Mod4 Facilitator
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A safer place to work – preventing and managing violent behaviour in the Health workplace
Module 4 AMT004 Aggression minimisation refresher training Facilitator manual
NSW Health is a zero tolerance zone
NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900 www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the NSW Department of Health. © NSW Department of Health 2003 SHPN (CMH) 030136 ISBN 0 7347 3557 X July 2003 updated August 2004
MODULE 4 Aggression minimisation refresher training
Contents Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Overview of the manual . . . . . . . . . . . . . . . . . . . . . . . . Modular structure of the aggression minimisation program How the manual is set out. . . . . . . . . . . . . . . . . . . . . . . . Facilitator preparation before training . . . . . . . . . . . . . . . . Recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . Other resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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3 3 4 6 7 8
Introduction to Module 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 How Module 4 fits into the whole program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Recommendation on the delivery of this module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Training room requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Assessment for Module 4 Assessment method . . . . . . Assessment conditions . . . . Assessment resources . . . . Assessment questions . . . . Self assessment checklist . . Peer assessment checklist .
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11 11 11 11 11 12 13
Session plan for Module 4 . Materials. . . . . . . . . . . . . . . . Equipment required. . . . . . . . Participant requirement . . . . .
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15 15 15 15
Beginning the training session . . . . . . . . . 1. Welcome participants to the module . . . . . 2. House keeping . . . . . . . . . . . . . . . . . . . . . 3. Principles of adult learning . . . . . . . . . . . . . 4. How Module 4 fits into the whole program . 5. Structure of Module 4 . . . . . . . . . . . . . . . . Assessment . . . . . . . . . . . . . . . . . . . . . . . . .
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. . . . . . . . . . . . . . . . . . 17 . . . . . . . . . . . . . . . . . . 17 . . . . . . . . . . . . . . . . . . 17 . . . . . . . . . . . . . . . . . . 18 . . . . . . . . . . . . . . . . . . 18 . . . . . . . . . . . . . . . . . . 19 . . . . . . . . . . . . . . . . . . 19
Background information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Learning outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Part 1 The zero tolerance response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Always remember your attitudes and behaviours are important in promoting a zero tolerance response to violence . . 25 Part 2 New developments in preventing and managing aggression and violence . . . . . . . . . . . . . . . . . . . . . 27 Part 3 The Prevention of aggression and violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Part 4 Managing aggression and violence Know your options for action . . . . . . . . . . . . . Short-term response options . . . . . . . . . . . . . Long-term response options . . . . . . . . . . . . . De-escalation strategies . . . . . . . . . . . . . . . .
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. . . . . . . . . . . . . . . . 39 . . . . . . . . . . . . . . . . 42 . . . . . . . . . . . . . . . . 43 . . . . . . . . . . . . . . . . 43 . . . . . . . . . . . . . . . . 46
Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
i
MODULE 4 Aggression minimisation refresher training
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 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
1
FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Introduction NSW Health: Preventing and managing aggression in the Health workplace What is it? A number of key projects have flowed from the work of the Violence Taskforce. One of these is the development of a statewide, appropriately accredited aggression minimisation training program. The focus of this training is to provide staff with the most up-to-date strategies, skills and techniques to prevent and minimise workplace aggression and violence. It is also based on relevant task force findings and incorporates key task force initiatives. The program includes a basic module for all staff identified as being at risk of workplace violence, a module for staff working in high risk environments, a module designed specifically for managers and a refresher module.
What materials are provided? A CD-ROM is available and includes: ●
Facilitator manual: Modules 1 through to 4 (in Acrobat PDF format).
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Participant manual: Modules 1 through to 4 (in Acrobat PDF format).
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Powerpoint slides for Modules 1 through to 4.
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Recognition of prior learning forms and assessment of competency forms (as a separate Acrobat PDF format).
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Assessment scenarios and Question sheets for Module 1 (as a separate Acrobat PDF format).
All of the above are included on the CD.
Who will attend? Module 1 should be attended by all staff identified as being at risk of workplace violence, and generally speaking is a prerequisite for all other modules. More detailed advice on the application of this training is provided in the covering circular. Attendance at additional modules is recommended for staff determined by the Health Service to be at higher risk of workplace violence and includes, but is not limited to, security, mental health, Emergency Department, admissions, drug and alcohol, disability services, brain injury and aged care staff. All managers of staff identified as being at risk of workplace violence should attend the manager’s module and all relevant staff should attend the refresher module at least every two years. Health Services may determine that some groups need to attend the refresher more regularly.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Overview of the manual This manual has been developed to provide educational resources for a facilitator to deliver a comprehensive education program in aggression minimisation. The manual is divided into four training manuals. Facilitators must have each of the following: 1.
Certificate IV in Assessment and Workplace Training.
2.
Experience in working in areas of significant violent risk.
3.
Experience in effectively managing violent incidents.
4.
An ability to related to staff at all levels of the organisation.
Modular structure of the aggression minimisation program Module 1 HLTCSD6A – Respond effectively to difficult or challenging behaviour This eight-hour program is designed for all staff identified as being at risk of workplace violence. It is designed to meet the Health Training Package competency HLTCSD6A – Respond Effectively to Difficult or Challenging Behaviour. The day is divided into five parts: 1.
Understanding difficult or challenging behaviour.
2.
Preventing aggression occurring.
3.
Preventing aggression escalating.
4.
Bullying, harassment and discrimination at work.
5.
Reporting and reviewing aggressive incidents.
Module 2 AMT002 – Aggression minimisation in high-risk environments This eight-hour program is designed for mental health and other staff working in high risk areas, eg emergency, security, community, aged care, disability, dental, midwifery and early childhood, methadone, brain injury, neurology, admissions and drug and alcohol services. Other staff members identified, via the risk assessment process, as being at significant risk of aggressive behaviour should also attend this module. The day is divided into four parts: 1.
Working in high-risk environments.
2.
Prevention in high-risk environments.
3.
Understanding aggression in high-risk environments.
4.
Managing aggression in high-risk environments.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
3
FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Module 3 90405NSW – Course in aggression minimisation for managers This four-hour module is designed for managers of health units and facilities. It provides the participant with detailed information, obligations and practical strategies for promoting a safe workplace environment free of aggression, assessing and managing risks and types of support to provide to staff, who have been victims of aggression. Completion of Module 1 is recommended prior to undertaking this module. The day is divided into three parts: 1.
The legal and policy framework for managing aggression.
2.
Promoting an aggression-free workplace.
3.
Assisting staff when aggression and violence occurs.
Module 4 AMT004 – Aggression minimisation refresher training This two-hour module is designed for all staff identified as being at risk of workplace violence, and should be repeated at a minimum of every two years after completion of Module 1. Depending on the level of risk, some staff may need to attend more frequently. It is designed to keep staff up-to-date with policies and practices, provide refresher training of skills, and workshop problems. The day is divided into four parts: 1.
The zero tolerance response.
2.
New developments in preventing and managing aggression and violence.
3.
The prevention of aggression and violence.
4.
Managing aggression and violence.
How the manual is set out The Facilitator manual is divided into the four modules. All facilitator notes throughout each module look like this. Basic course content in the Facilitator manual duplicates that found in the Participant manual. This course content forms the basic syllabus of the training and the trainer needs to know this material prior to conducting training. For each module, at the beginning of each section the relevant page number in the Participant manual is noted. Relevant slides that should be shown at each point are reproduced throughout this manual.
Layout icons The following symbols have been used throughout the Facilitator manual to assist in the presentation of material. In all cases, trainers should use their discretion in the presentation and timing of material depending on the mix of staff in the training group. Where possible, flexible delivery is encouraged and specific recommendations are made at the beginning of each module.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Key points
Key points help you to summarise the major themes and information from the section. Explain and discuss
This icon suggests that you will need some verbal explanation and discussion of this concept or topic. Background reading
This icon appears when further background information and reading is supplied on a topic to assist the facilitator in understanding and delivering the training course. It should be read before the facilitator conducts any training. The background information may be verbally summarised by the trainer as the need arises. Ask the group
Whenever this icon appears in the manual a large group activity is suggested. Facilitators should ask the suggested question to the group as a whole and elicit answers or suggestions as appropriate. Participants may choose to write answers in the space in their manuals. Small group exercise
This icon represents small group activity. Whenever this icon appears in the manual a small group activity is suggested. Facilitators may get the group to break into smaller groups of two to five participants to discuss the question, before reporting back to the group as a whole. Participants may choose to write answers in the space in their manuals. Individual reflection exercise
This icon represents personal reflective activity. Whenever this icon appears in the manual personal reflection is suggested. Individual participants may complete this exercise alone. The facilitator may then choose to address the question to the group as a whole and collect responses from individuals. Participants may choose to write answers in the space in their manuals. Answers
Suggested answers to the individual, small and large group activities are provided. These amplify and reinforce the subject material covered in the Participant manual. Important training point
Important training points are highlighted with this symbol. You are on Participant manual page X
These icons assist you to keep the training program in sequence with the Participant manual. It is suggested that you regularly refer participants to the relevant page in their Participant manual for further information or to complete an activity.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Show overhead slide
Suggested place to present slide. Facilitator instruction
Specific training hints are given here. Write responses on board
Suggested place where the trainer may wish to reinforce points or collect responses from the group on a whiteboard/blackboard/butcher’s paper. Session time
Suggested times to conduct sessions are given and a session plan is provided for each module. These are to be used flexibly to meet the needs of trainers and participants. Session overview
An overview of the session is given here. Suggested break time
Suggested breaks are provided. These are flexible. Readings and resources
Additional readings and resources are highlighted here and should be read prior to commencing training.
Facilitator preparation before training Before running this training it is important to be familiar with: ●
All NSW Health documents and policies relating to aggression minimisation, prevention and management (see reference lists at the end of each module).
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All local policies relevant to aggression minimisation. These will include documentation and emergency responses relating to aggression minimisation, prevention and management, eg duress response, reporting protocols.
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It is helpful if you have an awareness of recent incidents in your area, where these have been a particular problem and the outcome. This enables the training to be more relevant for participants.
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Facilitators need to familiarise themselves with the reference list at the end of the modules.
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Facilitators should ensure that participants are informed that prior to attending this module they need to review the contents of the Participant manual for Module 1 – Respond effectively to difficult or challenging behaviour, or the equivalent training attended.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Sequence and timing of the modules The individual modules do not need to be taught together as a block. The space between teaching individual modules may be separated by weeks or months. It is important to consider the retention of information from previous training and be ready to reinforce previous training material, particularly from Module 1. Each module contains some common material from other modules to help reinforce basic concepts, eg zero tolerance. Module 1 forms the prerequisite for the other modules so needs to be made available to participants prior to offering the other modules.
Assessment of competency Assessment activities accompany Modules 1-4 to facilitate demonstration of competency. Facilitators should ensure that training outcomes for each participant are appropriately documented. Recording forms accompany the Facilitator manual.
