Mod3 Participant

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

Module 3 90405NSW Course in aggression minimisation for managers Participant manual

NSW Health is a zero tolerance zone

NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900 www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the NSW Department of Health. © NSW Department of Health 2003 SHPN (CMH) 030207 ISBN 0 7347 3591 X July 2003 updated August 2004

MODULE 3 Course in aggression minimisation for managers

Contents Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Modular structure of preventing and managing aggression in the health workplace . . . . . . . . . . . . . . . . . . . 2 Assessment for Module 3 . . . . . . . . . . . . . Competency standards . . . . . . . . . . . . . . . . . Guidelines for course assessment assignment Assessment specification sheet . . . . . . . . . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

.................... .................... .................... ....................

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

3 3 5 7

Introduction to Module 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Learning outcomes for Module 3 – Aggression minimisation for managers . . . . . . . . . . . . . . . . . . . . . . . . . 10 Part 1 The legal and policy framework for managing aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 A zero tolerance response to aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Legal principles of civil and criminal actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 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 . . . . . . . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

.................. .................. .................. .................. .................. .................. ..................

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

17 17 17 18 19 21 23

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

25 25 26 27 27 28 29 30 31

Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Appendices Appendix A Bullying, harassment and discrimination . . . . . . . . . . . . . . . . . . . Appendix B Incident management plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix C Managers’ roles and responsibilities to reduce the incidence and severity of aggression and violence . . . . . . . . . . . . . . . . . . . . . . Appendix D Duress response planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix E Assessment assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NSW Health

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

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

i

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

1

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

Modular structure of preventing and managing aggression in the health workplace Module 1

HLTCSD6A – Respond effectively to difficult or challenging behaviour This eight-hour program is designed for all staff identified as being at risk of workplace violence. It is designed to meet the Health Training Package competency HLTCSD6A – Respond effectively to difficult or challenging behaviour. The day is divided into five parts: 1. Understanding difficult or challenging behaviour. 2. Preventing aggression occurring. 3. Preventing aggression escalating. 4. Bullying, harassment and discrimination at work. 5. Reporting and reviewing aggressive incidents.

Module 2

AMT002 – Aggression minimisation in high-risk environments This eight-hour program is designed for mental health and other staff working in high risk areas, eg emergency, security, community, aged care, disability, dental, midwifery and early childhood, methadone, brain injury, neurology, admissions and drug and alcohol services. Other staff members identified, via the risk assessment process, as being at significant risk of aggressive behaviour should also attend this module.

Module 3

90405NSW – Course in aggression minimisation for managers This nationally recognised qualification is a four-hour module designed for managers. It provides the participant with detailed information, obligations and practical strategies for promoting a safe workplace environment free of aggression, assessing and managing risks and types of support to provide to staff, who have been victims of aggression. Completion of Module 1 is recommended prior to undertaking this module.

Module 4

2

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

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 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 for Module 3 NSW Health a safer place to work – preventing and managing violent behaviour in the Health Workplace – Module 3 Course in aggression minimisation for managers (90405NSW).

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.

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

3

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

●

Indications as to the strategies which will be used to encourage staff in maintaining a positive, respectful workplace culture.

●

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).

4

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

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.

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?

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

5

MODULE 3 Aggression minimisation for managers

Assessment specification sheet Candidate’s name Telephone (w)

Work location Units of competency to be assessed

Assessment methods

Assessment activities

90405NSW Course in aggression minimisation for managers

Adequate completion of plan

Development of workplace plan to minimise aggression in the workplace

Details of special requirements:

Assessor’s name

Signature Date of assessment

/

/

Time

Confirmation of assessment I confirm that: ●

the purpose of this assessment has been clearly explained to me

●

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

●

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

●

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

●

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

Candidate’s signature Date of assessment NSW Health

/

/

A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004

7

MODULE 3 Course in aggression minimisation for managers

Introduction to Module 3 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. 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 Occupational Health and Safety 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.

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

9

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

Learning outcomes for Module 3 – Aggression minimisation for managers At the conclusion of this module, participants should 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.

10

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

Part 1 The legal and policy framework for managing aggression 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. 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.

A zero tolerance response to aggression NSW Health is committed to the minimisation of violence in the public health system and the focus should always be on the prevention of violence. However, in the event that a violent incident does occur, NSW Health, as a result of a key recommendation from the Taskforce on the Prevention and Management of Violence in the Health Workplace, has adopted a zero tolerance response to threatening, abusive or violent behaviour by any person towards any other person on health service premises or towards NSW Health staff working in the community. What does zero tolerance mean to you? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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

11

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

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’. For further information see the NSW Health Zero Tolerance Policy and Framework Guidelines. 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 long-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).

How can you communicate the zero tolerance response to staff, patients, visitors and members of the public? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

12

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

Legal principles of civil and criminal actions 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.

Crimes Act 1900 Under the Crimes Act 1900, 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.

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

defend himself or herself or another person, or

●

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.

