests the types of support to provide to staff who are victims of aggression.
Session times Part 1 Allow 60 minutes for Part 1 Part 2 Allow 60 minutes for Part 2 Part 3 Allow 100 minutes for Part 3 At the end of Part 3 participants need to be oriented to the take home assessment exercise. NB. A session plan is provided at the beginning of Module 3.
Recommendations on the delivery of this module Recommendation 1
The material in the Participant manual is too detailed for a four hour workshop. It is designed to be taken away as a resource for managers. The aim of the training workshop is to orient the manager to the major issues, and to discuss the implementation of aggression minimisation and management strategies. Recommendation 2
Flexible delivery of this module is recommended. Facilitators are encouraged to divide the workshop time as they see fit. For example, the training could be done in two two-hour blocks. The first two hours could be used to overview the whole package and the assessment exercise, the second two hours could be used to review the material once managers have taken it away and read it. In the second two hours the results of the assessment exercise could be discussed and some more of the discussion exercises in the module completed.
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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 onto overheads), a whiteboard and whiteboard pens (for writing up feedback from participant exercises) and hypothetical materials for participants. Participants will need pens or pencils for writing in their copy of the Participant manual. You will need handouts for the hypothetical exercise (see end of Facilitator manual).
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MODULE 3 Course in aggression minimisation for managers
Assessment for Module 3 Competency standards The competency standards are both from the National Frontline Management Competencies: ●
Develop and maintain a safe working environment (Unit 8).
●
Establish and maintain effective workplace relationships (Unit 3).
General competencies General competencies for the program include the ability to: ●
Collect, analyse and organise information
Level 3
●
Communicate ideas and information
Level 3
●
Plan and organise activities
Level 3
●
Work with others in teams
Level 3
●
Solve problems
Level 3
Learning outcomes 1. Demonstrate an understanding of the managers’ roles and responsibilities in preventing and managing aggression. 2. Demonstrate an understanding of the legal and ethical issues in managing aggression. 3. Promote workplace safety. 4. Assist with the integration of aggression minimisation principles in the workplace.
Assessment criteria ●
A policy and statement in relation to the minimisation of aggression and bullying.
●
Definitions of aggression and bullying.
●
An outline of what basic induction and training staff will be offered to support them in aggression minimisation.
●
Specific guidelines as to how, when and by whom risk assessment will be undertaken to minimise aggression. Address this using the risk management process. Use the following headings: Step 1 – Identifying the hazard (workplace aggression). Step 2 – Assessing the risk (determining how serious the aggression problem is). Step 3 – Eliminating or controlling the risk (risk controls need to be ranked from the most effective to the least effective). Step 4 – Monitoring, reviewing and improving the system.
●
Indications as to the strategies which will be used to encourage staff in maintaining a positive, respectful workplace culture.
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Preventative strategies to be taken to minimise risk.
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Specific guidelines in relation to immediate support and ongoing counselling options.
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Specific guidelines to the steps staff should take if feeling bullied.
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Methods to be taken to investigate incidents in a comprehensive manner.
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A list of counselling options available to staff.
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Details of plan implementation.
●
Details of evaluation.
Assessment method Following attendance at the course participants are to develop a workplace plan to minimise aggression. Guidelines for the development and assessment of the plan will be provided during the training. Participants are to submit the assessment assignment within three months of completing the training.
Assessment conditions The assessment is to occur on an individual basis and be submitted within three months of completing the training.
Assessment resources Guidelines for the development and assessment of the plan. NB. Evidence for the implementation of the plan is required, eg evidence of at least one induction activity and risk management activity).
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MODULE 3 Course in aggression minimisation for managers
Guidelines for course assessment assignment A strategic plan for aggression minimisation in the workplace The assessment for this course requires you to develop, document and produce evidence of initial implementation of a plan for aggression minimisation in your own work area. A report of this activity should be submitted to the course coordinator within three months of completing the course. The assignment report should be documented under the following headings: 1. The aggression minimisation plan. 2. Process of development and implementation of plan. 1. Plan – your plan should cover the following aspects of aggression minimisation: ●
A policy that includes a statement in relation to the philosophy of the unit toward aggression. This may include a statement in relation to workplace bullying or you may choose to make this a separate policy.
●
Definitions of aggression and bullying.
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A clear explanation of what basic induction and training staff will be offered to support them in aggression minimisation.
●
Guidelines as to how, when and by whom risk assessment will be undertaken to minimise aggression. Use the following headings: Step 1 – Identifying the hazard (workplace aggression). Step 2 – Assessing the risk (determining how serious the aggression problem is). Step 3 – Eliminating or controlling the risk (risk controls need to be ranked from the most effective to the least effective). Step 4 – Monitoring, reviewing and improving the system.
●
Clear guidelines as to what steps staff should take if they are being bullied.
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Indications as to how staff will be encouraged to maintain a positive workplace culture.
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Clear guidelines on what to do if a violent incident occurs.
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A protocol on safety equipment testing (eg duress alarms).
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Clear guidelines in relation to support. Who is responsible for initiating it, who should receive it and who should do it?
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A list of counselling options available to staff.
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Identification of the time schedules and methods of reviewing the plan, in order to evaluate effectiveness and appropriateness.
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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
2. Process of development and implementation of plan
This section should describe what you did to develop the plan. For example, what activities did you undertake to identify, assess and control violence risks, did you do any research, reading or ask other people in similar positions what they did? Did you consult with your staff or use some meeting time to develop a plan with team input? If needed, did you consult with any others outside your workplace? NB. Evidence for the implementation of the plan is required, eg evidence of at least one induction activity and risk management activity.
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MODULE 3 Course in aggression minimisation for managers
Marking key Assessor checklist Yes
No
Unsure
Policy and statement in relation to the philosophy of the unit toward aggression. Definition of aggression and bullying. Clear explanation of what basic induction and training staff will be offered to support aggression minimisation. Guidelines as to how, when and by whom risk assessment will be undertaken to minimise aggression. Clear guidelines as to what steps staff should take if they are being bullied. Indications as to how staff will be encouraged to maintain a positive workplace culture. Clear guidelines on what to do in a violent incident. A protocol on safety equipment testing (eg duress alarms). Clear guidelines in relation to support. Who is responsible for initiating it, who should receive it, and who should do it? A list of counselling options available to staff. Identification of the time schedules and methods of reviewing the plan, in order to evaluate effectiveness and appropriateness. Process of development. Process of implementation of plan.
When assessing for competence on the assignment, ensure that the plan is consistent with local policies and guidelines.
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MODULE 3 Course in aggression minimisation for managers
Session plan for Module 3 Training session: Module 3 Course in aggression minimisation for managers
Time
Topic
60 mins
●
Introduction.
●
The legal and policy framework for managing aggression.
60mins
●
Promoting an aggression-free workplace.
100mins
●
Assisting staff when aggression and violence occurs.
Date: Time:
Learning outcomes 1 and 2
3 and 4 4
Content/activity Small and large group discussions.
Small and large group discussions. ●
Small and large group discussions.
●
Hypothetical exercise.
Materials The training room should be comfortable with desks for participants so that they can write in their 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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MODULE 3 Course in aggression minimisation for managers
Beginning the training session Session time 10 minutes
Facilitator instruction The relevant slides that should be shown at each point are reproduced in small size in the Facilitator manual. You should begin with the title slide, which should be showing when participants begin to arrive at the workshop. To begin teaching this module you will need to do the following:
Show overhead slide
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.
2. House keeping Inform participants of: ●
program times
●
breaks and meals
●
toilets
●
mobile phones
●
message board
●
occupational health and safety (fire escapes).
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3. Principles of adult learning Inform participants that: ●
everyone’s opinion will be respected
●
every participant’s work experience will be valued.
Show overhead slide
4. How Module 3 fits into the whole program Module 3 is a four-hour module designed for managers of health units and facilities. It provides the participant with detailed information, obligations and practical strategies for promoting a safe, aggression free working environment and for assessing and managing aggression risks. It also suggests the types of support to provide to staff who are victims of aggression. Completion of Module 1, or its equivalent, is recommended for Module 3.
Show overhead slide
5. Overview of the program Explain that the program is divided into three parts: ●
Part 1 – looks at the legal and policy framework for managing aggression.
●
Part 2 – looks at how you can promote an aggression free workplace.
●
Part 3 – looks at assisting staff when aggression and violence occurs.
Explain that the aim of the module is not to go through the whole program but that most of the information is to be read in the participant’s own time.
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MODULE 3 Course in aggression minimisation for managers
Assessment At this point, introduce the assessment component of the course. Point out that a four hour course in itself could not be expected to provide participants with the competence and skill required of a manager in relation to aggression minimisation, though of course this would depend on the current skills and experience of the manager. However, when the training session is combined with the experience of carrying out the assessment exercise and using the skills and knowledge gained through these in an ongoing way, participants may develop the competence and skill that is required. Indicate that time will be spent at the end of the session discussing the assignment. At that time the discussion will be more meaningful to participants.
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MODULE 3 Course in aggression minimisation for managers
Background information Facilitator instruction The following is background information on the problem of aggression. Facilitators need to refer to key points from this and refer to any local issues or data relevant to the problem of aggression and aggression management.
You are on Participant manual page 9
Key points The key points that should be emphasised: ●
Aggression is a significant problem in the health industry.
●
Aggression affects both the individual and the organisation.
●
Managers play an important role in ensuring safety through organisational responsibilities and through leadership.
Background reading Aggression in the health industry is a significant problem.1,2,3 The costs of aggression in the workplace are human4,5,6,7 as well as economic.8,9,10 The economic costs include increased absenteeism, loss of earnings, compensation claims, impaired functioning and staff turnover. The human costs include reductions in physical and psychological health. Managers clearly have a vital role to play in ensuring the safety of the workplace, not only in terms of organisational responsibilities, but also in terms of leadership. The culture of a workplace is not solely dependent on managerial style and philosophy, however these are fundamental influencing factors for which managers need to accept responsibility. In order to effectively fulfil their role managers should not only be aware of the aggression minimisation principles required of their staff, but also their own particular responsibilities. The aim of this course is to assist managers of health units and facilities to promote a workplace, which is safe and free from aggression. The course is intended for managers at all levels. It will provide them with an opportunity to gain the knowledge and skills necessary to offer leadership, identify, assess and manage violence risks and provide support for their staff and colleagues in relation to aggression minimisation.
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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
By completing this training and continually improving the way in which you respond to aggression you may achieve the following: ●
Reduced injury to staff, patients and members of the public.
●
Reduced levels of stress in the workplace.
●
Reduced levels of aggression.
●
Fulfilment of your duty of care and responsibility under the NSW OHS Act 2000.
Many managers will have first hand experience in encountering aggression and conflict in the workplace. This course will enable you to draw on those experiences and use them to explore and develop best practice principles for the prevention and management of aggression.
Show overhead slide
You are on Participant manual page 10
Explain and discuss At the conclusion of this training program participants will be able to: 1. demonstrate an understanding of the manager’s roles and responsibilities in preventing and managing aggression 2. demonstrate an understanding of the legal and ethical issues in managing aggression 3. promote workplace safety 4. assist with the integration of aggression minimisation principles in the workplace.
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MODULE 3 Course in aggression minimisation for managers
Part 1 The legal and policy framework for managing aggression Session time 60 mins (including introduction)
Facilitator instruction To teach this part you will need to have familiarised yourself with NSW Health policies, as well as local policies, procedures and guidelines. Relevant departmental policies and local policies, procedures and guidelines should be shown to the participants when being discussed.
Show overhead slide
Session overview This section looks at the NSW Health zero tolerance response to aggression, other policies and guidelines in relation to aggression and the principles of legal and civil actions.
You are on Participant manual page 11 Background reading Legislative,a procedural and ethical laws and guidelines govern: a.
the way in which you manage aggression, and
b. those affected by aggression in the workplace. You have a responsibility to ensure that: ●
you are aware of all NSW Health policies on aggression minimisation and management
●
all relevant local policies, procedures and protocols that flow from them are communicated to your staff
●
they are effectively implemented in your area of responsibility.
It is also important to understand the impact of aggression on your staff and your responsibilities in relation to these impacts. NSW Health
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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
Important training point
Facilitator instruction Note: There are three slides to this section.
Explain and discuss Key NSW Health policies and guidelines in relation to violence prevention and management.
Show overhead slide
Facilitator instruction Mention each NSW Health policy and guideline on the overhead slide. As you mention each one, ask the group if they are aware of the policy or guideline and ask them to explain briefly what it is about. If no participant can explain a particular policy/guideline inform the group about the policy or guideline. A list of related NSW Health policies and guidelines can be located at the end of the Participant manual. Show each policy when being discussed.
Answers NSW Health Zero Tolerance Policy and Framework Guidelines This document sets out a policy framework utilising risk management principles to establish and maintain a work place culture of zero tolerance to violence. The framework includes provisions of work systems that enable and support the zero tolerance response, and physical work environments that sustain such an approach.
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MODULE 3 Course in aggression minimisation for managers
Answers C2001/22 Workplace Health and Safety: A Better Practice Guide (currently under review) This document provides guidance on better practice in workplace health and safety. It provides a comprehensive set of guidelines incorporating the roles of Health Service Chief Executive Officers, managers and staff on occupational health and safety and risk management, and an awareness of the responsibilities of all staff under the occupational health and safety legislation. C2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace This document provides guidelines for planning incident prevention and management protocols or procedures, and essential components for incident management. It also focuses on the impacts of incidents on staff and provides a framework to assist staff to deal with their experience. Protecting People and Property: NSW Health Policy and Guidelines for Security Risk Management in Health facilities Also known as the Security Manual, this document explains NSW Health policy and guidelines for maintaining client, visitor and staff security in health care facilities.
Show overhead slide
Answers Design Series (DS) Health Facility Guideline – Security and Safety 2003 This document aims to assist health facility planners and designers to minimise the risk of violent incidents by the provision of appropriate facilities, work spaces, building services and systems. It is a guideline to assist in the identification of potential areas of risk and must be addressed during the planning, design and construction phases of a health facility project. The planning and design standards should be regarded as the minimum standards. Management of Adults with Severe Behavioural Disturbance – Guidelines for Clinicians in NSW (amended May 2002) This document provides guidelines for clinicians in managing aggression and violence in adults.
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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
Answers Mental Health for Emergency Departments – A Reference Guide (amended May 2002) This document is a reference guide to assist staff in Emergency Departments in their care of people with mental illness. It also includes guidelines in managing aggression and violence in adults and is a useful resource for all clinical staff in areas where there is a risk of violence. It provides brief overviews of some common presentations to emergency departments and suggestions about important issues to address. C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination This policy outlines the commitment by NSW Health toward eliminating bullying, harassment and discrimination. It includes types of unacceptable behaviours, the impact of such behaviours on others, appropriate action staff can take and likely outcomes, as well as the responsibilities of all staff in fostering an environment free from bullying, harassment and discrimination. C2003/88 Reportable Incident Briefs to the NSW Department of Health This document identifies what incidents need to be reported to NSW Health.
Facilitator instruction Point out to participants that throughout the training these policies and guidelines will be referred to. Point out to participants that they have a list of these related NSW Health policies and guidelines at the end of their copy of the Participant manual.
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MODULE 3 Course in aggression minimisation for managers
A zero tolerance response to aggression Important training point
Facilitator instruction Introduce the topic of zero tolerance.
Show overhead slide
Explain and discuss NSW Health is committed to the minimisation of aggression and violence in the public health system and has adopted a zero tolerance response to aggression and violence.
Background reading 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.
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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 11 Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone in their group who will share their groups’ responses to the larger group at the end of their discussion.
What does zero tolerance mean to you? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Ask the group At the end of the small group discussion ask each elected participant to share their groups’ responses with the larger group.
Write responses on board After writing all the responses go to the next slide and compare the responses to the main points on the slide and elaborate further if required.
Show overhead slide
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MODULE 3 Course in aggression minimisation for managers
Facilitator instruction The key issues to highlight are: ●
That the focus must be on prevention at all times.
●
However, if an incident does occur the zero tolerance approach is about keeping health staff, patients and visitors safe, ie action must be taken to minimise the impact. Options will be discussed in Part 3.
●
It is not about punitive action against patients whose aggressive or violent behaviour is a result of a medical condition, but on prompt and effective clinical management of these patients while at the same time maintaining the safety of patients, staff and others.
●
It is about looking out for aggression and doing something about it, rather than accepting it as a normal part of the job.
Background reading The zero tolerance responseb means that in all instances of aggression appropriate action will be taken to protect staff, patients, visitors and health service property from the effects of such behaviour. It is about keeping health staff, patients and visitors safe. The zero tolerance response does not take the place of effective risk management, and at all times the focus must be on prevention. However, in the event of an aggressive incident action will be taken to minimise the impact on all concerned. Options for action will be discussed in Part 3. It should be noted that zero tolerance is NOT about taking punitive action against patients whose violent behaviour is a direct result of a medical condition. In these circumstances the emphasis is on prompt, effective clinical management and compassionate care of the patient, while at the same time protecting the safety of the patient, the staff and others who might be affected by the behaviour. 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’.
Readings and resources For further information see the NSW Health Zero Tolerance Policy and Framework Guidelines.
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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
You are on Participant manual page 12
Important training point Emphasise all the key points for the zero tolerance attitudes and behaviours below.
Zero tolerance attitudes and behaviours Putting up with aggression and violence in the health workplace IS NOT an acceptable part of your job (if you don't get the message neither will your staff). Lead by example (if you don't take aggressive incidents seriously, neither will your staff, patients or visitors). Make sure your staff know their options when confronted with violent behaviour (there are options and it is important that all staff know what they are). Encourage and support them in utilising these options (staff need to feel confident in the decisions they make when confronted with violence and that their decisions will be supported, particularly when police are involved and during any resulting legal process). Know and exercise your responsibilities as a manager in dealing with violence (both short term and longer term). Ensure that all violent incidents are reported (keep the system simple to encourage a culture of reporting). Investigate all violent incidents (this is the only way to ensure that risk management strategies continue to be effective). Respond promptly to all reports of bullying (if you don't staff will not take 'zero tolerance' seriously). Keep 'zero tolerance' on the agenda (discuss in staff meetings the factors that increase violence risks in the immediate workplace, run debriefs after aggressive incidents, communicate incident investigation results and remedial actions to your staff, encourage staff to feed back on how local protocols and procedures are working).
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MODULE 3 Course in aggression minimisation for managers
Show overhead slide
You are on Participant manual page 12
Ask the group How can you communicate the zero tolerance response to staff, patients, visitors and members of the public? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Write responses on the whiteboard. Elicit from participants any responses below that have not been identified.
Answers Responses include: ●
having zero tolerance and occupational health and safety issues, particularly in relation to aggression, as permanent agenda items in staff meetings
●
including information on zero tolerance in orientation sessions for staff
●
providing information to patients and visitors clearly outlining their rights AND behavioural responsibilities when in, or visiting, hospital
●
placing copies of related materials in all bedside lockers and patient information kits, and keeping supplies in waiting areas, Emergency Departments, public health units and other areas based on local needs
●
consulting with Health Service media relations personnel on promoting local initiatives aimed at providing violence-free health care environments
●
displaying zero tolerance posters in relevant areas
●
ensuring that staff see that there is an immediate and transparent response to aggressive incidents by management.
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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
Legal principles of civil and criminal actions Show overhead slide
Facilitator instruction Introduce the topic by briefly explaining the four main principles of the law, which protect an individual’s rights, as listed below.
Explain and discuss In general the law protects an individual’s rights in four main areas. These four main principles impact on the manner in which staff conduct themselves in the workplace. The right: ●
to freedom of movement
●
to immunity from unwarranted interference from bodily contact by others
●
to immunity from conduct by others that would subject the person to unreasonable risk of injury
●
of reputation.
Show overhead slide
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MODULE 3 Course in aggression minimisation for managers
Explain and discuss ●
Under the Crimes Act 1900 any persons who commit assaults and other acts of violence can be charged with criminal offences.
●
There are also provisions for apprehended violence orders to be taken out where a person has reasonable grounds to fear personal violence, harassment or molestation.
●
All significant incidents should be reported to the police, and where appropriate police may charge the perpetrator.
●
Recent changes to the Crimes Act now mean that the occupation of the victim of an assault will be considered in determining an appropriate sentence. These changes are designed to allow tougher penalties to be imposed on those who assault health staff or other ‘essential service workers’ in the course of their work.
Ask the group ●
Has anyone been involved in charging patients, visitors or others?
●
What are your experiences in trying to have patients, visitors or others charged?
Encourage a brief group discussion.
Answers Issues participants may raise include: ●
Often staff drop the charges further down the track.
●
There is a belief that it will be thrown out of court.
●
Pressure may come from relatives, consumer advocates, perhaps even central administration (eg ‘it doesn’t look good for the service’ if you charge a patient).
Raise the following: ●
all significant, violent incidents should be reported to the police, and where appropriate police may charge the perpetrator.
Crimes Act 1900
Under the Crimes Act, persons who commit assaults and other acts of violence can be charged with criminal offences. The Act also establishes provisions allowing apprehended personal violence orders to be taken out where a person has reasonable grounds to fear personal violence, harassment or molestation.b Recent changes to the Act now mean that the occupation of the victim of an assault will be considered in determining an appropriate sentence. These changes are designed to allow tougher penalties to be imposed on those who assault health staff or other ‘essential service workers’ in the course of their work. NSW Health
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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 Explain to participants that information on the definition of assault, reasonable force, use of restraint and duty of care is in their copy of the Participant manual. Explain that this is for reading in their own time, as it was covered in some detail in Module 1.
Important training point Employers have the responsibility of ensuring that employees are not put at risk of assault. From an administrative perspective, managers need to ensure that appropriate risk management initiatives are implemented in their area of responsibility. In particular, communication mechanisms need to be implemented to ensure that relevant information, relating to patients with a history of violence, is communicated to staff providing care to these patients. This allows for staff to be adequately prepared, and to develop patient management plans to reduce the risk of violent incidents.
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 for police to prove if they are to successfully secure a prosecution for assault. Employers have the responsibility of ensuring that employees are not put at risk of assault. From an administrative perspective, managers need to ensure that appropriate risk management initiatives are implemented in their area of responsibility. In particular, communication mechanisms need to be implemented to ensure that relevant information, relating to patients with a history of violence, is communicated to staff providing care to these patients. This allows for staff to be adequately prepared, and to develop patient management plans to reduce the risk of violent incidents. Reasonable force b
Section 418 of the Crimes Act 1900 states that a person may use self-defence if and only if the person believes the conduct is necessary to:
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defend himself or herself or another person, or
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prevent or terminate the unlawful deprivation of his or her liberty or the liberty of another person, or
●
protect property from unlawful taking, destruction, damage or interference, and the conduct is a reasonable response in the circumstances as he or she perceives them. These provisions were introduced in February 2002.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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This means that a person who assaults another person in self-defence is not criminally responsible if acting in lawful self-defence. As stated above self-defence is not limited to the defence of ones own person, and can be used as a defence for assaults that occur when protecting property or other people. In the past the test was whether the perception of a threat was reasonable in the circumstances, and whether a ‘reasonable person’ in the same circumstances would also have been able to come to the same conclusion. The defence is now broader and states that as long as the accused believed that they were under threat, it does not matter that a ‘reasonable person’ may not have perceived such a threat in the same circumstances. However, a reasonable response is still required for the law of self-defence to operate. The law states that there must be some reasonable proportion between the threat perceived by the accused and his or her response to it. So the key issue is that the person threatened must be able to persuade a court that they felt threatened, that the threat was real to them and that their response was appropriate.
Use of restraint Restraint may be necessary in emergency situations involving aggressive patients, where there is a foreseeable risk of harm to themselves or others. At all times NSW Health policy requirements relating to clinical restraint should be adhered to. See NSW Health documents: Management of Adults with Severe Behavioural Disturbance, May 2002; Mental Health for Emergency Departments, May 2002; Policies on Seclusion Practices: the Use of Restraint and the Use of IV Sedation in Psychiatric In-Patient Facilities, December 1994. When staff restrain a patient they must use only reasonable force in order to be protected from prosecution for assault. With regard to the restraint of others in the act of committing a crime, the first consideration for staff is their own safety and the safety of others. Attempting to restrain in these circumstances may expose staff to unnecessary risks, and unless there is an immediate and significant threat to the safety of others, staff should retreat and observe from a safe distance, and police should be called.