Flexible delivery The materials in this training program provide a core recommended syllabus for preventing and managing aggression in all NSW Health facilities. Each module has a set of learning outcomes and corresponding assessments. The training is designed in a modular format to allow ease of delivery, however it is possible that the training may be delivered using flexible delivery methods. Examples of how the training could be altered include (but are not limited to) the following: 1. Dividing a full day module into two parts, spread over two half days. 2. Emphasising some components of training over others for specific groups. For example, if the participant training group is non-clinical then the trainer may decide to focus more on communication strategies and bullying, harassment and discrimination than on some of the components that are more relevant for clinical staff. 3. Flexibly incorporating materials from other local training programs that overlap with the learning outcomes and provide additional training. 4. Shortening a module by providing advance reading materials and exercises to be reviewed in the participants’ own time and reinforced and assessed in the workshop. However, the trainer will need to determine that this approach is appropriate for the participant group. In considering flexible delivery options, it is important to ensure that the learning outcomes are met as set down in this program.
Recognition of prior learning Recognition of prior learning can be considered for this training. The relevant forms for recognition of prior learning accompany the Facilitator manual. Recognition of prior learning is based on the following: ●
Competence – a focus on the competencies an individual has acquired as a result of any formal or informal training and experience.
●
Commitment – to recognise prior learning of individuals, therefore individuals will not have to duplicate their training unnecessarily.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
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Access – every individual may have his or her prior learning recognised.
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Fairness – that the recognition of prior learning process is fair.
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Support – is provided for individuals in applying for recognition of prior learning. Certificate IV workplace trainers and assessors must provide support so that an efficient and effective service is maintained.
Portfolio documentation Appropriate documentation is to be filled in and evidence collected to be submitted with the application form. All documentation should be submitted as a portfolio. See below for types of evidence to be collected and included in a portfolio.
Evidence guide The following is a guide for the evidence to be provided for recognition of prior learning. For each item of evidence you will need to indicate which part of the item is relevant to which learning outcomes. The following types of evidence may be collected: ●
Formal accredited certificates of previous training programs attended, or transcripts of courses of study.
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Authenticated reports on activities participated in, relevant to aggression minimisation.
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Certified evidence of discussions of case studies that shows evidence of having attained learning outcomes.
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Authenticated reports of work, skills and experience in responding to aggressive behaviour.
Other Resources Participant manual A Participant manual is also available and should be used during the training. Participants are to use the manual during the training session, but also should take it away as a resource. There is additional information in the Participant manual, and it is not expected that every point can be covered during the training sessions. The training provides an orientation to the major issues in aggression minimisation and points the participant to further readings and resources in the area.
Lecture slides The CD-ROM contains the full set of Powerpoint slides. The Powerpoint slides can also be printed and transferred to overhead transparencies as needed.
Forms The CD-ROM contains the recognition of prior learning forms and the assessment of competency forms.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Introduction to Module 4 How Module 4 fits into the whole program Module 4 is the last module dealing with aggression prevention, minimisation and management. This two-hour module is a refresher training program designed for staff identified as being at risk of workplace violence, and should be completed every two years after finishing Module 1 of the training (or its equivalent). It is designed to keep staff up-to-date with policies and practices, provide refresher training of skills and enable problems to be discussed and worked through.
Session times Part 1 Allow 15 minutes for Part 1 Part 2 Allow 15 minutes for Part 2 Part 3 Allow 30 minutes for Part 3 Part 4 Allow 45 minutes for Part 4 Assessment of competency
Allow 15 minutes
NB. A session plan is provided at the beginning of Module 4.
Recommendations on the delivery of this module Recommendation 1
This module is designed to be flexible. Although there are tasks and exercises to complete, these are only suggestions and the individual trainer is encouraged to adapt the workshop to meet the needs of the training group. Recommendation 2
Staff from the same or similar work areas should be encouraged to train together. This will help the trainer focus the refresher onto issues that are relevant for the participants’ particular work area. Recommendation 3
Trainers need to keep up-to-date with new developments in aggression minimisation. Teaching this module presupposes recent knowledge of: a.
state legislation
b. NSW Health policies and guidelines c.
local policies, procedures and protocols
d. national research and initiatives and e.
NSW Health
international research and initiatives. As a trainer you will be specifically required to address each of these in the training.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Recommendation 4
Staff should be encouraged to review their Module 1 workbooks and any other relevant readings prior to attending the workshop.
Training room requirements The training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual. Equipment required: projection facilities for Powerpoint slides (or an overhead projector if the slides have been printed on overheads), a whiteboard and whiteboard pens (for writing up feedback from participant exercises). Participants will need pens or pencils for writing in their copy of the Participant manual. Refreshments should be available during the breaks.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Assessment for Module 4 Assessment questions
Learning outcomes
Question 1
1. Demonstrate an understanding of new developments in the prevention and management of violence.
Question 2
2. Acquire further understanding of how to prevent and manage violence.
Assessment method The learning outcomes are to be assessed through peer and self assessment. Participants are required to pair up. Each participant then directs the questions to their partner and assesses their partner’s verbal responses, using the peer assessment checklist. The partner is also given the opportunity to assess his or her own responses using the self assessment checklist. When this is complete, participants are to change roles. Participants may choose to jot down dot point answers in the column provided in the relevant checklist, though this is not mandatory. The participants, as a whole group, are then to be debriefed. The trainer may encourage the group members to share their responses and the discussion should focus on areas that need clarification. There are two critical aspects of the assessment relating to the two assessment questions. The questions have been designed to align with the critical aspects of the assessment. Participants are deemed competent if they demonstrate the correct responses to these questions. The critical aspects of the assessment are identified in the marking guide (checklists).
Assessment conditions Participants are to be informed about the assessment and what is required. Participants are to complete the assessment following the training.
Assessment resources ● ●
Assessment questions. Peer and self assessment checklists. NB. Assessment questions and Peer and Self assessment checklists are shown below and can also be found as a separate Acrobat PDF document on the CD-ROM, in order that the Assessment questions and checklists may be printed out and handed to participants.
Assessment questions 1. What are two new developments that have arisen in regards to aggression management and prevention in your local area in the last two years, or since you last attended aggression minimisation training? 2. Identify what new knowledge and skills you have acquired from the training provided in Module 4 (identify at least three).
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Self assessment checklist Yes
No Unsure
Briefly detail new developments, knowledge and skills (optional)
Identified new developments in the local area in the last two years (or since you last attended aggression minimisation training).
Identified acquired knowledge and skills from the training provided in Module 4.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Peer assessment checklist Yes
No Unsure
Briefly detail new developments, knowledge and skills (optional)
Identified new developments in the local area in the last two years (or since you last attended aggression minimisation training).
Identified acquired knowledge and skills from the training provided in Module 4.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Session plan for Module 4 Training session: Module 4 Aggression minimisation refresher training
Time
Topic
15 mins
●
Introduction.
●
The zero tolerance response.
15 mins
●
30 mins
45 mins
Time:
Learning outcomes
Content/activity
2
Small and large group discussions.
New developments in preventing and managing violence.
1
Small and large group discussions.
●
The prevention of violence.
2
Small and large group discussions.
●
Managing violence.
2
●
Small and large group discussions.
●
Role play activity.
●
15 mins
Date:
Assessment of competency.
1 and 2
Small and large group discussions.
Materials The training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual.
Equipment required ●
Projection facilities for Powerpoint slides (or an overhead projector if the slides have been printed on overheads).
●
A whiteboard and whiteboard pens (for writing up feedback from participant exercises).
Participant requirement Pens or pencils for writing in their copy of the Participant manual.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Beginning the training session Session time 15 mins for introduction and Part 1 The relevant slides that should be shown at each point are reproduced in small size in the facilitator manual. The title slide should be showing when participants begin to arrive at the workshop.
Show overhead slide
1. Welcome participants to the module You may wish to facilitate an introductory activity (ice -breaker). Example: Have participants pair off and: ●
introduce themselves and the area they work in
●
discuss what they hope to gain from the training.
After a few minutes have passed re-assemble the group and ask each participant to introduce their partner.
2. House keeping Inform participants of: ●
program times
●
breaks and meals
●
toilets
●
mobile phones
●
message board
●
occupational health and safety (fire escapes).
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
3. Principles of adult learning Inform participants that: ●
everyone’s opinion will be respected
●
every participant’s work experience will be valued.
Show overhead slide
4. How Module 4 fits into the whole program Module 4 is the final of four modules dealing with aggression prevention, minimisation and management. It builds upon Module 1. The material in Module 1 is assumed knowledge for this module, and completion of Module 1, or its equivalent, is recommended for completing Module 4. This two-hour module is designed for staff to complete every two years after finishing Module 1. It is designed to keep staff up-to-date with policies and practices, provide refresher training of skills and enable problems to be discussed and worked through.
Show overhead slide
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
5. Structure of Module 4 Explain that the program is divided into four parts: Part Part Part Part
1 2 3 4
– – – –
looks looks looks looks
at at at at
the zero tolerance response. new developments in preventing and managing violence. the prevention of violence. managing violence.
Explain that the aim of the program focuses on problem solving and that it is expected that during each section participants will raise examples of incidents that have occurred in the workplace that were difficult to manage. Explain that this will enable a group problem solving approach and permit participants to learn from the experience of others.
Assessment At this point, introduce the assessment component of the course.
Show overhead slide
You are on Participant manual page 3
Key points • Point out that the program aims to discuss difficult instances of violence in the workplace. • By completing this refresher training and continually updating your knowledge and improving the way in which you respond to aggression, you may achieve: – improved knowledge on new directions to prevent and manage aggression and violence – reduced physical injury to staff, patients and members of the public – reduced levels of stress on the job – reduced levels of aggression and violence in the workplace – fulfilment of your ‘duty of care’ responsibility under the Occupational Health and Safety Legislation.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Background information Background reading This two-hour module is designed for staff to complete every two years after finishing Module 1 (or its equivalent). It is designed to keep staff up-to-date with policies and practices, provide refresher training of skills and enable problems to be discussed and worked through. Aggression in the health industry is a significant problem.1,2,3 Regular ongoing education4,5 is important to help staff retain and improve their skills in the prevention and management of aggression and further increase staff confidence. The goals of this training are to revise and review health care workers’ knowledge on prevention and management of aggression within a problem solving perspective. This program aims for health care workers to discuss difficult instances of aggression and violence in the workplace. By completing this refresher training and continually updating your knowledge and improving the way in which you respond to aggression, you may achieve: ●
improved knowledge on new directions to prevent and manage violence
●
reduced physical injury to staff, patients and members of the public
●
reduced levels of stress on the job
●
reduced levels of violence in the workplace
●
fulfillment of your ‘duty of care’ responsibility under the occupational health and safety legislation.