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

13

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

This means that a person who assaults another person in self-defence is not criminally responsible if acting in lawful self-defence. As stated above self-defence is not limited to the defence of one’s own person, and can be used as a defence for assaults that occur when protecting property or other people. In the past the test was whether the perception of a threat was reasonable in the circumstances, and whether a ‘reasonable person’ in the same circumstances would also have been able to come to the same conclusion. The defence is now broader and states that as long as the accused believed that they were under threat, it does not matter that a ‘reasonable person’ may not have perceived such a threat in the same circumstances. However, a reasonable response is still required for the law of self-defence to operate. The law states that there must be some reasonable proportion between the threat perceived by the accused and his or her response to it. So the key issue is that the person threatened must be able to persuade a court that they felt threatened, that the threat was real to them and that their response was appropriate.

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.

14

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

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? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ A patient, visitor or member of the public seeks to have charges laid against a staff member? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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

Local policies and guidelines 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? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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

15

MODULE 3 Course in aggression minimisation for managers

Part 2 Promoting an aggression-free workplace 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 • utilising the risk management process.

Promoting a culture of safety Violence has generally been seen as part of the job in health care,11 with staff expecting to be physically assaulted at some stage in their careers.12 Feeling unsafe in the workplace can cause: ●

additional stress for staff13

●

negative attitudes that influence behaviour.14

For detailed information on workplace safety refer to: NSW Health Security Manual and Workplace Health and Safety: A Better Practice Guide (currently under review).a As a manager, what are some of the challenges to ensuring safety is a top priority for your staff? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Occupational health and safety legislation 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

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

17

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

Under this regulation employers are responsible for: ●

identifying workplace hazards, including violence

●

assessing the risks associated with the hazards

●

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. Penalties can be issued to employers 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. How can ‘due diligence’ be shown? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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.

Occupational health and safety responsibilities for managers 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 action:a ●

Developing safe work practices and procedures.

●

Consulting with employees on all safety issues.

●

Considering decisions from an OHS perspective.

●

Ensuring compliance with safety rules.

●

Ensuring line managers do not cut corners, introduce ambiguity or condone unsafe work practices.

●

Raising OHS issues at staff meetings.

18

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

●

Encouraging staff to support OHS committee meetings and related activities.

●

Reporting back to staff on OHS initiatives and trends.

●

Involving staff in all decisions that affect them.

●

Enforcing safety policies and procedures.

●

Promptly and visibly investigating all significant OHS issues.

●

Ensuring effective OHS training and development for employees.

●

Developing easy and non-threatening procedures to report accidents, injury, illness and ‘near misses’.

How do you as a manager ensure that staff are involved in the promotion of workplace safety? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Risk management and the consulting process 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: ●

whenever examining or reviewing risks to health and safety

●

when making decisions about measures taken to eliminate or control risks

●

when introducing or altering procedures for identifying and monitoring risks

●

whenever changes are being proposed that could affect health and safety in the workplace, the systems of work or equipment used for work

●

whenever decisions are made about consultation arrangements.

Risk management is an interactive process consisting of clearly defined steps.15,16 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.

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

19

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

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

●

incident investigation reports and emergency response reviews

●

reports of staff and unions

●

visual workplace inspections and violence vulnerability audits

●

security surveys

●

related OHS and workers compensation data

●

staff records, eg to identify areas of high staff turnover

●

staff grievance records

●

patient complaint records

●

observations.

Factors to consider when assessing and prioritising risks b ●

What is the nature of the risk or hazard, eg is it physical, psychological, chemical?

●

What is the degree or severity of harm that the hazard/risk may cause?

●

How likely is it that harm will occur as a result of the exposure?

●

How often are staff exposed to the risk or hazard?

●

How long are the periods of exposure?

●

How many staff are exposed to the risk or hazard?

●

How many patients are exposed to the risk or hazard?

●

What is the level of experience of staff?

●

How much training has staff received?

●

How effective are the existing control strategies?

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

20

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

Designing a safer workplace 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. When designingb, 2,17 new facilities or re-furbishingb,2,17 it is important to reduce the opportunity for criminal activity. This can be achieved through: ●

increasing the risk for offenders

●

reducing the opportunity for the offender to make an excuse to trespass

●

reducing the likely rewards for criminal behaviour.

Target hardening and territorial reinforcementb,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

●

barriers and grates

●

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: ●

encouraging staff to be responsible for the facility and its use

●

designing facilities that have clear transitions and boundaries between the health facility and the general community and between ‘staff only’ areas and other areas

●

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

Natural surveillanceb,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

●

effective lighting for visibility

●

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

●

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

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

21

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

Space managementb,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

●

keeping all furniture, fittings and facilities in good repair

●

attending quickly to the repair of vandalism and graffiti

●

replacing any burned out external lighting

●

removing or refurbishing any decayed physical surroundings.

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 ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Surveillance and lighting ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Fittings and furniture ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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.

22

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

Regular monitoring, reviewing and evaluating 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. 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.

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

23

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

What are the risks of trying to do all on the previous page yourself? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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. 1. Discuss what information can be used to evaluate whether there is a reduction in the frequency and severity of aggressive and violent incidents. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

24

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

Part 3 Assisting staff when aggression and violence occurs 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.

