Guidelines for Prevention and Mangement of Workplace Aggression 4358

Prevention and Management

of Workplace Aggression: Guidelinesand Case Studies from the NSW HealthIndustry

Prepared by Jim Delaney on behalf of Central Sydney Area Health Service December 2001WorkCover NSW Injury Prevention, Education and Research Grants Scheme Grant No 97/0050

N EW SOUTH WALES

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

I have pleasure in writing the foreword to“Guidelines for the Prevention andManagement of Workplace Aggression: CaseStudies from the NSW Health Industry”.This publication and the research thatis reported herein demonstrate a willingnessby WorkCover NSW and Area Health Servicesthroughout NSW Health to work togetherto improve workplace safety in health caresettings.

Workplace safety is an issue of great importanceand practices that support hazard identification,risk assessment, risk management and postincident responses relating to workplaceviolence need to be continually highlighted.The staff who work in health care settings are avaluable resource and we wish to support andprotect them by providing safe and healthyworkplaces.

This publication provides an insight into thecurrent context of care delivery withincontemporary health care settings with regardto violence in the workplace and identifiesexamples of better practice as benchmarks, forall services to consider and incorporate intotheir risk management strategies.

As Chief Executive Officer of Central SydneyArea Health Service (CSAHS) I am most

Foreword

iii

gratified to be associated with this researchproject which has been funded under theWorkCover NSW Injury Prevention,Education and Research Grants Scheme.It recognises the need for such work to beundertaken and CSAHS’s ability to do so.I am delighted in this confidence and theacknowledgment of the work of CSAHS staff,particularly those such as Mr Jim Delaneywho, prior to this project, was actively involvedwith the CSAHS mental health services, whohave over the years gained an Australia widereputation in the training of critical incidentmanagement.

I am reassured by the degree of co-operationand collaboration involved in the researchand the completion of this project and thecommitment demonstrated by large numbersof staff from Area Health Services, theAmbulance Service of NSW, CorrectionsHealth NSW and WorkCover NSW whocontributed significantly to this work.

I look forward to a continuation of thisco-operation.

Dr Diana G. Horvath AO

Chief Executive OfficerCentral Sydney Area Health Service



Foreword _________________________________________________________________ iii

Executive Summary__________________________________________________________ ix

Acknowledgments ___________________________________________________________ xi

1. Overview of the Project ___________________________________________________ 1

1.1 Description of project ________________________________________________ 1

1.2 Funding for the project _______________________________________________ 1

1.3 Aims of the project __________________________________________________ 1

1.4 Project design ______________________________________________________ 2

1.5 Advisory group _____________________________________________________ 2

1.6 Site visits to Area Health Services andother identified specialty areas within NSW _______________________________ 2

1.7 Case studies ________________________________________________________ 3

1.8 Nominated staff from NSW Area Health Servicesand other health related services ________________________________________ 5

2. Background ____________________________________________________________ 7

2.1 Violence in health care settings _________________________________________ 7

2.2 Definition of the problem _____________________________________________ 7

2.3 Workplace violence __________________________________________________ 8

2.4 Data relating to violence in the workplace _________________________________ 9

2.5 Data relating to violence in health care settings _____________________________ 9

2.6 The cost of violence in health care _______________________________________ 10

2.7 Assessment of violence ________________________________________________ 11

2.8 Factors impacting on increased levels of violence in health care _________________ 12

Table of Contents


2.9 Inpatient psychiatric facilities __________________________________________ 13

2.10 Medical staff _______________________________________________________ 13

2.11 Nurses ____________________________________________________________ 14

2.12 Remote area nurses __________________________________________________ 14

2.13 Community services _________________________________________________ 15

2.14 The Ambulance Service _______________________________________________ 16

2.15 Emergency Departments ______________________________________________ 17

3. Legislation and Policy ____________________________________________________ 19

3.1 NSW Occupational Health & Safety Act 2000 _____________________________ 19

3.2 NSW Occupational Health & Safety Regulation 2001 _______________________ 19

3.3 Prosecutions _______________________________________________________ 19

3.4 Policy development __________________________________________________ 20

3.5 The NSW Health Occupational Health Safety & Rehabilitation(OHS&R) Numerical Profile __________________________________________ 20

3.6 WorkCover Authority of NSW _________________________________________ 20

3.7 WorkCover NSW reporting ___________________________________________ 21

4. Risk Management _______________________________________________________ 23

4.1 Australian Standard for Risk Management AS/NZS 4360-1999 ________________ 23

4.2 The risk management process __________________________________________ 23

4.3 Hazard identification_________________________________________________ 24

4.4 Risk assessment _____________________________________________________ 24

4.5 Risk control ________________________________________________________ 24

4.6 Evaluation _________________________________________________________ 24

4.7 Resources and equipment _____________________________________________ 24

4.8 Risk management model for workplace aggression __________________________ 25

4.9 Case studies from a risk management perspective ___________________________ 26


5. Case Studies ____________________________________________________________ 27

Case Study 1 (South Western Sydney Area Health Service)Security and Minimisation/Management of Aggression (SAMMA) Profile _____________ 29

Case Study 2 (Wentworth Area Health Service)Area Wide Strategic Plan 1997–2000 _________________________________________ 35

Case Study 3 (Central Sydney Area Health Service)Critical Incident Management Plan __________________________________________ 39

Case Study 4 (Northern Rivers Area Health Service)Notice of Non-acceptance of Aggression_______________________________________ 43

Case Study 5 (Central Sydney Area Health Services)24 Hour On-Call EAP Service for Critical Incidents in the Workplace _______________ 47

Case Study 6 (South Western Sydney Area Health Service)Peer Support Program ____________________________________________________ 53

Case Study 7 (South Eastern Sydney Area Health Service)Minimisation of Violence and Aggression: A Self-learning Package __________________ 57

Case Study 8 (Central Sydney Area Health Service)Safety Zone Alarm System _________________________________________________ 61

6. Literature Sources _______________________________________________________ 63

7. Conclusion _____________________________________________________________ 77

8. References _____________________________________________________________ 79


This publication is based on a project todevelop guidelines for the prevention andmanagement of workplace aggression in theNSW Health Industry, conducted during theperiod April 1999 to March 2000. This is aninitiative of Central Sydney Area HealthService (CSAHS) supported by a grant fromWorkCover NSW. It provides guidancematerial to assist health services within NSWmeet their occupational, health, safety andrehabilitation obligations to minimise andmanage violence in the workplace. Thematerial adopts a risk management approachto identify, assess and control aggressiveincidents in the NSW health industry.

An advisory group was established to providepractical and representative direct industryexperience to inform the project. Expressionsof interest were sought from variousprofessional organisations, the AmbulanceService of NSW, Corrections Health NSWand specialty services within the seventeen AreaHealth Services in NSW. Both public andprivate facilities were invited to participate.The project consisted of a series of interviewsand discussion groups and involved reviewingmaterials collected from a number of sources.

In addition, the report contains an extensiveliterature review examining workplace violence.It identifies health service workers as amongthe worst affected occupational groups and

Executive Summary

ix

explores the implications for a number ofprofessional groups such as medical staff,ambulance staff, nurses working in a varietyof settings such as Emergency Departmentsand in remote areas, and health care staffworking in both community and inpatientsettings. The literature provides manydefinitions of workplace violence and someof these are included. For example, thedefinition used by the Worksafe CommissionWestern Australia (WA) is, “any action orincident that physically or psychologically harmsanother person. It includes such situations whereworkers and other people are threatened, attackedor physically assaulted at work”.

The report also includes data relating toviolence in health care settings and enumeratessome of the costs associated with workplaceviolence. It provides information on therelevant legislation and highlights some ofthe complexities associated with workplaceviolence including a lack of consistency indefining the problem and the variations inreporting which contribute to the confusionthat surrounds this phenomenon.

The guidelines are based upon experiencesfrom across the NSW health system anddescribe examples of better practice in the formof case studies. The case studies that best meetthe evaluative criteria decided by the advisorygroup are included in the report. These vary


from an area wide strategic plan to a peersupport program and a notice to deter violencein a specialty area of practice.

The recognition of workplace safety as acrucial issue for managers and employees ishighlighted and through the provision of casestudies, a comprehensive review of availableresources and a list of further contacts in thefield this publication seeks to inform andempower health care workers.

x


Acknowledgements

This research and publication was supportedby a WorkCover NSW grant. The authorwishes to thank all those colleagues whoparticipated in this study as well as Dr DianaHorvath, Chief Executive Officer of CentralSydney Area Health Service (CSAHS), theNSW Department of Health and theWorkCover NSW advisors for theirencouragement and support. The authorwishes to acknowledge the contributions ofNSW Health and the Chief Executive Officersfrom Area Health Services, Ambulance Serviceof NSW and Corrections Health NSW as wellas nominated staff from these services. Theproject team also wishes to thank the membersof the Advisory Group and everyone else whocontributed to this project.

Project Steering Committee

Mr Jim Delaney, Project Officer, CSAHS

Ms Aurelia Pompelli, WorkCover ProjectAdviser (to September 1999)

Ms Pam Estreich, WorkCover Project Adviser(from September 1999)

Ms Shayne Byer, WorkCover Project Adviser

Dr Margy Halliday, Project Co-ordinator,Risk Manager, CSAHS

Mr Chris Patchett, Project Co-ordinator,Manager Employee Assistance Program, CSAHS

Members of the Advisory Group

Ms Trish Butrej, NSW Nurses’ Association

Mr David Cain, Corrections Health NSW

Ms Maggie Christensen, Central Coast AreaHealth Service

Mr Jim Delaney, Project Officer, CSAHS

Ms Pam Estreich, WorkCover NSW

Mr Simon Gould, Project Officer,Ambulance Service of NSW

Mr Stuart Greenway, Centre for MentalHealth NSW

Mr Mark Haldane, Darlinghurst CommunityHealth Centre

Dr Margy Halliday, Project Co-ordinator,Risk Manager, CSAHS

xi

The Project Steering Committee


Ms Jenelle Langham, Project Officer, CentralCoast Area Health Service

Mr Andrew Lillicrap, Health and ResearchEmployees Association

Mr Greg Martin, Security Services NSW

Mr Dominic McLauglin, Private HospitalsAssociation NSW

Mr Ben Nielsen, Centre for Mental HealthNSW

Mr Chris Patchett, Project Co-ordinator,Manager Employee Assistance ProgramCSAHS

Ms Carol Pearson, WorkCover NSW

Ms Linda Simm, Emergency NursesAssociation NSW

Ms Cathy Springall, NSW Health

Ms Sue Wade, Rural Health Alliance

Other people who assisted with

the project

Ms Lisa Carroll, Senior Project Officer,WorkCover NSW (to January 2000)

Ms Margaret Coffey, Department of HealthNSW

Ms Carol Hines, Grants Project Officer,WorkCover NSW (from January 2000)

Ms Jan Whalan, Director of CorporateServices, CSAHS

Project Officer

Jim Delaney, RN Dip. App.Sc. (Nursing), B App.