Show overhead slide
You are on Participant manual page 3
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Explain and discuss Learning outcomes At the conclusion of this module, participants will: 1. be able to demonstrate an understanding of new developments in the prevention and management of violence 2. have acquired further understanding about how to prevent and manage violence.
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MODULE 4 Aggression minimisation refresher training
Part 1 The zero tolerance response Session time 15 mins for introduction and part 1
Show overhead slide
Session overview This section looks at the zero tolerance response to aggression.
You are on Participant manual page 5 Ask the group What does a zero tolerance response to violence mean to you? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Write responses on the whiteboard.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Answers Responses could include: ●
not accepting that violence is part of the job
●
reporting all violent incidents
●
encouraging others to report all violent incidents
●
knowing all of the various response options for dealing with violence in both the short and long-term
●
ensuring that all violent incidents are promptly, appropriately and consistently managed
●
promoting a zero tolerance culture
●
being aware of violence triggers and risks
●
participating in risk management.
Individual reflection exercise List some practical ways in which you have implemented a zero tolerance response to violence in your workplace. List some practical ways you could implement a zero tolerance approach in the future. Things you have done. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Things you could do. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Always remember your attitudes and behaviours are important in promoting a zero tolerance response to violence Show overhead slide
You are on Participant manual page 6
Key points Point out the zero tolerance attitudes and behaviours below.
Zero tolerance attitudes and behaviours Putting up with violence in the health workplace IS NOT an acceptable part of your job (if you don’t get the message, neither will patients and visitors). Know your options when confronted with violent behaviour and exercise them consistently (the most effective way of protecting yourself AND getting the message to patients and visitors). Management will support you in utilising these options (this is part of their responsibility). Report all violent incidents (problems that don’t get reported don’t get fixed). Be aware of violence as an occupational risk (it is just as real as other more recognised OHS risks, eg manual handling, exposure to hazardous substances, etc). Be vigilant of factors contributing to the risk of violence (prevention is better than cure).
For more detailed information on the zero tolerance response see the NSW Health Zero Tolerance Policy and Framework Guidelines.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Part 2 New developments in preventing and managing aggression and violence Session time 15 mins
Facilitator instruction To teach this part you will need to have familiarised yourself with any recent developments in preventing and managing aggression. This will involve doing some research and preparation in the following areas: State legislation Check whether there have been any recent, relevant legislative changes in the: ● OHS, injury management and workers compensation ● privacy and freedom of information ● anti-discrimination ● criminal law ● mental health laws ● laws covering the security industry areas. Useful websites: www.austlii.edu.au www.workcover.nsw.gov.au www.noschc.gov.au NSW Health policies and guidelines Check whether there have there been any recent amendments, additions or updates to NSW Department of Health policies and guidelines in the: ● reportable incident requirements ● NSW Health, NSW Police MOU (Memorandum of Understanding) ● incident and post incident management requirements ● security and safety requirements ● OHS and risk management training requirements ● violence prevention and management requirements ● general OHS and injury management requirements ● emergency management requirements ● duress response requirements ● requirements regarding working in the community ● mental health policies and guidelines, eg relating to seclusion, restraint, clinical guidelines for the management of the mentally ill, Emergency Department guidelines for managing challenging behaviour etc. Useful website: www.internal.health.nsw.gov.au NSW Health
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Local policies, procedures and protocols Check whether there have been any changes to local policies, procedures and protocols in response to changed department policies and guidelines or as part of the ongoing internal monitoring and review of existing activities, including: ● ● ● ● ● ● ● ● ● ● ●
incident reporting requirements hazard reporting requirements incident and post incident management requirements security and safety requirements liaison with local police, including NSW Police MOU violence prevention and management requirements general OHS and injury management requirements emergency management requirements duress response plans requirements regarding working in the community protocols covering seclusion, restraint, management of the mentally ill, Emergency Department guidelines for managing challenging behaviour etc.
Useful website: See your local Area Health Service intranet site. National research and initiatives ● Indigenous mental health. ● National responses to suicide and depression. ● Rights of children and responses to adolescent mental health. ● Aged care policies. ● Use of medicines. ● National responses to trauma and terrorism. Useful websites: NSW interagency guidelines for child protection 2000: www.kids.nsw.gov.au Youth and violence: www.acys.utas.edu.au/ncys/ysa/index/bullying.htm International research and initiatives ● Aggression and social justice – marginalised groups. ● Bullying in the workplace. ● Communication skills – developments and programs. ● Causes and prevalence of aggression. ● Controversies around restraint and seclusion. Useful websites: Aggression and the workplace: www.hrmguide.co.uk/relations/violence.htm Theories of aggression: www.nursing-standard.co.uk/archives/vol12-27/research.htm
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MODULE 4 Aggression minimisation refresher training
Discretion will need to be used as to the amount and level of detail provided, depending on the amount of information gathered, the time constraints and the characteristics of the target group, eg clinical, security, administration staff etc. However, as a general guide, relevant legislative changes, and any changed departmental and local requirements should be given priority. You may wish to provide summaries of the changes to the group for future discussion, or elicit as many as possible from the group prior to tabling any information. A third option is for participants to make their own notes in the section provided in their copy of the Participant manual as you lead or guide the discussion on the changes. Facilitators should also have copies of any updated policies, procedures, publications and protocols to show the group, and advise of where copies can be obtained. Depending on the size of the group, copies of the more relevant documents could be provided at the session.
Show overhead slide
Session overview This section looks at new developments in aggression prevention and minimisation.
Show overhead slide
Facilitator instruction Use the whiteboard when introducing a new development.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
The field of aggression minimisation is continually evolving. This module is designed for a flexible update and review of new developments. These developments usually fall into five areas: 1. State legislation. 2. NSW Health policies and guidelines. 3. Local policies, procedures and protocols. 4. National research and initiatives. 5. International research and initiatives. 1. State legislation
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. NSW Health policies and guidelines
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. Local policies, procedures and protocols
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
4. National research and initiatives
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 5. International research and initiatives
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Ask the group Is anyone aware of any recent developments?
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Part 3 The prevention of aggression and violence Session time 30 mins
Show overhead slide
Session overview This section looks at the prevention of violence.
You are on Participant manual page 9
Explain and discuss ●
Prevention should always be the first priority.
●
The aim is to prevent or reduce levels of violence as far as possible.
Prevention of violence in the workplace is your first priority. While not all incidents of aggression can be prevented, the aim is always to prevent or reduce levels of aggression and violence as far as possible, and to have in place appropriate control measures if a violent incident does occur.
Important training point Prevention of violence in the workplace should always be the first priority.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Ask the group How have you actively participated in preventing violence in your work area? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Responses could include: ●
reporting workplace violence hazards eg locks on windows and doors that are not working, burnt out external lighting, facilities not working such as phones and food and drink dispensers in patient waiting areas etc
●
testing emergency equipment, eg fixed or personal duress alarms
●
instigating changes to the workplace including the physical environment and work practices and systems
●
attending aggression minimisation and management training
●
using de-escalation techniques in a potentially violent situation
●
reviewing the duress response
●
having been part of a working party to propose control strategies for a specific violence hazard, eg violence from patients in Emergency Departments.
Have participants give specific examples.
Explain and discuss Point out the importance of effectively preventing and managing bullying in the workplace, in terms of OHS legislative requirements, and also in terms of the zero tolerance response. It is hard for staff to take zero tolerance seriously if bullying is a feature of the workplace.
Ask the group Where might there be a high risk of encountering bullying? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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MODULE 4 Aggression minimisation refresher training
Answers Responses could include: ●
highly stressful situations, eg tight or unreasonable deadlines, limited resources
●
culture that condones bullying
●
where there is a high degree of change
●
where there are closed systems that are not open and accountable, eg where there is limited interaction with other areas.
Ask the group How would you reduce bullying to as low a level as possible? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers ●
Have a clear, anti-bullying statement signed off and supported by the CEO.
●
Ensure that it is communicated to all staff.
●
Have a clear reporting mechanism for bullying.
●
Train managers and other relevant persons in how to investigate and manage bullying.
●
Ensure that managers respond promptly and appropriately to all reported incidents of bullying.
●
Ensure that hazards/risks associated with bullying are considered as part of the overall OHS risk assessment and risk management process.
Show overhead slide
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Ask the group What are the key steps in the risk management process?
Answers ●
Identify the problem.
●
Assess the risk.
●
Eliminate or control the risk.
●
Monitor, review and improve the system.
The risk management process Step 1. Identifying the problem (hazard identification). Step 2. Assessing the risk (determining how serious the problem is). Step 3. Eliminating or controlling the risk (deciding what needs to be done to solve the problem and in what order. Risk controls need to be ranked from the most effective to the least effective). Step 4. Monitoring, reviewing and improving the system.
Facilitator instruction Give the following example as a simple illustration of the risk management process in action. Example: Hazard – violence from intruders. Risk – a faulty exit door that fails to open to allow exit. Risk assessment – high, as staff may possibly become trapped inside by a violent patient or an intruder. Risk control – repair the door, consult with staff on the existing circumstances (to determine why the door was unable to be opened, or why the system failed), ensure there is a future procedure in place for regularly checking all relevant locks, for reporting faults and for ensuring urgent repairs take place. Monitor the system and improve if necessary – if random checks of locks still show that all locks are not working effectively all of the time, this suggests that the system for checking and repair is not working satisfactorily. Consult with staff to determine why the system isn’t working, discuss how it might be improved and implement the recommended changes to the system.
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MODULE 4 Aggression minimisation refresher training
Small group exercise Ask participants to work in small groups and complete the following exercise. Allow fifteen minutes. Ask participants to elect someone in their group who will share their responses with the larger group at the end of the discussion.
Consider an aggressive incident that has occurred at your workplace. Use the results of the incident investigation, and risk management principles to do the following in order to prevent a recurrence of the incident. For example, if the incident investigation identified that lack of knowledge of how to operate the duress alarm was a factor in the incident, the level of risk associated with not being able to summon urgent assistance would be high. A risk control measure would be to train all relevant staff in how to operate the duress alarm, and a monitoring activity would be regular drills in its operation. Identify the main hazards and/or risk factors that led to, caused and/or contributed to the incident. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Assess the level of risk resulting from the various factors, and prioritise for elimination or control. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Identify measures that would eliminate or control the hazards and risks associated with this incident, to prevent a recurrence. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Monitor, review and improve the system. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Ask the group At the end of the small group discussion, ask each elected participant to share their groups’ responses with the larger group.
Write responses on board
Facilitator instruction Reinforce the key points.
Key points ●
Prevention of violence in the workplace should always be your first priority.
●
The risk management process: – – – –
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Identify the hazard. Assess the risk. Eliminate or control the risk. Monitor, review and improve the system.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Part 4 Managing aggression and violence Session time 45 mins
Show overhead slide
Session overview This section looks at the management of violence.