Duty of care Duty of care requires that a staff member act in the best interests of the patient. However, it is essential to note that a duty of care does not suggest that staff should remain in dangerous situations or place themselves at unacceptable risk. At times a staff member’s duty of care to a patient may justify the use of detainment, restraint or sedation for the patient’s own safety or the safety of others. In these situations having exercised a duty of care may be a defence for staff members against claims of false imprisonment or assault. Not exercising a duty of care may result in a claim of negligence depending on the circumstances.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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 15 Small group exercise Ask participants to work in small groups and discuss the following two questions for ten minutes. Ask them to elect someone in their group who will share their responses to the larger group at the end of their discussion.
What is the role of the manager when: A staff member seeks to have charges laid against a patient, visitor or a member of the public? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board If the group fails to identify any of the responses below prompt for the responses.
Answers Responses need to include the following: ●
Support staff who are pressing charges if it is reasonable.
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Let staff know that they have your support and the support of senior management.
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Where an incident requires legal proceedings it is important that you provide practical support for staff who may be required to give evidence. This includes: – – – –
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making provisions where appropriate for legal advice providing support leading up to and during the legal process requesting that police press charges as appropriate providing a support person during court hearings, when attending the police station to make a statement, etc.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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A patient, visitor or member of the public seeks to have charges laid against a staff member? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board If the group fails to identify any of the responses below prompt for the responses.
Answers Responses need to include the following: ●
Investigate the incident.
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You may need to involve an independent investigator.
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Arrange for legal representation if the organisation is supporting you.
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Arrange for any counselling.
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Refer the staff member to their industrial organisation.
Ask the group If police are involved in investigating the incident, do you still need to investigate?
Answers Yes – OHS Act requires that you investigate.
Explain and discuss You need to be aware that you and your investigation can be subpoenaed by the court and legal representatives.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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 support would you advise for the patient, visitor or member of the public?
Answers ●
Refer them to a legal rights advocate.
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Any counselling needs are to be independent of the organisation.
Facilitator instruction Familiarise yourself with the following: 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.
Ask the group Has anyone been involved in the process of having an AVO obtained for a staff member? If yes, ask them to explain the process and any difficulties they had and how this may have been overcome. If no participant has been involved then briefly explain and discuss the AVO.
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Facilitator instruction Familiarise yourself with the NSW Health Memorandum of Understanding (MOU) between NSW Police and NSW Health, and your related local protocols.
Explain and discuss The NSW Health Memorandum of Understanding between NSW Police and NSW Health has been developed to provide a framework for the effective management of people with a mental illness when the services of both NSW Health and the NSW Police service are required. It has grown out of the need for a formalised system for cooperation between these two important areas of service delivery, particularly when dealing with mental health crisis intervention.
Ask the group If anyone has been involved in the development of their local protocols for the MOU. If yes, ask them to briefly explain the local protocols. If local protocols are still under development, explain where they are up to. If no, briefly explain the MOU.
Background reading NSW Health Memorandum of Understanding between NSW Police and NSW Health
The NSW Health Memorandum of Understanding (MOU) between NSW Police and NSW Health was developed and released in 1998 to establish a clear framework for the management of situations involving police and health staff, and persons who may have a mental illness. The objective was to improve the response to and outcomes in the management of mental health crises that involved responses from multiple services. The MOU clearly defines the roles of each of the service providers, formalising those roles into a workable and complementary framework. However, the framework is intentionally broad, to allow for specific protocols to be developed at the local level utilising local service components and addressing local needs. The MOU was reviewed in 2000 and resulted in a number of practical tools being developed that support the MOU and provide more detailed guidance for the development of local protocols. These documents were released in July 2002.b
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
Local policies and guidelines
Individual reflection exercise
Facilitator instruction Ask the group to think about this question and write their responses. Give the group ten minutes.
Identify all the local policies and procedures on aggression within your Health Service that are relevant to your work area of responsibility. How do you ensure that staff are familiar with them? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Suggested break time
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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Part 2 Promoting an aggression-free workplace Session time 60 minutes
Show overhead slide
Session overview This section of the course focuses on prevention of aggression in the workplace and the role of managers in this process. While it is widely acknowledged that not all aggression in the workplace can be prevented, the focus of all staff including managers should be to prevent the vast majority of potentially aggressive incidents from occurring. In this process it is important that managers have a leading role in: ●
promoting a culture of safety
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utilising the risk management process.
You are on Participant manual page 17
Important training point ●
Feeling unsafe in the workplace can cause additional stress for staff and negative attitudes that influence behaviour.
●
Emphasise that prevention is the first and most important response.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
Promoting a culture of safety Violence has generally been seen as part of the job in health care11, with staff expecting to be physically assaulted at some stage in their careers12. Feeling unsafe in the workplace can cause: ●
additional stress for staff13
●
negative attitudes that influence behaviour.14
Readings and resources For detailed information on workplace safety refer to: NSW Health Security Manualc and Workplace Health and Safety: A Better Practice Guide (currently under review).a
Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone else in their group who will share their responses to the larger group at the end of their discussion.
As a manager, what are some of the challenges to ensuring safety is a top priority for your staff? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Ask the group At the end of the small group discussion, ask each elected participant to share their group’s responses with the larger group.
Write responses on one side of the whiteboard. Answers Responses could include: ●
encouraging staff to see this as not only the manager’s responsibility
●
changing staff attitudes.
Facilitator instruction Explain that later in this section we will look at how to overcome these challenges.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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Occupational health and safety legislation Facilitator instruction Familiarise yourself with the responsibilities of employers under the Occupational Health and Safety Act 2000 and Occupational Health and Safety Regulation 2001 (over the page).
Show overhead slide
You are on Participant manual page 17 Facilitator instruction Explain to participants that this information is to be read later. Briefly emphasise the following: ●
The OHS Act 2000 is supported by the OHS Regulation 2001.
●
There are various offences and penalties for non-compliance with the Act and Regulation even if no one has been injured.
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These penalties are for employers, managers and employees.
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Non-compliance includes employers not having done enough to eliminate or reduce risks, even if no one has been injured.
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If the organisation is in breach of the Act or Regulation, depending on the circumstances, managers may be held liable unless they are able to show that they could not have influenced the organisation’s conduct in the matter, or that they used ‘due diligence’ to stop the corporation from contravening the Act.
NSW Health
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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
Background reading Under the NSW Occupational Health and Safety Act 2000a employers have a duty of care for the health and safety of all people in the workplace. This requires employers to: ●
ensure that premises controlled by the employer where people work are safe and without risk to health
●
ensure that systems of work and the working environment are safe and without risk to health
●
ensure that any equipment or substance provided, for use by the employees at work is safe and without risk to health when properly used
●
provide necessary information, instruction, training and supervision for the health and safety of their employees.
This Act is supported by the Occupational Health and Safety Regulation 2001.a Under this regulation employers are responsible for: ●
identifying workplace hazards, including violence
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assessing the risks associated with the hazards
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implementing risk control measures
●
consulting with their employees during the process
●
providing training.
There are various offences and penalties for non-compliance with the Act and Regulation even if no one has been injured. These penalties are for employers, managers and employees. Non-compliance with the Act and Regulation includes employers not having done enough to eliminate or reduce risks even if no one has been injured. If the organisation is in breach of the Act or Regulation managers may be held liable unless they are able to show that they could not have influenced the organisation’s conduct in the matter, or that they used ‘due diligence’ to stop the corporation from contravening the Act.
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Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone in their group who will share their responses to the larger group at the end of their discussion.
How can ‘due diligence’ be shown? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board If the group fails to identify any of the responses below prompt for the responses.
Answers Responses need to include: ●
ensuring legal obligations are met
●
implementing safe work practices and systems within their area of responsibility
●
keeping records on responses to workplace hazards
●
providing appropriate information, instruction, training and supervision
●
monitoring and auditing OHS and injury management programs.
Employers need to ensure the health and safety of persons who are at their place of work and who may be affected by their acts or omissions at work. Employees must cooperate with employers in complying with OHS requirements.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
Occupational health and safety responsibilities for managers You are on Participant manual page 18 Explain and discuss Explain to participants that information on occupational health and safety responsibilities is to be read in their own time.
Background reading Managers coordinate the overall safety effort within their area of responsibility. This requires them to understand their duty of care and be familiar with the OHS system in their organisation. The following are examples of an OHS system in actiona. ●
Developing safe work practices and procedures.
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Consulting with employees on all safety issues.
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Considering decisions from an OHS perspective.
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Ensuring compliance with safety rules.
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Ensuring line managers do not cut corners, introduce ambiguity or condone unsafe work practices.
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Raising OHS issues at staff meetings.
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Encouraging staff to support OHS committee meetings and related activities.
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Reporting back to staff on OHS initiatives and trends.
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Involving staff in all decisions that affect them.
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Enforcing safety policies and procedures.
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Promptly and visibly investigating all significant OHS issues.
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Ensuring effective OHS training and development for employees.
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Developing easy and non-threatening procedures to report accidents, injury, illness and ‘near misses’.
Facilitator instruction Suggested wording: “Previously we spoke about challenges managers have in ensuring that safety is a priority for staff, now we’ll look at how you can ensure that staff are involved in the promotion of workplace safety”.
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Ask the group How do you as a manager ensure that staff are involved in the promotion of workplace safety? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Answers If the group fails to identify any of the responses below prompt for the responses. 1. Consult with staff: ● on aggression management training needs ●
when designing, purchasing or customising equipment aimed at improving safety and security
●
when developing new facilities or refurbishing existing facilities
●
when identifying, assessing and controlling violence risks.
NB. Keep staff informed of all relevant aggression minimisation activities.
2. Education ● Provide training, eg aggression minimisation training, OHS training as part of orientation into the workplace for new staff. 3. Get staff involved in safety ● Get staff involved in conducting risk assessments and coming up with strategies.
NSW Health
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Allocate duties to individual staff to be responsible for specific safety related activities (give staff the skills and training and allow time for this).
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Ask staff for suggestions on how to manage safety issues.
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Provide staff with feedback and follow-up on violence prevention activities.
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Support staff representation on OHS committees.
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Set a good example.
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Risk management and the consulting process Show overhead slide
Explain and discuss ●
Under the OHS Act employers are required to consult with staff.
●
Staff need to be consulted when: – identifying, assessing, prioritising and reviewing risks – deciding on measures to eliminate or control risks – altering or introducing new procedures – changing work systems or introducing new equipment – making decisions about consulting arrangements.
●
Managers have a responsibility to consult with their staff. Both clinical and non-clinical staff will often have a good understanding of the risks they face and how they can best be controlled.
Under the OHS Act 2000a employers are required to consult with employees and take into account their views when decisions are made that affect their health, safety and welfare. Some examples of when you need to consult staff include:
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whenever examining or reviewing risks to health and safety
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when making decisions about measures taken to eliminate or control risks
●
when introducing or altering procedures for identifying and monitoring risks
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whenever changes are being proposed that could affect health and safety in the workplace, the systems of work or equipment used for work
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whenever decisions are made about consultation arrangements.
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Show overhead slide
You are on Participant manual page 19 Explain and discuss Explain the four steps in the risk management process: ●
Identify the hazard, which in this case is aggression. Examples of sources of information for determining the types of violence risks can be found in the Participant manual.
●
Assess the risk: – What is the likelihood of violence occurring? – Consider the severity of the potential outcomes. – Prioritise the risks for preventive action (factors to consider when prioritising violence risks are included in the Participant manual). Eliminate or control the risk. Under the OHS Regulation, employers are required to eliminate any ‘reasonably foreseeable’ risks. If this is not possible then risk control measures need to be implemented. In most cases several control measures will be needed. These can include engineering controls, administrative controls and personal protective equipment.
●
Engineering controls include: – designing out the risk or hazard when planning new premises, equipment and work systems – redesigning existing work environments, equipment and work systems to eliminate risks – isolating the risk or hazard from staff. Administrative controls include: – rotating staff to reduce frequency and duration of exposure to the risk – maintenance programs and house keeping – providing information and training – developing procedures and protocols for hazardous activities. ●
NSW Health
Monitor and review the control implemented and if need be further improve the system.
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Facilitator instruction Discuss with participants any issues arising from this and have the whole group problem solve. Risk management is an interactive process consisting of clearly defined steps15,16. By following the steps you can make informed decisions on how best to avoid or control violence risks. The risk management process Step 1. Identify the hazard. Step 2. Assess the risk. Step 3. Eliminate or control the risk. Step 4. Monitor, review and improve the system.
Background reading The process of identifying risks in your workplace
For the process of identifying risks, some potential sources of information are: ●
aggression/violence reports and associated aggregated data
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incident investigation reports and emergency response reviews
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reports of staff and unions
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visual workplace inspections and violence vulnerability audits
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security surveys
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related OHS and workers compensation data
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staff records, eg to identify areas of high staff turnover
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staff grievance records
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patient complaint records
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observations.
Factors to consider when assessing and prioritising risks b
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What is the nature of the risk or hazard, eg is it physical, psychological, chemical?
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What is the degree or severity of harm that the hazard/risk may cause?
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How likely is it that harm will occur as a result of the exposure?
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How often are staff exposed to the risk or hazard?
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How long are the periods of exposure?
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How many staff are exposed to the risk or hazard?
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How many patients are exposed to the risk or hazard?
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What is the level of experience of staff?
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How much training has staff received?
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How effective are the existing control strategies?
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Eliminating or controlling risks
Eliminating or controlling risks involves deciding what needs to be done to eliminate or control the problem. Under the Occupational Health and Safety Regulation 2001 employers are required to eliminate any ‘reasonably foreseeable’ risks to the health and safety of their employees. Risk control measures need to be developed and implemented in a manner consistent with the hierarchy of controls set out in the legislation. The hierarchy ranks control measures from the most effective to the least effective. In most cases several control measures will be needed.b
Designing a safer workplace Facilitator instruction Introduce crime prevention through environmental design and situational crime prevention as examples of the engineering controls discussed above.
Show overhead slide
You are on Participant manual page 21
Readings and resources NSW Health has developed the Design Series (DS) Health Facility Guideline – Security and Safety 2003d to assist facility planners and designers to reduce violence and security risks through the design and layout of workplaces, by incorporating ‘crime prevention through environmental design’ (CPTED) principles into the Health building process. Considering the design of the environment can reduce situational crime.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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 The design of new facilities or refurbished facilities can reduce criminal activity. The main concepts are: ●
‘Target hardening’, which refers to reducing access to specific high-risk areas through architectural or engineering designs or redesigns.
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‘Territorial reinforcement’, which refers to ensuring that staff only areas are clearly identified and separated from other areas, so that staff are more likely to notice an intruder.
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‘Natural surveillance’, which refers to increasing visibility in the workplace therefore discouraging offenders as this improves the chance of others witnessing and reporting offenders. An example of natural surveillance is office windows overlooking car parks, walkways etc.
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‘Space management’, which refers to having appropriate fittings and furniture and therefore reducing the likelihood of the perpetrator being able to commit a crime or hurt someone.
Background reading When designing b, 2,17 new facilities or refurbishingb,2,17 it is important to reduce the opportunity for criminal activity. This can be achieved through: ●
increasing the risk for offenders
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reducing the opportunity for the offender to make an excuse to trespass
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reducing the likely rewards for criminal behaviour.
Target hardening and territorial reinforcement b,2
‘Target hardening’ refers to reducing access to specific high-risk areas through architectural or engineering designs or redesigns. Target hardening strategies include: ●
access controls
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barriers and grates
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deadlocks on drug cabinets.
‘Territorial reinforcement’ refers to ensuring that staff only areas are clearly identified and separated from other areas so that staff are more likely to notice an intruder. Staff can be encouraged to view the health care setting as something that is theirs. A sense of protectiveness of the facility by staff is an important aspect of safety. Staff are more likely to pay attention to areas where ‘staff only’ are permitted. Strategies for territorial reinforcement include:
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encouraging staff to be responsible for the facility and its use
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designing facilities that have clear transitions and boundaries between the health facility and the general community and between ‘staff only’ areas and other areas
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establishing clearly visible signs on who is to use a space and its purpose.
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Natural surveillance b,2
Increasing visibility in the workplace discourages offenders as it improves the chance of others witnessing and reporting the offenders. Examples include: ●
having clear sightlines between public and staff areas
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effective lighting for visibility
●
ensuring that areas that are landscaped are not places where offenders have an opportunity to hide or entrap victims
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designing pathways to car parks to be in full view of passers-by and/or overlooked by windows.
Space management b,2
The types of fittings and furniture used in the workplace can reduce the risk of aggression by making it more difficult for perpetrators to commit a crime and cause injury to others. Some strategies include: ●
keeping sites clean
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keeping all furniture, fittings and facilities in good repair
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attending quickly to the repair of vandalism and graffiti
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replacing any burned out external lighting
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removing or refurbishing any decayed physical surroundings.
Facilitator instruction For this exercise three small groups are required. Give each group an example of a specific type of engineering control, ie either target hardening, surveillance and lighting or furniture and fittings to discuss for the exercise. Give participants ten minutes.
You are on Participant manual page 22
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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
Small group exercise Ask the groups to complete the exercise according to the type of engineering control designated. Ask each group to elect someone who will share their responses to the larger group at the end of the discussion. Discuss what environmental control measures you have in your workplace and what environmental control measures need to be implemented for each of the following to reduce the risk of aggression and violence: Target hardening ______________________________________________________________________________ ________________________________________________________________________________
Write responses on board Answers Responses can include: ●
deadlocking drug storage areas
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designating safe escape routes
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having key or card access to staff working areas
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using metal detection systems
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installing duress alarms
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minimising public entry points
●
installing barriers at reception desks.
Surveillance and lighting ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Answers Responses can include:
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ensuring adequate lighting in car parks, corridors and storage areas.
●
ensuring safety glass windows in interview rooms so that patient/staff interactions can be seen by outsiders, while at the same time providing reasonable privacy for patients and others.
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installing closed circuit television.
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installing large signs indicating that the workplace is being monitored continuously.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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Fittings and furniture ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Answers Responses can include: ●
Ensure comfortable waiting areas.
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Have clear signs giving explanations for any delays.
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Enquiry desks may be fitted with well designed clear screens with appropriately placed slits for communications and passage of documents.
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Have duress alarms in discreet places.
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Interview rooms should have two doors.
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Furniture should be comfortable but kept to a minimum.
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Provide easy access to food and drinks in waiting areas.
Readings and resources For further information on making your workplace safe and on risk management, refer to Workplace Health and Safety: A Better Practice Guide (currently under review).a When making decisions about the appropriate purchasing and acquiring of equipment such as alarms, communication systems, security lighting, locks, key controls, etc refer to NSW Health Security Manual.c The police can also provide advice about security issues.
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Regular monitoring, reviewing and evaluating Show overhead slide
You are on Participant manual page 23 Explain and discuss As mentioned previously the workplace needs to be regularly monitored for hazards and risks. The violence prevention and management system also needs to be regularly monitored, reviewed and evaluated. The areas that need formal monitoring, evaluating and reviewing are in the individual reflection exercise over the page.
A key component of aggression prevention and management is the need to regularly monitor the work area for hazards and risks. The violence prevention and management system also needs to be regularly monitored, reviewed and evaluated. The following are examples of possible monitoring, review and evaluation activities.
Facilitator instruction Allow five minutes for the individual reflection exercise.
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Individual reflection exercise Consider who should be involved in carrying out each of the following and tick the appropriate boxes. Managers
Staff
Regular security and violence vulnerability audits. Implementing and monitoring recommendations from the audits. Reviewing local policies, procedures and protocols for continuing relevance and effectiveness. Testing and maintaining safety equipment such as duress alarms and communication devices. Ensuring safety equipment continues to effectively meet the needs/ purposes for which it was initially provided. Monitoring the incident reporting system/procedures and compliance. Investigating incidents and ensuring recommendations from the investigation are implemented in a timely manner. Ensuring that appropriate post-incident support is provided to those involved in aggressive or violent incidents. Reviewing responses to the aggressive and/or violent incidents, including the duress response. Implementing and monitoring recommended modifications to the response protocols. Ensuring staff are appropriately trained, including induction/orientation of new staff. Ensuring that training meets the needs of the target staff. Ensuring that all related legal requirements are met. Identifying and regularly reviewing system performance indicators.
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Ask the group What did you tick?
Answers The correct answer for all checkboxes above is both – staff in consultation with managers and managers in consultation with staff. Both groups have a key role to play in these activities.
Ask the group What are the risks of trying to do all of the previous page yourself? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers ●
One possible risk is that some items on the checklist would not be carried out.
●
Another is that staff may not be interested because they were not given a role.The key is delegation: getting others involved, eg have the people who are working in the area assist in conducting the audits.
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OHS legislation requires that staff be consulted on OHS matters.
Explain and discuss Employees who are allocated responsibilities for any of the above need to have the appropriate skills, training and authority to carry them out.
To determine whether the prevention and management systems are effective in preventing and reducing aggression, managers need to look at whether there is a reduction in the frequency and severity of aggressive and violent incidents.
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Small group exercise Ask participants to discuss the following two questions. Ask each group to elect someone in their group who will share their responses with the larger group at the end of their discussion.
1. Discuss what information can be used to evaluate whether there is a reduction in the frequency and severity of aggressive and violent incidents. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Answers If the group fail to identify any of the responses below prompt for the responses. Responses include: ●
hazard reports
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frequency of calls to police
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number of times charges are laid
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number of times the duress response is instigated
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results of safety and security audits and vulnerability audits
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workers compensation data
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first aid records
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workplace grievance records
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staff turnover in high risk areas.
Qualitative data could include staff interviews and/or surveys on their perceptions regarding their personal safety.
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Explain and discuss An increase in reported incidents may not necessarily be an increase in the number of actual aggressive incidents, especially if staff have only recently been focusing on reporting all aggressive and violent incidents including ‘near misses’.
2. As part of the evaluation process managers should also be looking at and monitoring the degree of implementation of key violence prevention initiatives. What indicators could be used to evaluate this? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Answers If the group fails to identify any of the responses below prompt for the responses. Responses could include: ●
degree of implementation of key aspects of the department’s zero tolerance policy
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number of violence vulnerability audits conducted and where
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number of improvements instigated as a result of the audits
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percentage of incidents investigated
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number of improvements implemented as the result of incident investigations
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percentage of incidents that resulted in changes or additions to the environment, incident response protocols or other existing risk control measures
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increased numbers of security related personnel
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proportion of staff who have attended aggression minimisation and management training
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outcomes of training evaluation.
Suggested break time
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Part 3 Assisting staff when aggression and violence occurs Session time 100 minutes
Facilitator instruction To teach this section you need to familiarise yourself with local policies, procedures and protocols governing immediate and longer term options for responding to violence.
Show overhead slide
Session overview This section looks at bullying, harassment and discrimination, response options when confronted with violence, the duress response, reporting and investigating aggressive incidents, responding to staff stress after an incident and the role of managers in supporting staff.
You are on Participant manual page 25 Dealing with bullying, harassment and discrimination in the workplace Show overhead slide
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Readings and resources NSW Health is committed to providing safe and equitable working conditions for all employees. It seeks to eliminate bullying, harassment and discrimination from the workplace and ensure that employees are not subjected to treatment that is hostile and unprofessional. See C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discriminatione.
Explain and discuss ●
Bullying, harassment and discrimination is the repeated, unfavourable treatment of a person in the workplace, which may be considered unreasonable and an inappropriate workplace practice.
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It can involve employees, managers, contractors, visitors or patients.
Bullying, harassment and discrimination can be defined as the repeated, unfavourable treatment of a person in the workplace, which may be considered unreasonable and an inappropriate workplace practice. It can involve employees, managers, contractors, visitors or patients.e See Appendix A for further information on bullying, harassment and discrimination.