Sc. (Nursing), MN (Education), Honorary Clinical

Associate University of Sydney, FANZCMHN,

IAFN, RCN, CON (NSW)

Jim Delaney was recruited as the project officeron the basis of his skills and experience. Jimhas been a Staff Educator with RozelleHospital and CSAHS and has held theposition of Critical Incident Co-ordinatorwithin CSAHS. He has worked as an educatorin the area of aggression management for thepast ten years and has updated his knowledgeand skills by undertaking advanced training inrecognised accredited training programs in theUnited Kingdom and through networking andfamiliarity with latest research findings.

In addition to conducting workshops, trainingprograms and refresher training he hasundertaken extensive needs analyses in avariety of clinical and non-clinical areas inboth public and private health sectors in ruraland metropolitan locations. Subsequent toconducting needs assessments he has beeninvolved in policy development, serviceplanning and restructuring, clinical practiceguidelines, review of critical incidents anddevelopment of defusing and debriefingmodels specific to individual service needs.

He has provided specialist training in themanagement of difficult behaviours fornursing homes, voluntary organisations, daycare centres, and Government agenciesthroughout Australia. Following a nationalreview of nurse education in Tasmania, Jimwas invited by the Department of Health, todeliver training programs for staff withinmental health facilities.

xii


He completed a Masters in Nursingspecialising in education and his majorresearch study examined the impact ofeducational intervention on anxiety andattitudes of nurses towards aggressivebehaviour in a mental health setting. Sincethen Jim has collaborated on several projectsrelating to the identification of risk factors in

the area of aggression management receivingresearch funding as a principal investigatorfrom both the NSW Nurses’ Association(Cavell Trust) and the Nurses RegistrationBoard of NSW.

The Steering Committee is grateful for thedepth of experience Jim Delaney was able tobring to the project.

xiii



Overview of the Project

1.1 Description of project

This project aimed to develop guidancematerial to assist health services within NSWmeet their occupational, health, safety andrehabilitation obligations to minimise andmanage violence in the workplace. The materialadopts a risk management approach toidentify, assess and control aggressive incidentsin the NSW health industry. Health Servicemanagers were invited to contribute materials(such as policies, procedures, protocols, flowcharts, business plans and educationalmaterials) that they had identified as beinghelpful in the prevention and management ofaggression in their work settings. The guidelinesare based upon experiences from across theNSW health system and describe examples ofbetter practice in the form of case studies. Theresearch for this project was conducted duringthe period April 1999 to March 2000. A projectofficer was appointed on a full time basis tooversee the project. Ethics approval was obtainedfrom CSAHS Ethics Review Committee.

1.2 Funding for the project

This project was funded by the WorkCoverNSW Injury Prevention, Education andResearch Grants Scheme initiative. Thepurpose of the WorkCover NSW GrantsScheme is to improve practice in the area of

workplace health and safety, workplace injurymanagement and workers compensation. Thisis achieved by funding prevention, educationand research initiatives, which promoteWorkCover NSW objectives and priorities andhave practical relevance to industry. CentralSydney Area Health Service (CSAHS) wassuccessful in securing a grant to undertake thisproject and has benefited enormously from theinput, support, encouragement and guidanceprovided by WorkCover NSW advisers.

1.3 Aims of the project

The aims of the project were as follows:

• to review the literature relating to theprevention, assessment, management andpost incident management of workplaceaggression

• to review policies, procedures, protocols,flow charts and business plans provided bya wide range of NSW and other relevanthealth services

• to develop guidelines consistent with arisk management approach for theprevention and management of workplaceaggression

• to identify examples of better practice thatcan be applied to public and private healthcare settings

Prevention and Management of Workplace Aggression Guidelines and Case Studies from the NSW Health Industry2


• to develop case studies from the NSWhealth care industry with practicalexamples of successful prevention,management and post-incidentmanagement strategies, and

• to provide information on a range ofresources relating to the management ofaggression in health care settings.

1.4 Project design

The project consisted of a series of interviewsand discussion groups and involved reviewingmaterials provided. Information was collectedfrom a number of sources, scrutinised andcollated into a format that would provide auseful resource for others.

• A review of the literature relating to theassessment, prevention, management andpost incident management of workplaceaggression was undertaken.

• The seventeen Area Health Services inNSW and other selected services wereinvited to participate, by providingrelevant information such as procedures,protocols, flow charts, business plans andeducational materials.

• Consultation occurred with advisorygroup members in the form of regularmeetings, discussion groups andinterviews. Comment on draft materialswas invited.

• Data relating to the number and severityof incidents reported by employees andworkers compensation claims related toworkplace violence and aggression wasexamined using summary informationobtained from WorkCover, TreasuryManaged Fund and the NSW Departmentof Health. Statistics were analysed fortrends across the health care field.

1.5 Advisory group

An advisory group was established to providepractical and representative direct industryexperience to inform the project. Expressionsof interest were sought from various relevantprofessional organisations and specialty serviceswithin the seventeen Area Health Services inNSW, the Ambulance Service of NSW,Corrections Health NSW and from the privatehospitals of NSW. Information outlining thepurpose of the project was provided topromote participation and support for theproject. The organisations were asked to seekexpressions of interest from their members. Itwas anticipated that through this consultativeprocess the project would develop comprehensiveguidelines for the prevention and managementof workplace aggression using case studies fromthe NSW health industry to support post-incident management and the facilitation ofrehabilitation and early return to work ofaffected workers. Members of the advisorygroup were requested to identify key policies,procedural documents, training approachesand examples of innovative responses in themanagement of workplace violence.

1.6 Site visits to Area Health

Services and other identified

specialty areas within NSW

A letter was a sent to each Area Health ServiceChief Executive Officer (CEO) by NSWHealth and the CEO from CSAHS requestingtheir cooperation with the project. Each areawas asked to nominate a representative whowould liaise with the project officer. Theproject officer visited each of the seventeenArea Health Services and conducted interviewswith the nominated staff. A schedule ofquestions was prepared to ensure consistencyin the methodology. The interviews were

Overview of the Project 3


conducted over a period of several weeks, oftennecessitating follow-up interviews, phone calls,faxes and e-mails. The positive response to thispart of the project was encouraging. HealthService managers were asked to identify issuesrelating to violence in the work setting, toidentify strategies in place to manage workplaceviolence, to explore training needs and shareinformation relating to current training,policies and procedural guidelines pertainingto their area of work. Staff representatives whowere nominated to participate in this part ofthe project are listed in the appendices(see Table 1 on the next page).

1.7 Case studies

The guidance material gathered from AreaHealth Service managers was reviewed andanalysed by the advisory group to identifypositive better practice in the prevention andmanagement of workplace aggression anddevelop case studies. Discussion groups andindividual interviews were conducted withadvisory group members to assist in theselection of case studies for publication. Onlysome of the examples provided were selectedfor use as case studies as there were too manyto include in the final report. The examplesthat best met the evaluative criteria decided bythe advisory group were included.

Evaluative criteria

The following criteria were used to evaluate thecase studies presented. They:

• were validated by literature

• demonstrated evidence of strategic planningbased on continued improvement and anoutcome focus

• were considered to be useful and practical

• were transferable and flexible

• satisfied legal requirements as set outunder relevant legislation and guidelines(OH&S Act, Mental Health Act, NursesAct, Health Services Act, CorrectionsHealth Act, Security Act, AmbulanceServices Act, Anti Discrimination Act andNSW Health guidelines)

• adopted a risk management framework

• demonstrated evidence of consultationwith staff

• demonstrated management commitment

• were cost effective

• were informed by the latest developmentsin the particular area, they were innovativeand they demonstrated evidence ofefficacy, and

• were evaluated by the Area Health Serviceand approval was given to publish.

Selected case studies

The following case studies were selected asexamples of better practice from the NSWhealth industry.

• South Western Sydney Area HealthServiceSecurity and Minimisation/Managementof Aggression (SAMMA) Profile

• Wentworth Area Health ServiceArea Wide Strategic Plan 1997–2000

• Central Sydney Area Health ServiceCritical Incident Management Plan

• Northern Rivers Area Health ServiceNotice of Non-Acceptance of Aggression

• Central Sydney Area Health Service24 Hour EAP On-Call Service for CriticalIncidents in the Workplace



• South Western Sydney Area HealthServicePeer Support Program

• South Eastern Sydney Area Health ServiceMinimisation of Violence and Aggression:A Self Learning Package

• Central Sydney Area Health ServiceSafety Zone Alarm System

The eight case studies selected adopt acommitment to a risk management frameworkand they demonstrate evidence of strategicplanning based on continued improvementwith an outcome focus. They satisfy legal

requirements and are practical, and whilecaution is advised in applying solutions andstrategies developed in one area of practicewithout a full and thorough assessment andconsideration of local contexts, it is envisagedthat these examples will provide direction andguidance for other areas interested indeveloping similar programs focusing onimproving workplace safety.

Although it was recognised that there wereinitiatives in training staff in the preventionand management of workplace aggression,these were not included here as was plannedthat these be investigated as a future project.

Overview of the Project 5


1.8 Nominated staff from NSW Area Health Services

and other health related services

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2.1 Violence in health care settings

The risk of work related aggression faced byhealth and social services workers is wellrecognised1,2 with almost a universal acceptancethat violence is a significant problem formanagers and practitioners in health caresettings.3 The International Council of Nursesreported that health care workers are morelikely to be attacked at work than prisonofficers or police officers.4 Aggression continuesto increase and represents a serious health andsafety risk for employees of these services. Theconcern that violence is on the increase in healthcare is acknowledged by Paterson, McComish& Bradley5 who point out that this trend is notonly occurring in the traditional high risk areasof practice such as accident and emergencyservices, disability services and mental healthservices but has infiltrated other areas ofpractice. A study conducted in the UnitedKingdom (UK) involving human serviceworkers showed that nurses and ambulancepersonnel were the two occupational groupsidentified as being most at risk from assault.6,7

Health workers identified as being particularlyat risk include ambulance staff, nurses, familypractitioners working in lower socio-economicareas, accident and emergency staff, staff inprimary health care settings, and healthworkers caring for psychologically disturbedindividuals including people with mentalillness, and developmental disability.6,8,9,10

2.2 Definition of the problem

“Violence is the unjust or unwarranted use offorce or power”.11 There is substantial evidenceregarding increasing levels of violence insociety12,13,14,15 with increasing crime ratesreported in Australia and overseas.16,17 Thepervasiveness of violence in today’s society isindisputable.18 Estimates show that almost onethird of all Americans are assaulted each yearand that ten to fifteen per cent of theseincidents occur in the workplace.19 Crimereports tend to indicate that in addition to theoverall increase in violent incidents there is acorresponding increase in the intensity ofaggression used.20 However, there are inherentdifficulties in over-reliance on statistics due tovariations in how crimes are grouped, disparityin reporting systems, variations in reportingtools, dissimilarity in services, and sometimescontradictory reports.17,21

Violence is described by the World HealthOrganisation (WHO) as a generic termincorporating all types of abuse includingbehaviour that humiliates, degrades or injuresthe wellbeing, dignity and worth of anindividual.22 Elliott23 highlights that it canrange in intensity from verbal threats tophysical attacks, brutality and murder and is anindividual perceptual experience influenced bya range of factors including culture, context,environment and past experience. Violence in

Background



the workplace is perceived as a manifestationof the overall increase in societal aggression20.Statistics in the United States indicate thatbetween 10% to 15% of violence reportedoccurs in the workplace. Elliott23 suggests thatin the USA 25 million people are victimisedby fear and violence in the workplace, withworkplace homicide occurring on average fourtimes a day, twenty times a week and 1000times a year.