Show overhead slide
You are on Participant manual page 13
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Explain and discuss ●
There are always options available to you when you are confronted with an aggressive person, therefore, it is most important that you are aware of these response options, and when to use them.
●
The responses used will depend on a number of factors; the nature and severity of the event; whether it is a patient, visitor or intruder; the experience, skills and confidence of the staff member/s involved. This may include going straight to calling for back-up, security or local police.
●
When choosing your response options, your aim is to maintain safety to yourself and others, and prevent an aggressive incident from escalating.
●
Emphasise the importance of safety eg in all violent situations you should immediately seek help, regardless of whether you decide to stay or leave.
Explain and discuss When considering your options you always need to keep in mind the following: ●
Whether the person has an underlying physical or mental condition that is contributing to the person’s aggressive or violent behaviour.
●
Always remain calm and assess the level of threat and the different levels of aggression displayed as this will help you to make a decision on the appropriate response to take.
●
Regardless of the response option you choose, de-escalating and containing the situation should be considered where possible.
●
If at any time you feel unsafe you need to call for support and/or leave.
●
At all times your priority is for the safety of yourself and others.
●
Be aware of the potential for violence, look for contributing factors or warning signs.
You can use more than one option, depending on the circumstances.
Facilitator instruction Familiarise yourself with local policies and procedures for short and long-term response options. Briefly go through each short and long-term response option.
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MODULE 4 Aggression minimisation refresher training
Important training point Explain and discuss Short-term response options (in no particular order): ●
Issue a verbal warning This may be appropriate in some circumstances. Emphasise the importance of staff using appropriate, respectful communication skills. When issuing a verbal warning, do so in an ‘informative’ manner. It is helpful when doing this to draw the person’s attention to any displayed zero tolerance poster and/or information brochures outlining behavioural responsibilities. Explain the impact their aggressive behaviour may have on yourself, others etc, eg on your ability to deliver quality health care.
●
Seek support from other staff Sometimes the presence of others, particularly the presence of more senior staff can have a settling effect on aggressive patients or visitors, and the targeted staff member may feel more confident. Point out the importance of knowing the emergency duress response procedures and procedures for calling security or police.
●
Request that a person behaving aggressively leave This might help remove a trigger for the aggressive behaviour, eg if a relative is causing a patient distress and the patient is showing signs of aggression, asking the relative to leave may be appropriate, explaining that this may assist in the better management of the patient.
●
Request that the patient be reviewed by a clinician A patient in the Emergency Department for example, may be aggressive as a result of a medical condition, so it is important that this always be a consideration, and that clinical assessment is sought as appropriate.
●
Negotiate treatment If appropriate, negotiate treatment, eg a patient behaving aggressively may be offered medication to help calm their distressed state.
●
Use verbal de-escalation and distraction techniques Model calm and appropriate behaviour, acknowledge the person’s needs and negotiate solutions. Seeking to make the aggressive individual more comfortable may be a helpful distraction technique.
●
Stay and call for help If you stay and call for help, continually monitor your safety.
●
Leave and seek help It is most important that if you do leave a violent situation that assistance is still sought.
●
Utilise the unit emergency duress response Always ensure you are up-to-date with the procedures.
●
Initiate external emergency response, eg police Always ensure you know the procedure.
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Explain and discuss Long-term response options For persons with repeated aggressive behaviour, long-term response options may be appropriate. These are generally developed and implemented in consultation with management and other key stake holders, eg clinicians, treating staff, medical records, security, local police as necessary etc. Long-term response options include: ●
formal patient management plans
●
written warnings
●
conditional treatment agreements
●
exclusion from visits
●
conditional visiting rights
●
patient alerts in conjunction with support management plan
●
formal recognition of inability to treat in certain circumstances
●
taking out an AVO to protect staff
●
having charges laid.
When managing aggression in the workplace, both short-term and long-term options need to be considered. Short-term options are important to prevent an episode of aggression from escalating and to maintain the safety of all concerned. Long-term options are important for the prevention of repeated violent incidents and ensuring the safety of all concerned when the risk of future aggression is significant.
Know your options for action There are always options available when confronted with an aggressive person and it is important that staff know the appropriate response options. These responses will depend on a number of factors including the nature and severity of the event, whether it is a patient, visitor or intruder, and the skills, experience and confidence of the staff member/s involved. This may include going straight to calling for back-up, security or local police.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
When considering your options you always need to keep in mind the following: ●
Whether the person has an underlying physical or mental condition that is contributing to the person’s aggressive or violent behaviour.
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Always remain calm and assess the level of threat and the different levels of aggression displayed as this will help you to make a decision on the appropriate response to take.
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Regardless of the response option you choose, de-escalating and containing the situation should be considered where possible.
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If at any time you feel unsafe you need to call for support and/or leave.
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At all times your priority is for the safety of yourself and others.
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Be aware of the potential for violence, look for contributing factors or warning signs.
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You can use more than one option, depending on the circumstances.
Short-term response options Short-term response options (in no particular order): ●
Issue a verbal warning.
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Seek support from other staff.
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Request that the person behaving aggressively leave.
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Request that the patient be reviewed by a clinician.
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Negotiate treatment.
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Use verbal de-escalation and distraction techniques.
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Stay and call for help.
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Leave and seek help.
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Utilise the unit emergency duress response.
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Initiate external emergency response, eg police.
Long-term response options Long-term response options: ●
Formal patient management plans.
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Written warnings.
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Conditional treatment agreements.
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Exclusion from visits.
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Conditional visiting rights.
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Patient alerts in conjunction with support management plan.
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Formal recognition of inability to treat in certain circumstances.
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Taking out an AVO to protect staff.
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Having charges laid.
For more detailed information on short-term and long-term options, see the NSW Health Zero Tolerance Policy Framework and Guidelines. NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
You are on Participant manual page 15
Small group exercise Ask participants to work in small groups and discuss the following question for ten minutes. Ask them to elect someone in their group who will share their group’s responses with the larger group at the end of the discussion.
Think of an aggressive incident in your workplace that was difficult to manage. NB. An incident that you feel comfortable talking about.
Discuss the following: During the incident
What were some of your response options to this incident? Were the appropriate options used? What are some other options that could have been used? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How did you ensure the safety of yourself and others? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
After the incident
What happened after the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Who was the incident reported to and what was the outcome? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Was management supportive of you after the incident? How was this support demonstrated? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Ask the group At the end of the small group discussion, ask each elected participant to share the group’s responses with the larger group.
Write responses on board
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
De-escalation strategies Show overhead slide
You are on Participant manual page 16
Facilitator instruction Briefly review the appropriate strategies for dealing with a fearful or frustrated person and an intimidating or threatening person. Appropriate behaviours are included below. Point out that the strategies you choose will vary depending on whether the person being aggressive is fearful and frustrated or intimidating and threatening. Emphasise the importance of being aware of cultural differences, eg facial expressions, body language, tone of voice. The fearful/frustrated person ●
Often the individual is out of control and you need to help the individual to gain control.
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The approach to use with this person is more empathic (more emotionally engaging).
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A useful technique is to provide the person with options and focus on these options.
The intimidating/threatening person
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Often the individual is in control.
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This individual is more likely to be antagonistic and less likely to be accommodating.
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The approach to use with this person is more assertive.
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Asking the person to tell you what they need may be a more useful strategy to persuade the individual to talk about the issue, than offering a broad range of options.
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Focus on the consequences of the individual’s behaviour.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
The strategies you choose will vary depending on whether the person being aggressive is fearful and frustrated or intimidating and threatening.
Fearful and frustrated person
Intimidating and threatening person
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Be assertive – however your voice can range from being calm and confident to forceful. You may need to be repetitive.
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Be assertive – your voice is more matter of fact displaying less emotion. Repetitive statements are more important especially regarding the consequences of threatening behaviour.
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Make direct eye contact but not for long periods of time, ie do not stare.
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Eye contact can range from direct to evasive depending on the person behaving aggressively.
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Provide a range of options when you attempt to problem solve.
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Ask the person what they need and provide options and consequences for the threats made.
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Show empathy and be emotionally engaging with your responses.
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You need to be emotionally neutral when stating the options and consequences.
Facilitator instruction In this exercise you are to de-escalate the person’s aggressive behaviour using strategies that are correct and incorrect.
Large group exercise Ask for a participant to volunteer to role-play a situation where the participant takes on the role of a fearful and frustrated person who is acting out aggressively. Have the participant think of a situation that has occurred in their workplace that will help them with the role-play. Inform participants that you will try to de-escalate the aggressive behaviour. Ensure you use both correct and incorrect strategies. The aim is to illustrate for the group what works and what does not work.
Ask the group What were some helpful and unhelpful strategies used to de-escalate the person’s aggressive behaviour?
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Write responses on board Write responses on one side of the board.
Facilitator instruction Ask for another volunteer and repeat the exercise, with the volunteer taking the role of an intimidating and threatening person being the aggressor.
Ask the group What were some helpful and unhelpful strategies used to de-escalate the person’s aggressive behaviour?
Write responses on board Write responses on the other side of the board.
Facilitator instruction As a way of concluding the training session ask the group to compare and contrast the more successful and less successful techniques used for de-escalating the behaviour shown in the role-plays.
Key points • Know your short-term and long-term options when confronted with violent behaviour. • De-escalation strategies will differ depending on whether the person being aggressive is fearful and frustrated or intimidating and threatening.
Show overhead slide
Assessment exercise is now facilitated. Details of the assessment are at the front of the module.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
Related NSW Health policies and guidelines a.
Mental Health for Emergency Departments, May 2002 (red book).
b. Management of Adults with Severe Behavioural Disturbance, May 2002 (green book). c.
C2003/88 Reportable Incident Briefs to the NSW Department of Health.
d. C2001/22 Workplace Health and Safety: A Better Practice Guide (currently under review). e.
C2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace.
f.
C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination.
g. NSW Health Security Manual. h. NSW Health Zero Tolerance Policy and Framework Guidelines. i.
C2003/75 NSW Health Policy and Procedures for Injury Management and Return-to-Work.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
References 1. Mayhew C, Chappell D (2001a). Occupational violence: types, reporting patterns, and variations between health sectors. Working Paper Series no. 139, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 2. Mayhew C, Chappell D (2001b). Prevention of occupational violence in the health workplace. Working Paper Series no. 140, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 3. Mayhew C, Chappell D (2001c). Internal violence (or bullying) and the health workforce. Working Paper Series no. 141, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 4. Delaney J, Cleary M, Jordan R, Horsfall J (2001) An exploratory investigation into the nursing management of aggression in acute psychiatric settings. Journal of Psychiatric and Mental Health Nursing, 8 (1), 77-84. 5. Ilkiw-lavalle O, Grenyer BFS, Graham L (2002). Does prior training and staff occupation influence knowledge acquisition from an aggression management training program? International Journal of Mental Health Nursing, 11, 233-239.