Ask the group What types of behaviours represent bullying, harassment and discrimination? ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Answers Responses could include:
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belittling opinions or unconstructive criticism
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isolating an employee from normal work interactions, training and development or career opportunities
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undermining work performance, deliberately withholding work-related information or resources
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overwork, unnecessary pressure or impossible deadlines
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unexplained job changes, meaningless tasks, underwork, tasks beyond a person’s skills and failure to give credit where due
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regularly being made the brunt of pranks or practical jokes
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displaying degrading or offensive written or pictorial material or sending degrading or offensive emails
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unreasonable administrative sanctions
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yelling, abuse, offensive language, insults, inappropriate comments about a person’s appearance or lifestyle and slandering an employee or his/her family
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Sexual or other unwanted advances.
Important training point It is useful to personalise bullying by discussing how managers may often be the victim of bullying.
Explain and discuss The bully does not necessarily need to have organisational power, they may have social power, eg a popular person who has been in the organisation for a long time. The bully may mobilise their social power to get other staff to act in the same way towards the victim. Examples of bullying of managers can include: ●
isolating managers
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not inviting managers to work social events
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not complying with reasonable requests
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attempting to ‘sabotage’ the manager’s work.
Managers are responsible for fostering a work environment which is free from bullying, harassment and discrimination and they must not themselves be perpetrators of bullying, harassment and discrimination.e
Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone in the group who will share their responses with the larger group at the end of the discussion.
How can managers promote a workplace that is free from bullying, harassment and discrimination? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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Write responses on board Answers Responses could include: ●
developing a workplace policy and communicating this to staff
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treating others with respect at all times
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not condoning bullying, harassment or discrimination
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promoting behaviour that does not condone bullying, harassment and discrimination
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encouraging staff to report incidences of bullying, harassment and discrimination either against themselves or others
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responding promptly to allegations of bullying
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other responses may include information from Appendix A.
Facilitator instruction Allow forty minutes for the hypothetical. The hypothetical information is at the back of the manual and is also available as a document on the CD-ROM to allow ease of printing for handing out to participants. Inform the group that a hypothetical exercise will be conducted. The exercise is designed to enable participants to explore the issues and behaviours associated with workplace aggression, via simulation of a real life scenario in a ‘hypothetical’. If you have a group of nine or less, include the whole class. If more, select about eight or nine participants to form a panel. In selecting your panel from a larger group, try to have a range of: level of responsibility, departments and experience. Arrange the panel in a semi-circle which more or less faces the other participants in the class. Participants are selected for the individual roles by the facilitator on the basis of their observed interactive style during the first part of the module. Each participant is given a copy of the scenario outline and a copy of their individual character profile. Advise participants that they should respond as if they were in the characters’ shoes. The facilitator explains the scenario context and relationship dynamics between the main characters. The facilitator will then commence the discussion process by the posing of problems and questions to individual participants and having them respond to another character. This character then provides a response to either that person or another character.
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The facilitator, playing the role of an invisible author, will keep the discussion moving towards an impasse, whereby the conflict becomes increasingly messy and the characters more immovable in their attitudes. Aggressive behaviour in various forms should become evident in the discussion process. Questions the facilitator may use to commence the hypothetical and sustain the momentum of the discussion: 1. Dr Apriadi, you are approached by Dr Kahn, who is seeking your support against the two nurses who have complained about his behaviour. Dr Kahn please talk to Dr Apriadi. 2. Dr Kahn you are stressed and become short tempered with the nursing staff. 3. Dr Apriadi could you advise Dr Kahn of an appropriate course of action? 4. Nurse Silleto you approach Nurse James to discuss the behaviour of Dr Kahn as you are very troubled by what is happening. 5. Mr Brown, a private patient, is suffering from a mix-up in his medication regime, as a consequence his wife complains to Mr Williams. 6. Mr Williams you contact a few colleagues, including Nurse James and Dr Apriadi, to complain about Dr Kahn’s apparent inefficiency. 7. Dr Kahn you call the nurses to a meeting in your office to tell them that they had better be careful in what they are saying otherwise you will be making complaints about them. 8. Mr Williams you call Dr Kahn to your office to issue a formal ‘please explain’. 9. Dr Kahn please respond. At the end of the discussion (approximately thirty minutes) the facilitator will debrief the participants by having them reveal the details included in their individual character profiles. A debriefing discussion should follow to draw out the various aspects of aggressive behaviour experienced during the hypothetical, its symptoms, causes and impact. Key issues you would hope to address in this exercise would be: ●
existing understanding of protocols
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definitions of harrassment and workplace bullying
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issues of confidentiality, staff support and counselling
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what plans or procedures these managers already have in place in relation to aggression in the workplace
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what they know of mediation and to whom they would delegate mediation if required.
Suggested break time
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Response options when confronted with aggression or violence Show overhead slide
You are on Participant manual page 26 Explain and discuss
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Staff need to be aware that there are always options when confronted with aggressive behaviour.
●
Short-term and long-term options were discussed in Module 1 and 2 and are in the Participant manual.
●
Some short term response options (in no particular order) include: – issuing a verbal warning – seeking support from other staff – requesting that the person behaving aggressively leave – requesting that the patient be reviewed by a clinician – negotiating treatment – useing verbal de-escalation and distraction techniques – staying and calling for help – leaving and seeking help – utilising the emergency duress response – initiating external emergency response, eg police.
●
Longer term response options were discussed in more detail with staff in Module 2. The longer term response options include (in no particular order) include: – written warnings – formal patient management plans – conditional treatment agreements – exclusion from visits – conditional visiting rights – patient alerts in conjunction with support management plan – formal recognition of inability to treat in certain circumstances – taking out an AVO to protect staff – having charges laid.
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Refer participants to their local policies for further information on short and longer term response options.
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You need to ensure that your staff are aware that there are always options when confronted with an aggressive or violent incident. These options can be applied both in the short and longer term, and more than one type of response may be used.
Background reading Short-term response options
The type of response staff choose will depend on the nature and severity of the incident and whether the perpetrator is a patient, visitor or intruder, and the skill, experience and confidence of the staff member involved. For guidelines on managing patients who are violent refer to NSW Health Mental Health for Emergency Departments (red book) and NSW Health Management of Adults with Severe Behavioural Disturbance (green book).
Important training point Refer participants to Module 1 where these options were discussed.
Some short-term response optionsb (in no particular order) include: ●
issuing a verbal warning
●
seeking support from other staff
●
requesting that the person behaving aggressively leave
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requesting that the patient be reviewed by a clinician
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negotiating treatment
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using verbal de-escalation and distraction techniques
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staying and calling for help
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leaving and seeking help
●
utilising the emergency duress response
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initiating external emergency response, eg police.
Long-term response options
The following options should be considered for the management of repeated aggressive behaviour.
Readings and resources For further information, refer to the NSW Health Zero Tolerance Policy and Framework Guidelines.
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Some longer term response options (in no particular order) include: ●
written warnings
●
formal patient management plans
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conditional treatment agreements
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exclusion from visits
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conditional visiting rights
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patient alerts in conjunction with support management plan
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recognition of inability to treat in certain circumstances
●
taking out an AVO to protect staff
●
having charges laid.
Both short and longer term options are discussed in some detail in the NSW Health Zero Tolerance Policy and Framework Guidelines.
Ask the group How do you ensure that your staff have been trained in violence minimisation, and how can you ensure that staff are aware of their response options? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Answers Responses could include:
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keeping a register of who has attended training and when they last attended
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keeping aggression and violence as an agenda item at meetings
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discussing incidents and outcomes at meetings and regularly reminding staff of their response options
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having response options and key phone numbers on laminated cards in key areas.
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What is required for the effective management of aggression? Show overhead slide
You are on Participant manual page 27 Explain and discuss Managers are responsible for ensuring staff are able to manage an aggressive or violent incident effectively. During this process the risk of harm to themselves and others must be minimised as far as possible. Appendix B outlines managers’ roles and responsibilities for a facility’s incident management plan and Appendix C outlines managers’ roles and responsibilities to reduce the incidence and severity of aggression and violence.
Managers have an administrative responsibility to ensure that their workplace areas of responsibility have processes in place to ensure that: ●
staff are able to effectively manage violent behaviour
●
the risk of harm to themselves and others is minimised as far as possible.
See Appendix B for managers’ roles and responsibilities for a facility’s incident management plan and Appendix C for managers’ roles and responsibilities to reduce the frequency and severity of violent behaviour in their area of responsibility. Processes need to be in place to manage all forms of violence in the workplace, regardless of the source of violence, or the target. This includes: ●
violence from members of the public to staff
●
patient violence to staff
●
patient violence to other patients
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staff violence to other staff
●
staff violence to patients or members of the public
●
violence from members of the public to other members of the public.
Response options will vary depending on the circumstances.
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The duress response Facilitator instruction You need to be aware of the local procedures for the duress response.
Show overhead slide
You are on Participant manual page 27 Explain and discuss Staff need to be aware of when to activate the duress response and should not be blamed or judged for activating the duress response plan. Appendix D outlines managers’ responsibilities for the duress response. The principles of the duress response are in your copy of the Participant manual for reading in your own time.
Background reading All staff need access to assistance in an emergency, and all areas should have in place an emergency response. In particular, all high-risk areas need a well planned, defined and clearly articulated duress response. Duress response plans should identify, establish and promote a range of procedures that aim to contain and control a violent or potentially violent incident, and that minimise or eliminate the risk of injury in a violent incident. Staff need to be aware of when to activate the duress response and should not be blamed or judged for activating the duress responseb if they feel it is necessary. See Appendix D for managers’ responsibilities for the duress response.
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Principles of the duress response ●
The call or trigger should be earlier rather than later.
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Only one call or alarm trigger should be required.
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Response should be appropriate, timely and effective.
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Response should be standardised to reduce any confusion between team members.
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Staff in the duress response team need to be clearly aware of their roles and responsibilities and have formal training in the procedures, particularly those relating to restraint and sedation.
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All shifts need to be covered and there needs to be processes in place to cover unexpected staff shortages, eg due to sick leave, etc.
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Post-incident support is to be provided.
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Operational review and debriefings are to be conducted following the duress response.
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The duress response is to be regularly evaluated and updated.
Ask the group What policies and procedures are in place in your area for the duress response? How is the effectiveness of the duress response evaluated? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers The effectiveness of the duress response is evaluated by an operational review/debrief.
Ask the group What is involved in an operational review/debrief?
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Answers This is the process of analysing the effectiveness of the response and management of the incident. It allows improvements to be made to the duress response and incident management plan and procedures if necessary. It involves: ●
a review of the incident by the team of workers who experienced the incident
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a discussion of the incident and analysis of components of the response
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a clarification of what was successful and not successful in the response.
Operational procedures should include: ●
involving staff who experienced the incident
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consulting with others who may have been involved, eg police
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identifying the positive and negative aspects of the response
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identifying ways of improving future responses
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allocating responsibility for implementing improvements.
At the conclusion of the review the following would be answered: ●
What were the achievements and successes of the response?
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What can be done in the future and what has been learnt?
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How could the management of the incident be improved?
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Who needs to know about the recommendations of the review?
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Has everyone who needs to be notified about the outcomes of the incident been notified?
Some formal (even if brief) report or summary of the findings of the review should be developed to identify any changes to the duress response plan, to identify any budgetary implications and to allocate responsibility for implementing the changes. Such reports may also assist with closure of the incident, particularly after recommended modifications have been implemented.
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Reporting aggressive incidents Important training point Staff need to be encouraged to report all aggressive incidents including ‘near misses’. In addition to local reporting requirements, there are mandatory requirements for reporting a range of incidents to both WorkCover NSW and NSW Health.
Many aggressive incidents remain unreported.1,11,18 All aggressive incidents need to be reported and documented on the appropriate forms. This includes verbal threats, bullying, ‘near miss’ events, workers’ compensation claims, property damage insurance claims and security incidents. In addition to local reporting requirements, there are mandatory requirements for reporting a range of incidents to the NSW WorkCover Authority and NSW Health.b
Readings and resources For further information see NSW Health circular 2003/88 Reportable Incident Briefs to the NSW Department of Health,g circular 2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace, and circular 2003/75 NSW Health Policy and Procedures for Injury Management and Return-to-Work, and WorkCover NSW The New Simple Way to Notify Work-Related Incidents (Catalogue no. 1287.1).
Ask the group Why do you think many aggressive incidents remain unreported? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Responses could include: ●
the incident was not seen as serious enough
●
perception that ‘nothing will be done about the incident’
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fear of being blamed for the incident
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feeling that management would not be supportive
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the incident may reflect badly on the victim
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in areas where many incidents involve low levels of aggression, staff feel other duties are unable to be completed if they are continually completing incident forms for less serious incidents
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fear of victimisation
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avoidance and denial of aggression
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bullying is less likely to be reported until it is repeated and has escalated in intensity.
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Ask the group How can you encourage staff to report all aggressive incidents? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Responses could include: ●
keeping forms simple
●
providing feedback on incidents at staff meetings so that staff see that reports are dealt with
●
encouraging a ‘no fault’ expectation when incidents are reported.
Investigating aggressive and violent incidents You are on Participant workbook page 29
Explain and discuss In addition to reviewing the duress response, the incident itself must also be investigated. When investigating aggressive incidents the aim is not to look at who was to blame but to identify the causes so that a repeat of the incident can be avoided. Your approach should be sensitive and supportive and not judgmental. You need to be empathic and acknowledge the person’s experience and distress where appropriate.
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When interviewing staff and other witnesses, the aim is not to look at who was to blame for the incident occurring but to identify the cause(s) and what measures are needed to prevent similar or more serious incidents.h Key points to remember during the interview ●
Approach – be supportive.
●
Tone and attitude – be empathic and acknowledge the person’s experience and distress. Your tone and attitude should not be harsh or judgmental.
Establishing the facts
Show overhead slide
Explain and discuss It is important that all the facts be established during an incident investigation. This can be achieved by asking the following questions: ●
What happened?
●
Who was involved?
●
Where did it happen?
●
When did it happen?
●
How did it happen?
●
Why did it happen?
All contributing factors need to be considered and these are listed in their copy of the Participant manual. Questions that you need to ask yourself, to be sure that the investigation is complete, are also listed in the Participant manual over the page.
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Background reading ●
What happened?
●
Who was involved?
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Where did it happen?
●
When did it happen?
●
How did it happen?
●
Why did it happen?
All contributing factors should be considered: ●
Work environment.
●
Status of the perpetrator/s, eg patient, intruder, visitor etc.
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Equipment.
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Work practices.
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Supervision.
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Staff skill.
●
Education and training.
An investigation is complete when the following questions can be answered:
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Do you have all the facts and details on the causes and contributors to the incident?
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Who was or should have been involved in the response and management of the incident (this should have been gleaned in part from the operational review/debrief)?
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What systems were in place to minimise the risk of the incident occurring?
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What were the identified system gaps or failures, ie why didn’t the system work?
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What were the achievements/positive actions and outcomes from the incident?
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Were all policy/legislative requirements met concerning pre and post-incident management?
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How could this or similar incidents be prevented?
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What are the recommendations for changes to policies, procedures, equipment, environment, staffing or competencies? The recommendations should be followed by budgetary requirements if any, who is responsible for their implementation and time frames for completion.
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Who is responsible for monitoring and evaluating the changes?
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Responding to staff stress after an incident Show overhead slide
You are on Participant manual page 30
Explain and discuss ●
Stress reactions following an aggressive incident were covered in Module 1.
●
The types of stress reactions staff can experience include emotional, physical, cognitive and interpersonal.
●
Managers must provide the necessary support to assist staff to recover from the event.
●
Immediate managers need to support staff returning to their normal work duties.
●
The type of support offered will depend on the nature and severity of the aggressive incident and the way the person is coping and managing.
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All staff involved in aggressive incidents need to be followed up to identify the employees who may require further support services or time away from their department/unit.
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Two weeks following the incident, all staff involved should be contacted even if they had initially declined support or assistance.
●
If staff continue to decline support or assistance, further follow-up with them is advisable four weeks after the incident.
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Background reading People react to stress differently and their reactions are a normal response to an abnormal event. The level of fear a person feels and the way they respond during and after an aggressive incident relates to their own experiences, skills and personality. One of the major outcomes of aggression against workers, apart from physical injury, is the resulting anxiety and stress experienced by that person.h,7 Although many aggressive incidents may be minor in nature, on a continuing basis they may produce severe psychological consequences including post traumatic stress disorder and substance abuse. It is important to remember that witnesses to violence may also suffer similar emotional reactions.19 For many people these stress reactions will be managed with the person’s own coping mechanisms, support networks and material resources and will diminish over a period of a few weeks.h Type of stress reactions ●
Emotional – shock, anger, irritability, helplessness, loss of control.
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Physical – fatigue, sleep disturbance, hyperarousal, eg hypervigilance, somatic complaints (psychological disorders with physical symptoms).
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Cognitive – poor concentration and memory, worry, intrusive thoughts.
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Interpersonal – social withdrawal, relationship difficulties.
Immediate managers need to support staff returning to their normal work duties; this ongoing support is important for the staff member’s overall well being. Due to the fact that victims of aggression manage the trauma and stress of their experience differently, the type of support offered will depend on this factor as well as the nature and severity of the aggressive incident. All staff involved in aggressive incidents need to be followed up to identify the employees who may require further support services or time away from their department/unit. Two weeks following the incident all staff should be contacted even if they had initially declined support or assistance. If staff continue to decline support or assistance, further follow-up is advisable four weeks after the incident.h
Readings and resources For further information refer to NSW Health Effective Incident Response: A framework for Prevention and Management in the Health Workplace.h
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Show overhead slide
Explain and discuss The different types of support that can be offered include: ●
psychological first aid – Immediate social and practical help
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employee assistance programs and peer support programs
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supportive counselling
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supportive group discussion
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operational debriefing
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specialised counselling
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mental health care.
Important training point NSW Health does not recommend compulsory critical incident debriefing as a structured post-incident intervention.
Ask the group Are they aware of all of the types of support?
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Facilitator instruction ●
If yes continue.
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If no explain what is involved for the unfamiliar types of support.
Psychological first aid – Immediate social and practical help: ●
Initial intervention following an incident.
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Focuses on the establishment of safety, providing basic human needs and physical care, ie comfort, support, safety and communication.
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Provision of practical help.
Employee assistance programs and peer support programs: ●
Utilise volunteers for a work group that are trained in appropriate methods for assisting colleagues in their workplace.
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The identified peer support persons should not have been directly involved in the incident and such assistance is only implemented if the affected person has agreed.
Specialised counselling: ●
For people experiencing severe or prolonged distress or disturbance following an incident or for those determined to be at significant risk of adverse outcomes, and is provided after appropriate clinical assessment.
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A specialist clinical professional (usually mental health) provides this counselling and it may be linked to a range of other interventions.
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The specialised counselling should be provided by clinicians who have no working relationship with the distressed staff member.
Supportive counselling: ●
Carried out by a trained counsellor for an acutely distressed person.
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Involves comforting and reassurance, practical advice, allowing the person to discuss their experience (only if they feel they need to do so), linking them to support networks and identifying those at risk who may need follow-up and specialised services.
Supportive group discussion: ●
Groups of people who have been affected by an incident may come together naturally in the aftermath and talk through or discuss their experience. This is often seen as helpful and people may consider it an opportunity to ‘debrief’ about their experience.
Operational review/debriefing: as discussed earlier in the course. Mental health care: ●
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Mental health care may involve psychiatric treatment which may include counselling and possible medication for those who have developed psychiatric problems.
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The following types of support can be offered:h ●
Psychological first aid – Immediate social and practical help.
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Employee assistance programs and peer support programs.
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Supportive counselling.
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Supportive group discussion.
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Operational debriefing.
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Specialised counselling.
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Mental health care.
NB. NSW Health does not recommend compulsory critical incident debriefing as a structured post-incident intervention.
You are on Participant manual page 31 Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone in the group who will share their responses with the larger group at the end of the discussion. Discuss the following: What staff support mechanisms do you have in place in your own workplace and how are staff aware of these? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Answers Responses for how staff are aware of these can include: ●
they are in the policies
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staff passing information onto others
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EAP program information displayed on noticeboards
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managers inform staff.
Important training point Point out that the seriousness with which an incident is taken after the event, has an important bearing on how much staff feel supported.
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Role of managers in supporting staff Show overhead slide
You are on Participant manual page 31
Explain and discuss ●
Staff do not always feel supported by managers.
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Managers have an important role to play in supporting their staff.
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How managers can provide support to staff is listed in the Participant manual for participants to read in their own time.
Background reading Staff have generally perceived that they are not always supported by management following aggressive incidents.13 Staff who are victims of aggression and violence are entitled to have the aggressive incidents dealt with through the legal system.20,21 Managers need to provide support to staff in the following ways:a,b
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Through assistance with appropriate support mechanisms.
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Not forcing staff to provide care for a patient who has injured them.
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Supporting staff when they return to work.
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Providing access to injury management programs, eg return to work programs, retraining.
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Helping with compensation issues.
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When required, requesting police take out apprehended violence orders on behalf of staff.
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When required, requesting police press charges.
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Providing practical and legal support for staff who have to give evidence in court, eg educating staff on what to expect.
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Providing support, eg a support person during court hearings, or when staff attend the police station to make a statement.
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Employers under the Workplace Injury Management and Workers Compensation Act 1998a are required to: ●
participate in the insurer’s injury management program
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provide early notification of work place injuries to the insurer
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provide suitable work if practical for injured employees
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cooperate with the insurer’s injury management plan
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establish a return-to-work program for the organisation and an injury management plan for the injured employees.
For more information refer to your Risk Management Unit or Return to Work Coordinator and C2003/75 NSW Health Policy and Procedures for Injury Management and Returnto-Work.
Show overhead slide
Facilitator instruction To conclude the session, outline the roles and responsibilities of managers in preventing and managing workplace aggression and violence.
Roles and responsibilities to assist managers in preventing and managing workplace aggression and violence ●
Prevent workplace aggression and violence in consultation with staff through the risk management process.
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Encourage and support staff to report all aggressive and violent incidents.
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Investigate incidents promptly and efficiently and implement the resulting recommendations.
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Be aware of all relevant policies, procedures and protocols for aggression and violence prevention.
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Be aware of all the short and longer term options for preventing and managing violence.
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Ensure that staff are trained in violence prevention strategies, procedures and protocols.
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Ensure staff are aware of their options when confronted with violence.
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Implement all violence prevention and management policies, protocols and procedures in their area of responsibility.
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Ensure that relevant post incident management policies, procedures and protocols are implemented following a violent incident.
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Facilitator instruction Orient participants to the Appendix. Orient participants to the assessment task and due date in Appendix E.
Ask the group Are there any questions about the assessment assignment?
Facilitator instruction The assessment exercise is a report that is to be prepared after the training has been completed. It is recommended that the assessment be a tailored activity as this would be most helpful for the manager. The nature of the report should be agreed upon between the participant and the facilitator. As an example, the task may be tailored by choosing the most common aggression problem in the manager’s area as the focus for the strategic plan. It could also require the participant to compile all the local policies that are relevant, and identify those that may need revision and updating.
Show overhead slide
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Related NSW Health policies and guidelines a.
C2001/22 Workplace Health and safety: A Better Practice Guide (currently under review).
b. NSW Health Zero Tolerance Policy and Framework Guidelines. c.
NSW Health Security Manual.
d. Design Series (DS) Health Facility Guideline – Security and Safety 2003. e.
C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination.
f.
Management of Adults with Severe Behavioural Disturbance, May 2002 (green book) and Mental Health for Emergency Departments, May 2002 (red book).
g. C2003/88 Reportable Incident Briefs to the NSW Department of Health. h. C2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace. i.
C94/127 Policies on Seclusion Practices: the Use of Restraint and the Use of IV Sedation in Psychiatric In-Patient Facilities (currently under review).
j.
C2003/75 NSW Health Policy and Procedures for Injury Management and Return-to-Work.