This is in stark contrast to the traditional viewof the workplace as a relatively benign andviolence free environment where workplaceconfrontation and conciliatory dialogue occursas part of the normal milieu.12 There areinstances when this course of events fails tohave a positive outcome and, according toGregg & Krause12, the work setting istransformed into a hostile and dangerousenvironment. Violence in the workplace isdefined as “incidents where persons are abused,threatened or assaulted in circumstances relatingto their work, involving explicit or implicitchallenge to their safety”.24 The InternationalLabour Organisation (ILO) noted thatworkplace violence has “gone global”, crossingborders, work settings and occupational groupsand concludes that it is now a public healthconcern of epidemic proportions.25 Perrone26

fills a void in the Australian literature andprovides a valuable insight into the currentcontext of violence in the workplace and inthis way achieves the objectives of her study byhighlighting factors that impinge on themaintenance of a safe working environment.

2.3 Workplace violence

Workplace violence is defined by the WorkSafeCommission Western Australia (WA) as “anyaction or incident that physically or

psychologically harms another person. It includessuch situations where workers and other peopleare threatened, attacked or physically assaulted atwork”.27 The Commission also acknowledgesthe impact of verbal abuse and intimidation onthe worker’s health and well being.27 Thedefinition of work-related violence adopted bythe National Health Service (UK) andpublished in guidance material prepared byRoyal College of Nursing (UK) is described as“incidents where staff are abused, threatened orassaulted in circumstances related to their work,involving an explicit or implicit challenge to theirsafety, well being or health” and includes violencefrom co-workers and other professionals as wellas service users.28 In addition to the physicalconsequences of violence it is important toacknowledge the emotional consequencesintegral to the spectrum of violence.29

Elliott23 defines workplace violence as “anyincident in which employers, self-employed peopleand others are abused, threatened or assaulted incircumstances arising out of, or in the course of,the work undertaken”. Estreich1 describes threetypes of work situations that can produceviolence: (a) intra-organisational conflictbetween employees; (b) client originatedviolence; and (c) violence from the generalpublic. The main focus of the literatureappears to concentrate on client originatedviolence. However it is important toacknowledge that other situations have thepotential to produce violence. The RoyalCollege of Nursing (RCN) in the UKacknowledges intra-organisational conflictwhere the aggressor is another employee, asupervisor or a manager and provides bullying,harassment and intimidation as examples ofincidents encountered.28,30 Such abuses areoften systemic and ingrained in the culture ofthe organisation and their very pervasiveness

Background 9


renders them difficult to identify and henceaddress.26 Inter-group conflict is also describedas horizontal violence and is manifested inovert and covert non-physical hostility such assabotage, infighting, scapegoating, underminingand excessive criticism. It is clearly recognisedas a workplace phenomenon and while it is notthe major focus of this project it is importantto acknowledge its existence.26,31 McClure21

identifies the most likely targets of workplaceviolence perpetrated by employees as workersand supervisors in the human service industrieswho are often the people responsible for resolvingand mediating workplace disagreements.

2.4 Data relating to violence in the

workplace

Several authors acknowledge the difficulty inobtaining definitive data relating to workplaceviolence5,26,32 and acknowledge that this iscompounded by different interpretations ofwhat constitutes violence6,33 as well as thevarying perceptions of violence in differentcontexts and cultures.16 In a study of alloccupations in the United States of America(USA) from 1980 to 1988, Jenkins, Layne &Kesner34 reported that homicide was the thirdleading cause of occupational death among allworkers. More recent studies indicate thathomicide has become the second leading causeof occupational death.34 Levin, Hewitt &Misner35 reported that for the period 1980–1985 homicide was the leading cause of fataloccupational injury among female workersand this remains unchanged. Grainger18

acknowledges the insidious nature ofoccupational violence and the fact that it is nolonger limited to those occupations where itwas considered the norm, such as the policeforce and those working in areas of accidentand emergency and psychiatry. Higher rates of

homicide were found in the retail and serviceindustries and Kiely, McCafferty, McMahon,& Kraus9 suggest that this may be explained bycontact with the public and the handling ofmoney. Libscomb & Love36 suggest thatexposure to the public is an important riskfactor in determining workplace safety. Therisk is further increased when workers areexposed to emotionally charged situations andlack protection, confidence and training wheninteracting with people affected by a mentalillness.37,38,39 It is important to acknowledge“that the overwhelming majority of people withmental illness present no such risk”.40

2.5 Data relating to violence in

health care settings

A campaign to stop violence against staffworking in the National Health Service (NHS)in the United Kingdom (UK) was launched inlate 1999 by the Health Minister and the LordChancellor with full support from thegovernment. This was in response to concernsthat violence in the NHS was spiralling out ofcontrol with workers facing 1.2 million violentincidents a year41. Recent research funded bythe Health and Safety Executive in the UKrevealed that NHS workers experienced523,000 physical assaults and 703,000 threatsfrom members of the public in 1997. Workersin health care settings were identified as beinga high risk group and the Lord Chancelloremphasised the need for support and respectfor “dedicated professionals often working indifficult circumstances”.41 This initiative wasdesigned to stamp out incidents where staff areassaulted, abused or threatened during thecourse of their work. The campaign whichadopts a “zero tolerance” slogan has twoprincipal objectives, namely to communicateto members of the public that violence against



staff working in the National Health Serviceis unacceptable and will not be tolerated andto send a clear message to all employees thatviolence and intimidation is unacceptable andmeasures are in hand to tackle this problem.42

Statistics available from the National HealthService (UK) regarding the severity of theproblem suggest that up to 65,000 incidentsof violence against staff occur each year inNational Health Service Trusts in England(calculated at seven incidents of violence perthousand staff per month). National HealthService Trusts are urged to have systems inplace to record all incidents of violence againststaff and have identified strategies in place toreduce incidents by April 2000. Nationaltargets aim to reduce the incidents of violenceagainst National Health Service staff by 20%by 2001 and 30% by 2003. Part of thisapproach is to liaise closely with the policeto formulate and implement local crimeprevention strategies.42

Workers compensation data for the period July1995 to June 1998 in Western Australia (WA)indicate that almost half of all workplaceassaults resulting in injuries or time lost fromwork are in health related industries andcommunity services. Specific reference is madeto work settings such as hospitals,developmental disability services, aged carefacilities and prisons. Staff identified as mostfrequently injured are nurses and other hospitalstaff, welfare officers, security personnel, prisonofficers, childcare workers, teachers andteachers’ aides. The increased risk of workplaceaggression for people who work alone incommunity settings is also recognised.27

A factor contributing to inadequate datacollection is that many workplace violenceepisodes are not included in national workers

compensation databases. In Australia, as inCanada and the USA, incidents resulting infewer than five days absence from work areexcluded, despite representing forty six percent of all new claims lodged annually.43,44

2.6 The cost of violence in health care

The cost of workplace violence according toKoch and Hudson43 extends beyond inflictingphysical or psychological harm on an individual.It impacts on family, friends, work colleaguesand the organisation. Whatever the context ofviolence it is important to acknowledge that itcauses immediate and long-term disruption tointerpersonal relationships, the organisation ofwork and the overall working environment.According to a report prepared by theInternational Labour Organisation in 199825

employers bear the direct cost of employeetime lost from work and are also liable for thecost of improving safety in the workplace.Elliott41 estimates conservatively that in theUSA the costs are in excess of US$4.3 billionannually or US$250,000 per incident andcautions that this is not inclusive of the hiddenexpenses, from the emotional pain victims,witnesses and family members suffer such asdepression, isolation and anxiety.

Perrone26 suggests that this is a grossunderestimation of total expenses involved,and describes indirect or hidden costs as non-tangible and cumulative and attempts tocatalogue these from the perspective of theindividual, the employer and the organisation.Victims are faced with the obvious costs ofmeeting the immediate and future medicalexpenses incurred. Other costs include shortand long term psychological distress with thepossible onset of post traumatic stress disorder(PTSD). Costs are also associated with theonset of substance abuse, stress related physical

Background 11


diseases and mental disorders like anxiety anddepression. There are also opportunity costsassociated with reduced employment optionsor loss of promotional prospects, jobdisplacement, fear of crime and a diminishedquality of life. Costs associated with theemployer identified by Perrone include damageto property or loss of takings through theft ordamage, affected employees’ medical expenses,increased workers compensation insurancepremiums, legal expenses defending civilactions, absenteeism, disruption to workperformance, increased staff turnover,increased costs associated with recruitment,orientation and training and costs ofmodifying the environment to create a saferwork setting. Other indirect costs identifiedinclude reduced efficiency and productivity,loss in quality of products, loss of companyimage, and a reduction in the number ofclients. Costs borne by society in relation toworkplace violence include stress, trauma andfinancial expenses incurred by the victims,family and friends, interpersonal conflictbetween the victim and family members,elevated workers compensation premiums,lost taxation revenue, increased medicarepayments, increased disability claims,retraining and rehabilitation costs, crimescompensation payouts and a loss of confidencein certain areas of business or certainprofessions leading to shortages in these areasand further recruitment costs. At afundamental level the provision of a safeworking environment is seen as a basic humanright and the pervasive, enduring andmultifaceted nature of workplace violenceseriously threatens this premise.