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Module 4 AMT004 Aggression minimisation refresher training Facilitator manual
NSW Health is a zero tolerance zone
NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900 www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the NSW Department of Health. © NSW Department of Health 2003 SHPN (CMH) 030136 ISBN 0 7347 3557 X July 2003 updated August 2004
MODULE 4 Aggression minimisation refresher training
Contents Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Overview of the manual . . . . . . . . . . . . . . . . . . . . . . . . Modular structure of the aggression minimisation program How the manual is set out. . . . . . . . . . . . . . . . . . . . . . . . Facilitator preparation before training . . . . . . . . . . . . . . . . Recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . Other resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Introduction to Module 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 How Module 4 fits into the whole program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Recommendation on the delivery of this module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Training room requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Assessment for Module 4 Assessment method . . . . . . Assessment conditions . . . . Assessment resources . . . . Assessment questions . . . . Self assessment checklist . . Peer assessment checklist .
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Session plan for Module 4 . Materials. . . . . . . . . . . . . . . . Equipment required. . . . . . . . Participant requirement . . . . .
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Beginning the training session . . . . . . . . . 1. Welcome participants to the module . . . . . 2. House keeping . . . . . . . . . . . . . . . . . . . . . 3. Principles of adult learning . . . . . . . . . . . . . 4. How Module 4 fits into the whole program . 5. Structure of Module 4 . . . . . . . . . . . . . . . . Assessment . . . . . . . . . . . . . . . . . . . . . . . . .
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Background information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Learning outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Part 1 The zero tolerance response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Always remember your attitudes and behaviours are important in promoting a zero tolerance response to violence . . 25 Part 2 New developments in preventing and managing aggression and violence . . . . . . . . . . . . . . . . . . . . . 27 Part 3 The Prevention of aggression and violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Part 4 Managing aggression and violence Know your options for action . . . . . . . . . . . . . Short-term response options . . . . . . . . . . . . . Long-term response options . . . . . . . . . . . . . De-escalation strategies . . . . . . . . . . . . . . . .
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Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
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 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Introduction NSW Health: Preventing and managing aggression in the Health workplace What is it? A number of key projects have flowed from the work of the Violence Taskforce. One of these is the development of a statewide, appropriately accredited aggression minimisation training program. The focus of this training is to provide staff with the most up-to-date strategies, skills and techniques to prevent and minimise workplace aggression and violence. It is also based on relevant task force findings and incorporates key task force initiatives. The program includes a basic module for all staff identified as being at risk of workplace violence, a module for staff working in high risk environments, a module designed specifically for managers and a refresher module.
What materials are provided? A CD-ROM is available and includes: ●
Facilitator manual: Modules 1 through to 4 (in Acrobat PDF format).
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Participant manual: Modules 1 through to 4 (in Acrobat PDF format).
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Powerpoint slides for Modules 1 through to 4.
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Recognition of prior learning forms and assessment of competency forms (as a separate Acrobat PDF format).
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Assessment scenarios and Question sheets for Module 1 (as a separate Acrobat PDF format).
All of the above are included on the CD.
Who will attend? Module 1 should be attended by all staff identified as being at risk of workplace violence, and generally speaking is a prerequisite for all other modules. More detailed advice on the application of this training is provided in the covering circular. Attendance at additional modules is recommended for staff determined by the Health Service to be at higher risk of workplace violence and includes, but is not limited to, security, mental health, Emergency Department, admissions, drug and alcohol, disability services, brain injury and aged care staff. All managers of staff identified as being at risk of workplace violence should attend the manager’s module and all relevant staff should attend the refresher module at least every two years. Health Services may determine that some groups need to attend the refresher more regularly.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Overview of the manual This manual has been developed to provide educational resources for a facilitator to deliver a comprehensive education program in aggression minimisation. The manual is divided into four training manuals. Facilitators must have each of the following: 1.
Certificate IV in Assessment and Workplace Training.
2.
Experience in working in areas of significant violent risk.
3.
Experience in effectively managing violent incidents.
4.
An ability to related to staff at all levels of the organisation.
Modular structure of the aggression minimisation program Module 1 HLTCSD6A – Respond effectively to difficult or challenging behaviour This eight-hour program is designed for all staff identified as being at risk of workplace violence. It is designed to meet the Health Training Package competency HLTCSD6A – Respond Effectively to Difficult or Challenging Behaviour. The day is divided into five parts: 1.
Understanding difficult or challenging behaviour.
2.
Preventing aggression occurring.
3.
Preventing aggression escalating.
4.
Bullying, harassment and discrimination at work.
5.
Reporting and reviewing aggressive incidents.
Module 2 AMT002 – Aggression minimisation in high-risk environments This eight-hour program is designed for mental health and other staff working in high risk areas, eg emergency, security, community, aged care, disability, dental, midwifery and early childhood, methadone, brain injury, neurology, admissions and drug and alcohol services. Other staff members identified, via the risk assessment process, as being at significant risk of aggressive behaviour should also attend this module. The day is divided into four parts: 1.
Working in high-risk environments.
2.
Prevention in high-risk environments.
3.
Understanding aggression in high-risk environments.
4.
Managing aggression in high-risk environments.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Module 3 90405NSW – Course in aggression minimisation for managers This four-hour module is designed for managers of health units and facilities. It provides the participant with detailed information, obligations and practical strategies for promoting a safe workplace environment free of aggression, assessing and managing risks and types of support to provide to staff, who have been victims of aggression. Completion of Module 1 is recommended prior to undertaking this module. The day is divided into three parts: 1.
The legal and policy framework for managing aggression.
2.
Promoting an aggression-free workplace.
3.
Assisting staff when aggression and violence occurs.
Module 4 AMT004 – Aggression minimisation refresher training This two-hour module is designed for all staff identified as being at risk of workplace violence, and should be repeated at a minimum of every two years after completion of Module 1. Depending on the level of risk, some staff may need to attend more frequently. It is designed to keep staff up-to-date with policies and practices, provide refresher training of skills, and workshop problems. The day is divided into four parts: 1.
The zero tolerance response.
2.
New developments in preventing and managing aggression and violence.
3.
The prevention of aggression and violence.
4.
Managing aggression and violence.
How the manual is set out The Facilitator manual is divided into the four modules. All facilitator notes throughout each module look like this. Basic course content in the Facilitator manual duplicates that found in the Participant manual. This course content forms the basic syllabus of the training and the trainer needs to know this material prior to conducting training. For each module, at the beginning of each section the relevant page number in the Participant manual is noted. Relevant slides that should be shown at each point are reproduced throughout this manual.
Layout icons The following symbols have been used throughout the Facilitator manual to assist in the presentation of material. In all cases, trainers should use their discretion in the presentation and timing of material depending on the mix of staff in the training group. Where possible, flexible delivery is encouraged and specific recommendations are made at the beginning of each module.
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MODULE 4 Aggression minimisation refresher training
Key points
Key points help you to summarise the major themes and information from the section. Explain and discuss
This icon suggests that you will need some verbal explanation and discussion of this concept or topic. Background reading
This icon appears when further background information and reading is supplied on a topic to assist the facilitator in understanding and delivering the training course. It should be read before the facilitator conducts any training. The background information may be verbally summarised by the trainer as the need arises. Ask the group
Whenever this icon appears in the manual a large group activity is suggested. Facilitators should ask the suggested question to the group as a whole and elicit answers or suggestions as appropriate. Participants may choose to write answers in the space in their manuals. Small group exercise
This icon represents small group activity. Whenever this icon appears in the manual a small group activity is suggested. Facilitators may get the group to break into smaller groups of two to five participants to discuss the question, before reporting back to the group as a whole. Participants may choose to write answers in the space in their manuals. Individual reflection exercise
This icon represents personal reflective activity. Whenever this icon appears in the manual personal reflection is suggested. Individual participants may complete this exercise alone. The facilitator may then choose to address the question to the group as a whole and collect responses from individuals. Participants may choose to write answers in the space in their manuals. Answers
Suggested answers to the individual, small and large group activities are provided. These amplify and reinforce the subject material covered in the Participant manual. Important training point
Important training points are highlighted with this symbol. You are on Participant manual page X
These icons assist you to keep the training program in sequence with the Participant manual. It is suggested that you regularly refer participants to the relevant page in their Participant manual for further information or to complete an activity.
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Show overhead slide
Suggested place to present slide. Facilitator instruction
Specific training hints are given here. Write responses on board
Suggested place where the trainer may wish to reinforce points or collect responses from the group on a whiteboard/blackboard/butcher’s paper. Session time
Suggested times to conduct sessions are given and a session plan is provided for each module. These are to be used flexibly to meet the needs of trainers and participants. Session overview
An overview of the session is given here. Suggested break time
Suggested breaks are provided. These are flexible. Readings and resources
Additional readings and resources are highlighted here and should be read prior to commencing training.
Facilitator preparation before training Before running this training it is important to be familiar with: ●
All NSW Health documents and policies relating to aggression minimisation, prevention and management (see reference lists at the end of each module).
●
All local policies relevant to aggression minimisation. These will include documentation and emergency responses relating to aggression minimisation, prevention and management, eg duress response, reporting protocols.
●
It is helpful if you have an awareness of recent incidents in your area, where these have been a particular problem and the outcome. This enables the training to be more relevant for participants.
●
Facilitators need to familiarise themselves with the reference list at the end of the modules.
●
Facilitators should ensure that participants are informed that prior to attending this module they need to review the contents of the Participant manual for Module 1 – Respond effectively to difficult or challenging behaviour, or the equivalent training attended.
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MODULE 4 Aggression minimisation refresher training
Sequence and timing of the modules The individual modules do not need to be taught together as a block. The space between teaching individual modules may be separated by weeks or months. It is important to consider the retention of information from previous training and be ready to reinforce previous training material, particularly from Module 1. Each module contains some common material from other modules to help reinforce basic concepts, eg zero tolerance. Module 1 forms the prerequisite for the other modules so needs to be made available to participants prior to offering the other modules.
Assessment of competency Assessment activities accompany Modules 1-4 to facilitate demonstration of competency. Facilitators should ensure that training outcomes for each participant are appropriately documented. Recording forms accompany the Facilitator manual.
Flexible delivery The materials in this training program provide a core recommended syllabus for preventing and managing aggression in all NSW Health facilities. Each module has a set of learning outcomes and corresponding assessments. The training is designed in a modular format to allow ease of delivery, however it is possible that the training may be delivered using flexible delivery methods. Examples of how the training could be altered include (but are not limited to) the following: 1. Dividing a full day module into two parts, spread over two half days. 2. Emphasising some components of training over others for specific groups. For example, if the participant training group is non-clinical then the trainer may decide to focus more on communication strategies and bullying, harassment and discrimination than on some of the components that are more relevant for clinical staff. 3. Flexibly incorporating materials from other local training programs that overlap with the learning outcomes and provide additional training. 4. Shortening a module by providing advance reading materials and exercises to be reviewed in the participants’ own time and reinforced and assessed in the workshop. However, the trainer will need to determine that this approach is appropriate for the participant group. In considering flexible delivery options, it is important to ensure that the learning outcomes are met as set down in this program.