Dealing with bullying, harassment and discrimination in the workplace 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 Discrimination.e 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. What types of behaviours represent bullying, harassment and discrimination? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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 How can managers promote a workplace that is free from bullying, harassment and discrimination? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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

25

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

Response options when confronted with aggression or violence 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 long-term, and more than one type of response may be used.

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). Some short term response optionsb (in no particular order): ●

Issue a verbal warning.

●

Seek support from other staff.

●

Request that the person behaving aggressively leave.

●

Request that the patient be reviewed by a clinician.

●

Negotiate treatment.

●

Use verbal de-escalation and distraction techniques.

●

Stay and call for help.

●

Leave and seek help.

●

Utilise the emergency duress response.

●

Initiate external emergency response, eg police.

Longer term response options The following options should be considered for the management of repeated aggressive behaviour. For further information, refer to the NSW Health Zero Tolerance Policy and Framework Guidelines. Some long-term response options (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

●

Recognition of inability to treat in certain circumstances

●

taking out an AVO to protect staff

●

having charges laid.

Both short and long-term options are discussed in some detail in the NSW Health Zero Tolerance Policy and Framework Guidelines.

26

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

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? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

What is required for the effective management of aggression? 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

●

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.

The duress response 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.

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

27

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

Principles of the duress response in ●

The call or trigger should be earlier rather than later.

●

Only one call or alarm trigger should be required.

●

Response should be appropriate, timely and effective.

●

Response should be standardised to reduce any confusion between team members.

●

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.

●

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.

●

Post-incident support is to be provided.

●

Operational review and debriefings are to be conducted following the duress response.

●

The duress response is to be regularly evaluated and updated.

What policies and procedures are in place in your area for the duress response? How is the effectiveness of the duress response evaluated? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Reporting aggressive incidents 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 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. Why do you think many aggressive incidents remain unreported? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ How can you encourage staff to report all aggressive incidents? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

28

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

Investigating aggressive and violent incidents 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 ●

What happened?

●

Who was involved?

●

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

●

Equipment.

●

Work practices.

●

Supervision.

●

Staff skill.

●

Education and training.

An investigation is complete when the following questions can be answered: ●

Do you have all the facts and details on the causes and contributors to the incident?

●

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)?

●

What systems were in place to minimise the risk of the incident occurring?

●

What were the identified system gaps or failures, ie why didn’t the system work?

●

What were the achievements/positive actions and outcomes from the incident?

●

Were all policy/legislative requirements met concerning pre and post-incident management?

●

How could this or similar incidents be prevented?

●

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.

●

Who is responsible for monitoring and evaluating the changes?

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

29

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

Responding to staff stress after an incident 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.

●

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 For further information refer to NSW Health Effective Incident Response: A framework for Prevention and Management in the Health Workplaceh. 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.

30

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

Discuss the following: What staff support mechanisms do you have in place in your own workplace and how are staff aware of these? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Role of managers in supporting staff 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 waysa,b: ●

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.

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 workplace 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 a return-to-work program for the injured employees.

For more information refer to your Risk Management Unit or Return to Work Coordinator and see circular 2003/75 NSW Health Policy and Procedures for Injury management and Return-to-Work.

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

31

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

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 long-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.

●

32

Always keep violence as an agenda item at relevant staff meetings.

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

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.

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

33

MODULE 3 Course in aggression minimisation for managers

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.

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

35

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

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 (2003) (on-line). Available www.workcover.nsw.gov.au

36

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

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: ●

making a complaint

●

being free from victimisation having made this complaint

●

accessing 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 following rights: ●

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 do the following: ●

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.

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

37

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

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: ●

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.

38

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

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.

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

39

MODULE 3 Course in aggression minimisation for managers

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 2003/88 Reportable Incident Briefs to the NSW Department of Health,g The New Simple Way to Notify Work-Related Incidents22 and Circular 2003/75 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.

●

Attend the appropriate training so that any psychological reactions and symptoms can be identified that may follow an incident.

●

Ensure that counselling and access to other professional assistance is arranged and accessible to staff as the need arises.

●

Participate in post-incident review/investigation and initiate any recommended preventative action.

●

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

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

41

MODULE 3 Course in aggression minimisation for managers

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

●

areas of risk to staff, patients and visitors are identified, assessed, eliminated where reasonably practicable and controlled

●

work systems and procedures minimise the risk of violence

●

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

●

local violence prevention policies and procedures are in place and that staff are aware of them

●

their staff receive appropriate training and that ongoing training needs are identified

●

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

●

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.

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

43

MODULE 3 Course in aggression minimisation for managers

Appendix D Duress response planning Responsibilities of managers ●

Ensuring a duress response exists in their area of responsibility – this includes community services.

●

Consulting with staff on the development and review of duress response plans.

●

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.

●

Ensuring staff and response team partners, eg other government, non-government and/or community respondents attend relevant training.

●

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

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

45

MODULE 3 Course in aggression minimisation for managers

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. ● 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. ● ● ● ● ●

● ●

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, other communication devices. Clear guidelines in relation to support – who is responsible for initiating it, who should get 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.

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

47

PA RT I C I PA N T 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 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.

48

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