For the victims of violence it is recognised thatviolence is a cause of stress and a review ofoccupational stress reports indicates that

related illnesses carry considerable human andeconomic costs to the individual and theirfamilies. In England and Wales 3.3 millionwork hours were lost due to violence in 1997with estimates of the cost of work relatedviolence inclusive of medical costs and time offwork at around $150 million.45 Human costshave been measured in terms of bothpsychological and physical ill health. Economiccosts have been measured in terms of staffturnover, loss of earnings, absenteeism andimpaired functioning.24,46

2.7 Assessment of violence

Predicting aggressive behaviour has been acentral issue for mental health professionalsduring the latter half of the twentiethcentury.47,48,49 Accuracy in predicting aggressionis an issue of concern for clinicians48,50,51,52 anda history of aggression is still considered thebest predictor of future aggression.7,48,53 Muchof the research focuses on the relationshipbetween specific cues or risk factors and theoccurrence of aggressive behaviour.54 Severalauthors acknowledge the inherent difficultiesin researching aggressive behaviour andattribute this in part to difficulties in definingand measuring aggression and to unreliabledata collection systems that fail to reflect thecomplexity of the problem.20,55,56,57,58 Theeclectic approach to the use of assessment toolsadopted by many facilities and services iscriticised by Collins, Robinson & Lange50 whohighlight the consequences of relying oninadequate assessments and instruments thatlack any developmental or theoretical base.Almik & Woods37 identify the need toundertake validation of assessment tools incurrent use and acknowledge potentialdifficulties with inter-rater reliability in thepractice setting. Monoghan48 concludes that



the most striking characteristic of researchin the area of risk assessment is that it isinconclusive. It is however important toacknowledge that a relatively small numberof patients is responsible for a high proportionof assaults.59

Distasio60 advocates a more comprehensiveapproach to assessment that recognises thatviolence occurs in association with patient,staff, situational and environmental variablesand as such is predictable in some instances.There is little doubt that alcohol and drugs,particularly central nervous system stimulantssuch as amphetamines and cocaine, contributeto violence in the short term.61 The importanceof considering situational variables as part of anintegrated approach to risk assessment forpsychiatric inpatients is well documented.47,62

Identified situational variables that mayprovoke aggression in inpatient settingsinclude limit setting, conflict with patients,personal space, night time, inactivity and staffcharacteristics.8,47 In a project conducted inNSW focusing on acute inpatient careincreased violent behaviour was noted insituations involving rapid hospitalisation anddischarge, overcrowding, poorly defined wardstructure, negative ward atmosphere and anunsatisfactory mix of patients with psychiatricdisorders and patients with criminal andantisocial behaviour.63 Specific environmentalvariables included overcrowding, barren anduninteresting surroundings, long periods ofunstructured activity leading to boredom,social climate of the unit (how staff andpatients interacted) and an expectation ofa therapeutic milieu (that there would beno aggression in the unit).

Other risk factors associated with assault inhealth care settings include low levels of staff,

frequent changes in staffing, working inisolation, inadequate security, lack of trainedstaff and situations where therapeutic activity isat a minimum.7 However despite extensiveresearch and validation studies the generalconsensus from the literature is that riskassessment in relation to violence is still anequivocal science.37,48,54,55,56,63

2.8 Factors impacting on increased

levels of violence in health care

Weiner & Crosby (1986) cited in Bowie8

suggest some of the reasons for the increase inviolence in health related services may be dueto changes in service policy, and changes infunding allocations and living arrangementsfor specific groups. Successful fostering andplacement of children in more permanentarrangements may result in an increasedconcentration of children with behaviouralproblems remaining in residential care. Davis61

identifies that at a structural level, a shortage ofacute inpatient beds and community resourcesmay result in higher numbers of acutelydisturbed patients concentrated in inpatientunits and also people with higher levels ofdisability and subjective distress cared for inthe community.8 The prevailing economicclimate places additional burdens on lowersocio-economic groups with greater disparitybetween the rich and poor and this may triggerresentment, discord and conflict. The emphasison community based care and mainstreamingof services has placed unprecedented demandson community services, aged care services,accident and emergency services, securityservices, non-government agencies, disabilityservices, unemployment and welfare agencies,prison and detention services, and often theresources, skills and training of staff areinadequate to effectively respond to the diverse

Background 13


needs of consumers8. Elliott23 reports a numberof key factors in the health care environmentcorrelating with the increased risk of violencein health care settings. Key factors identifiedinclude:

• “twenty-four hour open door” policies forpatient access

• decrease in available services for peoplewith a mental illness and for people withsubstance abuse problems

• availability of drugs and money in hospitalsetting

• the prevalence of weapons amongst patients

• the current cost-cutting focus andwidespread downsizing within the healthcare industry

• working alone during the night and earlyhours of the morning

• traditional staffing patterns – often lowstaffing levels at times of increasedactivity, and

• “circumstantial factors, such asunrestricted movement of the public inhealth care settings, presence of gangmembers, drug or alcohol abuse, traumapatients, distraught family members, longwaiting times and the inability to obtaincare or treatment”.23

2.9 Inpatient psychiatric facilities

Assault in psychiatric inpatient facilities is asignificant problem according to the literatureand much of the research literature pertainingto violence in health care focuses on this areaof practice.36,51 A number of researchers havefound that a small number of patients areresponsible for the majority of incidents.59,61

Several studies investigating aggression inpsychiatric settings have been conducted with

findings indicating that assault victims inhospital settings are most likely to benurses.10,24,64,65 Rogers66 found that nurses areon average three times more likely to experienceworkplace violence than other occupationalgroups. Poster67 found that seventy five percent of all psychiatric nurses had been assaultedat least once in their careers. Several studieshave identified the discrepancies betweenactual incidents of violence and abuse andreported incidents9,10,68 The difficulties inaccurately assessing the extent of the problemis highlighted by several authors whoacknowledge that staff often choose not toreport incidents of violence and are reluctantto draw attention to themselves21,69,70,71 TheAmerican Medical Association (AMA) suggeststhe development of specific educationalmaterials to assist staff in identifying their legaloptions13.

2.10 Medical staff

The American Medical Association (AMA)acknowledges the lack of definitive datarelating to the incidence of violent acts againstphysicians but suggests from anecdotalaccounts and media reports that somespecialists are more at risk, with psychiatristsand emergency physicians heading the list13.Despite these concerns the AMA suggests thatworkplace violence against physicians andother health workers is far less frequent thanthat against other workers in industries such asthe retail trade, transportation, public utilities,communications and public administration13.However, statistics collected during the period1980–1984 revealed that the leading cause ofdeath from work related injuries in the healthcare industry overall was homicide (22%).Physicians were more likely to die from workinjuries (19%) than other occupational groups



in health care, followed by registered nurses(17%), nurse’s aides (6%) and dentists (5%).Findings from an annual survey of 160hospitals undertaken by the InternationalAssociation of Health Care Security in theUSA indicated that 1 homicide, 24 armedrobberies, 32 sexual assaults, 703 other assaultsand 124 bomb threats were reported inrelation to workplace violence in 1990.13

Doctors, like others in the helping profession,are frequently expected to accept workplaceviolence as an intrinsic feature of the daily risksassociated with certain occupations andPerrone26 cautions that by contextualisingviolence in this way “as a permissible, systemicwork-related risk”, it becomes accepted and isnot viewed as an inherently “unnecessary violentand harmful activity”. More significantly shesuggests that “it has the effect of deflectingattention away from possibly negligent workingenvironments and practices”.26 Doctors, likeothers, are reviewing traditional roles and workpractices. In the UK female doctors are insome instances refusing to make house calls atnight71 and in Australia there have been mediareports of general practitioners utilisingsecurity personnel to facilitate night calls incertain locations.

2.11 Nurses

The International Council of Nurses4 identifiesthat nurses are the health care workers most atrisk with women considered the mostvulnerable. Nursing has been identified as themost dangerous occupation in the UK withone in three nurses verbally or physicallyabused each year.72 There is an addeddimension to the problem due to thewidespread acceptance of violence as anunavoidable occupational hazard41. Legalsystems have failed to award compensation

claims to nurse victims and this has beenjustified on the grounds that to engage innursing practice is to accept that nurses arelegitimate targets and that violence is part ofthe job4. Some relevant statistics released bythe International Council of Nurses4 includethe following:

• physical assault in health care settings isalmost exclusively perpetrated by clientsof the service

• ninety seven per cent of nurses surveyedknew a nurse who had been physicallyassaulted during the previous year, and

• seventy two percent of nurses do not feelsafe from assault in the workplace.

Norko, Zonana & Philips73 propose guidelinesfor prosecuting violent patients. These includethe following:

• criteria for pursuing prosecutions shouldbe established as a matter of policy

• incidents by patients should be reviewedby clinicians not involved in their directtreatment

• violent incidents should be evaluatedagainst the established criteria forpursuing prosecutions, and

• when the decision is made to proceed withlegal action, the treatment team shouldnot be responsible for initiating thecomplaint.

2.12 Remote area nurses

The plight of remote area nurses (RANs) ishighlighted in a study undertaken by Fisheret al32 who also acknowledge under-reportingof incidents. This is attributed in part to theperception by RANs that except in the case ofphysical violence there is a tendency “toperceive both the frequency and severity of their

Background 15


experiences with violence as low and notpersonally directed”. 32 However, anecdotalevidence suggests that violence directed towardRANs is on the increase and the findings ofthis study support this view. The isolation andparticular vulnerabilities of RANs as a groupworking in small rural communities areidentified as significant factors. The studyhighlights the need to acknowledge RANs asvictims, institute supportive measures, developpolicies and intervention programs to addressthe issue of safety, change the culture of under-reporting and involve managers and employersin accepting responsibility for the occupationalhealth and safety of RANs. Elliott23 highlightsthe importance of communicating violentevents, and suggests that under-reportingfrequently occurs in work environments wherethe culture discourages reporting, where thereis a lack of institutional reporting policy, whereemployees believe that reporting will notbenefit them, or they may fear that employersmay perceive assaults resulted from negligenceor incompetence.

2.13 Community services

The incidence of aggression toward staff inthe community is, according to Beale andLeather74, no higher than for many otherhealth care workers, but what is different isthat when community workers are faced withaggression and violence they are frequentlyalone, in unfamiliar settings and distant fromtheir colleagues and organisational support27.This is compounded by a lack of policies andprocedures for emergency action if staff requireassistance or fail to check in after a home visitor an appointment with a client. When suchpolicies do exist they are often not backed upwith adequate training70. The availability andcontent of training in aggression management

for community staff is an issue with reportsthat training programs frequently emphasisephysical responses rather than strategies inprevention and defusing techniques74. Cherryand Upston53 suggest some useful protocols toimprove staff safety in community settings.These include self awareness, self control, selfpreservation, responding to actual andpotential violence, post incident managementand organisational responses. According to aNational Health Service report many violentincidents involving community nurses takeplace on the way to or from the client’shome71. The report suggests that trainingnurses in self defence or providing them withtwo way radios or alarms will not make anyreal difference to their safety but acknowledgesthat some aspects of home visiting can beimproved such as visits to risky areas beforedark and working in pairs. However it wassuggested that the key to reducing the numberof violent incidents is in the careful selectionof mature, experienced community nurses withgood social skills. This should be reinforced byappropriate training in recognising signs ofpotential violence and how to defuseaggression71. Beale and Leather74 identify somebasic steps to be taken to improve safety forcommunity staff if problems are encounteredduring home visits. These include thefollowing:

• arrange for the patient to come to theclinic or request other support

• allow yourself adequate time for thejourney, check that you have emergencyequipment and that it works

• make sure somebody knows where you aregoing and when you are due back

• remain alert and continually reassess thesituation

• don’t go where you don’t feel safe



• if problems do occur, put your own safetyfirst. If you do not feel safe, leave.