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References 1. Mayhew C, Chappell D (2001a). Occupational violence: types, reporting patterns, and variations between health sectors. Working Paper Series no. 139, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of New South Wales, Sydney. 2. Mayhew C, Chappell D (2001b). Prevention of occupational violence in the health workplace. Working Paper Series no. 140, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 3. Mayhew C, Chappell D (2001c). Internal violence (or bullying) and the health workforce. Working Paper Series no. 141, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 4. O’Connell B, Young J, Brooks J, Hutchings J, Lofthouse J (2000). Nurses’ perceptions of the nature and frequency of aggression in general ward settings and high dependency areas. Journal of Clinical Nursing, 9 (4), 602-610. 5. Everley GS, Lasting JM (1995). Psychotraumatology: key papers and care concepts in post traumatic stress. New York: Plenum Press. 6. Ilkiw-Lavalle O, Grenyer B (2003). Differences between patient and staff perceptions of aggression in mental health units. Psychiatric Services, 54, 389-393. 7. Perrone S (1999). Violence in the workplace. Research and Public Policy Series no. 22, Australian Institute of Criminology, Canberra. 8. Baron SA (1996). Organisational factors in workplace violence: developing effective programs to reduce workplace violence. Occupational Medicine: State of the Art Reviews, 11 (2), 335-348. 9. Fletcher TA, Brakel SM, Cavanaugh JL (2000). Violence in the workplace: new perspectives in forensic mental health services in the USA. British Journal of Psychiatry, 176, 339-344. 10. Smith-Pittman MH, McKoy D (1999). Workplace violence in healthcare environments. Nursing Forum, 34 (3), 5-13. 11. Jones J, Lyneham J (2000). Violence: part of the job for Australian nurses? Australian Journal of Advanced Nursing, 18 (2), 27-32. 12. Erickson L, Williams-Evans SA (2000). Attitudes of emergency nurses regarding patient assaults. Journal of Emergency Nursing, 26 (3), 210-215. 13. Jackson D, Clare J, Mannix J (2002). Who would want to be a nurse? Violence in the workplace – a factor in recruitment and retention. Journal of Nursing Management, 0 (1), 13-20.
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14. Poster EC, Ryan JA (1989). Nurses’ attitudes toward physical assaults by patients. Archives of Psychiatric Nursing, 3 (6), 315-332. 15. WorkCover NSW Health and Safety Guide. (2001). Risk management at work (on-line). Available www.workcover.nsw.gov.au/. 16. WorkCover NSW. HAZPAK. Making your workplace safer: A practical guide to basic risk management. 17. Bowie V (2000). Preventing and managing violence by intruders in the workplace: a situational, organisational and societal response. Journal of Occupational Health and Safety: Australia and New Zealand, (16) 5, 443-448. 18. Macdonald G, Sirotich F (2001). Reporting client violence. Social Work, 46 (2), 107-114. 19. Rees C, Lehane P (1996). Witnessing violence to staff: a study of nurses’ experiences. Nursing Standard, 11 (13-15), 45-47. 20. Coyne A (2002). Should patients who assault staff be prosecuted? Journal of Psychiatric and Mental Health Nursing, 8, 139-145. 21. Till U (1998). The prosecution of psychiatric inpatients for assault: benefits and ethics. Psychiatric Care, 5 (6), 219-224. 22. WorkCover NSW. The new simple way to notify work-related incidents (on-line). Available www.workcover.nsw.gov.au.
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Appendix A Bullying, harassment and discrimination The person making the complaint and the person who is being complained against have rights that need to be considered and observed. These rights are consistent with the principles of: ●
natural justice
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equal opportunity
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workplace awards and conditions.
Rights of the person making the complaint The person who believes he/she is a victim of bullying, harassment or discrimination at work has the right to: ●
make a complaint
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being free from victimisation having made this complaint
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access advice and support from either the Human Resources Unit or a professional or industrial body.
Rights of the person that is being complained against The person who is being complained against has the right to: ●
being informed of the complaint
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being able to respond to the complaint
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having the complaint kept confidential.
Grievance procedure The person allegedly being bullied could: ●
approach the contact person for advice, support and assistance
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inform their immediate supervisor and together attempt to resolve the problem (if this does not work, or the immediate supervisor is part of the problem, approach the next in line)
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seek mediation, eg from the Dispute Resolution Centre.
The person being allegedly bullied may lodge a written complaint where the other approaches are unsuccessful, or the allegations are so serious that other approaches are inappropriate. The procedure for lodging a written complaint should include when and how a written complaint is to be lodged. The grievance procedure should include methods for ensuring people are not victimised as a result of using the grievance procedure.
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The investigation Bullying, harassment and discrimination usually follow a predictable pattern. If you are investigating the incident, try to determine such patterns. You should encourage workers who experience workplace bullying, harassment or discrimination to keep a diary of the alleged behaviours. The procedure for carrying out an investigation should address: ●
when an investigation is to occur (usually if a complaint is received or you become aware of the bullying)
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who will carry out the investigation (the person must be seen to be competent to conduct the investigation, impartial and be given an appropriate amount of time to enable them to carry out the investigation effectively)
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how the complaint will be investigated, eg through interviews with: – the person making the complaint – the alleged bully – witnesses
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whether and on what basis the alleged bully will be suspended pending the investigation
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the need for each party to receive a report on the outcome of the investigation.
Possible outcomes of the investigation could include: ●
dismissal of the complaint where it is not upheld
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finding that bullying, harassment or discrimination occurred.
Disciplinary action for the perpetrator could include one or a combination of the following: ●
An apology and an undertaking that the behaviour will not occur again.
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A formal warning.
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Counselling.
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Transferring the perpetrator to another work area away from the complainant, or vice versa if the complainant is agreeable.
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A suspension from the workplace.
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Dismissal as a final resort.
Follow-up Procedures should be outlined for following-up on the actions taken to stop the bullying, harassment or discrimination in order to determine if the actions are effective.
Appeal Mechanisms should be set out for appealing against a decision (internally and externally). For example, where the dispute is between a worker and their employer, a person may apply to the Industrial Relations Commission.
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Access to counselling and training You should provide access to counselling and training where appropriate for: ●
the person making the complaint, eg for coping strategies to deal with the bullying while the problem is being resolved, assertiveness training
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the alleged bully, to enable him/her to recognise and change their behaviour
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others who may have been witness to the events and may have been affected by them.
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Appendix B Incident management plan Role of managers ●
Implement the facility’s incident management program and procedures and promote this to all staff.
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Ensure that staff attend relevant training.
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Ensure that a preventative and risk management approach is used.
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Ensure incidents are reported in accordance with the health facility protocols and legislative requirements. All aggressive incidents need to be reported and documented on the appropriate forms. This includes verbal threats, bullying, ‘near miss’ events, workers’ compensation claims, property damage insurance claims and security incidents. There are also mandatory requirements for reporting significant incidents to the NSW WorkCover Authority and NSW Health. For further information see Circular 97/58 Incidents Reportable to the Departmentg (currently under review ) and C2003/75 NSW Health Policy and Procedures for Injury Management and Return-to-Work.
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Ensure staff involved in violent incidents receive appropriate support and necessary medical treatment.
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Ensure that the consequences of the incident’s impact on the service provided are identified, assessed and managed effectively and efficiently.
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Attend the appropriate training so that any psychological reactions and symptoms can be identified that may follow an incident.
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Ensure that counselling and access to other professional assistance is arranged and accessible to staff as the need arises.
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Participate in post-incident review/investigation and initiate any recommended preventative action.
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Coordinate and provide legal and practical support for any legal proceedings.
For further information on the incident management plan refer to NSW Health Effective Incident Response: A Framework for Prevention and Management in the Health Workplace and NSW Health Security Manual.c
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Appendix C Managers’ roles and responsibilities to reduce the incidence and severity of aggression and violence Managers have administrative responsibilities to ensure the safety of staff and others under their control. For further detailed information, see NSW Health Security Manual.c In general, managers are responsible for ensuring, in their area of responsibility, that: ●
general security measures are established
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areas of risk to staff, patients and visitors are identified, assessed, eliminated where reasonably practicable, or controlled
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work systems and procedures minimise the risk of violence
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procedures are in place for identifying those who have a potential for violent behaviour, and that appropriate, clearly documented patient plans, including actions to be implemented to reduce the risk of violent behaviour, are developed
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local violence prevention policies and procedures are in place and that staff are aware of them
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their staff receive appropriate training and that ongoing training needs are identified
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staff working in isolated facilities/units are rostered with a minimum of two staff on each shift. If this cannot be achieved then staff must be provided with adequate security, eg access controls, communication mechanisms, duress alarms, prompt access to back-up and assistance etc
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adequate security is provided in all circumstances, including community health, based on the level of risk determined by the risk management process, eg CCTV, duress alarms, duress response, video intercoms, access control and adequate lighting etc.
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Appendix D Duress response planning Responsibilities of managers ●
Ensuring a duress response exists in their area of responsibility – this includes community services.
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Consulting with staff on the development and review of duress response plans.
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Respecting the rights of staff to call for a duress response if and when they identify a need. Staff should be encouraged to call the duress response team at any time when they feel at risk.
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Ensuring staff and response team partners, eg other government, non-government and/or community respondents attend relevant training.
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Ensuring that operational review/debrief occurs after a duress response event.
For further information on duress response, planning and principles see NSW Health Security Manual.c
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Appendix E Assessment assignment Guidelines for course assessment assignment A strategic plan for aggression minimisation in the workplace The assessment for this course requires you to develop, document and produce evidence of initial implementation of a plan for aggression minimisation in your own work area. A report of this activity should be submitted to the course coordinator within three months of completing the course. The assignment report should be documented under the following headings: 1. The aggression minimisation plan. 2. Process of development and implementation of plan. 1. Plan
Your plan should cover the following aspects of aggression minimisation: ●
A policy that includes a statement in relation to the philosophy of the unit toward aggression. This may include a statement in relation to workplace bullying, or you may choose to make this a separate policy.
●
Definitions of aggression and bullying.
●
A clear explanation of what basic induction and training staff will be offered to support them in aggression minimisation.
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Guidelines as to how, when and by whom risk assessment will be undertaken to minimise aggression. Address this using the risk management process. Use the following headings: – Step 1 – Identifying the hazard (workplace aggression). – Step 2 – Assessing the risk (determining how serious the aggression problem is). – Step 3 – Eliminating or controlling the risk (risk controls need to be ranked from the most effective to the least effective). – Step 4 – Monitoring, reviewing and improving the system.
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Clear guidelines as to what steps staff should take if they are being bullied.
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Indications as to how staff will be encouraged to maintain a positive workplace culture.
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Clear guidelines on what to do in a violent incident.
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A protocol on safety equipment testing, eg duress alarms, other communication devices.
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Clear guidelines in relation to support – who is responsible for initiating it, who should get it and who should do it?
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A list of counselling options available to staff.
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Identification of the time schedules and methods of reviewing the plan in order to evaluate effectiveness and appropriateness.
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2. Process of development and implementation of plan
This section should describe what you did to develop the plan. For example, what activities did you undertake to identify, assess, eliminate and control violence risks, did you do any research, reading or ask other people in similar positions what they did? Did you consult with your staff or use some meeting time to develop a plan from team input? If needed, did you consult with any others outside your workplace? NB. Evidence for the implementation of the plan is required, eg evidence of at least one induction activity and risk management activity.
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Hypothetical exercise Clinical scenario Post heart surgery ward
Players VMO (Visiting medical officer) surgeon – Mr Williams Senior clinician 1 – Dr Kahn Senior clinician 2 – Dr Apriadi NUM (Nursing unit manager) – Sister Keane Nurse 1 – Nurse Silleto Nurse 2 – Nurse James Ward clerk – Ms Ludlow Patient – Mr Brown Patient relative – Mrs Brown Clinical director – Dr Armitage
Situation Dr Kahn normally of a very calm demeanor, is showing signs of stress, is behaving aggressively towards other staff members and has recently taken regular periods of sick leave. The apparent reason for this change is that Mr Williams, the visiting medical specialist, has been questioning Dr Kahn’s professional and personal decisions on the ward, in particular the therapy for patients in post-operative recovery. Mr Williams joined this clinical team three months ago, while Dr Kahn has worked on the ward for three years. Dr Kahn has complained to his colleague, Dr Apriadi, of the comments made by Mr Williams both to him directly and to other staff members. Dr Kahn feels that this aggressive behaviour is unwarranted and he is considering taking action under the laws of defamation. However, during this period Dr Kahn has been bullying the two nurses with aggressive remarks and threats of lodging formal complaints against them. Nurse James has complained about Dr Kahn’s behaviour to the NUM, Sister Keane. Sister Keane is related by marriage to Mr Williams, and is reluctant to escalate the matter because of this relationship. Meanwhile the patient, Mr Brown, has complained to the Clinical Director about the standard of care he is receiving. Mr Williams has a personal agenda of getting rid of Dr Kahn and replacing him with an old university colleague. Upon learning of the patient’s complaint, Dr Kahn has been bullying the two nurses, yelling at them and abusing and blaming them for minor mix-ups with the administering of medication to his patients.
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Character profiles for the hypothetical Dr Kahn – Senior clinician 1 As one of the two senior clinicians on the post heart surgery ward you work approximately sixty hours per week. You have been working at the hospital for three years, have a young family and reside eight kms from the hospital. This is your first full time work assignment. You like to work in a very methodical and highly organised manner, and become agitated if anything disrupts your schedule. You enjoy your work and up until recently believed your professional service to patients was delivering the best possible outcomes. You have enjoyed the respect and support of other staff on the ward, and while not developing close relationships with anyone in particular feel that you are valued and appreciated by all the team members. During the last six months you have taken regular sick leave to spend time with your father who is in a nursing home and not expected to live beyond Christmas. You have not advised anyone at work of the reason for this leave as you believe that private matters should not be discussed in the workplace. Nevertheless this matter is causing you much anguish and stress. Some three months ago Mr Williams, a new visiting medical specialist, was appointed to the unit. Mr Williams is an older person, seems arrogant and has a very ‘in your face’ style. You have taken an immediate dislike of him. However, you are prepared to work with him providing he treats you with respect and does not interfere with your patient service provision. Further, two of the nursing staff have been making life difficult during this last six months. They have complained of high workloads, lack of communication from your self and of having to listen to complaints from patient family members. You have reacted angrily to the two nurses and advised them that their attitudes are far from desirable. You have at times threatened them with disciplinary action and of lodging a formal complaint about them. You feel that such threats will bring them to their senses. Your colleague Dr Apriadi has confided in you that Mr Williams has been making remarks about some of your professional decisions and personal attitudes to staff members. This has infuriated you and you have told Dr Apriadi that you would consider legal action against Mr Williams under the defamation laws. You consider making a formal complaint against Mr Williams to the Executive Director of the hospital. You decide now that attack is the best form of defence, accordingly you make formal complaints against the two nursing staff to the NUM Sister Keane. In your interactions with staff members and some patient relatives you become very terse and agitated, sometimes verbally abusing them for stupidity and ignorance. You blame all of this on the arrival of Mr Williams. To make matters worse a patient has lodged a formal complaint about the standard of clinical care received.
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Dr Apriadi – Senior clinician 2 You have worked in the post heart surgery unit for just over twelve months. You work with Dr Kahn and the team. You enjoy the work and although this is not what you want to do in the longer term, you are happy to spend another year or two here while you undertake further studies. You are younger than Dr Kahn and while you find him to be very conservative, reserved and somewhat inflexible in his habits, you find him easy enough to work with. You have noticed though that Dr Kahn has become increasingly anxious and agitated over recent months. You are not sure why, but believe that the new visiting medical specialist, Mr Williams, may have something to do with this. You have overheard Mr Williams complaining of Dr Kahn’s behaviour towards staff members, in particular nurses, and he has questioned Dr Kahn’s decisions re provision of patient care believing them to be overly cautious resulting in a longer than average length of stay in the ward. You mentioned this to Dr Kahn as you sense that Mr Williams may have another agenda, namely to get rid off Dr Kahn, and replace him with a former colleague. You also suspect that Mr Williams is not particularly disposed towards people from Indian backgrounds – but you are not definite about this. You are prepared to support Dr Kahn and have indicated this to him privately, and warned him that he should be more careful in how he communicates with other staff and patients or their families. If pressured your first instinct is to protect your own position however, you do not feel that Dr Kahn has done anything to deserve being reprimanded. You have just learned that a patient has lodged a formal complaint, and that the nursing staff had confused the levels of medication for this patient. Apparently this occurred following an altercation between Dr Kahn and the nurses involved.
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Mr Williams – VMO (Visiting medical officer) surgeon You have recently taken up your appointment and five-year contract. Your plan is to retire after this and provide a part-time consultancy service to the hospital in a similar professional capacity. You intend making a few changes in the unit, and plan to staff the key clinical positions with people you know as this will secure your longer term plan. A former colleague and friend is interested in moving to this area to live and work, you would very much like to accommodate him. You are a sixth generation Australian and have strong feelings about national identity and immigration issues. You have a low level of tolerance for people whose values are not in harmony with your own. You have a very smooth and charming interpersonal style and are adept at getting others to share your views. Dr Kahn who is the longest serving clinician on the team is annoying and frustrating you. His patient length of stay and consumable figures are very high and you have heard, informally from the NUM, Sister Keane, that two of the nurses are being bullied by Dr Kahn. In addition there has been a complaint about poor service from a patient. You feel that this is sufficient information to have Dr Kahn face disciplinary action which will, you hope, lead to a termination of his contract or force him to resign in the near future. You need to somehow get the nurses to make formal complaints about Dr Kahn’s bullying behaviour. You also need to talk to the other senior clinician, Dr Apriadi, and get him on side to gather evidence against Dr Kahn’s professional practice. You are not sure of Dr Apriadi’s allegiances but feel that with the right inducements he will support your actions against his colleague. You are confident that the Director of Clinical Services will support your initiatives, you are regular golfing partners.
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Sister Keane – Nursing unit manager You report to Mr Williams whom you find to be somewhat distant, even secretive, although he is quite charming. You are hoping that the work relationships between all the staff can be improved with the arrival of Mr Williams. You have been in the nursing profession for twenty-one years, and NUM for seven years. Your relationship with both the unit senior clinicians Kahn and Apriadi has been cordial and marked by mutual respect. Over recent months you have noticed Dr Kahn become increasingly irritable and bad tempered. You believe this to be out of character. However two of the nursing staff, nurses Silleto and James, have complained to you that Dr Kahn has been behaving aggressively towards them. That a few days ago he behaved in a threatening manner towards them both and that this was witnessed by the ward clerk, Joy Ludlow. You are very disturbed by these events and extremely concerned by the possible implications. The nursing staff are very upset and apprehensive about working with Dr Kahn for fear of another verbal attack. The nurses admit to you that there was a mix-up with a patient’s medication following the incident with Dr Kahn but do not believe that it was too serious.
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Nancy Silleto – Nurse 1 You have been a nurse for three years, working in the acute care area. Since joining the post heart surgery ward, eighteen months ago, you have found the work rewarding and the team quite good to work with. You are normally an easy going person who deals very effectively with crisis situations within the clinical arena. Both the clinicians, Dr Kahn and Apriadi, are demanding but fair, and Nurse James whom you normally work with is someone with whom you feel a natural rapport. You often go for a drink together after work. With the arrival of the new VMO surgeon, Mr Williams, you feel that the atmosphere in the ward has deteriorated somewhat. There is not as much communication with staff, and Dr Kahn has become noticeably edgy and short tempered. In fact over the last few months Dr Kahn has been behaving quite aggressively towards you and Nurse James. This reached a climax earlier this week when Dr Kahn called you both to his office and screamed that you were not performing to a satisfactory standard. He threatened you both with dismissal unless things improved significantly. He also accused you of going behind his back to Mr Williams in relation to his treatment of patients.
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Cynthia James – Nurse 2 You have worked on this ward for over two years, and in the hospital for the least six years. Your nursing colleague, Nancy Silleto and yourself work together very well, and the unit as a whole has in the past operated as a cohesive team. Unfortunately since the arrival of the new VMO surgeon, Mr Williams, the working relationships within the whole team have deteriorated badly. As far as you are concerned Dr Kahn has been behaving in an aggressive manner towards both you and Nurse Silleto. This seems out of character for Dr Kahn, as usually he is calm and very courteous towards you and the other staff. Last week Dr Kahn bailed you and Nurse Silleto up in his office and accused both of you of not doing your job properly, of undermining him and threatened to have both of you sacked. This attack surprised and upset you, you feel that things may get worse and are contemplating looking for another position.
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Joy Ludlow – Ward clerk You are nearing retirement, and have been the ward clerk for several years. You have enjoyed working on this ward because all the staff are compassionate and caring individuals. You are looking forward to retiring and joining your husband on an extended overseas trip in about eighteen months time. You have discussed this with Dr Kahn as you plan to travel extensively in India. Dr Kahn has provided you with much information and offered to arrange free accommodation for you in Goa where he has relatives. Recently though you have witnessed Dr Kahn yelling and screaming at Nurses Silleto and James, and saw them leaving his office in tears. You were frightened by this incident and are now feeling very uncomfortable with Dr Kahn but feel that his behaviour is out of character and so choose not to say anything about it. Later, when queried about the incident by Sister Keane and Mr Williams you decide to tell the whole story as you feel threatened by the consequences of a formal inquiry.
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Patient – Paul Brown You are recovering from open heart surgery, twenty-four hours after surgery, in the recovery ward, the pain killing medication given to you by the nursing staff is the wrong strength and causes your blood pressure to fall dramatically. After much added pain your recovery resumes its normal course. Several days later with the help of your good friend, John Smith, you lodge a formal complaint to the Director of Clinical Nurses and demand a formal inquiry by a Parliamentary Committee. When you do not hear anything about your complaint you call Dr Kahn, the clinician in charge at the time of your incident and abuse him for the mix up, accuse him of being incompetent and threaten to have him deregistered. At least now you feel a bit of satisfaction.
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Patient relative – Mrs Brown At the time of the mix-up in the issuing of the medication you were visiting your former husband, you quickly realise that something is seriously wrong when your former husband’s breathing slows and he loses consciousness. As the nurses answer the emergency alarm, it is apparent to you that they realise that they have made a mistake. Dr Kahn arrives shortly afterwards and checks the documentation and questions the nurses. He becomes very agitated and asks the nurses to step into the corridor, where Mrs Brown hears Dr Kahn abuse the nurses using language which she thought only her former husband used as a football coach. You decide that a formal complaint should be made about the standard of care being delivered in the ward and decide to speak with Mr Williams, an old friend of yours.
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Clinical services director – Dr Armitage You have been aware of the complaints from patients and staff in the post heart surgery ward by Mr Williams, your recent appointment. This is of concern to you as the potential bad publicity could impact on the hospital’s funding. You advise Mr Williams to resolve the matter as expeditiously as possible, with a minimum of fuss and definitely no staff terminations. You report to the CEO and are aiming for a senior position within the NSW Department of Health, and do not want any negative publicity or gossip. Your last resort would be to terminate Mr Williams as he is still in the probationary period of his contract.
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Module 3 90405NSW Course in aggression minimisation for managers 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 3 Course in aggression minimisation for managers
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 . . . . . . . . . . . . . . . . Recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . Other resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Introduction to Module 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 How Module 3 fits into the whole program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Assessment for Module 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Competency standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 General competencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Learning outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Assessment criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Assessment method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Assessment conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Assessment resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Guidelines for course assessment assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 A strategic plan for aggression minimisation in the workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Marking key – Assessor checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Session plan for Module 3 . Materials. . . . . . . . . . . . . . . . Equipment required. . . . . . . . Participant requirement . . . . .
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Beginning the training session . . . . . . . . . 1. Welcome participants to the module . . . . . 2. House keeping . . . . . . . . . . . . . . . . . . . . . 3. Principles of adult learning . . . . . . . . . . . . . 4. How Module 3 fits into the whole program . 5. Overview of the program . . . . . . . . . . . . . . Assessment . . . . . . . . . . . . . . . . . . . . . . . . .
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Background information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Part 1 The legal and policy framework for managing aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 A zero tolerance response to aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Legal principles of civil and criminal actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Part 2 Promoting an aggression-free workplace . . . . . . Promoting a culture of safety . . . . . . . . . . . . . . . . . . . . . . . . Occupational health and safety legislation. . . . . . . . . . . . . . . Occupational health and safety responsibilities for managers . Risk management and the consulting process . . . . . . . . . . . Designing a safer workplace . . . . . . . . . . . . . . . . . . . . . . . . Regular monitoring, reviewing and evaluating . . . . . . . . . . . .