Recognition of prior learning Recognition of prior learning can be considered for this training. The relevant forms for recognition of prior learning accompany the Facilitator manual. Recognition of prior learning is based on the following: ●
Competence – a focus on the competencies an individual has acquired as a result of any formal or informal training and experience.
●
Commitment – to recognise prior learning of individuals, therefore individuals will not have to duplicate their training unnecessarily.
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Access – every individual may have his or her prior learning recognised.
●
Fairness – that the recognition of prior learning process is fair.
●
Support – is provided for individuals in applying for recognition of prior learning. Certificate IV workplace trainers and assessors must provide support so that an efficient and effective service is maintained.
Portfolio documentation Appropriate documentation is to be filled in and evidence collected to be submitted with the application form. All documentation should be submitted as a portfolio. See below for types of evidence to be collected and included in a portfolio.
Evidence guide The following is a guide for the evidence to be provided for recognition of prior learning. For each item of evidence you will need to indicate which part of the item is relevant to which learning outcomes. The following types of evidence may be collected: ●
Formal accredited certificates of previous training programs attended, or transcripts of courses of study.
●
Authenticated reports on activities participated in, relevant to aggression minimisation.
●
Certified evidence of discussions of case studies that shows evidence of having attained learning outcomes.
●
Authenticated reports of work, skills and experience in responding to aggressive behaviour.
Other Resources Participant manual A Participant manual is also available and should be used during the training. Participants are to use the manual during the training session, but also should take it away as a resource. There is additional information in the Participant manual, and it is not expected that every point can be covered during the training sessions. The training provides an orientation to the major issues in aggression minimisation and points the participant to further readings and resources in the area.
Lecture slides The CD-ROM contains the full set of Powerpoint slides. The Powerpoint slides can also be printed and transferred to overhead transparencies as needed.
Forms The CD-ROM contains the recognition of prior learning forms and the assessment of competency forms.
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MODULE 4 Aggression minimisation refresher training
Introduction to Module 4 How Module 4 fits into the whole program Module 4 is the last module dealing with aggression prevention, minimisation and management. This two-hour module is a refresher training program designed for staff identified as being at risk of workplace violence, and should be completed every two years after finishing Module 1 of the training (or its equivalent). It is designed to keep staff up-to-date with policies and practices, provide refresher training of skills and enable problems to be discussed and worked through.
Session times Part 1 Allow 15 minutes for Part 1 Part 2 Allow 15 minutes for Part 2 Part 3 Allow 30 minutes for Part 3 Part 4 Allow 45 minutes for Part 4 Assessment of competency
Allow 15 minutes
NB. A session plan is provided at the beginning of Module 4.
Recommendations on the delivery of this module Recommendation 1
This module is designed to be flexible. Although there are tasks and exercises to complete, these are only suggestions and the individual trainer is encouraged to adapt the workshop to meet the needs of the training group. Recommendation 2
Staff from the same or similar work areas should be encouraged to train together. This will help the trainer focus the refresher onto issues that are relevant for the participants’ particular work area. Recommendation 3
Trainers need to keep up-to-date with new developments in aggression minimisation. Teaching this module presupposes recent knowledge of: a.
state legislation
b. NSW Health policies and guidelines c.
local policies, procedures and protocols
d. national research and initiatives and e.
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international research and initiatives. As a trainer you will be specifically required to address each of these in the training.
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Recommendation 4
Staff should be encouraged to review their Module 1 workbooks and any other relevant readings prior to attending the workshop.
Training room requirements The training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual. Equipment required: projection facilities for Powerpoint slides (or an overhead projector if the slides have been printed on overheads), a whiteboard and whiteboard pens (for writing up feedback from participant exercises). Participants will need pens or pencils for writing in their copy of the Participant manual. Refreshments should be available during the breaks.
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MODULE 4 Aggression minimisation refresher training
Assessment for Module 4 Assessment questions
Learning outcomes
Question 1
1. Demonstrate an understanding of new developments in the prevention and management of violence.
Question 2
2. Acquire further understanding of how to prevent and manage violence.
Assessment method The learning outcomes are to be assessed through peer and self assessment. Participants are required to pair up. Each participant then directs the questions to their partner and assesses their partner’s verbal responses, using the peer assessment checklist. The partner is also given the opportunity to assess his or her own responses using the self assessment checklist. When this is complete, participants are to change roles. Participants may choose to jot down dot point answers in the column provided in the relevant checklist, though this is not mandatory. The participants, as a whole group, are then to be debriefed. The trainer may encourage the group members to share their responses and the discussion should focus on areas that need clarification. There are two critical aspects of the assessment relating to the two assessment questions. The questions have been designed to align with the critical aspects of the assessment. Participants are deemed competent if they demonstrate the correct responses to these questions. The critical aspects of the assessment are identified in the marking guide (checklists).
Assessment conditions Participants are to be informed about the assessment and what is required. Participants are to complete the assessment following the training.
Assessment resources ● ●
Assessment questions. Peer and self assessment checklists. NB. Assessment questions and Peer and Self assessment checklists are shown below and can also be found as a separate Acrobat PDF document on the CD-ROM, in order that the Assessment questions and checklists may be printed out and handed to participants.
Assessment questions 1. What are two new developments that have arisen in regards to aggression management and prevention in your local area in the last two years, or since you last attended aggression minimisation training? 2. Identify what new knowledge and skills you have acquired from the training provided in Module 4 (identify at least three).
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Self assessment checklist Yes
No Unsure
Briefly detail new developments, knowledge and skills (optional)
Identified new developments in the local area in the last two years (or since you last attended aggression minimisation training).
Identified acquired knowledge and skills from the training provided in Module 4.
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MODULE 4 Aggression minimisation refresher training
Peer assessment checklist Yes
No Unsure
Briefly detail new developments, knowledge and skills (optional)
Identified new developments in the local area in the last two years (or since you last attended aggression minimisation training).
Identified acquired knowledge and skills from the training provided in Module 4.
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MODULE 4 Aggression minimisation refresher training
Session plan for Module 4 Training session: Module 4 Aggression minimisation refresher training
Time
Topic
15 mins
●
Introduction.
●
The zero tolerance response.
15 mins
●
30 mins
45 mins
Time:
Learning outcomes
Content/activity
2
Small and large group discussions.
New developments in preventing and managing violence.
1
Small and large group discussions.
●
The prevention of violence.
2
Small and large group discussions.
●
Managing violence.
2
●
Small and large group discussions.
●
Role play activity.
●
15 mins
Date:
Assessment of competency.
1 and 2
Small and large group discussions.
Materials The training room should be comfortable with desks for participants so that they can write in their copy of the Participant manual.
Equipment required ●
Projection facilities for Powerpoint slides (or an overhead projector if the slides have been printed on overheads).
●
A whiteboard and whiteboard pens (for writing up feedback from participant exercises).
Participant requirement Pens or pencils for writing in their copy of the Participant manual.
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MODULE 4 Aggression minimisation refresher training
Beginning the training session Session time 15 mins for introduction and Part 1 The relevant slides that should be shown at each point are reproduced in small size in the facilitator manual. The title slide should be showing when participants begin to arrive at the workshop.
Show overhead slide
1. Welcome participants to the module You may wish to facilitate an introductory activity (ice -breaker). Example: Have participants pair off and: ●
introduce themselves and the area they work in
●
discuss what they hope to gain from the training.
After a few minutes have passed re-assemble the group and ask each participant to introduce their partner.
2. House keeping Inform participants of: ●
program times
●
breaks and meals
●
toilets
●
mobile phones
●
message board
●
occupational health and safety (fire escapes).
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3. Principles of adult learning Inform participants that: ●
everyone’s opinion will be respected
●
every participant’s work experience will be valued.
Show overhead slide
4. How Module 4 fits into the whole program Module 4 is the final of four modules dealing with aggression prevention, minimisation and management. It builds upon Module 1. The material in Module 1 is assumed knowledge for this module, and completion of Module 1, or its equivalent, is recommended for completing Module 4. This two-hour module is designed for staff to complete every two years after finishing Module 1. It is designed to keep staff up-to-date with policies and practices, provide refresher training of skills and enable problems to be discussed and worked through.
Show overhead slide
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MODULE 4 Aggression minimisation refresher training
5. Structure of Module 4 Explain that the program is divided into four parts: Part Part Part Part
1 2 3 4
– – – –
looks looks looks looks
at at at at
the zero tolerance response. new developments in preventing and managing violence. the prevention of violence. managing violence.
Explain that the aim of the program focuses on problem solving and that it is expected that during each section participants will raise examples of incidents that have occurred in the workplace that were difficult to manage. Explain that this will enable a group problem solving approach and permit participants to learn from the experience of others.
Assessment At this point, introduce the assessment component of the course.
Show overhead slide
You are on Participant manual page 3
Key points • Point out that the program aims to discuss difficult instances of violence in the workplace. • By completing this refresher training and continually updating your knowledge and improving the way in which you respond to aggression, you may achieve: – improved knowledge on new directions to prevent and manage aggression and violence – reduced physical injury to staff, patients and members of the public – reduced levels of stress on the job – reduced levels of aggression and violence in the workplace – fulfilment of your ‘duty of care’ responsibility under the Occupational Health and Safety Legislation.
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MODULE 4 Aggression minimisation refresher training
Background information Background reading This two-hour module is designed for staff to complete every two years after finishing Module 1 (or its equivalent). It is designed to keep staff up-to-date with policies and practices, provide refresher training of skills and enable problems to be discussed and worked through. Aggression in the health industry is a significant problem.1,2,3 Regular ongoing education4,5 is important to help staff retain and improve their skills in the prevention and management of aggression and further increase staff confidence. The goals of this training are to revise and review health care workers’ knowledge on prevention and management of aggression within a problem solving perspective. This program aims for health care workers to discuss difficult instances of aggression and violence in the workplace. By completing this refresher training and continually updating your knowledge and improving the way in which you respond to aggression, you may achieve: ●
improved knowledge on new directions to prevent and manage violence
●
reduced physical injury to staff, patients and members of the public
●
reduced levels of stress on the job
●
reduced levels of violence in the workplace
●
fulfillment of your ‘duty of care’ responsibility under the occupational health and safety legislation.
Show overhead slide
You are on Participant manual page 3
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Explain and discuss Learning outcomes At the conclusion of this module, participants will: 1. be able to demonstrate an understanding of new developments in the prevention and management of violence 2. have acquired further understanding about how to prevent and manage violence.
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MODULE 4 Aggression minimisation refresher training
Part 1 The zero tolerance response Session time 15 mins for introduction and part 1
Show overhead slide
Session overview This section looks at the zero tolerance response to aggression.