• if you are sure the aggression is “letting offsteam” and not directed at you personally,listen, calm the agitated person and try tohelp with their problem

• after an aggressive incident take time toallow yourself to recover and contact yourteam

• report the incident through the reportingsystem

• be prepared for post trauma reactionsfollowing aggressive incidents, evensupposedly minor ones. These reactionsare entirely normal and usually diminishover time, and

• do not be afraid or embarrassed to ask fordebriefing or counselling if reactions aredifficult or persistent.74

Individuals, teams and organisations haveresponsibilities to ensure that strategies are inplace to increase workplace safety and reducerisks74,75. Some innovations have commencedin this area. WorkCover Victoria76 hasestablished minimum standards for specificareas of practice, such as undertakingcommunity visits, conducting interviews andmodifying reception and waiting areas. A bestpractice model for work in the community hasbeen identified by the Royal District NursingServices Research Unit as part of a projectfunded by WorkCover SA43. This modelincludes features of the work of Cherry andUpston53 and Bowie8 who identified a range ofstrategies to manage violence in the workplace.The model involves nine awareness and actionoptions for staff to consider. These include,referral and triage, assessment, awareness ofoptions if a violent event is experienced,

reporting the incident, support, defuse,debrief, follow up, and moving on43.

2.14 The Ambulance Service

Similar to other areas of practice there is nocomprehensive database available to trackincidents of violence within the AmbulanceService and there are inherent difficulties inobtaining local statistical data both withinAustralia and overseas.77 Harkins78, in herexamination of the effects of critical incidentstress on emergency workers within theMetropolitan Ambulance Service (Victoria)for the period 1992–93, found that of the 73%of staff who had first contact with supportservices, “11% were solely related to trauma atwork, 28% related to work in general, 22%related to personal issues and 39% wereattributed to a combination of the above” 78.Field77, responding to increasing concernsregarding assaults on Ambulance Officers inNSW, commented on the vulnerability of theposition due to lack of prior knowledge of thepatient’s behaviour patterns, the emotionalvolatility of the situation and the uncertaintyof the environment because it is bothunknown and uncontrolled. Fieldadministered a questionnaire to 880Ambulance Officers in the MetropolitanAmbulance Service, Sydney and analysed dataobtained from 324 meaningful responses(36% response rate). The average length ofservice for these officers was 6.9 years. Findingsindicated that there is a 22.8% chance that anAmbulance Officer will be attacked in any year(these range from relatively minor attacks toattacks of a more serious nature). Genderdifferences were recorded with each maleofficer experiencing 0.22 attacks each yearwhile 0.48 attacks were recorded for femaleofficers. Field acknowledged that these findings

Background 17


were at variance with other studies thatindicated that more males are victims ofassault than females and offered the followingby way of explanation:

• there are fewer females in the service thanmales (sample size small)

• females have a much shorter averagelength of service (females 1.9 years; males7.4 years), and

• violence in society has increaseddramatically in recent times correspondingwith a time of increased numbers offemales entering the service.

The most frequently recorded means of attackwas with fists, which accounted for almost halfof all attacks. A further 20% of attacks involvedkicking, 13% were attacks with weapons and20% were defined as others (eg. walking stick,timber, chairs, cricket bats, hammers). Oneofficer was bitten and 2 officers were attackedwith equipment from the ambulance. Themajority of assaults occurred when respondingto emergency calls (88.9%) rather than onroutine calls (11.1%). Field76 categorised thetype of emergency call the officers wereresponding to when assaulted and suggests thatthis information is important in risk assessmentas it highlights the need to obtain additionalinformation from the caller and serves to warnof increased risk in certain situations.Responding to calls relating to alcohol anddrug overdose accounted for almost 35% of allassaults with the assailant being male in 80%of instances. Responding to emergency callsresulting from domestic disputes accounted for20% of all assaults. This information hasimplications for staff training, the type ofinformation requested from callers, expectedresponses of ambulance officers andcommunication with Police services and other

services on the scene. In a review of statisticsrelating to violent incidents involvingAmbulance Officers in the Hunter Area ofNSW78 95% of reported incidents fromDecember 1996 to August 1997 related toalcohol and drugs and 36% of these related tocall outs as a result of domestic violence.Seventy three per cent of reported incidentsfrom September 1997 to May 1998 related toalcohol and drugs with 39% of call outs inresponse to domestic violence.79

2.15 Emergency Departments

In a similar project, The California EmergencyNurses Association surveyed 104 hospitals inthe state. Findings revealed that injuries tostaff, patients or visitors occurred in 58% ofhospitals as a result of violence. The highincidence of violence located in EmergencyDepartments (EDs) was acknowledged with53% of all hospital assaults occurring in EDs.13

Some of the reasons attributed to theconcentration of violence within EDs includedthe 24-hour accessibility of the service, easyaccess, a wide range of clientele (includingsubstance users, gang members and thehomeless), minimal security, overcrowding,long waiting times, and inadvertentprovocation by overworked or insensitivestaff.13,80 Other factors included the stressfulnature of the environment and the fact thatpatients are often anxious, in physical pain,experiencing discomfort and distress, confusedand under the influence of mind-alteringdrugs. Gang violence in EDs has also beenreported and strategies to counteract the effectsof gang violence infiltrating EDs have beenidentified.81

In a retrospective study conducted by Pane,Winiarski & Salness82 to determine the scopeand magnitude of patient and visitor



aggression directed towards emergencydepartment staff, the findings confirmed thatviolence is a significant and under-reportedproblem. The study setting was an emergencyunit situated in a medium sized teachinghospital in the USA treating approximately40,000 patients annually. All violent incidentsinvolving patients and visitors which resultedin a police response were included in the study.A total of 686 incidents were recorded inpolice logs for the study period.

A corresponding review of official incidentreports relating to patient and visitor violencecompleted by ED staff and sent to the riskmanagement section of the hospital revealedthat only seven incident forms had beencompleted.83 Similar studies examiningreporting practices have found that all types ofaggressive incidents are grossly under-reported.83 A study conducted in the UKfound that only 35% of incidents involvingphysical aggression were reported, 31% ofincidents involving weapons were reported andthat only 18% of incidents involving verbalthreats were reported.84 Findings from theseand other studies are useful in objectivelyquantifying the scope of violence in health caresettings. They provide a frame of reference andbase line data from which appropriate and costeffective strategies can be formulated andimplemented.82

The importance of EDs in delivering mentalhealth care within NSW was the focus of aspecial initiative undertaken by the Centre for

Mental Health reported in 1998.85 Particularconcerns were identified in relation toassessment and management of people withmental health problems, accessing appropriatemental health services, co-ordination withother agencies and ensuring appropriateeducation and training for staff in EDs andMental Health staff. A number of problemswere identified by patients in relation toassessment practices in EDs. These includedthe lack of recognition that a patient has apsychiatric illness, problems in the managementof patients with psychiatric illness anddifficulties in safely supervising patients withpsychiatric illness. Problems identified in thereport by staff included difficulties inrecognising some forms of mental illness,difficulties in appropriately triaging patientswith mental health problems, difficulties indealing with disturbed or violent behaviourand difficulties in obtaining adequate andtimely access to specialised mental healthservices.85 The report contains a number ofrecommendations to address these deficits anda commitment to assist health services meettheir obligations by making it a requirementthat these recommendations be incorporatedinto Performance Agreements between NSWHealth and Area Health Services.85 While onlya small number of people with a mental illnessengage in violent or aggressive acts59,61 it isanticipated that assisting staff to develop skillsin the assessment, triage, management andappropriate referral will impact on the overallmanagement of violence within EDs.


3.1 NSW Occupational Health &

Safety Act 2000

Workplace safety has become a crucial issuefor managers and employees alike. The NSWOccupational Health and Safety (OH&S) Act200086 clearly states that employers mustensure the health safety and welfare at workof their employees. Similar legislation in otherAustralian states and territories as well asoverseas has made the responsibilities ofemployers more explicit, requiring employersto conduct formal risk assessments to plan andimplement safe systems of practice.5

3.2 NSW Occupational Health &

Safety Regulation 2001

The NSW Occupational Health & SafetyRegulation 200187 consolidates requirementsfor health and safety at work into one document.This regulation replaces all regulationspreviously made under the OH&S Act 1983,the Factories Shops and Industries Act 1962and the Construction Safety Act 1912. Someof this legislation being replaced is prescriptivein nature, somewhat dated and may actuallylimit the employer or self-employed personfrom using more modern and effective controlmeasures. The main changes to the riskmanagement content are contained in ChapterTwo of the Regulation 2001. It is a legalrequirement to identify hazards and assessrisks in the workplace. This will mean that

managers are obliged to identify and assess thepotential for workplace violence. Currently,there is no regulation specific to workplaceviolence, no Australian code of practice and nostandard for the control of workplace violencein NSW.