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Part 3 Assisting staff when aggression and violence occurs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dealing with bullying, harassment and discrimination in the workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Response options when confronted with aggression or violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What is required for the effective management of aggression?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The duress response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reporting aggressive incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Investigating aggressive and violent incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Responding to staff stress after an incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of managers in supporting staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Appendices Appendix A Bullying, harassment and discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Appendix B Incident management plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Appendix C Managers’ roles and responsibilities to reduce the incidence and severity of aggression and violence . . 97 Appendix D Duress response planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Appendix E Assessment assignment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Hypothetical exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
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MODULE 3 Course in aggression minimisation for managers
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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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
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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MODULE 3 Course in aggression minimisation for managers
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 related 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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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 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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MODULE 3 Course in aggression minimisation for managers
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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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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MODULE 3 Course in aggression minimisation for managers
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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MODULE 3 Course in aggression minimisation for managers
Introduction to Module 3 How Module 3 fits into the whole program Module 3 is the third 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 recommended for completing Module 3. 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, aggression free working environment and for assessing and managing aggression risks. It also suggests the types of support to provide to staff who are victims of aggression.
Session times Part 1 Allow 60 minutes for Part 1 Part 2 Allow 60 minutes for Part 2 Part 3 Allow 100 minutes for Part 3 At the end of Part 3 participants need to be oriented to the take home assessment exercise. NB. A session plan is provided at the beginning of Module 3.
Recommendations on the delivery of this module Recommendation 1
The material in the Participant manual is too detailed for a four hour workshop. It is designed to be taken away as a resource for managers. The aim of the training workshop is to orient the manager to the major issues, and to discuss the implementation of aggression minimisation and management strategies. Recommendation 2
Flexible delivery of this module is recommended. Facilitators are encouraged to divide the workshop time as they see fit. For example, the training could be done in two two-hour blocks. The first two hours could be used to overview the whole package and the assessment exercise, the second two hours could be used to review the material once managers have taken it away and read it. In the second two hours the results of the assessment exercise could be discussed and some more of the discussion exercises in the module completed.
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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 onto overheads), a whiteboard and whiteboard pens (for writing up feedback from participant exercises) and hypothetical materials for participants. Participants will need pens or pencils for writing in their copy of the Participant manual. You will need handouts for the hypothetical exercise (see end of Facilitator manual).
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MODULE 3 Course in aggression minimisation for managers
Assessment for Module 3 Competency standards The competency standards are both from the National Frontline Management Competencies: ●
Develop and maintain a safe working environment (Unit 8).
●
Establish and maintain effective workplace relationships (Unit 3).
General competencies General competencies for the program include the ability to: ●
Collect, analyse and organise information
Level 3
●
Communicate ideas and information
Level 3
●
Plan and organise activities
Level 3
●
Work with others in teams
Level 3
●
Solve problems
Level 3
Learning outcomes 1. Demonstrate an understanding of the managers’ roles and responsibilities in preventing and managing aggression. 2. Demonstrate an understanding of the legal and ethical issues in managing aggression. 3. Promote workplace safety. 4. Assist with the integration of aggression minimisation principles in the workplace.
Assessment criteria ●
A policy and statement in relation to the minimisation of aggression and bullying.
●
Definitions of aggression and bullying.
●
An outline of what basic induction and training staff will be offered to support them in aggression minimisation.
●
Specific guidelines as to how, when and by whom risk assessment will be undertaken to minimise aggression. Address this using the risk management process. Use the following headings: Step 1 – Identifying the hazard (workplace aggression). Step 2 – Assessing the risk (determining how serious the aggression problem is). Step 3 – Eliminating or controlling the risk (risk controls need to be ranked from the most effective to the least effective). Step 4 – Monitoring, reviewing and improving the system.
●
Indications as to the strategies which will be used to encourage staff in maintaining a positive, respectful workplace culture.
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●
Preventative strategies to be taken to minimise risk.
●
Specific guidelines in relation to immediate support and ongoing counselling options.
●
Specific guidelines to the steps staff should take if feeling bullied.
●
Methods to be taken to investigate incidents in a comprehensive manner.
●
A list of counselling options available to staff.
●
Details of plan implementation.
●
Details of evaluation.
Assessment method Following attendance at the course participants are to develop a workplace plan to minimise aggression. Guidelines for the development and assessment of the plan will be provided during the training. Participants are to submit the assessment assignment within three months of completing the training.
Assessment conditions The assessment is to occur on an individual basis and be submitted within three months of completing the training.
Assessment resources Guidelines for the development and assessment of the plan. NB. Evidence for the implementation of the plan is required, eg evidence of at least one induction activity and risk management activity).
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MODULE 3 Course in aggression minimisation for managers
Guidelines for course assessment assignment A strategic plan for aggression minimisation in the workplace The assessment for this course requires you to develop, document and produce evidence of initial implementation of a plan for aggression minimisation in your own work area. A report of this activity should be submitted to the course coordinator within three months of completing the course. The assignment report should be documented under the following headings: 1. The aggression minimisation plan. 2. Process of development and implementation of plan. 1. Plan – your plan should cover the following aspects of aggression minimisation: ●
A policy that includes a statement in relation to the philosophy of the unit toward aggression. This may include a statement in relation to workplace bullying or you may choose to make this a separate policy.
●
Definitions of aggression and bullying.
●
A clear explanation of what basic induction and training staff will be offered to support them in aggression minimisation.
●
Guidelines as to how, when and by whom risk assessment will be undertaken to minimise aggression. Use the following headings: Step 1 – Identifying the hazard (workplace aggression). Step 2 – Assessing the risk (determining how serious the aggression problem is). Step 3 – Eliminating or controlling the risk (risk controls need to be ranked from the most effective to the least effective). Step 4 – Monitoring, reviewing and improving the system.
●
Clear guidelines as to what steps staff should take if they are being bullied.
●
Indications as to how staff will be encouraged to maintain a positive workplace culture.
●
Clear guidelines on what to do if a violent incident occurs.
●
A protocol on safety equipment testing (eg duress alarms).
●
Clear guidelines in relation to support. Who is responsible for initiating it, who should receive it and who should do it?
●
A list of counselling options available to staff.
●
Identification of the time schedules and methods of reviewing the plan, in order to evaluate effectiveness and appropriateness.
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2. Process of development and implementation of plan
This section should describe what you did to develop the plan. For example, what activities did you undertake to identify, assess and control violence risks, did you do any research, reading or ask other people in similar positions what they did? Did you consult with your staff or use some meeting time to develop a plan with team input? If needed, did you consult with any others outside your workplace? NB. Evidence for the implementation of the plan is required, eg evidence of at least one induction activity and risk management activity.
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MODULE 3 Course in aggression minimisation for managers
Marking key Assessor checklist Yes
No
Unsure
Policy and statement in relation to the philosophy of the unit toward aggression. Definition of aggression and bullying. Clear explanation of what basic induction and training staff will be offered to support aggression minimisation. Guidelines as to how, when and by whom risk assessment will be undertaken to minimise aggression. Clear guidelines as to what steps staff should take if they are being bullied. Indications as to how staff will be encouraged to maintain a positive workplace culture. Clear guidelines on what to do in a violent incident. A protocol on safety equipment testing (eg duress alarms). Clear guidelines in relation to support. Who is responsible for initiating it, who should receive it, and who should do it? A list of counselling options available to staff. Identification of the time schedules and methods of reviewing the plan, in order to evaluate effectiveness and appropriateness. Process of development. Process of implementation of plan.
When assessing for competence on the assignment, ensure that the plan is consistent with local policies and guidelines.
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MODULE 3 Course in aggression minimisation for managers
Session plan for Module 3 Training session: Module 3 Course in aggression minimisation for managers
Time
Topic
60 mins
●
Introduction.
●
The legal and policy framework for managing aggression.
60mins
●
Promoting an aggression-free workplace.
100mins
●
Assisting staff when aggression and violence occurs.
Date: Time:
Learning outcomes 1 and 2
3 and 4 4
Content/activity Small and large group discussions.
Small and large group discussions. ●
Small and large group discussions.
●
Hypothetical exercise.
Materials The training room should be comfortable with desks for participants so that they can write in their 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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MODULE 3 Course in aggression minimisation for managers
Beginning the training session Session time 10 minutes
Facilitator instruction The relevant slides that should be shown at each point are reproduced in small size in the Facilitator manual. You should begin with the title slide, which should be showing when participants begin to arrive at the workshop. To begin teaching this module you will need to do the following:
Show overhead slide
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.
2. House keeping Inform participants of: ●
program times
●
breaks and meals
●
toilets
●
mobile phones
●
message board
●
occupational health and safety (fire escapes).
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3. Principles of adult learning Inform participants that: ●
everyone’s opinion will be respected
●
every participant’s work experience will be valued.
Show overhead slide
4. How Module 3 fits into the whole program Module 3 is a four-hour module designed for managers of health units and facilities. It provides the participant with detailed information, obligations and practical strategies for promoting a safe, aggression free working environment and for assessing and managing aggression risks. It also suggests the types of support to provide to staff who are victims of aggression. Completion of Module 1, or its equivalent, is recommended for Module 3.
Show overhead slide
5. Overview of the program Explain that the program is divided into three parts: ●
Part 1 – looks at the legal and policy framework for managing aggression.
●
Part 2 – looks at how you can promote an aggression free workplace.
●
Part 3 – looks at assisting staff when aggression and violence occurs.
Explain that the aim of the module is not to go through the whole program but that most of the information is to be read in the participant’s own time.
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MODULE 3 Course in aggression minimisation for managers
Assessment At this point, introduce the assessment component of the course. Point out that a four hour course in itself could not be expected to provide participants with the competence and skill required of a manager in relation to aggression minimisation, though of course this would depend on the current skills and experience of the manager. However, when the training session is combined with the experience of carrying out the assessment exercise and using the skills and knowledge gained through these in an ongoing way, participants may develop the competence and skill that is required. Indicate that time will be spent at the end of the session discussing the assignment. At that time the discussion will be more meaningful to participants.
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MODULE 3 Course in aggression minimisation for managers
Background information Facilitator instruction The following is background information on the problem of aggression. Facilitators need to refer to key points from this and refer to any local issues or data relevant to the problem of aggression and aggression management.
You are on Participant manual page 9
Key points The key points that should be emphasised: ●
Aggression is a significant problem in the health industry.
●
Aggression affects both the individual and the organisation.
●
Managers play an important role in ensuring safety through organisational responsibilities and through leadership.
Background reading Aggression in the health industry is a significant problem.1,2,3 The costs of aggression in the workplace are human4,5,6,7 as well as economic.8,9,10 The economic costs include increased absenteeism, loss of earnings, compensation claims, impaired functioning and staff turnover. The human costs include reductions in physical and psychological health. Managers clearly have a vital role to play in ensuring the safety of the workplace, not only in terms of organisational responsibilities, but also in terms of leadership. The culture of a workplace is not solely dependent on managerial style and philosophy, however these are fundamental influencing factors for which managers need to accept responsibility. In order to effectively fulfil their role managers should not only be aware of the aggression minimisation principles required of their staff, but also their own particular responsibilities. The aim of this course is to assist managers of health units and facilities to promote a workplace, which is safe and free from aggression. The course is intended for managers at all levels. It will provide them with an opportunity to gain the knowledge and skills necessary to offer leadership, identify, assess and manage violence risks and provide support for their staff and colleagues in relation to aggression minimisation.
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By completing this training and continually improving the way in which you respond to aggression you may achieve the following: ●
Reduced injury to staff, patients and members of the public.
●
Reduced levels of stress in the workplace.
●
Reduced levels of aggression.
●
Fulfilment of your duty of care and responsibility under the NSW OHS Act 2000.
Many managers will have first hand experience in encountering aggression and conflict in the workplace. This course will enable you to draw on those experiences and use them to explore and develop best practice principles for the prevention and management of aggression.
Show overhead slide
You are on Participant manual page 10
Explain and discuss At the conclusion of this training program participants will be able to: 1. demonstrate an understanding of the manager’s roles and responsibilities in preventing and managing aggression 2. demonstrate an understanding of the legal and ethical issues in managing aggression 3. promote workplace safety 4. assist with the integration of aggression minimisation principles in the workplace.
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MODULE 3 Course in aggression minimisation for managers
Part 1 The legal and policy framework for managing aggression Session time 60 mins (including introduction)
Facilitator instruction To teach this part you will need to have familiarised yourself with NSW Health policies, as well as local policies, procedures and guidelines. Relevant departmental policies and local policies, procedures and guidelines should be shown to the participants when being discussed.
Show overhead slide
Session overview This section looks at the NSW Health zero tolerance response to aggression, other policies and guidelines in relation to aggression and the principles of legal and civil actions.
You are on Participant manual page 11 Background reading Legislative,a procedural and ethical laws and guidelines govern: a.
the way in which you manage aggression, and
b. those affected by aggression in the workplace. You have a responsibility to ensure that: ●
you are aware of all NSW Health policies on aggression minimisation and management
●
all relevant local policies, procedures and protocols that flow from them are communicated to your staff
●
they are effectively implemented in your area of responsibility.
It is also important to understand the impact of aggression on your staff and your responsibilities in relation to these impacts. NSW Health
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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
Important training point
Facilitator instruction Note: There are three slides to this section.
Explain and discuss Key NSW Health policies and guidelines in relation to violence prevention and management.
Show overhead slide
Facilitator instruction Mention each NSW Health policy and guideline on the overhead slide. As you mention each one, ask the group if they are aware of the policy or guideline and ask them to explain briefly what it is about. If no participant can explain a particular policy/guideline inform the group about the policy or guideline. A list of related NSW Health policies and guidelines can be located at the end of the Participant manual. Show each policy when being discussed.
Answers NSW Health Zero Tolerance Policy and Framework Guidelines This document sets out a policy framework utilising risk management principles to establish and maintain a work place culture of zero tolerance to violence. The framework includes provisions of work systems that enable and support the zero tolerance response, and physical work environments that sustain such an approach.
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MODULE 3 Course in aggression minimisation for managers
Answers C2001/22 Workplace Health and Safety: A Better Practice Guide (currently under review) This document provides guidance on better practice in workplace health and safety. It provides a comprehensive set of guidelines incorporating the roles of Health Service Chief Executive Officers, managers and staff on occupational health and safety and risk management, and an awareness of the responsibilities of all staff under the occupational health and safety legislation. C2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace This document provides guidelines for planning incident prevention and management protocols or procedures, and essential components for incident management. It also focuses on the impacts of incidents on staff and provides a framework to assist staff to deal with their experience. Protecting People and Property: NSW Health Policy and Guidelines for Security Risk Management in Health facilities Also known as the Security Manual, this document explains NSW Health policy and guidelines for maintaining client, visitor and staff security in health care facilities.
Show overhead slide
Answers Design Series (DS) Health Facility Guideline – Security and Safety 2003 This document aims to assist health facility planners and designers to minimise the risk of violent incidents by the provision of appropriate facilities, work spaces, building services and systems. It is a guideline to assist in the identification of potential areas of risk and must be addressed during the planning, design and construction phases of a health facility project. The planning and design standards should be regarded as the minimum standards. Management of Adults with Severe Behavioural Disturbance – Guidelines for Clinicians in NSW (amended May 2002) This document provides guidelines for clinicians in managing aggression and violence in adults.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
Answers Mental Health for Emergency Departments – A Reference Guide (amended May 2002) This document is a reference guide to assist staff in Emergency Departments in their care of people with mental illness. It also includes guidelines in managing aggression and violence in adults and is a useful resource for all clinical staff in areas where there is a risk of violence. It provides brief overviews of some common presentations to emergency departments and suggestions about important issues to address. C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination This policy outlines the commitment by NSW Health toward eliminating bullying, harassment and discrimination. It includes types of unacceptable behaviours, the impact of such behaviours on others, appropriate action staff can take and likely outcomes, as well as the responsibilities of all staff in fostering an environment free from bullying, harassment and discrimination. C2003/88 Reportable Incident Briefs to the NSW Department of Health This document identifies what incidents need to be reported to NSW Health.
Facilitator instruction Point out to participants that throughout the training these policies and guidelines will be referred to. Point out to participants that they have a list of these related NSW Health policies and guidelines at the end of their copy of the Participant manual.
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A zero tolerance response to aggression Important training point
Facilitator instruction Introduce the topic of zero tolerance.
Show overhead slide
Explain and discuss NSW Health is committed to the minimisation of aggression and violence in the public health system and has adopted a zero tolerance response to aggression and violence.
Background reading 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.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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 11 Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone in their group who will share their groups’ responses to the larger group at the end of their discussion.
What does zero tolerance mean to you? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Ask the group At the end of the small group discussion ask each elected participant to share their groups’ responses with the larger group.
Write responses on board After writing all the responses go to the next slide and compare the responses to the main points on the slide and elaborate further if required.
Show overhead slide
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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Facilitator instruction The key issues to highlight are: ●
That the focus must be on prevention at all times.
●
However, if an incident does occur the zero tolerance approach is about keeping health staff, patients and visitors safe, ie action must be taken to minimise the impact. Options will be discussed in Part 3.
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It is not about punitive action against patients whose aggressive or violent behaviour is a result of a medical condition, but on prompt and effective clinical management of these patients while at the same time maintaining the safety of patients, staff and others.
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It is about looking out for aggression and doing something about it, rather than accepting it as a normal part of the job.
Background reading The zero tolerance responseb means that in all instances of aggression appropriate action will be taken to protect staff, patients, visitors and health service property from the effects of such behaviour. It is about keeping health staff, patients and visitors safe. The zero tolerance response does not take the place of effective risk management, and at all times the focus must be on prevention. However, in the event of an aggressive incident action will be taken to minimise the impact on all concerned. Options for action will be discussed in Part 3. It should be noted that zero tolerance is NOT about taking punitive action against patients whose violent behaviour is a direct result of a medical condition. In these circumstances the emphasis is on prompt, effective clinical management and compassionate care of the patient, while at the same time protecting the safety of the patient, the staff and others who might be affected by the behaviour. 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’.
Readings and resources For further information see the NSW Health Zero Tolerance Policy and Framework Guidelines.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
You are on Participant manual page 12
Important training point Emphasise all the key points for the zero tolerance attitudes and behaviours below.
Zero tolerance attitudes and behaviours Putting up with aggression and violence in the health workplace IS NOT an acceptable part of your job (if you don't get the message neither will your staff). Lead by example (if you don't take aggressive incidents seriously, neither will your staff, patients or visitors). Make sure your staff know their options when confronted with violent behaviour (there are options and it is important that all staff know what they are). Encourage and support them in utilising these options (staff need to feel confident in the decisions they make when confronted with violence and that their decisions will be supported, particularly when police are involved and during any resulting legal process). Know and exercise your responsibilities as a manager in dealing with violence (both short term and longer term). Ensure that all violent incidents are reported (keep the system simple to encourage a culture of reporting). Investigate all violent incidents (this is the only way to ensure that risk management strategies continue to be effective). Respond promptly to all reports of bullying (if you don't staff will not take 'zero tolerance' seriously). Keep 'zero tolerance' on the agenda (discuss in staff meetings the factors that increase violence risks in the immediate workplace, run debriefs after aggressive incidents, communicate incident investigation results and remedial actions to your staff, encourage staff to feed back on how local protocols and procedures are working).
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Show overhead slide
You are on Participant manual page 12
Ask the group How can you communicate the zero tolerance response to staff, patients, visitors and members of the public? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Write responses on the whiteboard. Elicit from participants any responses below that have not been identified.
Answers Responses include: ●
having zero tolerance and occupational health and safety issues, particularly in relation to aggression, as permanent agenda items in staff meetings
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including information on zero tolerance in orientation sessions for staff
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providing information to patients and visitors clearly outlining their rights AND behavioural responsibilities when in, or visiting, hospital
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placing copies of related materials in all bedside lockers and patient information kits, and keeping supplies in waiting areas, Emergency Departments, public health units and other areas based on local needs
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consulting with Health Service media relations personnel on promoting local initiatives aimed at providing violence-free health care environments
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displaying zero tolerance posters in relevant areas
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ensuring that staff see that there is an immediate and transparent response to aggressive incidents by management.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
Legal principles of civil and criminal actions Show overhead slide
Facilitator instruction Introduce the topic by briefly explaining the four main principles of the law, which protect an individual’s rights, as listed below.
Explain and discuss In general the law protects an individual’s rights in four main areas. These four main principles impact on the manner in which staff conduct themselves in the workplace. The right: ●
to freedom of movement
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to immunity from unwarranted interference from bodily contact by others
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to immunity from conduct by others that would subject the person to unreasonable risk of injury
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of reputation.
Show overhead slide
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Explain and discuss ●
Under the Crimes Act 1900 any persons who commit assaults and other acts of violence can be charged with criminal offences.
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There are also provisions for apprehended violence orders to be taken out where a person has reasonable grounds to fear personal violence, harassment or molestation.
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All significant incidents should be reported to the police, and where appropriate police may charge the perpetrator.
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Recent changes to the Crimes Act now mean that the occupation of the victim of an assault will be considered in determining an appropriate sentence. These changes are designed to allow tougher penalties to be imposed on those who assault health staff or other ‘essential service workers’ in the course of their work.
Ask the group ●
Has anyone been involved in charging patients, visitors or others?
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What are your experiences in trying to have patients, visitors or others charged?
Encourage a brief group discussion.
Answers Issues participants may raise include: ●
Often staff drop the charges further down the track.
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There is a belief that it will be thrown out of court.
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Pressure may come from relatives, consumer advocates, perhaps even central administration (eg ‘it doesn’t look good for the service’ if you charge a patient).
Raise the following: ●
all significant, violent incidents should be reported to the police, and where appropriate police may charge the perpetrator.
Crimes Act 1900
Under the Crimes Act, persons who commit assaults and other acts of violence can be charged with criminal offences. The Act also establishes provisions allowing apprehended personal violence orders to be taken out where a person has reasonable grounds to fear personal violence, harassment or molestation.b Recent changes to the Act now mean that the occupation of the victim of an assault will be considered in determining an appropriate sentence. These changes are designed to allow tougher penalties to be imposed on those who assault health staff or other ‘essential service workers’ in the course of their work. NSW Health
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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 Explain to participants that information on the definition of assault, reasonable force, use of restraint and duty of care is in their copy of the Participant manual. Explain that this is for reading in their own time, as it was covered in some detail in Module 1.
Important training point Employers have the responsibility of ensuring that employees are not put at risk of assault. From an administrative perspective, managers need to ensure that appropriate risk management initiatives are implemented in their area of responsibility. In particular, communication mechanisms need to be implemented to ensure that relevant information, relating to patients with a history of violence, is communicated to staff providing care to these patients. This allows for staff to be adequately prepared, and to develop patient management plans to reduce the risk of violent incidents.
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 for police to prove if they are to successfully secure a prosecution for assault. Employers have the responsibility of ensuring that employees are not put at risk of assault. From an administrative perspective, managers need to ensure that appropriate risk management initiatives are implemented in their area of responsibility. In particular, communication mechanisms need to be implemented to ensure that relevant information, relating to patients with a history of violence, is communicated to staff providing care to these patients. This allows for staff to be adequately prepared, and to develop patient management plans to reduce the risk of violent incidents. Reasonable force b
Section 418 of the Crimes Act 1900 states that a person may use self-defence if and only if the person believes the conduct is necessary to:
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defend himself or herself or another person, or
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prevent or terminate the unlawful deprivation of his or her liberty or the liberty of another person, or
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protect property from unlawful taking, destruction, damage or interference, and the conduct is a reasonable response in the circumstances as he or she perceives them. These provisions were introduced in February 2002.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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This means that a person who assaults another person in self-defence is not criminally responsible if acting in lawful self-defence. As stated above self-defence is not limited to the defence of ones own person, and can be used as a defence for assaults that occur when protecting property or other people. In the past the test was whether the perception of a threat was reasonable in the circumstances, and whether a ‘reasonable person’ in the same circumstances would also have been able to come to the same conclusion. The defence is now broader and states that as long as the accused believed that they were under threat, it does not matter that a ‘reasonable person’ may not have perceived such a threat in the same circumstances. However, a reasonable response is still required for the law of self-defence to operate. The law states that there must be some reasonable proportion between the threat perceived by the accused and his or her response to it. So the key issue is that the person threatened must be able to persuade a court that they felt threatened, that the threat was real to them and that their response was appropriate.