You are on Participant manual page 5 Ask the group What does a zero tolerance response to violence mean to you? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Write responses on board Write responses on the whiteboard.
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Answers Responses could include: ●
not accepting that violence is part of the job
●
reporting all violent incidents
●
encouraging others to report all violent incidents
●
knowing all of the various response options for dealing with violence in both the short and long-term
●
ensuring that all violent incidents are promptly, appropriately and consistently managed
●
promoting a zero tolerance culture
●
being aware of violence triggers and risks
●
participating in risk management.
Individual reflection exercise List some practical ways in which you have implemented a zero tolerance response to violence in your workplace. List some practical ways you could implement a zero tolerance approach in the future. Things you have done. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Things you could do. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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MODULE 4 Aggression minimisation refresher training
Always remember your attitudes and behaviours are important in promoting a zero tolerance response to violence Show overhead slide
You are on Participant manual page 6
Key points Point out the zero tolerance attitudes and behaviours below.
Zero tolerance attitudes and behaviours Putting up with violence in the health workplace IS NOT an acceptable part of your job (if you don’t get the message, neither will patients and visitors). Know your options when confronted with violent behaviour and exercise them consistently (the most effective way of protecting yourself AND getting the message to patients and visitors). Management will support you in utilising these options (this is part of their responsibility). Report all violent incidents (problems that don’t get reported don’t get fixed). Be aware of violence as an occupational risk (it is just as real as other more recognised OHS risks, eg manual handling, exposure to hazardous substances, etc). Be vigilant of factors contributing to the risk of violence (prevention is better than cure).
For more detailed information on the zero tolerance response see the NSW Health Zero Tolerance Policy and Framework Guidelines.
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MODULE 4 Aggression minimisation refresher training
Part 2 New developments in preventing and managing aggression and violence Session time 15 mins
Facilitator instruction To teach this part you will need to have familiarised yourself with any recent developments in preventing and managing aggression. This will involve doing some research and preparation in the following areas: State legislation Check whether there have been any recent, relevant legislative changes in the: ● OHS, injury management and workers compensation ● privacy and freedom of information ● anti-discrimination ● criminal law ● mental health laws ● laws covering the security industry areas. Useful websites: www.austlii.edu.au www.workcover.nsw.gov.au www.noschc.gov.au NSW Health policies and guidelines Check whether there have there been any recent amendments, additions or updates to NSW Department of Health policies and guidelines in the: ● reportable incident requirements ● NSW Health, NSW Police MOU (Memorandum of Understanding) ● incident and post incident management requirements ● security and safety requirements ● OHS and risk management training requirements ● violence prevention and management requirements ● general OHS and injury management requirements ● emergency management requirements ● duress response requirements ● requirements regarding working in the community ● mental health policies and guidelines, eg relating to seclusion, restraint, clinical guidelines for the management of the mentally ill, Emergency Department guidelines for managing challenging behaviour etc. Useful website: www.internal.health.nsw.gov.au NSW Health
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Local policies, procedures and protocols Check whether there have been any changes to local policies, procedures and protocols in response to changed department policies and guidelines or as part of the ongoing internal monitoring and review of existing activities, including: ● ● ● ● ● ● ● ● ● ● ●
incident reporting requirements hazard reporting requirements incident and post incident management requirements security and safety requirements liaison with local police, including NSW Police MOU violence prevention and management requirements general OHS and injury management requirements emergency management requirements duress response plans requirements regarding working in the community protocols covering seclusion, restraint, management of the mentally ill, Emergency Department guidelines for managing challenging behaviour etc.
Useful website: See your local Area Health Service intranet site. National research and initiatives ● Indigenous mental health. ● National responses to suicide and depression. ● Rights of children and responses to adolescent mental health. ● Aged care policies. ● Use of medicines. ● National responses to trauma and terrorism. Useful websites: NSW interagency guidelines for child protection 2000: www.kids.nsw.gov.au Youth and violence: www.acys.utas.edu.au/ncys/ysa/index/bullying.htm International research and initiatives ● Aggression and social justice – marginalised groups. ● Bullying in the workplace. ● Communication skills – developments and programs. ● Causes and prevalence of aggression. ● Controversies around restraint and seclusion. Useful websites: Aggression and the workplace: www.hrmguide.co.uk/relations/violence.htm Theories of aggression: www.nursing-standard.co.uk/archives/vol12-27/research.htm
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MODULE 4 Aggression minimisation refresher training
Discretion will need to be used as to the amount and level of detail provided, depending on the amount of information gathered, the time constraints and the characteristics of the target group, eg clinical, security, administration staff etc. However, as a general guide, relevant legislative changes, and any changed departmental and local requirements should be given priority. You may wish to provide summaries of the changes to the group for future discussion, or elicit as many as possible from the group prior to tabling any information. A third option is for participants to make their own notes in the section provided in their copy of the Participant manual as you lead or guide the discussion on the changes. Facilitators should also have copies of any updated policies, procedures, publications and protocols to show the group, and advise of where copies can be obtained. Depending on the size of the group, copies of the more relevant documents could be provided at the session.
Show overhead slide
Session overview This section looks at new developments in aggression prevention and minimisation.
Show overhead slide
Facilitator instruction Use the whiteboard when introducing a new development.
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The field of aggression minimisation is continually evolving. This module is designed for a flexible update and review of new developments. These developments usually fall into five areas: 1. State legislation. 2. NSW Health policies and guidelines. 3. Local policies, procedures and protocols. 4. National research and initiatives. 5. International research and initiatives. 1. State legislation
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. NSW Health policies and guidelines
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. Local policies, procedures and protocols
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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MODULE 4 Aggression minimisation refresher training
4. National research and initiatives
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 5. International research and initiatives
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Ask the group Is anyone aware of any recent developments?
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MODULE 4 Aggression minimisation refresher training
Part 3 The prevention of aggression and violence Session time 30 mins
Show overhead slide
Session overview This section looks at the prevention of violence.
You are on Participant manual page 9
Explain and discuss ●
Prevention should always be the first priority.
●
The aim is to prevent or reduce levels of violence as far as possible.
Prevention of violence in the workplace is your first priority. While not all incidents of aggression can be prevented, the aim is always to prevent or reduce levels of aggression and violence as far as possible, and to have in place appropriate control measures if a violent incident does occur.
Important training point Prevention of violence in the workplace should always be the first priority.
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Ask the group How have you actively participated in preventing violence in your work area? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers Responses could include: ●
reporting workplace violence hazards eg locks on windows and doors that are not working, burnt out external lighting, facilities not working such as phones and food and drink dispensers in patient waiting areas etc
●
testing emergency equipment, eg fixed or personal duress alarms
●
instigating changes to the workplace including the physical environment and work practices and systems
●
attending aggression minimisation and management training
●
using de-escalation techniques in a potentially violent situation
●
reviewing the duress response
●
having been part of a working party to propose control strategies for a specific violence hazard, eg violence from patients in Emergency Departments.
Have participants give specific examples.
Explain and discuss Point out the importance of effectively preventing and managing bullying in the workplace, in terms of OHS legislative requirements, and also in terms of the zero tolerance response. It is hard for staff to take zero tolerance seriously if bullying is a feature of the workplace.
Ask the group Where might there be a high risk of encountering bullying? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Answers Responses could include: ●
highly stressful situations, eg tight or unreasonable deadlines, limited resources
●
culture that condones bullying
●
where there is a high degree of change
●
where there are closed systems that are not open and accountable, eg where there is limited interaction with other areas.
Ask the group How would you reduce bullying to as low a level as possible? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Answers ●
Have a clear, anti-bullying statement signed off and supported by the CEO.
●
Ensure that it is communicated to all staff.
●
Have a clear reporting mechanism for bullying.
●
Train managers and other relevant persons in how to investigate and manage bullying.
●
Ensure that managers respond promptly and appropriately to all reported incidents of bullying.
●
Ensure that hazards/risks associated with bullying are considered as part of the overall OHS risk assessment and risk management process.
Show overhead slide
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Ask the group What are the key steps in the risk management process?
Answers ●
Identify the problem.
●
Assess the risk.
●
Eliminate or control the risk.
●
Monitor, review and improve the system.
The risk management process Step 1. Identifying the problem (hazard identification). Step 2. Assessing the risk (determining how serious the problem is). Step 3. Eliminating or controlling the risk (deciding what needs to be done to solve the problem and in what order. Risk controls need to be ranked from the most effective to the least effective). Step 4. Monitoring, reviewing and improving the system.
Facilitator instruction Give the following example as a simple illustration of the risk management process in action. Example: Hazard – violence from intruders. Risk – a faulty exit door that fails to open to allow exit. Risk assessment – high, as staff may possibly become trapped inside by a violent patient or an intruder. Risk control – repair the door, consult with staff on the existing circumstances (to determine why the door was unable to be opened, or why the system failed), ensure there is a future procedure in place for regularly checking all relevant locks, for reporting faults and for ensuring urgent repairs take place. Monitor the system and improve if necessary – if random checks of locks still show that all locks are not working effectively all of the time, this suggests that the system for checking and repair is not working satisfactorily. Consult with staff to determine why the system isn’t working, discuss how it might be improved and implement the recommended changes to the system.
36
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Small group exercise Ask participants to work in small groups and complete the following exercise. Allow fifteen minutes. Ask participants to elect someone in their group who will share their responses with the larger group at the end of the discussion.
Consider an aggressive incident that has occurred at your workplace. Use the results of the incident investigation, and risk management principles to do the following in order to prevent a recurrence of the incident. For example, if the incident investigation identified that lack of knowledge of how to operate the duress alarm was a factor in the incident, the level of risk associated with not being able to summon urgent assistance would be high. A risk control measure would be to train all relevant staff in how to operate the duress alarm, and a monitoring activity would be regular drills in its operation. Identify the main hazards and/or risk factors that led to, caused and/or contributed to the incident. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Assess the level of risk resulting from the various factors, and prioritise for elimination or control. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Identify measures that would eliminate or control the hazards and risks associated with this incident, to prevent a recurrence. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Monitor, review and improve the system. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Ask the group At the end of the small group discussion, ask each elected participant to share their groups’ responses with the larger group.
Write responses on board
Facilitator instruction Reinforce the key points.
Key points ●
Prevention of violence in the workplace should always be your first priority.
●
The risk management process: – – – –
38
Identify the hazard. Assess the risk. Eliminate or control the risk. Monitor, review and improve the system.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Part 4 Managing aggression and violence Session time 45 mins
Show overhead slide
Session overview This section looks at the management of violence.
Show overhead slide
You are on Participant manual page 13
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
39
FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Explain and discuss ●
There are always options available to you when you are confronted with an aggressive person, therefore, it is most important that you are aware of these response options, and when to use them.