3.3 Prosecutions

Prosecutions serve as a warning to health, agedcare facilities and community services employersthat they are not exempt from liability and thatWorkCover NSW is serious about enforcinglegislation in service industries and the publicsector as well as in the more traditional areasof construction and manufacturing. It is nowrecognised that individual managers who failto comply with their responsibilities underOH&S legislation may face prosecution.88 InQueensland, a Director in the manufacturingindustry was imprisoned for eighteen monthsfor breaches of OH&S legislation. Failure tomaintain a brake system to a front loaderresulted in an employee being crushed whenthe machine lost all braking power during aroutine loading procedure. In determiningthe sentence in a Queensland District Courtthe judge specifically took into account theneed for some form of public retribution overthe actions of the Director and the need totangibly convey the message of deterrence tothose who commit criminal acts under OH&SLegislation. The judgement in this case is a

Legislation and Policy



clear message that the judiciary will nothesitate to use imprisonment to communicatethat contravening OH&S legislation is aserious matter.89

The current NSW OH&S legislation containsprovision for fines for first offenders and fineand/or prison sentence for repeat offenders.Within health care and community servicesettings in NSW no imprisonments haveresulted to date, however substantial fines havebeen given. For example, the Department ofCommunity Services was fined $95,000 as aresult of a serious assault on an employee andseveral other prosecutions are currentlyunderway.90

3.4 Policy development

NSW Health issued a circular “The CriticalIncident Manual: Policy and Guidelines toAssist Public Health Facilities Develop aPlanned Response to a Critical IncidentEvent”91 which clearly states the following:

“It is the policy of NSW Department of Healththat every health care facility shall develop asystematic and coordinated Critical IncidentManagement plan. This plan should identify,establish and promote a range of measures whichminimise or eliminate the potential occurrence ofa critical incident, identify the action to be takenshould a critical incident occur and have protocolsin place to reduce the trauma to staff and otherswho experience distressing incidents. It will alsoensure the timely investigation and reporting ofthe incident”.91

3.5 The NSW Health Occupational

Health Safety & Rehabilitation

(OHS&R) Numerical Profile

The Occupational Health Safety & Rehabilitation(OHS&R) Numerical Profile is acknowledged

as a valuable tool. It is used in NSW healthfacilities for monitoring and improvingOHS&R performance and includes a specificquestion on security. It provides a structure forworkplace managers to assess their OHS&Rperformance against set criteria and receivefeedback. The integrity of the process relies inpart on the ability of profilers to apply the toolconsistently and communicate issues clearlywith participating workplace managers andstaff when conducting Numerical Profile audits.Profilers are accredited to increase inter raterreliability and managers are encouraged to providefeedback on the implementation of the NumericalProfile assessments within their facilities.92

3.6 WorkCover Authority of NSW

“The general functions of the WorkCoverAuthority of NSW (WorkCover NSW) as setout in the Workplace Injury Management andWorkers Compensation Act 1998, Chapter 2,Part 2, Division 3 are:

(a) to be responsible for ensuring compliancewith the workers compensation legislationand the occupational health and safetylegislation

(b) to be responsible for the day to dayoperational matters relating to theschemes to which any such legislationrelates

(c) to monitor and report to the Ministeron the operation and effectiveness of theworkers compensation legislation and theoccupational health and safety legislation,and on the performance of the schemes towhich that leglislation relates

(d) to monitor and review key indicators offinancial viability and other aspects ofany such schemes, and

Legislation and Policy 21


(e) to report and make recommendations tothe Minister on such matters as theMinister requests or WorkCoverAuthority considers appropriate.

WorkCover NSW has such other functionsas are conferred or imposed on it by or underthe workers compensation legislation, theoccupational health and safety legislationor any other legislation. In exercising itsfunctions, WorkCover Authority must:

(a) promote the prevention of injuries anddiseases at the workplace and thedevelopment of healthy and safeworkplaces

(b) promote the prompt, efficient andeffective management of injuries topersons at work

(c) ensure the efficient operation of workerscompensation insurance arrangementshaving regard to policies of the AdvisoryCouncil, and

(d) ensure the appropriate co-ordination ofarrangements for the administration ofthe schemes to which the workerscompensation legislation or the occupationalhealth and safety legislation relates.

Specific functions include a range of activitiesimpacting on the prevention and managementof occupational injury and rehabilitation andreturn to work of injured workers. Theseinclude the initiation and encouragement ofresearch to identify efficient and effectivestrategies for the prevention and managementof occupational injury and rehabilitation ofinjured workers”.93

3.7 WorkCover NSW reporting

WorkCover NSW is monitoring developmentsacross the state and acknowledges thatworkplace violence is difficult to quantify dueto variations in reporting and coding44. TheHealth Industry Injury Classification Project94

was initiated as a joint project between NSWHealth and WorkCover NSW to reviewclassifications systems used for coding datarelating to workers compensation claims.It was recognised that the coding system wasnot suitable for identifying specific high riskgroups, such as occupations, activities,locations and types of accidents. One of theoutcomes of this project was the developmentof an enhanced classification system specific tothe health industry. While the projectacknowledged that it would not be practical touse such a system on a continuous basis it wassuggested that this system would facilitateretrospective audits and other research activities.

An examination of workers compensationclaims relating to violence during 1995/96presented by Estreich1 on behalf of aWorkCover NSW working party indicatedthat work related violence is most prevalentin the following industry groupings shownin Table 1.

Table 1 Worst affected industries by rank order

.1 htlaeH

.2 secivresytinummocdnaerafleW

.3 sbulcdnasletohstnaruatseR

.4 noitacudE

.5 secivresssenisubdnaytreporP

.6 edartliateR

.7 noitartsinimdacilbuP

.8 tropsnartliardnadaoR



The worst affected occupational groupingswere those providing human services as shownin Table 2. The following nine occupationalgroupings accounted for 85% of all majorviolence claims for 1995/96.1

(2.2%) and cost $13.1 million, whichrepresented 2.1% of total costs. These injuriesinvolved a total of 19,860 weeks in lost time.The most common injuries in this categorywere sprains, strains, contusions and fractures.Two hundred and forty incidents recordedinvolved assault by another person. Thirteenincidents for injury sustained as a result ofbeing hit by a moving object involved anotherperson. It is not possible to determine if theserelate to assault with a weapon or toaccidental injury.44

“Mental Disorders” is the category used foroccupational stress conditions. This includesdepression, anxiety, and other psychologicaland/or psychiatric conditions, which resultedfrom workplace stresses. WorkCover NSWhas noted a significant increase in the “mentaldisorder” category over the last seven years.

“The introduction of legislative amendments on1 January 1996 restricted compensation forpsychological or psychiatric disorders. To beeligible for compensation, employment must be asubstantial cause and injury must not be whollyor predominantly caused by specified reasonablestaffing actions. With the introduction of thesechanges mental disorder cases dropped in 1996/97 by 8.7% over the previous year. However in1997/98 the numbers increased by 20.2%”.44

On average mental disorders accounted for18.8% of all occupational diseases and weremost frequently reported in the followingindustries; finance and insurance (71.6%),education (62%) health and community services(46.4%) and personnel services (45.9%). Thetotal cost of mental disorders for 1997/1998was $37 million and total time lost as a resultof mental disorders was 42,392 weeks. 44

The Statistical Bulletin 1997–1998 relatingto NSW workers compensation data releasedby WorkCover NSW44 codes injuries relatingto workplace violence according to themechanism of injury. Violence related injuryis defined:

“as an injury where the mechanism of injury iseither “hit by a person” or “hit by a movingobject” and the agency of the injury is coded as“other person”. Obviously while many of theseinjuries will involve violence, some will involveaccidental injuries”.

There were a total of 952 injuries during1997/98 that may be regarded as involvingviolence. Violence related injuries account foronly a small proportion of workplace injuries

Table 2 Worst affected occupations by rank order

.1 srekrowdetalerdnasreruobalsuoenallecsiMdrawdnasreciffoytiruces,sdraugsedulcni(

)srepleh

.2 sesrunderetsigeR

.3 sedulcni(slanoisseforp-arapsuoenallecsiM)sreciffonosirpdnasrekrowytinummoceraflew

.4 eciloP

.5 srevirdtropsnartliardnadaoR

.6 srehcaetloohcS

.7 rabsedulcni(snosrepselassuoenallecsiM)sessertiawdnasretiawstnadnetta

.8 laicosytinummocsedulcni(lanoisseforplaicoS)srekrowesaclaicosdnasrekrow

.9 ecivresdnaselas(srosivrepusgniganaM,eciffotsop,letoh,tnaruatser,pohssedulcni

)sreganam,noitatsyawliar


4.1 Australian Standard for Risk

Management AS/NZS 4360-1999

Risk management is an interactive processconsisting of clearly defined steps that supportimproved decision making by contributing agreater insight into risks and their impact.AS/NZS 4360: 199995 is a revision of previousstandards established to assist organisationsand services to adopt a risk managementperspective in their place of work. It providesa framework for establishing the context,identification, analysis, evaluation, treatment,monitoring and communication of risk. It isgeneric and as such is independent of anyspecific industry or economic sector. To bemost effective risk management needs to beincorporated into the culture of theorganisation and become part of the overallphilosophy, practices and business plans ratherthan be viewed as a separate program.

4.2 The risk management process

The risk management process can be appliedto any situation where an undesired orunexpected outcome could be significant orwhere opportunities are identified. Decision-makers are encouraged to be aware of possibleadverse outcomes and to take steps to controlthem. Risk management is an integral part ofthe management process. It is a multifacetedprocess of continual improvement and can be

applied at many levels in the organisation.The key elements of a risk managementprogram are to establish the context, identify,analyse, evaluate and treat risks and to monitorreview communicate and consult. Riskmanagement can be applied at many levels inthe organisation, such as at strategic andoperational levels and can also be applied tospecific projects to assist with decision makingor to manage recognised risks. Risk managementinvolves hazard identification, risk assessment,risk control, developing workplace guidelines,consultation, training, audit review andevaluation.76

The requirements of the NSW OH&Slegislation to ensure that the health, safetyand welfare of employees and others in theworkplace are best met with an appropriatemanagement system, which includes:

• OH&S policy, codes of practice andprograms for implementing andmonitoring safe systems of work

• consultation at all levels of theorganisation

• clearly identified lines of responsibilityand accountability

• training at all levels, and

• allocation of resources (time, financialand personnel).

Risk Management



The development of an effective OH&SProgram requires the identification, assessmentand control of workplace hazards. A hazardis a situation with the potential to harm life,health or property. Hazards arise from theworkplace environment, use of plant orequipment, use of substances, poor workdesign, inappropriate management systemsand procedures and as a result of humanbehaviour. The CSAHS Critical Incident RiskManagement Plan96 suggests the following toassist in the identification, assessment andcontrol of workplace hazards.

4.3 Hazard identification

• Literature and observation of similarworkplaces

• Workplace inspections

• Direct observation of the workplace

• Consultation with employees

• Complaints

• Accident and injury reports and statistics

• Accident investigations

• OH&S audits

4.4 Risk assessment

• Likelihood of exposure (level of risk)

• Level of exposure (frequency andduration)

• Severity of resulting injury or illness

• Human differences (allergies, physicalparameters)

• Contributing factors and their interactions

• Environmental monitoring

• Health monitoring

4.5 Risk control

• Elimination of hazard (not using aproduct or designing out a hazard)

• Substitution (using a safer product orsafer equipment)

• Isolation/enclosure (screens, guards)

• Ventilation to reduce exposure

• Policies and procedures

• Work organisation

• Training

• Supervision

• Personal protective equipment

4.6 Evaluation

• Monitor

• Audit the program

• Evaluate outcomes

4.7 Resources and equipment

• Commitment of all levels of management

• Employee cooperation

• Allocation of time and money

• Prioritise: consider hazard and riskassessment and costs and complexityof controls

This approach recognises that the predictionof aggression can be very difficult due to arange of causative factors, such as heightenedemotions, drug and alcohol induced aggression,various medical conditions (such as headinjuries and psychological and psychiatricdisorders) pain and frustration.76

Risk Management 25


4.8 Risk management model for workplace aggression

Adapted from CSAHS Critical Incident Risk Management Plan.96 which has considered theguidance material from WorkCover NSW, The NSW Department of Health Safety CriticalIncident Manual: Policy & Guidelines and the NSW Department of Health Safety & SecurityManual.