Use of restraint Restraint may be necessary in emergency situations involving aggressive patients, where there is a foreseeable risk of harm to themselves or others. At all times NSW Health policy requirements relating to clinical restraint should be adhered to. See NSW Health documents: Management of Adults with Severe Behavioural Disturbance, May 2002; Mental Health for Emergency Departments, May 2002; Policies on Seclusion Practices: the Use of Restraint and the Use of IV Sedation in Psychiatric In-Patient Facilities, December 1994. When staff restrain a patient they must use only reasonable force in order to be protected from prosecution for assault. With regard to the restraint of others in the act of committing a crime, the first consideration for staff is their own safety and the safety of others. Attempting to restrain in these circumstances may expose staff to unnecessary risks, and unless there is an immediate and significant threat to the safety of others, staff should retreat and observe from a safe distance, and police should be called.
Duty of care Duty of care requires that a staff member act in the best interests of the patient. However, it is essential to note that a duty of care does not suggest that staff should remain in dangerous situations or place themselves at unacceptable risk. At times a staff member’s duty of care to a patient may justify the use of detainment, restraint or sedation for the patient’s own safety or the safety of others. In these situations having exercised a duty of care may be a defence for staff members against claims of false imprisonment or assault. Not exercising a duty of care may result in a claim of negligence depending on the circumstances.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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 15 Small group exercise Ask participants to work in small groups and discuss the following two questions for ten minutes. Ask them to elect someone in their group who will share their responses to the larger group at the end of their discussion.
What is the role of the manager when: A staff member seeks to have charges laid against a patient, visitor or a member of the public? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board If the group fails to identify any of the responses below prompt for the responses.
Answers Responses need to include the following: ●
Support staff who are pressing charges if it is reasonable.
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Let staff know that they have your support and the support of senior management.
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Where an incident requires legal proceedings it is important that you provide practical support for staff who may be required to give evidence. This includes: – – – –
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making provisions where appropriate for legal advice providing support leading up to and during the legal process requesting that police press charges as appropriate providing a support person during court hearings, when attending the police station to make a statement, etc.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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A patient, visitor or member of the public seeks to have charges laid against a staff member? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board If the group fails to identify any of the responses below prompt for the responses.
Answers Responses need to include the following: ●
Investigate the incident.
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You may need to involve an independent investigator.
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Arrange for legal representation if the organisation is supporting you.
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Arrange for any counselling.
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Refer the staff member to their industrial organisation.
Ask the group If police are involved in investigating the incident, do you still need to investigate?
Answers Yes – OHS Act requires that you investigate.
Explain and discuss You need to be aware that you and your investigation can be subpoenaed by the court and legal representatives.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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 support would you advise for the patient, visitor or member of the public?
Answers ●
Refer them to a legal rights advocate.
●
Any counselling needs are to be independent of the organisation.
Facilitator instruction Familiarise yourself with the following: 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.
Ask the group Has anyone been involved in the process of having an AVO obtained for a staff member? If yes, ask them to explain the process and any difficulties they had and how this may have been overcome. If no participant has been involved then briefly explain and discuss the AVO.
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Facilitator instruction Familiarise yourself with the NSW Health Memorandum of Understanding (MOU) between NSW Police and NSW Health, and your related local protocols.
Explain and discuss The NSW Health Memorandum of Understanding between NSW Police and NSW Health has been developed to provide a framework for the effective management of people with a mental illness when the services of both NSW Health and the NSW Police service are required. It has grown out of the need for a formalised system for cooperation between these two important areas of service delivery, particularly when dealing with mental health crisis intervention.
Ask the group If anyone has been involved in the development of their local protocols for the MOU. If yes, ask them to briefly explain the local protocols. If local protocols are still under development, explain where they are up to. If no, briefly explain the MOU.
Background reading NSW Health Memorandum of Understanding between NSW Police and NSW Health
The NSW Health Memorandum of Understanding (MOU) between NSW Police and NSW Health was developed and released in 1998 to establish a clear framework for the management of situations involving police and health staff, and persons who may have a mental illness. The objective was to improve the response to and outcomes in the management of mental health crises that involved responses from multiple services. The MOU clearly defines the roles of each of the service providers, formalising those roles into a workable and complementary framework. However, the framework is intentionally broad, to allow for specific protocols to be developed at the local level utilising local service components and addressing local needs. The MOU was reviewed in 2000 and resulted in a number of practical tools being developed that support the MOU and provide more detailed guidance for the development of local protocols. These documents were released in July 2002.b
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
Local policies and guidelines
Individual reflection exercise
Facilitator instruction Ask the group to think about this question and write their responses. Give the group ten minutes.
Identify all the local policies and procedures on aggression within your Health Service that are relevant to your work area of responsibility. How do you ensure that staff are familiar with them? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Suggested break time
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Part 2 Promoting an aggression-free workplace Session time 60 minutes
Show overhead slide
Session overview This section of the course focuses on prevention of aggression in the workplace and the role of managers in this process. While it is widely acknowledged that not all aggression in the workplace can be prevented, the focus of all staff including managers should be to prevent the vast majority of potentially aggressive incidents from occurring. In this process it is important that managers have a leading role in: ●
promoting a culture of safety
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utilising the risk management process.
You are on Participant manual page 17
Important training point ●
Feeling unsafe in the workplace can cause additional stress for staff and negative attitudes that influence behaviour.
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Emphasise that prevention is the first and most important response.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
Promoting a culture of safety Violence has generally been seen as part of the job in health care11, with staff expecting to be physically assaulted at some stage in their careers12. Feeling unsafe in the workplace can cause: ●
additional stress for staff13
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negative attitudes that influence behaviour.14
Readings and resources For detailed information on workplace safety refer to: NSW Health Security Manualc and Workplace Health and Safety: A Better Practice Guide (currently under review).a
Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone else in their group who will share their responses to the larger group at the end of their discussion.
As a manager, what are some of the challenges to ensuring safety is a top priority for your staff? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Ask the group At the end of the small group discussion, ask each elected participant to share their group’s responses with the larger group.
Write responses on one side of the whiteboard. Answers Responses could include: ●
encouraging staff to see this as not only the manager’s responsibility
●
changing staff attitudes.
Facilitator instruction Explain that later in this section we will look at how to overcome these challenges.
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Occupational health and safety legislation Facilitator instruction Familiarise yourself with the responsibilities of employers under the Occupational Health and Safety Act 2000 and Occupational Health and Safety Regulation 2001 (over the page).
Show overhead slide
You are on Participant manual page 17 Facilitator instruction Explain to participants that this information is to be read later. Briefly emphasise the following: ●
The OHS Act 2000 is supported by the OHS Regulation 2001.
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There are various offences and penalties for non-compliance with the Act and Regulation even if no one has been injured.
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These penalties are for employers, managers and employees.
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Non-compliance includes employers not having done enough to eliminate or reduce risks, even if no one has been injured.
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If the organisation is in breach of the Act or Regulation, depending on the circumstances, managers may be held liable unless they are able to show that they could not have influenced the organisation’s conduct in the matter, or that they used ‘due diligence’ to stop the corporation from contravening the Act.
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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
Background reading Under the NSW Occupational Health and Safety Act 2000a employers have a duty of care for the health and safety of all people in the workplace. This requires employers to: ●
ensure that premises controlled by the employer where people work are safe and without risk to health
●
ensure that systems of work and the working environment are safe and without risk to health
●
ensure that any equipment or substance provided, for use by the employees at work is safe and without risk to health when properly used
●
provide necessary information, instruction, training and supervision for the health and safety of their employees.
This Act is supported by the Occupational Health and Safety Regulation 2001.a Under this regulation employers are responsible for: ●
identifying workplace hazards, including violence
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assessing the risks associated with the hazards
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implementing risk control measures
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consulting with their employees during the process
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providing training.
There are various offences and penalties for non-compliance with the Act and Regulation even if no one has been injured. These penalties are for employers, managers and employees. Non-compliance with the Act and Regulation includes employers not having done enough to eliminate or reduce risks even if no one has been injured. If the organisation is in breach of the Act or Regulation managers may be held liable unless they are able to show that they could not have influenced the organisation’s conduct in the matter, or that they used ‘due diligence’ to stop the corporation from contravening the Act.
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Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone in their group who will share their responses to the larger group at the end of their discussion.
How can ‘due diligence’ be shown? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board If the group fails to identify any of the responses below prompt for the responses.
Answers Responses need to include: ●
ensuring legal obligations are met
●
implementing safe work practices and systems within their area of responsibility
●
keeping records on responses to workplace hazards
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providing appropriate information, instruction, training and supervision
●
monitoring and auditing OHS and injury management programs.
Employers need to ensure the health and safety of persons who are at their place of work and who may be affected by their acts or omissions at work. Employees must cooperate with employers in complying with OHS requirements.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © 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
Occupational health and safety responsibilities for managers You are on Participant manual page 18 Explain and discuss Explain to participants that information on occupational health and safety responsibilities is to be read in their own time.
Background reading Managers coordinate the overall safety effort within their area of responsibility. This requires them to understand their duty of care and be familiar with the OHS system in their organisation. The following are examples of an OHS system in actiona. ●
Developing safe work practices and procedures.
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Consulting with employees on all safety issues.
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Considering decisions from an OHS perspective.
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Ensuring compliance with safety rules.
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Ensuring line managers do not cut corners, introduce ambiguity or condone unsafe work practices.
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Raising OHS issues at staff meetings.
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Encouraging staff to support OHS committee meetings and related activities.
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Reporting back to staff on OHS initiatives and trends.
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Involving staff in all decisions that affect them.
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Enforcing safety policies and procedures.
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Promptly and visibly investigating all significant OHS issues.
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Ensuring effective OHS training and development for employees.
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Developing easy and non-threatening procedures to report accidents, injury, illness and ‘near misses’.
Facilitator instruction Suggested wording: “Previously we spoke about challenges managers have in ensuring that safety is a priority for staff, now we’ll look at how you can ensure that staff are involved in the promotion of workplace safety”.
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Ask the group How do you as a manager ensure that staff are involved in the promotion of workplace safety? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Answers If the group fails to identify any of the responses below prompt for the responses. 1. Consult with staff: ● on aggression management training needs ●
when designing, purchasing or customising equipment aimed at improving safety and security
●
when developing new facilities or refurbishing existing facilities
●
when identifying, assessing and controlling violence risks.
NB. Keep staff informed of all relevant aggression minimisation activities.
2. Education ● Provide training, eg aggression minimisation training, OHS training as part of orientation into the workplace for new staff. 3. Get staff involved in safety ● Get staff involved in conducting risk assessments and coming up with strategies.
NSW Health
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Allocate duties to individual staff to be responsible for specific safety related activities (give staff the skills and training and allow time for this).
●
Ask staff for suggestions on how to manage safety issues.
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Provide staff with feedback and follow-up on violence prevention activities.
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Support staff representation on OHS committees.
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Set a good example.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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Risk management and the consulting process Show overhead slide
Explain and discuss ●
Under the OHS Act employers are required to consult with staff.
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Staff need to be consulted when: – identifying, assessing, prioritising and reviewing risks – deciding on measures to eliminate or control risks – altering or introducing new procedures – changing work systems or introducing new equipment – making decisions about consulting arrangements.
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Managers have a responsibility to consult with their staff. Both clinical and non-clinical staff will often have a good understanding of the risks they face and how they can best be controlled.
Under the OHS Act 2000a employers are required to consult with employees and take into account their views when decisions are made that affect their health, safety and welfare. Some examples of when you need to consult staff include:
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whenever examining or reviewing risks to health and safety
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when making decisions about measures taken to eliminate or control risks
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when introducing or altering procedures for identifying and monitoring risks
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whenever changes are being proposed that could affect health and safety in the workplace, the systems of work or equipment used for work
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whenever decisions are made about consultation arrangements.
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Show overhead slide
You are on Participant manual page 19 Explain and discuss Explain the four steps in the risk management process: ●
Identify the hazard, which in this case is aggression. Examples of sources of information for determining the types of violence risks can be found in the Participant manual.
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Assess the risk: – What is the likelihood of violence occurring? – Consider the severity of the potential outcomes. – Prioritise the risks for preventive action (factors to consider when prioritising violence risks are included in the Participant manual). Eliminate or control the risk. Under the OHS Regulation, employers are required to eliminate any ‘reasonably foreseeable’ risks. If this is not possible then risk control measures need to be implemented. In most cases several control measures will be needed. These can include engineering controls, administrative controls and personal protective equipment.
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Engineering controls include: – designing out the risk or hazard when planning new premises, equipment and work systems – redesigning existing work environments, equipment and work systems to eliminate risks – isolating the risk or hazard from staff. Administrative controls include: – rotating staff to reduce frequency and duration of exposure to the risk – maintenance programs and house keeping – providing information and training – developing procedures and protocols for hazardous activities. ●
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Monitor and review the control implemented and if need be further improve the system.
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Facilitator instruction Discuss with participants any issues arising from this and have the whole group problem solve. Risk management is an interactive process consisting of clearly defined steps15,16. By following the steps you can make informed decisions on how best to avoid or control violence risks. The risk management process Step 1. Identify the hazard. Step 2. Assess the risk. Step 3. Eliminate or control the risk. Step 4. Monitor, review and improve the system.
Background reading The process of identifying risks in your workplace
For the process of identifying risks, some potential sources of information are: ●
aggression/violence reports and associated aggregated data
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incident investigation reports and emergency response reviews
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reports of staff and unions
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visual workplace inspections and violence vulnerability audits
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security surveys
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related OHS and workers compensation data
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staff records, eg to identify areas of high staff turnover
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staff grievance records
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patient complaint records
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observations.
Factors to consider when assessing and prioritising risks b
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What is the nature of the risk or hazard, eg is it physical, psychological, chemical?
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What is the degree or severity of harm that the hazard/risk may cause?
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How likely is it that harm will occur as a result of the exposure?
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How often are staff exposed to the risk or hazard?
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How long are the periods of exposure?
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How many staff are exposed to the risk or hazard?
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How many patients are exposed to the risk or hazard?
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What is the level of experience of staff?
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How much training has staff received?
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How effective are the existing control strategies?
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Eliminating or controlling risks
Eliminating or controlling risks involves deciding what needs to be done to eliminate or control the problem. Under the Occupational Health and Safety Regulation 2001 employers are required to eliminate any ‘reasonably foreseeable’ risks to the health and safety of their employees. Risk control measures need to be developed and implemented in a manner consistent with the hierarchy of controls set out in the legislation. The hierarchy ranks control measures from the most effective to the least effective. In most cases several control measures will be needed.b
Designing a safer workplace Facilitator instruction Introduce crime prevention through environmental design and situational crime prevention as examples of the engineering controls discussed above.
Show overhead slide
You are on Participant manual page 21
Readings and resources NSW Health has developed the Design Series (DS) Health Facility Guideline – Security and Safety 2003d to assist facility planners and designers to reduce violence and security risks through the design and layout of workplaces, by incorporating ‘crime prevention through environmental design’ (CPTED) principles into the Health building process. Considering the design of the environment can reduce situational crime.
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Explain and discuss The design of new facilities or refurbished facilities can reduce criminal activity. The main concepts are: ●
‘Target hardening’, which refers to reducing access to specific high-risk areas through architectural or engineering designs or redesigns.
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‘Territorial reinforcement’, which refers to ensuring that staff only areas are clearly identified and separated from other areas, so that staff are more likely to notice an intruder.
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‘Natural surveillance’, which refers to increasing visibility in the workplace therefore discouraging offenders as this improves the chance of others witnessing and reporting offenders. An example of natural surveillance is office windows overlooking car parks, walkways etc.
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‘Space management’, which refers to having appropriate fittings and furniture and therefore reducing the likelihood of the perpetrator being able to commit a crime or hurt someone.
Background reading When designing b, 2,17 new facilities or refurbishingb,2,17 it is important to reduce the opportunity for criminal activity. This can be achieved through: ●
increasing the risk for offenders
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reducing the opportunity for the offender to make an excuse to trespass
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reducing the likely rewards for criminal behaviour.
Target hardening and territorial reinforcement b,2
‘Target hardening’ refers to reducing access to specific high-risk areas through architectural or engineering designs or redesigns. Target hardening strategies include: ●
access controls
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barriers and grates
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deadlocks on drug cabinets.
‘Territorial reinforcement’ refers to ensuring that staff only areas are clearly identified and separated from other areas so that staff are more likely to notice an intruder. Staff can be encouraged to view the health care setting as something that is theirs. A sense of protectiveness of the facility by staff is an important aspect of safety. Staff are more likely to pay attention to areas where ‘staff only’ are permitted. Strategies for territorial reinforcement include:
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encouraging staff to be responsible for the facility and its use
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designing facilities that have clear transitions and boundaries between the health facility and the general community and between ‘staff only’ areas and other areas
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establishing clearly visible signs on who is to use a space and its purpose.
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Natural surveillance b,2
Increasing visibility in the workplace discourages offenders as it improves the chance of others witnessing and reporting the offenders. Examples include: ●
having clear sightlines between public and staff areas
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effective lighting for visibility
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ensuring that areas that are landscaped are not places where offenders have an opportunity to hide or entrap victims
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designing pathways to car parks to be in full view of passers-by and/or overlooked by windows.
Space management b,2
The types of fittings and furniture used in the workplace can reduce the risk of aggression by making it more difficult for perpetrators to commit a crime and cause injury to others. Some strategies include: ●
keeping sites clean
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keeping all furniture, fittings and facilities in good repair
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attending quickly to the repair of vandalism and graffiti
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replacing any burned out external lighting
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removing or refurbishing any decayed physical surroundings.
Facilitator instruction For this exercise three small groups are required. Give each group an example of a specific type of engineering control, ie either target hardening, surveillance and lighting or furniture and fittings to discuss for the exercise. Give participants ten minutes.
You are on Participant manual page 22
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Small group exercise Ask the groups to complete the exercise according to the type of engineering control designated. Ask each group to elect someone who will share their responses to the larger group at the end of the discussion. Discuss what environmental control measures you have in your workplace and what environmental control measures need to be implemented for each of the following to reduce the risk of aggression and violence: Target hardening ______________________________________________________________________________ ________________________________________________________________________________
Write responses on board Answers Responses can include: ●
deadlocking drug storage areas
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designating safe escape routes
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having key or card access to staff working areas
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using metal detection systems
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installing duress alarms
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minimising public entry points
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installing barriers at reception desks.
Surveillance and lighting ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Answers Responses can include:
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ensuring adequate lighting in car parks, corridors and storage areas.
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ensuring safety glass windows in interview rooms so that patient/staff interactions can be seen by outsiders, while at the same time providing reasonable privacy for patients and others.
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installing closed circuit television.
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installing large signs indicating that the workplace is being monitored continuously.
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Fittings and furniture ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Answers Responses can include: ●
Ensure comfortable waiting areas.
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Have clear signs giving explanations for any delays.
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Enquiry desks may be fitted with well designed clear screens with appropriately placed slits for communications and passage of documents.
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Have duress alarms in discreet places.
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Interview rooms should have two doors.
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Furniture should be comfortable but kept to a minimum.
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Provide easy access to food and drinks in waiting areas.
Readings and resources For further information on making your workplace safe and on risk management, refer to Workplace Health and Safety: A Better Practice Guide (currently under review).a When making decisions about the appropriate purchasing and acquiring of equipment such as alarms, communication systems, security lighting, locks, key controls, etc refer to NSW Health Security Manual.c The police can also provide advice about security issues.
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Regular monitoring, reviewing and evaluating Show overhead slide
You are on Participant manual page 23 Explain and discuss As mentioned previously the workplace needs to be regularly monitored for hazards and risks. The violence prevention and management system also needs to be regularly monitored, reviewed and evaluated. The areas that need formal monitoring, evaluating and reviewing are in the individual reflection exercise over the page.
A key component of aggression prevention and management is the need to regularly monitor the work area for hazards and risks. The violence prevention and management system also needs to be regularly monitored, reviewed and evaluated. The following are examples of possible monitoring, review and evaluation activities.
Facilitator instruction Allow five minutes for the individual reflection exercise.
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Individual reflection exercise Consider who should be involved in carrying out each of the following and tick the appropriate boxes. Managers
Staff
Regular security and violence vulnerability audits. Implementing and monitoring recommendations from the audits. Reviewing local policies, procedures and protocols for continuing relevance and effectiveness. Testing and maintaining safety equipment such as duress alarms and communication devices. Ensuring safety equipment continues to effectively meet the needs/ purposes for which it was initially provided. Monitoring the incident reporting system/procedures and compliance. Investigating incidents and ensuring recommendations from the investigation are implemented in a timely manner. Ensuring that appropriate post-incident support is provided to those involved in aggressive or violent incidents. Reviewing responses to the aggressive and/or violent incidents, including the duress response. Implementing and monitoring recommended modifications to the response protocols. Ensuring staff are appropriately trained, including induction/orientation of new staff. Ensuring that training meets the needs of the target staff. Ensuring that all related legal requirements are met. Identifying and regularly reviewing system performance indicators.
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Ask the group What did you tick?
Answers The correct answer for all checkboxes above is both – staff in consultation with managers and managers in consultation with staff. Both groups have a key role to play in these activities.
Ask the group What are the risks of trying to do all of the previous page yourself? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers ●
One possible risk is that some items on the checklist would not be carried out.
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Another is that staff may not be interested because they were not given a role.The key is delegation: getting others involved, eg have the people who are working in the area assist in conducting the audits.
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OHS legislation requires that staff be consulted on OHS matters.
Explain and discuss Employees who are allocated responsibilities for any of the above need to have the appropriate skills, training and authority to carry them out.
To determine whether the prevention and management systems are effective in preventing and reducing aggression, managers need to look at whether there is a reduction in the frequency and severity of aggressive and violent incidents.
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Small group exercise Ask participants to discuss the following two questions. Ask each group to elect someone in their group who will share their responses with the larger group at the end of their discussion.
1. Discuss what information can be used to evaluate whether there is a reduction in the frequency and severity of aggressive and violent incidents. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Answers If the group fail to identify any of the responses below prompt for the responses. Responses include: ●
hazard reports
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frequency of calls to police
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number of times charges are laid
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number of times the duress response is instigated
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results of safety and security audits and vulnerability audits
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workers compensation data
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first aid records
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workplace grievance records
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staff turnover in high risk areas.
Qualitative data could include staff interviews and/or surveys on their perceptions regarding their personal safety.
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Explain and discuss An increase in reported incidents may not necessarily be an increase in the number of actual aggressive incidents, especially if staff have only recently been focusing on reporting all aggressive and violent incidents including ‘near misses’.
2. As part of the evaluation process managers should also be looking at and monitoring the degree of implementation of key violence prevention initiatives. What indicators could be used to evaluate this? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Answers If the group fails to identify any of the responses below prompt for the responses. Responses could include: ●
degree of implementation of key aspects of the department’s zero tolerance policy
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number of violence vulnerability audits conducted and where
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number of improvements instigated as a result of the audits
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percentage of incidents investigated
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number of improvements implemented as the result of incident investigations
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percentage of incidents that resulted in changes or additions to the environment, incident response protocols or other existing risk control measures
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increased numbers of security related personnel
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proportion of staff who have attended aggression minimisation and management training
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outcomes of training evaluation.
Suggested break time
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Part 3 Assisting staff when aggression and violence occurs Session time 100 minutes
Facilitator instruction To teach this section you need to familiarise yourself with local policies, procedures and protocols governing immediate and longer term options for responding to violence.
Show overhead slide
Session overview This section looks at bullying, harassment and discrimination, response options when confronted with violence, the duress response, reporting and investigating aggressive incidents, responding to staff stress after an incident and the role of managers in supporting staff.