●
The responses used will depend on a number of factors; the nature and severity of the event; whether it is a patient, visitor or intruder; the experience, skills and confidence of the staff member/s involved. This may include going straight to calling for back-up, security or local police.
●
When choosing your response options, your aim is to maintain safety to yourself and others, and prevent an aggressive incident from escalating.
●
Emphasise the importance of safety eg in all violent situations you should immediately seek help, regardless of whether you decide to stay or leave.
Explain and discuss When considering your options you always need to keep in mind the following: ●
Whether the person has an underlying physical or mental condition that is contributing to the person’s aggressive or violent behaviour.
●
Always remain calm and assess the level of threat and the different levels of aggression displayed as this will help you to make a decision on the appropriate response to take.
●
Regardless of the response option you choose, de-escalating and containing the situation should be considered where possible.
●
If at any time you feel unsafe you need to call for support and/or leave.
●
At all times your priority is for the safety of yourself and others.
●
Be aware of the potential for violence, look for contributing factors or warning signs.
You can use more than one option, depending on the circumstances.
Facilitator instruction Familiarise yourself with local policies and procedures for short and long-term response options. Briefly go through each short and long-term response option.
40
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Important training point Explain and discuss Short-term response options (in no particular order): ●
Issue a verbal warning This may be appropriate in some circumstances. Emphasise the importance of staff using appropriate, respectful communication skills. When issuing a verbal warning, do so in an ‘informative’ manner. It is helpful when doing this to draw the person’s attention to any displayed zero tolerance poster and/or information brochures outlining behavioural responsibilities. Explain the impact their aggressive behaviour may have on yourself, others etc, eg on your ability to deliver quality health care.
●
Seek support from other staff Sometimes the presence of others, particularly the presence of more senior staff can have a settling effect on aggressive patients or visitors, and the targeted staff member may feel more confident. Point out the importance of knowing the emergency duress response procedures and procedures for calling security or police.
●
Request that a person behaving aggressively leave This might help remove a trigger for the aggressive behaviour, eg if a relative is causing a patient distress and the patient is showing signs of aggression, asking the relative to leave may be appropriate, explaining that this may assist in the better management of the patient.
●
Request that the patient be reviewed by a clinician A patient in the Emergency Department for example, may be aggressive as a result of a medical condition, so it is important that this always be a consideration, and that clinical assessment is sought as appropriate.
●
Negotiate treatment If appropriate, negotiate treatment, eg a patient behaving aggressively may be offered medication to help calm their distressed state.
●
Use verbal de-escalation and distraction techniques Model calm and appropriate behaviour, acknowledge the person’s needs and negotiate solutions. Seeking to make the aggressive individual more comfortable may be a helpful distraction technique.
●
Stay and call for help If you stay and call for help, continually monitor your safety.
●
Leave and seek help It is most important that if you do leave a violent situation that assistance is still sought.
●
Utilise the unit emergency duress response Always ensure you are up-to-date with the procedures.
●
Initiate external emergency response, eg police Always ensure you know the procedure.
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Explain and discuss Long-term response options For persons with repeated aggressive behaviour, long-term response options may be appropriate. These are generally developed and implemented in consultation with management and other key stake holders, eg clinicians, treating staff, medical records, security, local police as necessary etc. Long-term response options include: ●
formal patient management plans
●
written warnings
●
conditional treatment agreements
●
exclusion from visits
●
conditional visiting rights
●
patient alerts in conjunction with support management plan
●
formal recognition of inability to treat in certain circumstances
●
taking out an AVO to protect staff
●
having charges laid.
When managing aggression in the workplace, both short-term and long-term options need to be considered. Short-term options are important to prevent an episode of aggression from escalating and to maintain the safety of all concerned. Long-term options are important for the prevention of repeated violent incidents and ensuring the safety of all concerned when the risk of future aggression is significant.
Know your options for action There are always options available when confronted with an aggressive person and it is important that staff know the appropriate response options. These responses will depend on a number of factors including the nature and severity of the event, whether it is a patient, visitor or intruder, and the skills, experience and confidence of the staff member/s involved. This may include going straight to calling for back-up, security or local police.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
When considering your options you always need to keep in mind the following: ●
Whether the person has an underlying physical or mental condition that is contributing to the person’s aggressive or violent behaviour.
●
Always remain calm and assess the level of threat and the different levels of aggression displayed as this will help you to make a decision on the appropriate response to take.
●
Regardless of the response option you choose, de-escalating and containing the situation should be considered where possible.
●
If at any time you feel unsafe you need to call for support and/or leave.
●
At all times your priority is for the safety of yourself and others.
●
Be aware of the potential for violence, look for contributing factors or warning signs.
●
You can use more than one option, depending on the circumstances.
Short-term response options Short-term response options (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 unit emergency duress response.
●
Initiate external emergency response, eg police.
Long-term response options Long-term response options: ●
Formal patient management plans.
●
Written warnings.
●
Conditional treatment agreements.
●
Exclusion from visits.
●
Conditional visiting rights.
●
Patient alerts in conjunction with support management plan.
●
Formal recognition of inability to treat in certain circumstances.
●
Taking out an AVO to protect staff.
●
Having charges laid.
For more detailed information on short-term and long-term options, see the NSW Health Zero Tolerance Policy Framework and Guidelines. NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
You are on Participant manual page 15
Small group exercise Ask participants to work in small groups and discuss the following question for ten minutes. Ask them to elect someone in their group who will share their group’s responses with the larger group at the end of the discussion.
Think of an aggressive incident in your workplace that was difficult to manage. NB. An incident that you feel comfortable talking about.
Discuss the following: During the incident
What were some of your response options to this incident? Were the appropriate options used? What are some other options that could have been used? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How did you ensure the safety of yourself and others? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
After the incident
What happened after the incident? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Who was the incident reported to and what was the outcome? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Was management supportive of you after the incident? How was this support demonstrated? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Ask the group At the end of the small group discussion, ask each elected participant to share the group’s responses with the larger group.
Write responses on board
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
45
FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
De-escalation strategies Show overhead slide
You are on Participant manual page 16
Facilitator instruction Briefly review the appropriate strategies for dealing with a fearful or frustrated person and an intimidating or threatening person. Appropriate behaviours are included below. Point out that the strategies you choose will vary depending on whether the person being aggressive is fearful and frustrated or intimidating and threatening. Emphasise the importance of being aware of cultural differences, eg facial expressions, body language, tone of voice. The fearful/frustrated person ●
Often the individual is out of control and you need to help the individual to gain control.
●
The approach to use with this person is more empathic (more emotionally engaging).
●
A useful technique is to provide the person with options and focus on these options.
The intimidating/threatening person
46
●
Often the individual is in control.
●
This individual is more likely to be antagonistic and less likely to be accommodating.
●
The approach to use with this person is more assertive.
●
Asking the person to tell you what they need may be a more useful strategy to persuade the individual to talk about the issue, than offering a broad range of options.
●
Focus on the consequences of the individual’s behaviour.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
The strategies you choose will vary depending on whether the person being aggressive is fearful and frustrated or intimidating and threatening.
Fearful and frustrated person
Intimidating and threatening person
●
Be assertive – however your voice can range from being calm and confident to forceful. You may need to be repetitive.
●
Be assertive – your voice is more matter of fact displaying less emotion. Repetitive statements are more important especially regarding the consequences of threatening behaviour.
●
Make direct eye contact but not for long periods of time, ie do not stare.
●
Eye contact can range from direct to evasive depending on the person behaving aggressively.
●
Provide a range of options when you attempt to problem solve.
●
Ask the person what they need and provide options and consequences for the threats made.
●
Show empathy and be emotionally engaging with your responses.
●
You need to be emotionally neutral when stating the options and consequences.
Facilitator instruction In this exercise you are to de-escalate the person’s aggressive behaviour using strategies that are correct and incorrect.
Large group exercise Ask for a participant to volunteer to role-play a situation where the participant takes on the role of a fearful and frustrated person who is acting out aggressively. Have the participant think of a situation that has occurred in their workplace that will help them with the role-play. Inform participants that you will try to de-escalate the aggressive behaviour. Ensure you use both correct and incorrect strategies. The aim is to illustrate for the group what works and what does not work.
Ask the group What were some helpful and unhelpful strategies used to de-escalate the person’s aggressive behaviour?
NSW Health
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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FA C I L I TAT O R M A N U A L NSW Health is a zero tolerance zone
Write responses on board Write responses on one side of the board.
Facilitator instruction Ask for another volunteer and repeat the exercise, with the volunteer taking the role of an intimidating and threatening person being the aggressor.
Ask the group What were some helpful and unhelpful strategies used to de-escalate the person’s aggressive behaviour?
Write responses on board Write responses on the other side of the board.
Facilitator instruction As a way of concluding the training session ask the group to compare and contrast the more successful and less successful techniques used for de-escalating the behaviour shown in the role-plays.
Key points • Know your short-term and long-term options when confronted with violent behaviour. • De-escalation strategies will differ depending on whether the person being aggressive is fearful and frustrated or intimidating and threatening.
Show overhead slide
Assessment exercise is now facilitated. Details of the assessment are at the front of the module.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
NSW Health
MODULE 4 Aggression minimisation refresher training
Related NSW Health policies and guidelines a.
Mental Health for Emergency Departments, May 2002 (red book).
b. Management of Adults with Severe Behavioural Disturbance, May 2002 (green book). c.
C2003/88 Reportable Incident Briefs to the NSW Department of Health.
d. C2001/22 Workplace Health and Safety: A Better Practice Guide (currently under review). e.
C2002/19 Effective Incident Response: A Framework for Prevention and Management in the Health Workplace.
f.
C2002/50 Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination.
g. NSW Health Security Manual. h. NSW Health Zero Tolerance Policy and Framework Guidelines. i.
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 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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MODULE 4 Aggression minimisation refresher training
References 1. Mayhew C, Chappell D (2001a). Occupational violence: types, reporting patterns, and variations between health sectors. Working Paper Series no. 139, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 2. Mayhew C, Chappell D (2001b). Prevention of occupational violence in the health workplace. Working Paper Series no. 140, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 3. Mayhew C, Chappell D (2001c). Internal violence (or bullying) and the health workforce. Working Paper Series no. 141, School of Industrial Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper written for the Taskforce on the Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney. 4. Delaney J, Cleary M, Jordan R, Horsfall J (2001) An exploratory investigation into the nursing management of aggression in acute psychiatric settings. Journal of Psychiatric and Mental Health Nursing, 8 (1), 77-84. 5. Ilkiw-lavalle O, Grenyer BFS, Graham L (2002). Does prior training and staff occupation influence knowledge acquisition from an aggression management training program? International Journal of Mental Health Nursing, 11, 233-239.
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A safer place to work – preventing and managing violent behaviour in the Health workplace Module 4 AMT004 Aggression minimisation refresher training (Version 1) © July 2003 updated August 2004
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