Hazard/Risk Identification• Local workplace inspections• Area health service security assessments and external security audits• Local incident and accident reports• Area Health Service incident and accident investigations• WorkCover investigations• Consultation with employees• WorkCover statistics• Literature review

Risk Assessment• Assessment of level of risk – frequency, duration and severity of incidents• Assessment of factors contributing to risk and their interaction• Assessment of human differences in staff and patients; size, gender, culture• Assessment of patient physical and psychological state• Incident/accident and workers compensation data• Hazpak (a practical guide to risk assessment published by WorkCover)

Risk Control• Design for safety eg visibility, lighting, barriers, access, safety signs• Isolation or enclosure such as locks, fences, screens, shutters or raised barriers, visibility barriers,

perspex instead of glass, seclusion rooms• Elimination by altering design of an area, not using a product or changing a procedure• Substituting a safer piece of equipment or product• Policies and procedures in place for safer work practices eg two staff to respond, maintaining

communication• Aggression management training as part of orientation, focused training and refresher programs• Personal protective equipment such as phones, pagers, safety zone system, buzzers, video surveillance,

flagging systems, safety communication systems• Post-incident management

Monitoring and Evaluation• Continuous monitoring and evaluation of outcomes• Hazard specific audit programs – eg SAMMA (Security and Minimisation/Management of Aggression

Profile published by South Western Sydney Area Health Service)• OHS&R numerical profile• ACHS accreditation

Resources and Commitment• Co-operative approaches involving all staff• Commitment from all levels of management• Allocation of resources in time, money and personnel



4.9 Case studies from a risk management perspective

Risk Identification and Assessment

• Security and Minimisation/Management of Aggression (SAMMA) ProfileSouth Western Sydney AHS

Risk Control

• Area Wide Strategic Plan 1997–2000Wentworth Area Health Service

• Critical Incident Management PlanCentral Sydney Area Health Service

• Notice of Non-Acceptance of AggressionNorthern Rivers Area Health Service

• 24 Hour On-Call Service for Critical Incidents in the WorkplaceCentral Sydney Area Health Service

• Peer Support ProgramSouth Western Sydney Area Health Service

• Minimisation of Violence and Aggression: A Self Learning PackageSouth Eastern Sydney Area Health Service

• Safety Zone Alarm SystemCentral Sydney Area Health Service

Risk Monitoring and Evaluation

• Security and Minimisation/Management of Aggression (SAMMA) ProfileSouth Western Sydney AHS


Case Studies

1. Security and Minimisation/Managementof Aggression (SAMMA) ProfileSouth Western Sydney Area HealthService

2. Area Wide Strategic Plan 1997–2000Wentworth Area Health Service

3. Critical Incident Management PlanCentral Sydney Area Health Service

4. Notice of Non-Acceptance of AggressionNorthern Rivers Area Health Service

5. 24 Hour On-Call EAP Service forCritical Incidents in the WorkplaceCentral Sydney Area Health Service

6. Peer Support ProgramSouth Western Sydney Area HealthService

7. Minimisation of Violence andAggression: A Self-Learning PackageSouth Eastern Sydney Area Health Service

8. Safety Zone Alarm SystemCentral Sydney Area Health Service




Introduction

The Security and Minimisation/Managementof Aggression (SAMMA) Profile providesfacilities with a comprehensive audit tool forassessing their performance in providingsecurity to staff and patients/clients as wellas minimising and managing aggression. Byconducting these annual assessments SouthWestern Sydney Area Health Service(SWSAHS) is meeting the NSW HealthDepartment’s requirement to conduct anannual security audit, as described in the Safetyand Security Manual. The profile has beendeveloped as part of the overall SAMMAProgram for SWSAHS. The SAMMA programincludes training for auditors in the use andapplication of the tool. The program alsoincorporates a training package for employeeswhich can be adopted by SWSAHS HealthSectors to provide opportunities for consistentapplication of local policies and procedures. Ithas been successfully introduced at SWSAHS.

Background

NSW Health released a document on “Policyand Guidelines for the Minimisation andManagement of Aggression in NSW HealthCare Establishments” (Circular 93/53).97

SWSAHS responded by establishing a workingparty to provide advice and recommendationson how best to deal with aggression in the

workplace in line with policy and guidelinesand the Chief Executive Officer (CEO) ofSWSAHS was appointed to the NSW Safetyand Security Steering Committee. Theworking party recommended the developmentof an assessment tool to establish baselineinformation and to assess and monitorperformance of health care facilities in themanagement of aggression. The intention wasto provide information to enable thedevelopment of strategies to minimise andmanage aggression and security risks. Theassessment tool, which was based on the NSWHealth Safety and Security Manual, wasdeveloped in 1995 and piloted in facilities bysector staff who had received training in theaudit process and application of the assessmenttool. The intention was to conduct auditsannually and provide written reports to sectorand area management on performance. Sectorsthen utilised the reports to develop action plansto address any shortfalls identified by the audits.

Case Study 1

Security and Minimisation/Management of Aggression (SAMMA) Profile

South Western Sydney Area Health Service



Rationale

A number of factors contributed to thedevelopment of this tool. Staff were concernedwith the increasing number of reportedincidents and breaches of security occurringwithin SWSAHS. The following table providesan example of this trend within the LiverpoolSector which is SWSAHS’s largest Health

Service. Managers were requesting assistance inmeeting their responsibilities regarding themanagement of incidents within their facilitiesin line with NSW Department of HealthCircular 93/53.

The following statistics are reported securityrelated incidents at the Liverpool Sector.

tnedicnIfoerutaN 7991 8991 )01/13ot(9991

noitcudbA 0 1 0

ruoivahebevisserggA 4 64 83

tpmettadnataerht,nosrA 0 1 0

nommoc,tluassA 3 22 11

lauxes,tluassA 0 3 1

redrumdetpmettA 0 1 0

yralgruB 2 1 0

tpmettayralgruB 6 2 0

etavirp,ytreporpotegamaD 1 9 5

ecivreshtlaeh,ytreporpotegamaD 5 4 11

tfeht/esusim,sgurdsuoregnaD 0 2 0

lareneg,ecnabrutsiD 1 7 0

tnemssaraH 0 2 6

etavirp,ytreporptsoL 0 4 0

ecivreshtlaeh,ytreporptsoL 0 1 0

tneitapgnirednaw/gnissiM 0 3 21

ksirtaytefastneitaP 0 1 0

tneitap,tniartseR 4 7 7

yrebboR 9 1 0

tpmetta,yrebboR 2 4 0

tnedicniciffartdnadaoR 0 3 0

hcaerbytiruceS 1 43 75

etavirp,ytreporpfotfehT 46 96 05

ecivreshtlaeh,ytreporpfotfehT 01 32 62

nosrepottaerhT 0 1 1

tnedicnisnopaeW 0 4 0

tluassalabreV 3 3 1

aeraderucesnU 1 2 0

latoT 611 162 622

Case Studies 31


Other contributing factors included:

1. The decision for SWSAHS to develop aSAMMA program including annual auditswas taken due to an identified need tomaintain a high level of awarenessregarding security and aggression issuesand to assist in changing the attitudes and“culture” of staff in thinking about theirown safety. An audit process wasconsidered a practical way of achievingsuch awareness and ensuring continuousimprovement in minimising securitybreaches and aggressive incidents as well asthe effects of any breaches and incidents.

2. WorkCover inspected facilities withinSWSAHS over the last few years inrelation to security of staff and issued anumber of Improvement Notices.

3. Sectors were requesting assistance withdevelopment and implementation ofappropriate policies, procedures, workpractices and staff education programs.

4. Staff were expressing concern regardingpersonal safety and security issues at theirworkplace. Aggressive incidents andbreaches of security had continued tooccur (some quite serious), whichsuggested that managers still requiredsupport with implementation of theDOH policy and procedures.

5. The OHS&R numerical profile is a NSWHealth Department initiative which wasdeveloped to address the broader issuesof safety within health care facilities.A review of this profile determined that itshould remain as a broad measure and thatindividual facilities should then developtheir own systems to meet the broadstandards within the OHS&R profile.

6. The SAMMA audit tool addresses eachpolicy statement contained in the HealthDepartment’s Safety and Security Manualand therefore was considered a verycomprehensive way of measuring theperformance of each Sector in every aspectof security and aggression.

7. The implementation and maintenance ofa SAMMA program was seen as a positivestep in developing a better practiceapproach for measuring and changingwork practices

How was it established?

In 1995, an audit tool was developed inresponse to the NSW Health DepartmentCircular 93/53, “Policy and Guidelines for theMinimisation and Management of Aggressionin NSW Health Care Establishments”.96 Thisaudit tool was reviewed later in 1995 to takeinto account the policy statements containedin the NSW Health “Security and Safety:Minimum Standards for Health CareFacilities”.98 An annual audit program wasthen established to measure performance inSAMMA issues.

In response to a need for review of the auditprocess and to address the ongoing issuesdescribed above (Rationale), agreement wassought and provided by General Managers, tohold a workshop with representatives from allfacilities, to identify the best way to establish a“whole of security” approach. A workshop wasconducted in 1998 and the following strategieswere identified to form part of an action plan.

• Security officers be accredited inaccordance with the requirements of theSecurity Industry Act.



• The Area Human Resources DevelopmentUnit investigate what SAMMA TrainingPackages are available.

• The SAMMA assessment tool be reviewedin accordance with the revised Safety andSecurity Manual.

• Additional staff be trained in conductingthe SAMMA audits.

• Central co-ordination of the audit programbe assigned to Area Commercial Services.

The strategy

1. Review of the SAMMA Profile: the 1995SAMMA assessment profile was reviewedand modified. The review took intoaccount all aspects of the NSW HealthDepartment’s Safety and Security Manual.The format of the assessment tool was alsoadapted to be consistent with the formatof the Health Department’s OHS&RNumerical Profile. The revised SAMMAwas piloted (as part of auditor training) toincorporate feedback from both auditorsand staff from the different Sectors withinthe area.

2. Consideration was given to the “scoring”aspect of the SAMMA Profile and as partof the pilot the trainee auditors decidedagainst using a numerical score. Instead ofa percentage score, performance reporting

would concentrate on whether a facilityachieved an A, B, C or D in each elementof the assessment tool. It was consideredthat this approach would allow facilities tofocus on performance for each elementrather than an overall score.Consequently, all reference to “scores” wasdeleted from the assessment tool andtrainee auditors proceeded with the agreedmethod of reporting performance asoutlined above (See attached outline ofSAMMA profile summary).