You are on Participant manual page 25 Dealing with bullying, harassment and discrimination in the workplace Show overhead slide
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Readings and resources NSW Health is committed to providing safe and equitable working conditions for all employees. It seeks to eliminate bullying, harassment and discrimination from the workplace and ensure that employees are not subjected to treatment that is hostile and unprofessional. See C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discriminatione.
Explain and discuss ●
Bullying, harassment and discrimination is the repeated, unfavourable treatment of a person in the workplace, which may be considered unreasonable and an inappropriate workplace practice.
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It can involve employees, managers, contractors, visitors or patients.
Bullying, harassment and discrimination can be defined as the repeated, unfavourable treatment of a person in the workplace, which may be considered unreasonable and an inappropriate workplace practice. It can involve employees, managers, contractors, visitors or patients.e See Appendix A for further information on bullying, harassment and discrimination.
Ask the group What types of behaviours represent bullying, harassment and discrimination? ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Answers Responses could include:
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belittling opinions or unconstructive criticism
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isolating an employee from normal work interactions, training and development or career opportunities
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undermining work performance, deliberately withholding work-related information or resources
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overwork, unnecessary pressure or impossible deadlines
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unexplained job changes, meaningless tasks, underwork, tasks beyond a person’s skills and failure to give credit where due
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regularly being made the brunt of pranks or practical jokes
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displaying degrading or offensive written or pictorial material or sending degrading or offensive emails
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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MODULE 3 Course in aggression minimisation for managers
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unreasonable administrative sanctions
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yelling, abuse, offensive language, insults, inappropriate comments about a person’s appearance or lifestyle and slandering an employee or his/her family
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Sexual or other unwanted advances.
Important training point It is useful to personalise bullying by discussing how managers may often be the victim of bullying.
Explain and discuss The bully does not necessarily need to have organisational power, they may have social power, eg a popular person who has been in the organisation for a long time. The bully may mobilise their social power to get other staff to act in the same way towards the victim. Examples of bullying of managers can include: ●
isolating managers
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not inviting managers to work social events
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not complying with reasonable requests
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attempting to ‘sabotage’ the manager’s work.
Managers are responsible for fostering a work environment which is free from bullying, harassment and discrimination and they must not themselves be perpetrators of bullying, harassment and discrimination.e
Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone in the group who will share their responses with the larger group at the end of the discussion.
How can managers promote a workplace that is free from bullying, harassment and discrimination? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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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
Write responses on board Answers Responses could include: ●
developing a workplace policy and communicating this to staff
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treating others with respect at all times
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not condoning bullying, harassment or discrimination
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promoting behaviour that does not condone bullying, harassment and discrimination
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encouraging staff to report incidences of bullying, harassment and discrimination either against themselves or others
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responding promptly to allegations of bullying
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other responses may include information from Appendix A.
Facilitator instruction Allow forty minutes for the hypothetical. The hypothetical information is at the back of the manual and is also available as a document on the CD-ROM to allow ease of printing for handing out to participants. Inform the group that a hypothetical exercise will be conducted. The exercise is designed to enable participants to explore the issues and behaviours associated with workplace aggression, via simulation of a real life scenario in a ‘hypothetical’. If you have a group of nine or less, include the whole class. If more, select about eight or nine participants to form a panel. In selecting your panel from a larger group, try to have a range of: level of responsibility, departments and experience. Arrange the panel in a semi-circle which more or less faces the other participants in the class. Participants are selected for the individual roles by the facilitator on the basis of their observed interactive style during the first part of the module. Each participant is given a copy of the scenario outline and a copy of their individual character profile. Advise participants that they should respond as if they were in the characters’ shoes. The facilitator explains the scenario context and relationship dynamics between the main characters. The facilitator will then commence the discussion process by the posing of problems and questions to individual participants and having them respond to another character. This character then provides a response to either that person or another character.
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The facilitator, playing the role of an invisible author, will keep the discussion moving towards an impasse, whereby the conflict becomes increasingly messy and the characters more immovable in their attitudes. Aggressive behaviour in various forms should become evident in the discussion process. Questions the facilitator may use to commence the hypothetical and sustain the momentum of the discussion: 1. Dr Apriadi, you are approached by Dr Kahn, who is seeking your support against the two nurses who have complained about his behaviour. Dr Kahn please talk to Dr Apriadi. 2. Dr Kahn you are stressed and become short tempered with the nursing staff. 3. Dr Apriadi could you advise Dr Kahn of an appropriate course of action? 4. Nurse Silleto you approach Nurse James to discuss the behaviour of Dr Kahn as you are very troubled by what is happening. 5. Mr Brown, a private patient, is suffering from a mix-up in his medication regime, as a consequence his wife complains to Mr Williams. 6. Mr Williams you contact a few colleagues, including Nurse James and Dr Apriadi, to complain about Dr Kahn’s apparent inefficiency. 7. Dr Kahn you call the nurses to a meeting in your office to tell them that they had better be careful in what they are saying otherwise you will be making complaints about them. 8. Mr Williams you call Dr Kahn to your office to issue a formal ‘please explain’. 9. Dr Kahn please respond. At the end of the discussion (approximately thirty minutes) the facilitator will debrief the participants by having them reveal the details included in their individual character profiles. A debriefing discussion should follow to draw out the various aspects of aggressive behaviour experienced during the hypothetical, its symptoms, causes and impact. Key issues you would hope to address in this exercise would be: ●
existing understanding of protocols
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definitions of harrassment and workplace bullying
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issues of confidentiality, staff support and counselling
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what plans or procedures these managers already have in place in relation to aggression in the workplace
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what they know of mediation and to whom they would delegate mediation if required.
Suggested break time
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Response options when confronted with aggression or violence Show overhead slide
You are on Participant manual page 26 Explain and discuss
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Staff need to be aware that there are always options when confronted with aggressive behaviour.
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Short-term and long-term options were discussed in Module 1 and 2 and are in the Participant manual.
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Some short term response options (in no particular order) include: – issuing a verbal warning – seeking support from other staff – requesting that the person behaving aggressively leave – requesting that the patient be reviewed by a clinician – negotiating treatment – useing verbal de-escalation and distraction techniques – staying and calling for help – leaving and seeking help – utilising the emergency duress response – initiating external emergency response, eg police.
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Longer term response options were discussed in more detail with staff in Module 2. The longer term response options include (in no particular order) include: – written warnings – formal patient management plans – conditional treatment agreements – exclusion from visits – conditional visiting rights – patient alerts in conjunction with support management plan – formal recognition of inability to treat in certain circumstances – taking out an AVO to protect staff – having charges laid.
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Refer participants to their local policies for further information on short and longer term response options.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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MODULE 3 Course in aggression minimisation for managers
You need to ensure that your staff are aware that there are always options when confronted with an aggressive or violent incident. These options can be applied both in the short and longer term, and more than one type of response may be used.
Background reading Short-term response options
The type of response staff choose will depend on the nature and severity of the incident and whether the perpetrator is a patient, visitor or intruder, and the skill, experience and confidence of the staff member involved. For guidelines on managing patients who are violent refer to NSW Health Mental Health for Emergency Departments (red book) and NSW Health Management of Adults with Severe Behavioural Disturbance (green book).
Important training point Refer participants to Module 1 where these options were discussed.
Some short-term response optionsb (in no particular order) include: ●
issuing a verbal warning
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seeking support from other staff
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requesting that the person behaving aggressively leave
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requesting that the patient be reviewed by a clinician
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negotiating treatment
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using verbal de-escalation and distraction techniques
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staying and calling for help
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leaving and seeking help
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utilising the emergency duress response
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initiating external emergency response, eg police.
Long-term response options
The following options should be considered for the management of repeated aggressive behaviour.
Readings and resources For further information, refer to the NSW Health Zero Tolerance Policy and Framework Guidelines.
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Some longer term response options (in no particular order) include: ●
written warnings
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formal patient management plans
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conditional treatment agreements
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exclusion from visits
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conditional visiting rights
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patient alerts in conjunction with support management plan
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recognition of inability to treat in certain circumstances
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taking out an AVO to protect staff
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having charges laid.
Both short and longer term options are discussed in some detail in the NSW Health Zero Tolerance Policy and Framework Guidelines.
Ask the group How do you ensure that your staff have been trained in violence minimisation, and how can you ensure that staff are aware of their response options? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board
Answers Responses could include:
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keeping a register of who has attended training and when they last attended
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keeping aggression and violence as an agenda item at meetings
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discussing incidents and outcomes at meetings and regularly reminding staff of their response options
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having response options and key phone numbers on laminated cards in key areas.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
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What is required for the effective management of aggression? Show overhead slide
You are on Participant manual page 27 Explain and discuss Managers are responsible for ensuring staff are able to manage an aggressive or violent incident effectively. During this process the risk of harm to themselves and others must be minimised as far as possible. Appendix B outlines managers’ roles and responsibilities for a facility’s incident management plan and Appendix C outlines managers’ roles and responsibilities to reduce the incidence and severity of aggression and violence.
Managers have an administrative responsibility to ensure that their workplace areas of responsibility have processes in place to ensure that: ●
staff are able to effectively manage violent behaviour
●
the risk of harm to themselves and others is minimised as far as possible.
See Appendix B for managers’ roles and responsibilities for a facility’s incident management plan and Appendix C for managers’ roles and responsibilities to reduce the frequency and severity of violent behaviour in their area of responsibility. Processes need to be in place to manage all forms of violence in the workplace, regardless of the source of violence, or the target. This includes: ●
violence from members of the public to staff
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patient violence to staff
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patient violence to other patients
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staff violence to other staff
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staff violence to patients or members of the public
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violence from members of the public to other members of the public.
Response options will vary depending on the circumstances.
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The duress response Facilitator instruction You need to be aware of the local procedures for the duress response.
Show overhead slide
You are on Participant manual page 27 Explain and discuss Staff need to be aware of when to activate the duress response and should not be blamed or judged for activating the duress response plan. Appendix D outlines managers’ responsibilities for the duress response. The principles of the duress response are in your copy of the Participant manual for reading in your own time.
Background reading All staff need access to assistance in an emergency, and all areas should have in place an emergency response. In particular, all high-risk areas need a well planned, defined and clearly articulated duress response. Duress response plans should identify, establish and promote a range of procedures that aim to contain and control a violent or potentially violent incident, and that minimise or eliminate the risk of injury in a violent incident. Staff need to be aware of when to activate the duress response and should not be blamed or judged for activating the duress responseb if they feel it is necessary. See Appendix D for managers’ responsibilities for the duress response.
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Principles of the duress response ●
The call or trigger should be earlier rather than later.
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Only one call or alarm trigger should be required.
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Response should be appropriate, timely and effective.
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Response should be standardised to reduce any confusion between team members.
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Staff in the duress response team need to be clearly aware of their roles and responsibilities and have formal training in the procedures, particularly those relating to restraint and sedation.
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All shifts need to be covered and there needs to be processes in place to cover unexpected staff shortages, eg due to sick leave, etc.
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Post-incident support is to be provided.
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Operational review and debriefings are to be conducted following the duress response.
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The duress response is to be regularly evaluated and updated.
Ask the group What policies and procedures are in place in your area for the duress response? How is the effectiveness of the duress response evaluated? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers The effectiveness of the duress response is evaluated by an operational review/debrief.
Ask the group What is involved in an operational review/debrief?
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Answers This is the process of analysing the effectiveness of the response and management of the incident. It allows improvements to be made to the duress response and incident management plan and procedures if necessary. It involves: ●
a review of the incident by the team of workers who experienced the incident
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a discussion of the incident and analysis of components of the response
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a clarification of what was successful and not successful in the response.
Operational procedures should include: ●
involving staff who experienced the incident
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consulting with others who may have been involved, eg police
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identifying the positive and negative aspects of the response
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identifying ways of improving future responses
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allocating responsibility for implementing improvements.
At the conclusion of the review the following would be answered: ●
What were the achievements and successes of the response?
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What can be done in the future and what has been learnt?
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How could the management of the incident be improved?
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Who needs to know about the recommendations of the review?
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Has everyone who needs to be notified about the outcomes of the incident been notified?
Some formal (even if brief) report or summary of the findings of the review should be developed to identify any changes to the duress response plan, to identify any budgetary implications and to allocate responsibility for implementing the changes. Such reports may also assist with closure of the incident, particularly after recommended modifications have been implemented.
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Reporting aggressive incidents Important training point Staff need to be encouraged to report all aggressive incidents including ‘near misses’. In addition to local reporting requirements, there are mandatory requirements for reporting a range of incidents to both WorkCover NSW and NSW Health.
Many aggressive incidents remain unreported.1,11,18 All aggressive incidents need to be reported and documented on the appropriate forms. This includes verbal threats, bullying, ‘near miss’ events, workers’ compensation claims, property damage insurance claims and security incidents. In addition to local reporting requirements, there are mandatory requirements for reporting a range of incidents to the NSW WorkCover Authority and NSW Health.b
Readings and resources For further information see NSW Health circular 2003/88 Reportable Incident Briefs to the NSW Department of Health,g circular 2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace, and circular 2003/75 NSW Health Policy and Procedures for Injury Management and Return-to-Work, and WorkCover NSW The New Simple Way to Notify Work-Related Incidents (Catalogue no. 1287.1).
Ask the group Why do you think many aggressive incidents remain unreported? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Responses could include: ●
the incident was not seen as serious enough
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perception that ‘nothing will be done about the incident’
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fear of being blamed for the incident
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feeling that management would not be supportive
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the incident may reflect badly on the victim
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in areas where many incidents involve low levels of aggression, staff feel other duties are unable to be completed if they are continually completing incident forms for less serious incidents
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fear of victimisation
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avoidance and denial of aggression
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bullying is less likely to be reported until it is repeated and has escalated in intensity.
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Ask the group How can you encourage staff to report all aggressive incidents? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Responses could include: ●
keeping forms simple
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providing feedback on incidents at staff meetings so that staff see that reports are dealt with
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encouraging a ‘no fault’ expectation when incidents are reported.
Investigating aggressive and violent incidents You are on Participant workbook page 29
Explain and discuss In addition to reviewing the duress response, the incident itself must also be investigated. When investigating aggressive incidents the aim is not to look at who was to blame but to identify the causes so that a repeat of the incident can be avoided. Your approach should be sensitive and supportive and not judgmental. You need to be empathic and acknowledge the person’s experience and distress where appropriate.
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When interviewing staff and other witnesses, the aim is not to look at who was to blame for the incident occurring but to identify the cause(s) and what measures are needed to prevent similar or more serious incidents.h Key points to remember during the interview ●
Approach – be supportive.
●
Tone and attitude – be empathic and acknowledge the person’s experience and distress. Your tone and attitude should not be harsh or judgmental.
Establishing the facts
Show overhead slide
Explain and discuss It is important that all the facts be established during an incident investigation. This can be achieved by asking the following questions: ●
What happened?
●
Who was involved?
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Where did it happen?
●
When did it happen?
●
How did it happen?
●
Why did it happen?
All contributing factors need to be considered and these are listed in their copy of the Participant manual. Questions that you need to ask yourself, to be sure that the investigation is complete, are also listed in the Participant manual over the page.
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Background reading ●
What happened?
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Who was involved?
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Where did it happen?
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When did it happen?
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How did it happen?
●
Why did it happen?
All contributing factors should be considered: ●
Work environment.
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Status of the perpetrator/s, eg patient, intruder, visitor etc.
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Equipment.
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Work practices.
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Supervision.
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Staff skill.
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Education and training.
An investigation is complete when the following questions can be answered:
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Do you have all the facts and details on the causes and contributors to the incident?
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Who was or should have been involved in the response and management of the incident (this should have been gleaned in part from the operational review/debrief)?
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What systems were in place to minimise the risk of the incident occurring?
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What were the identified system gaps or failures, ie why didn’t the system work?
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What were the achievements/positive actions and outcomes from the incident?
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Were all policy/legislative requirements met concerning pre and post-incident management?
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How could this or similar incidents be prevented?
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What are the recommendations for changes to policies, procedures, equipment, environment, staffing or competencies? The recommendations should be followed by budgetary requirements if any, who is responsible for their implementation and time frames for completion.
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Who is responsible for monitoring and evaluating the changes?
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Responding to staff stress after an incident Show overhead slide
You are on Participant manual page 30
Explain and discuss ●
Stress reactions following an aggressive incident were covered in Module 1.
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The types of stress reactions staff can experience include emotional, physical, cognitive and interpersonal.
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Managers must provide the necessary support to assist staff to recover from the event.
●
Immediate managers need to support staff returning to their normal work duties.
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The type of support offered will depend on the nature and severity of the aggressive incident and the way the person is coping and managing.
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All staff involved in aggressive incidents need to be followed up to identify the employees who may require further support services or time away from their department/unit.
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Two weeks following the incident, all staff involved should be contacted even if they had initially declined support or assistance.
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If staff continue to decline support or assistance, further follow-up with them is advisable four weeks after the incident.
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Background reading People react to stress differently and their reactions are a normal response to an abnormal event. The level of fear a person feels and the way they respond during and after an aggressive incident relates to their own experiences, skills and personality. One of the major outcomes of aggression against workers, apart from physical injury, is the resulting anxiety and stress experienced by that person.h,7 Although many aggressive incidents may be minor in nature, on a continuing basis they may produce severe psychological consequences including post traumatic stress disorder and substance abuse. It is important to remember that witnesses to violence may also suffer similar emotional reactions.19 For many people these stress reactions will be managed with the person’s own coping mechanisms, support networks and material resources and will diminish over a period of a few weeks.h Type of stress reactions ●
Emotional – shock, anger, irritability, helplessness, loss of control.
●
Physical – fatigue, sleep disturbance, hyperarousal, eg hypervigilance, somatic complaints (psychological disorders with physical symptoms).
●
Cognitive – poor concentration and memory, worry, intrusive thoughts.
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Interpersonal – social withdrawal, relationship difficulties.
Immediate managers need to support staff returning to their normal work duties; this ongoing support is important for the staff member’s overall well being. Due to the fact that victims of aggression manage the trauma and stress of their experience differently, the type of support offered will depend on this factor as well as the nature and severity of the aggressive incident. All staff involved in aggressive incidents need to be followed up to identify the employees who may require further support services or time away from their department/unit. Two weeks following the incident all staff should be contacted even if they had initially declined support or assistance. If staff continue to decline support or assistance, further follow-up is advisable four weeks after the incident.h
Readings and resources For further information refer to NSW Health Effective Incident Response: A framework for Prevention and Management in the Health Workplace.h
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Show overhead slide
Explain and discuss The different types of support that can be offered include: ●
psychological first aid – Immediate social and practical help
●
employee assistance programs and peer support programs
●
supportive counselling
●
supportive group discussion
●
operational debriefing
●
specialised counselling
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mental health care.
Important training point NSW Health does not recommend compulsory critical incident debriefing as a structured post-incident intervention.
Ask the group Are they aware of all of the types of support?
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Facilitator instruction ●
If yes continue.
●
If no explain what is involved for the unfamiliar types of support.
Psychological first aid – Immediate social and practical help: ●
Initial intervention following an incident.
●
Focuses on the establishment of safety, providing basic human needs and physical care, ie comfort, support, safety and communication.
●
Provision of practical help.
Employee assistance programs and peer support programs: ●
Utilise volunteers for a work group that are trained in appropriate methods for assisting colleagues in their workplace.
●
The identified peer support persons should not have been directly involved in the incident and such assistance is only implemented if the affected person has agreed.
Specialised counselling: ●
For people experiencing severe or prolonged distress or disturbance following an incident or for those determined to be at significant risk of adverse outcomes, and is provided after appropriate clinical assessment.
●
A specialist clinical professional (usually mental health) provides this counselling and it may be linked to a range of other interventions.
●
The specialised counselling should be provided by clinicians who have no working relationship with the distressed staff member.
Supportive counselling: ●
Carried out by a trained counsellor for an acutely distressed person.
●
Involves comforting and reassurance, practical advice, allowing the person to discuss their experience (only if they feel they need to do so), linking them to support networks and identifying those at risk who may need follow-up and specialised services.
Supportive group discussion: ●
Groups of people who have been affected by an incident may come together naturally in the aftermath and talk through or discuss their experience. This is often seen as helpful and people may consider it an opportunity to ‘debrief’ about their experience.
Operational review/debriefing: as discussed earlier in the course. Mental health care: ●
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Mental health care may involve psychiatric treatment which may include counselling and possible medication for those who have developed psychiatric problems.
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The following types of support can be offered:h ●
Psychological first aid – Immediate social and practical help.
●
Employee assistance programs and peer support programs.
●
Supportive counselling.
●
Supportive group discussion.
●
Operational debriefing.
●
Specialised counselling.
●
Mental health care.
NB. NSW Health does not recommend compulsory critical incident debriefing as a structured post-incident intervention.
You are on Participant manual page 31 Small group exercise Ask participants to work in small groups and discuss the following question for five minutes. Ask them to elect someone in the group who will share their responses with the larger group at the end of the discussion. Discuss the following: What staff support mechanisms do you have in place in your own workplace and how are staff aware of these? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Answers Responses for how staff are aware of these can include: ●
they are in the policies
●
staff passing information onto others
●
EAP program information displayed on noticeboards
●
managers inform staff.
Important training point Point out that the seriousness with which an incident is taken after the event, has an important bearing on how much staff feel supported.
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Role of managers in supporting staff Show overhead slide
You are on Participant manual page 31
Explain and discuss ●
Staff do not always feel supported by managers.
●
Managers have an important role to play in supporting their staff.
●
How managers can provide support to staff is listed in the Participant manual for participants to read in their own time.
Background reading Staff have generally perceived that they are not always supported by management following aggressive incidents.13 Staff who are victims of aggression and violence are entitled to have the aggressive incidents dealt with through the legal system.20,21 Managers need to provide support to staff in the following ways:a,b
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Through assistance with appropriate support mechanisms.
●
Not forcing staff to provide care for a patient who has injured them.
●
Supporting staff when they return to work.
●
Providing access to injury management programs, eg return to work programs, retraining.
●
Helping with compensation issues.
●
When required, requesting police take out apprehended violence orders on behalf of staff.
●
When required, requesting police press charges.
●
Providing practical and legal support for staff who have to give evidence in court, eg educating staff on what to expect.
●
Providing support, eg a support person during court hearings, or when staff attend the police station to make a statement.
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Employers under the Workplace Injury Management and Workers Compensation Act 1998a are required to: ●
participate in the insurer’s injury management program
●
provide early notification of work place injuries to the insurer
●
provide suitable work if practical for injured employees
●
cooperate with the insurer’s injury management plan
●
establish a return-to-work program for the organisation and an injury management plan for the injured employees.
For more information refer to your Risk Management Unit or Return to Work Coordinator and C2003/75 NSW Health Policy and Procedures for Injury Management and Returnto-Work.
Show overhead slide
Facilitator instruction To conclude the session, outline the roles and responsibilities of managers in preventing and managing workplace aggression and violence.
Roles and responsibilities to assist managers in preventing and managing workplace aggression and violence ●
Prevent workplace aggression and violence in consultation with staff through the risk management process.
●
Encourage and support staff to report all aggressive and violent incidents.
●
Investigate incidents promptly and efficiently and implement the resulting recommendations.
●
Be aware of all relevant policies, procedures and protocols for aggression and violence prevention.
●
Be aware of all the short and longer term options for preventing and managing violence.
●
Ensure that staff are trained in violence prevention strategies, procedures and protocols.
●
Ensure staff are aware of their options when confronted with violence.
●
Implement all violence prevention and management policies, protocols and procedures in their area of responsibility.
●
Ensure that relevant post incident management policies, procedures and protocols are implemented following a violent incident.
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Facilitator instruction Orient participants to the Appendix. Orient participants to the assessment task and due date in Appendix E.
Ask the group Are there any questions about the assessment assignment?
Facilitator instruction The assessment exercise is a report that is to be prepared after the training has been completed. It is recommended that the assessment be a tailored activity as this would be most helpful for the manager. The nature of the report should be agreed upon between the participant and the facilitator. As an example, the task may be tailored by choosing the most common aggression problem in the manager’s area as the focus for the strategic plan. It could also require the participant to compile all the local policies that are relevant, and identify those that may need revision and updating.
Show overhead slide
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Related NSW Health policies and guidelines a.
C2001/22 Workplace Health and safety: A Better Practice Guide (currently under review).
b. NSW Health Zero Tolerance Policy and Framework Guidelines. c.
NSW Health Security Manual.
d. Design Series (DS) Health Facility Guideline – Security and Safety 2003. e.
C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination.
f.
Management of Adults with Severe Behavioural Disturbance, May 2002 (green book) and Mental Health for Emergency Departments, May 2002 (red book).
g. C2003/88 Reportable Incident Briefs to the NSW Department of Health. h. C2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace. i.
C94/127 Policies on Seclusion Practices: the Use of Restraint and the Use of IV Sedation in Psychiatric In-Patient Facilities (currently under review).
j.
C2003/75 NSW Health Policy and Procedures for Injury Management and Return-to-Work.
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References 1. Mayhew C, Chappell D (2001a). Occupational violence: types, reporting patterns, and variations between health sectors. Working Paper Series no. 139, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of New South Wales, Sydney. 2. Mayhew C, Chappell D (2001b). Prevention of occupational violence in the health workplace. Working Paper Series no. 140, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 3. Mayhew C, Chappell D (2001c). Internal violence (or bullying) and the health workforce. Working Paper Series no. 141, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 4. O’Connell B, Young J, Brooks J, Hutchings J, Lofthouse J (2000). Nurses’ perceptions of the nature and frequency of aggression in general ward settings and high dependency areas. Journal of Clinical Nursing, 9 (4), 602-610. 5. Everley GS, Lasting JM (1995). Psychotraumatology: key papers and care concepts in post traumatic stress. New York: Plenum Press. 6. Ilkiw-Lavalle O, Grenyer B (2003). Differences between patient and staff perceptions of aggression in mental health units. Psychiatric Services, 54, 389-393. 7. Perrone S (1999). Violence in the workplace. Research and Public Policy Series no. 22, Australian Institute of Criminology, Canberra. 8. Baron SA (1996). Organisational factors in workplace violence: developing effective programs to reduce workplace violence. Occupational Medicine: State of the Art Reviews, 11 (2), 335-348. 9. Fletcher TA, Brakel SM, Cavanaugh JL (2000). Violence in the workplace: new perspectives in forensic mental health services in the USA. British Journal of Psychiatry, 176, 339-344. 10. Smith-Pittman MH, McKoy D (1999). Workplace violence in healthcare environments. Nursing Forum, 34 (3), 5-13. 11. Jones J, Lyneham J (2000). Violence: part of the job for Australian nurses? Australian Journal of Advanced Nursing, 18 (2), 27-32. 12. Erickson L, Williams-Evans SA (2000). Attitudes of emergency nurses regarding patient assaults. Journal of Emergency Nursing, 26 (3), 210-215. 13. Jackson D, Clare J, Mannix J (2002). Who would want to be a nurse? Violence in the workplace – a factor in recruitment and retention. Journal of Nursing Management, 0 (1), 13-20.
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14. Poster EC, Ryan JA (1989). Nurses’ attitudes toward physical assaults by patients. Archives of Psychiatric Nursing, 3 (6), 315-332. 15. WorkCover NSW Health and Safety Guide. (2001). Risk management at work (on-line). Available www.workcover.nsw.gov.au/. 16. WorkCover NSW. HAZPAK. Making your workplace safer: A practical guide to basic risk management. 17. Bowie V (2000). Preventing and managing violence by intruders in the workplace: a situational, organisational and societal response. Journal of Occupational Health and Safety: Australia and New Zealand, (16) 5, 443-448. 18. Macdonald G, Sirotich F (2001). Reporting client violence. Social Work, 46 (2), 107-114. 19. Rees C, Lehane P (1996). Witnessing violence to staff: a study of nurses’ experiences. Nursing Standard, 11 (13-15), 45-47. 20. Coyne A (2002). Should patients who assault staff be prosecuted? Journal of Psychiatric and Mental Health Nursing, 8, 139-145. 21. Till U (1998). The prosecution of psychiatric inpatients for assault: benefits and ethics. Psychiatric Care, 5 (6), 219-224. 22. WorkCover NSW. The new simple way to notify work-related incidents (on-line). Available www.workcover.nsw.gov.au.
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Appendix A Bullying, harassment and discrimination The person making the complaint and the person who is being complained against have rights that need to be considered and observed. These rights are consistent with the principles of: ●
natural justice
●
equal opportunity
●
workplace awards and conditions.
Rights of the person making the complaint The person who believes he/she is a victim of bullying, harassment or discrimination at work has the right to: ●
make a complaint
●
being free from victimisation having made this complaint
●
access advice and support from either the Human Resources Unit or a professional or industrial body.
Rights of the person that is being complained against The person who is being complained against has the right to: ●
being informed of the complaint
●
being able to respond to the complaint
●
having the complaint kept confidential.
Grievance procedure The person allegedly being bullied could: ●
approach the contact person for advice, support and assistance
●
inform their immediate supervisor and together attempt to resolve the problem (if this does not work, or the immediate supervisor is part of the problem, approach the next in line)
●
seek mediation, eg from the Dispute Resolution Centre.
The person being allegedly bullied may lodge a written complaint where the other approaches are unsuccessful, or the allegations are so serious that other approaches are inappropriate. The procedure for lodging a written complaint should include when and how a written complaint is to be lodged. The grievance procedure should include methods for ensuring people are not victimised as a result of using the grievance procedure.
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The investigation Bullying, harassment and discrimination usually follow a predictable pattern. If you are investigating the incident, try to determine such patterns. You should encourage workers who experience workplace bullying, harassment or discrimination to keep a diary of the alleged behaviours. The procedure for carrying out an investigation should address: ●
when an investigation is to occur (usually if a complaint is received or you become aware of the bullying)
●
who will carry out the investigation (the person must be seen to be competent to conduct the investigation, impartial and be given an appropriate amount of time to enable them to carry out the investigation effectively)
●
how the complaint will be investigated, eg through interviews with: – the person making the complaint – the alleged bully – witnesses
●
whether and on what basis the alleged bully will be suspended pending the investigation
●
the need for each party to receive a report on the outcome of the investigation.
Possible outcomes of the investigation could include: ●
dismissal of the complaint where it is not upheld
●
finding that bullying, harassment or discrimination occurred.
Disciplinary action for the perpetrator could include one or a combination of the following: ●
An apology and an undertaking that the behaviour will not occur again.
●
A formal warning.
●
Counselling.
●
Transferring the perpetrator to another work area away from the complainant, or vice versa if the complainant is agreeable.
●
A suspension from the workplace.
●
Dismissal as a final resort.
Follow-up Procedures should be outlined for following-up on the actions taken to stop the bullying, harassment or discrimination in order to determine if the actions are effective.
Appeal Mechanisms should be set out for appealing against a decision (internally and externally). For example, where the dispute is between a worker and their employer, a person may apply to the Industrial Relations Commission.
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Access to counselling and training You should provide access to counselling and training where appropriate for: ●
the person making the complaint, eg for coping strategies to deal with the bullying while the problem is being resolved, assertiveness training
●
the alleged bully, to enable him/her to recognise and change their behaviour
●
others who may have been witness to the events and may have been affected by them.
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Appendix B Incident management plan Role of managers ●
Implement the facility’s incident management program and procedures and promote this to all staff.
●
Ensure that staff attend relevant training.
●
Ensure that a preventative and risk management approach is used.
●
Ensure incidents are reported in accordance with the health facility protocols and legislative requirements. All aggressive incidents need to be reported and documented on the appropriate forms. This includes verbal threats, bullying, ‘near miss’ events, workers’ compensation claims, property damage insurance claims and security incidents. There are also mandatory requirements for reporting significant incidents to the NSW WorkCover Authority and NSW Health. For further information see Circular 97/58 Incidents Reportable to the Departmentg (currently under review ) and C2003/75 NSW Health Policy and Procedures for Injury Management and Return-to-Work.
●
Ensure staff involved in violent incidents receive appropriate support and necessary medical treatment.
●
Ensure that the consequences of the incident’s impact on the service provided are identified, assessed and managed effectively and efficiently.
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Attend the appropriate training so that any psychological reactions and symptoms can be identified that may follow an incident.
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Ensure that counselling and access to other professional assistance is arranged and accessible to staff as the need arises.
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Participate in post-incident review/investigation and initiate any recommended preventative action.
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Coordinate and provide legal and practical support for any legal proceedings.
For further information on the incident management plan refer to NSW Health Effective Incident Response: A Framework for Prevention and Management in the Health Workplace and NSW Health Security Manual.c
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Appendix C Managers’ roles and responsibilities to reduce the incidence and severity of aggression and violence Managers have administrative responsibilities to ensure the safety of staff and others under their control. For further detailed information, see NSW Health Security Manual.c In general, managers are responsible for ensuring, in their area of responsibility, that: ●
general security measures are established
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areas of risk to staff, patients and visitors are identified, assessed, eliminated where reasonably practicable, or controlled
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work systems and procedures minimise the risk of violence
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procedures are in place for identifying those who have a potential for violent behaviour, and that appropriate, clearly documented patient plans, including actions to be implemented to reduce the risk of violent behaviour, are developed
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local violence prevention policies and procedures are in place and that staff are aware of them
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their staff receive appropriate training and that ongoing training needs are identified
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staff working in isolated facilities/units are rostered with a minimum of two staff on each shift. If this cannot be achieved then staff must be provided with adequate security, eg access controls, communication mechanisms, duress alarms, prompt access to back-up and assistance etc
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adequate security is provided in all circumstances, including community health, based on the level of risk determined by the risk management process, eg CCTV, duress alarms, duress response, video intercoms, access control and adequate lighting etc.
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Appendix D Duress response planning Responsibilities of managers ●
Ensuring a duress response exists in their area of responsibility – this includes community services.
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Consulting with staff on the development and review of duress response plans.
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Respecting the rights of staff to call for a duress response if and when they identify a need. Staff should be encouraged to call the duress response team at any time when they feel at risk.
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Ensuring staff and response team partners, eg other government, non-government and/or community respondents attend relevant training.
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Ensuring that operational review/debrief occurs after a duress response event.
For further information on duress response, planning and principles see NSW Health Security Manual.c
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Appendix E Assessment assignment Guidelines for course assessment assignment A strategic plan for aggression minimisation in the workplace The assessment for this course requires you to develop, document and produce evidence of initial implementation of a plan for aggression minimisation in your own work area. A report of this activity should be submitted to the course coordinator within three months of completing the course. The assignment report should be documented under the following headings: 1. The aggression minimisation plan. 2. Process of development and implementation of plan. 1. Plan
Your plan should cover the following aspects of aggression minimisation: ●
A policy that includes a statement in relation to the philosophy of the unit toward aggression. This may include a statement in relation to workplace bullying, or you may choose to make this a separate policy.
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Definitions of aggression and bullying.
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A clear explanation of what basic induction and training staff will be offered to support them in aggression minimisation.
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Guidelines as to how, when and by whom risk assessment will be undertaken to minimise aggression. Address this using the risk management process. Use the following headings: – Step 1 – Identifying the hazard (workplace aggression). – Step 2 – Assessing the risk (determining how serious the aggression problem is). – Step 3 – Eliminating or controlling the risk (risk controls need to be ranked from the most effective to the least effective). – Step 4 – Monitoring, reviewing and improving the system.
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Clear guidelines as to what steps staff should take if they are being bullied.
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Indications as to how staff will be encouraged to maintain a positive workplace culture.
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Clear guidelines on what to do in a violent incident.
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A protocol on safety equipment testing, eg duress alarms, other communication devices.
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Clear guidelines in relation to support – who is responsible for initiating it, who should get it and who should do it?
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A list of counselling options available to staff.
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Identification of the time schedules and methods of reviewing the plan in order to evaluate effectiveness and appropriateness.
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2. Process of development and implementation of plan
This section should describe what you did to develop the plan. For example, what activities did you undertake to identify, assess, eliminate and control violence risks, did you do any research, reading or ask other people in similar positions what they did? Did you consult with your staff or use some meeting time to develop a plan from team input? If needed, did you consult with any others outside your workplace? NB. Evidence for the implementation of the plan is required, eg evidence of at least one induction activity and risk management activity.
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Hypothetical exercise Clinical scenario Post heart surgery ward
Players VMO (Visiting medical officer) surgeon – Mr Williams Senior clinician 1 – Dr Kahn Senior clinician 2 – Dr Apriadi NUM (Nursing unit manager) – Sister Keane Nurse 1 – Nurse Silleto Nurse 2 – Nurse James Ward clerk – Ms Ludlow Patient – Mr Brown Patient relative – Mrs Brown Clinical director – Dr Armitage
Situation Dr Kahn normally of a very calm demeanor, is showing signs of stress, is behaving aggressively towards other staff members and has recently taken regular periods of sick leave. The apparent reason for this change is that Mr Williams, the visiting medical specialist, has been questioning Dr Kahn’s professional and personal decisions on the ward, in particular the therapy for patients in post-operative recovery. Mr Williams joined this clinical team three months ago, while Dr Kahn has worked on the ward for three years. Dr Kahn has complained to his colleague, Dr Apriadi, of the comments made by Mr Williams both to him directly and to other staff members. Dr Kahn feels that this aggressive behaviour is unwarranted and he is considering taking action under the laws of defamation. However, during this period Dr Kahn has been bullying the two nurses with aggressive remarks and threats of lodging formal complaints against them. Nurse James has complained about Dr Kahn’s behaviour to the NUM, Sister Keane. Sister Keane is related by marriage to Mr Williams, and is reluctant to escalate the matter because of this relationship. Meanwhile the patient, Mr Brown, has complained to the Clinical Director about the standard of care he is receiving. Mr Williams has a personal agenda of getting rid of Dr Kahn and replacing him with an old university colleague. Upon learning of the patient’s complaint, Dr Kahn has been bullying the two nurses, yelling at them and abusing and blaming them for minor mix-ups with the administering of medication to his patients.
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Character profiles for the hypothetical Dr Kahn – Senior clinician 1 As one of the two senior clinicians on the post heart surgery ward you work approximately sixty hours per week. You have been working at the hospital for three years, have a young family and reside eight kms from the hospital. This is your first full time work assignment. You like to work in a very methodical and highly organised manner, and become agitated if anything disrupts your schedule. You enjoy your work and up until recently believed your professional service to patients was delivering the best possible outcomes. You have enjoyed the respect and support of other staff on the ward, and while not developing close relationships with anyone in particular feel that you are valued and appreciated by all the team members. During the last six months you have taken regular sick leave to spend time with your father who is in a nursing home and not expected to live beyond Christmas. You have not advised anyone at work of the reason for this leave as you believe that private matters should not be discussed in the workplace. Nevertheless this matter is causing you much anguish and stress. Some three months ago Mr Williams, a new visiting medical specialist, was appointed to the unit. Mr Williams is an older person, seems arrogant and has a very ‘in your face’ style. You have taken an immediate dislike of him. However, you are prepared to work with him providing he treats you with respect and does not interfere with your patient service provision. Further, two of the nursing staff have been making life difficult during this last six months. They have complained of high workloads, lack of communication from your self and of having to listen to complaints from patient family members. You have reacted angrily to the two nurses and advised them that their attitudes are far from desirable. You have at times threatened them with disciplinary action and of lodging a formal complaint about them. You feel that such threats will bring them to their senses. Your colleague Dr Apriadi has confided in you that Mr Williams has been making remarks about some of your professional decisions and personal attitudes to staff members. This has infuriated you and you have told Dr Apriadi that you would consider legal action against Mr Williams under the defamation laws. You consider making a formal complaint against Mr Williams to the Executive Director of the hospital. You decide now that attack is the best form of defence, accordingly you make formal complaints against the two nursing staff to the NUM Sister Keane. In your interactions with staff members and some patient relatives you become very terse and agitated, sometimes verbally abusing them for stupidity and ignorance. You blame all of this on the arrival of Mr Williams. To make matters worse a patient has lodged a formal complaint about the standard of clinical care received.
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Dr Apriadi – Senior clinician 2 You have worked in the post heart surgery unit for just over twelve months. You work with Dr Kahn and the team. You enjoy the work and although this is not what you want to do in the longer term, you are happy to spend another year or two here while you undertake further studies. You are younger than Dr Kahn and while you find him to be very conservative, reserved and somewhat inflexible in his habits, you find him easy enough to work with. You have noticed though that Dr Kahn has become increasingly anxious and agitated over recent months. You are not sure why, but believe that the new visiting medical specialist, Mr Williams, may have something to do with this. You have overheard Mr Williams complaining of Dr Kahn’s behaviour towards staff members, in particular nurses, and he has questioned Dr Kahn’s decisions re provision of patient care believing them to be overly cautious resulting in a longer than average length of stay in the ward. You mentioned this to Dr Kahn as you sense that Mr Williams may have another agenda, namely to get rid off Dr Kahn, and replace him with a former colleague. You also suspect that Mr Williams is not particularly disposed towards people from Indian backgrounds – but you are not definite about this. You are prepared to support Dr Kahn and have indicated this to him privately, and warned him that he should be more careful in how he communicates with other staff and patients or their families. If pressured your first instinct is to protect your own position however, you do not feel that Dr Kahn has done anything to deserve being reprimanded. You have just learned that a patient has lodged a formal complaint, and that the nursing staff had confused the levels of medication for this patient. Apparently this occurred following an altercation between Dr Kahn and the nurses involved.
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Mr Williams – VMO (Visiting medical officer) surgeon You have recently taken up your appointment and five-year contract. Your plan is to retire after this and provide a part-time consultancy service to the hospital in a similar professional capacity. You intend making a few changes in the unit, and plan to staff the key clinical positions with people you know as this will secure your longer term plan. A former colleague and friend is interested in moving to this area to live and work, you would very much like to accommodate him. You are a sixth generation Australian and have strong feelings about national identity and immigration issues. You have a low level of tolerance for people whose values are not in harmony with your own. You have a very smooth and charming interpersonal style and are adept at getting others to share your views. Dr Kahn who is the longest serving clinician on the team is annoying and frustrating you. His patient length of stay and consumable figures are very high and you have heard, informally from the NUM, Sister Keane, that two of the nurses are being bullied by Dr Kahn. In addition there has been a complaint about poor service from a patient. You feel that this is sufficient information to have Dr Kahn face disciplinary action which will, you hope, lead to a termination of his contract or force him to resign in the near future. You need to somehow get the nurses to make formal complaints about Dr Kahn’s bullying behaviour. You also need to talk to the other senior clinician, Dr Apriadi, and get him on side to gather evidence against Dr Kahn’s professional practice. You are not sure of Dr Apriadi’s allegiances but feel that with the right inducements he will support your actions against his colleague. You are confident that the Director of Clinical Services will support your initiatives, you are regular golfing partners.
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Sister Keane – Nursing unit manager You report to Mr Williams whom you find to be somewhat distant, even secretive, although he is quite charming. You are hoping that the work relationships between all the staff can be improved with the arrival of Mr Williams. You have been in the nursing profession for twenty-one years, and NUM for seven years. Your relationship with both the unit senior clinicians Kahn and Apriadi has been cordial and marked by mutual respect. Over recent months you have noticed Dr Kahn become increasingly irritable and bad tempered. You believe this to be out of character. However two of the nursing staff, nurses Silleto and James, have complained to you that Dr Kahn has been behaving aggressively towards them. That a few days ago he behaved in a threatening manner towards them both and that this was witnessed by the ward clerk, Joy Ludlow. You are very disturbed by these events and extremely concerned by the possible implications. The nursing staff are very upset and apprehensive about working with Dr Kahn for fear of another verbal attack. The nurses admit to you that there was a mix-up with a patient’s medication following the incident with Dr Kahn but do not believe that it was too serious.
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Nancy Silleto – Nurse 1 You have been a nurse for three years, working in the acute care area. Since joining the post heart surgery ward, eighteen months ago, you have found the work rewarding and the team quite good to work with. You are normally an easy going person who deals very effectively with crisis situations within the clinical arena. Both the clinicians, Dr Kahn and Apriadi, are demanding but fair, and Nurse James whom you normally work with is someone with whom you feel a natural rapport. You often go for a drink together after work. With the arrival of the new VMO surgeon, Mr Williams, you feel that the atmosphere in the ward has deteriorated somewhat. There is not as much communication with staff, and Dr Kahn has become noticeably edgy and short tempered. In fact over the last few months Dr Kahn has been behaving quite aggressively towards you and Nurse James. This reached a climax earlier this week when Dr Kahn called you both to his office and screamed that you were not performing to a satisfactory standard. He threatened you both with dismissal unless things improved significantly. He also accused you of going behind his back to Mr Williams in relation to his treatment of patients.
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Cynthia James – Nurse 2 You have worked on this ward for over two years, and in the hospital for the least six years. Your nursing colleague, Nancy Silleto and yourself work together very well, and the unit as a whole has in the past operated as a cohesive team. Unfortunately since the arrival of the new VMO surgeon, Mr Williams, the working relationships within the whole team have deteriorated badly. As far as you are concerned Dr Kahn has been behaving in an aggressive manner towards both you and Nurse Silleto. This seems out of character for Dr Kahn, as usually he is calm and very courteous towards you and the other staff. Last week Dr Kahn bailed you and Nurse Silleto up in his office and accused both of you of not doing your job properly, of undermining him and threatened to have both of you sacked. This attack surprised and upset you, you feel that things may get worse and are contemplating looking for another position.
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Joy Ludlow – Ward clerk You are nearing retirement, and have been the ward clerk for several years. You have enjoyed working on this ward because all the staff are compassionate and caring individuals. You are looking forward to retiring and joining your husband on an extended overseas trip in about eighteen months time. You have discussed this with Dr Kahn as you plan to travel extensively in India. Dr Kahn has provided you with much information and offered to arrange free accommodation for you in Goa where he has relatives. Recently though you have witnessed Dr Kahn yelling and screaming at Nurses Silleto and James, and saw them leaving his office in tears. You were frightened by this incident and are now feeling very uncomfortable with Dr Kahn but feel that his behaviour is out of character and so choose not to say anything about it. Later, when queried about the incident by Sister Keane and Mr Williams you decide to tell the whole story as you feel threatened by the consequences of a formal inquiry.
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Patient – Paul Brown You are recovering from open heart surgery, twenty-four hours after surgery, in the recovery ward, the pain killing medication given to you by the nursing staff is the wrong strength and causes your blood pressure to fall dramatically. After much added pain your recovery resumes its normal course. Several days later with the help of your good friend, John Smith, you lodge a formal complaint to the Director of Clinical Nurses and demand a formal inquiry by a Parliamentary Committee. When you do not hear anything about your complaint you call Dr Kahn, the clinician in charge at the time of your incident and abuse him for the mix up, accuse him of being incompetent and threaten to have him deregistered. At least now you feel a bit of satisfaction.
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Patient relative – Mrs Brown At the time of the mix-up in the issuing of the medication you were visiting your former husband, you quickly realise that something is seriously wrong when your former husband’s breathing slows and he loses consciousness. As the nurses answer the emergency alarm, it is apparent to you that they realise that they have made a mistake. Dr Kahn arrives shortly afterwards and checks the documentation and questions the nurses. He becomes very agitated and asks the nurses to step into the corridor, where Mrs Brown hears Dr Kahn abuse the nurses using language which she thought only her former husband used as a football coach. You decide that a formal complaint should be made about the standard of care being delivered in the ward and decide to speak with Mr Williams, an old friend of yours.
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Clinical services director – Dr Armitage You have been aware of the complaints from patients and staff in the post heart surgery ward by Mr Williams, your recent appointment. This is of concern to you as the potential bad publicity could impact on the hospital’s funding. You advise Mr Williams to resolve the matter as expeditiously as possible, with a minimum of fuss and definitely no staff terminations. You report to the CEO and are aiming for a senior position within the NSW Department of Health, and do not want any negative publicity or gossip. Your last resort would be to terminate Mr Williams as he is still in the probationary period of his contract.
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