3. Auditor training: a total of twenty-sevenstaff attended auditor training. Thetraining comprised three majorcomponents:– 1 day session covering the processfor audits and the assessment tool– completion of one “pilot” audit andwritten report to General Managers– review session to discuss issuesarising from the application of the newassessment tool and audit process

4. Resources required to undertake surveys:two to three auditors conduct surveys foreach Sector, depending on the locationand size of units within each Sector.Community Health centres will besurveyed as if they are a facility withintheir “parent” Sector. Following is anestimate of time allocation necessary.

rotceS )ETF(ytilicaFfoeziS srotiduAforebmuN rotiduAhcaerofnoitacollAemiTdetamitsE

stisiVetiS gnitirWtropeR

nwotsknaB 8.092,1 3 syad5.2 yad1

loopreviL 9.182,2 3 syad3 yad1

dleifriaF 4.516 3 syad5.2 yad1

ruhtracaM 2.031,1 3 syad5.3 yad1

eebirracegniW 5.222 2 syad5.2 yad1

notgnirraC 0.78 2 yad1 yad1

edisearB 0.461 2 yad1 yad1

latoT 8.1975 syad61 syad7

Case Studies 33


5. Central co-ordination of the program ofsurveys takes approximately eight hoursand is the responsibility of AreaCommercial Services.

6. Result of Pilot Surveys: Facilities weregiven a rating of A, B, C or D for eachelement, as opposed to an overallpercentage score. It was considered thatthis approach would allow facilities toconcentrate on improving the aspects ofSAMMA that are a priority for eachfacility. A detailed consolidated reportwas given to Sector Managers indicatingresults for each element. This provideda basis for networking across Sectors asmanagement could clearly see wherebetter practice was in place.

7. The trainee auditors reported that therewas support for the audit and sectorsdisplayed a positive approach to theassessment process. However, auditorsand Sectors commented that the surveytool needs to be less detailed and theterminology simplified.

Evaluation of the SAMMA Program

Evaluation of the SAMMA program will bethrough the following key performanceindicators:

• improvement in levels achieved for eachelement within the audit tool

• number and type of reported securityrelated incidents and outcomes, and

• analysis of evaluations from staffeducation.

Who else has adopted this as

a strategy?

The NSW Health OH&S AdvisoryCommittee, along with the NSW HealthSafety and Security Steering Committee, iscurrently discussing the issue of measuringperformance across health for security andmanagement of aggression risks. Thealternatives being discussed are:

• adopting a separate numerical profile forsecurity and management of aggressionacross all NSW Health facilities

• expanding on the current OHS&Rnumerical profile, Standard 2.6, CriticalIncidents and Security.

Preliminary discussions have indicated that theissue of security and personal safety of healthservice employees is of high enoughimportance to warrant a separate audit. Inaddition to this, the current standard 2.6requires, for a “B” level, the completion of anannual security survey. However, it is alsoconsidered desirable to have a simple buteffective assessment tool, in which case theSWSAHS audit may be used as the basis forthe development of an appropriate assessmentmechanism. Not withstanding the abovecomments and possible direction of NSWHealth, the SAMMA tool will now be refinedto incorporate, where appropriate, suggestedchanges as a result of the comments receivedfrom Sector Management and auditors. Inaddition, the number of elements within thetool will be reviewed with a view toamalgamating elements where appropriate, ordeletion of elements where there is significantoverlap with the OHS&R Numerical Profile.

For further information contact: Mr CraigTurner, Manager Commercial Services,SWSAHS.



SAMMA profile performance level summary

dradnatS1 deveihcAdradnatS

A B C D

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seiciloP1.1

noitceleSdnatnemtiurceReeyolpmE2.1

ecnamrofrePAMMASfoweiveR/noitaulavE3.1

sksiRfonoitacifitnedI4.1

sksiRdeifitnedIfolortnoCdnatnemssessA5.1

tnemnorivnElacisyhP0.2

tnemnorivnElanretxE1.2

tnemnorivnElanretnI2.2

secivreSytiruceS3.2

tfehTfolortnoC4.2

lortnoCsseccA5.2

noitamrofnIfoegarotSdnaytiruceS6.2

slacituecamrahPfoegarotSdnaytiruceS7.2

sesaGlacideMfoegarotSdnaytiruceS8.2

secnatsbuSevitcaoidaRfoegarotSdnaytiruceS9.2

gniniarTdnanoitacudE,tnemeganaMtnedicnI0.3

elpoePevisserggAfolortnoCdnanoitacifitnedI1.3

noitatneirOdnanoitcudnI2.3

gniniartnoitneverptnedicnI3.3

)MSIC(tnemeganaMssertStnedicnIlacitirC4.3

secnatsmucriClaicepS0.4

srekroWdleiF1.4

snoitautiSycnegremE2.4

ydotsuCnistneilC3.4

sffucdnaHdnasnotaB4.4

:sleveL”A“forebmunlatoT

:sleveL”B“forebmunlatoT

:sleveL”C“forebmunlatoT

:sleveL”D“forebmunlatoT


Introduction

The Wentworth Area Health Service (WAHS)has adopted a comprehensive approach toensuring the health, safety and welfare at workof all employees in accordance with the NSWOccupational Health & Safety Act 1983(OH&S Act). An area wide strategic plan wasdeveloped to assist the organisation to meet itsresponsibilities regarding OH&S legislation.The goals of the strategic plan are to promotean injury free and healthy workforce, tofacilitate a consistent and effective OH&Sinfrastructure across WAHS, to reduce andappropriately manage the impact of workplaceaccidents and injuries and to return injured orill employees to full health as safely as possible.The strategic plan encompasses thedevelopment, promotion and implementationof specific prevention programs to reduceworkplace illness and injury.

One section of the strategic plan relatesspecifically to minimising the risk of violenceand aggression in the workplace, (and providesdetailed information regarding the prevention,minimisation and post incident managementof aggression in the work setting). The plan iscontinually being updated and adapted inresponse to the changing needs and demandsof the work setting and also in response tochanges in NSW Health policy, proceduralguidelines and relevant legislation.

Rationale

The plan was established following theappointment of an area OH&S Co-ordinatorand as part of the WAHS commitment toadhere to the requirements of the NSWHealth policy and procedural guidelines,Circular 97/97 and the NSW Health Safetyand Security Manual.


A working party was established comprisingtwelve senior staff and OH&S representativesfrom the WAHS. The brief of this workingparty was to address the issue of health andsafety in the workplace. Workshops wereconducted to facilitate the development ofthe strategic plan and involved as many staffas possible in identifying key issues impactingon health and safety in the workplace. Outlineproposals of the plan were presented toworkshop participants to seek feedback andencourage involvement in the development ofa comprehensive strategic approach to reduceworkplace illness and injury. Some of the issuesidentified in the workshops related to manualhandling, slips trips and falls, and anecdotalinformation regarding the increasing amountof violent and aggressive behaviour directedtowards health care workers. Following thisfeedback the working party began developingthe area wide strategic plan with an emphasison a risk management approach.

Case Study 2

Area Wide Strategic Plan 1997–2000

Wentworth Area Health Service



The strategy

The strategic plan describes goals andobjectives required to meet OH&Srequirements regarding the provision of a safeworkplace. Each objective has identifiedstrategies, specific actions required,performance indicators and inbuiltaccountability by identifying individuals orgroups responsible, expected dates forcompletion, and outcome or achievements todate (see attachment).

Topics included in the strategic plan are asfollows:

• accident and injury investigation system

• contractor information

• documentation

• hazardous substances

• latex management

• manual handling

• needlestick program

• slips trips and falls

• staff counselling services, and

• violence and aggression.

Outcomes

As a result of adopting a strategic approach tominimise the risk of aggression in theworkplace a number of initiatives have beenundertaken, or are in the process of beingimplemented. This process has been assisted bythe appointment of a facility SecurityManager, who has area wide responsibilitiesinclude the ongoing development anddissemination of security policies for WAHS,setting minimum standards for safety andsecurity in accordance with policy andlegislation and ensuring safety and security

requirements for all health facilities within thearea are in place. The WAHS Security Policyhas recently been updated in response tocurrent practice issues.

The indicated Security Manager is alsoresponsible for convening an Area SecurityCommittee to assist facilities withimplementing security policies. Thiscommittee meets bi-monthly and reviews anumber of issues relating to safety and securityat work.

• High risk areas are currently beingidentified and statistical reports are issuedto all facilities on a regular basis.

• Actions to control risks are progressivelyimplemented as risks are identified.

• Security is a standing agenda item atOH&S committees.

• A review of all violence/aggressionmanagement training for staff has beenundertaken.

• Staff working in identified high risk areasare given priority access to training.

• Training programs are conductedthroughout the year to increase staff accessto training.

• Regular updates on the implementation ofthe strategic plan are provided to theWAHS executive to ensure performanceindicators are monitored and thatidentified outcomes are completed by thedue dates.

Patient/staff issues

Staff were provided with the opportunity to beinvolved in the development, implementationand ongoing evaluation of the strategic plan.A number of issues have been identified forstaff and patients.

Case Studies 37


• The strategic plan provides direction forstaff and reinforces the need to adopt apreventative approach to ensure safety inthe workplace.

• The expansion of the Security Manager’srole and a regular security and OH&Scommittee structure provides staff withaccess to a forum to further exploreincidents of concern and identify futuremanagement options.

• Statistics relating to accidents/incidentsare disseminated and reviewed on aregular basis by identified persons/teamsand this enables the service to identifytrends, monitor areas of high risk andinstitute appropriate preventativemeasures.

• Staff in identified high risk areas are givenpriority access to training and thisincreases individual responsibility in themaintenance of a safe workplace andincreases staff awareness of the need toundertake assessment and develop skills inresponding and appropriate referral.

Conclusion

The strategic plan reinforces the commitmentof WAHS to ensure the health, safety andwelfare of all employees in the workplace.It is a comprehensive approach and includesoperational details to ensure that specificstrategies are in place and provides inbuiltaccountability and target dates for deliveryof outcomes.

For further information contact: Ms RoslynSimpson, Risk Manager, WAHS.




Introduction

Central Sydney Area Health Service (CSAHS)has adopted a systematic and coordinatedapproach to critical incident managementthrough the development of a comprehensiveCritical Incident Management (CIM) Plan. Thepurpose of the CIM Plan is to develop a riskmanagement approach to critical incidents andstandardise this across the Area Health Service.The specific aims of the CIM Plan are to:

1. develop an operational environment thatreduces, minimises or prevents theoccurrence of critical incidents

2. implement systems to facilitate timely andeffective responses to critical incidents

3. identify and facilitate the provision ofresources necessary to ensure recoveryfrom critical incidents

4. review, investigate and report on incidentswith the purpose of reducing the potentialfor similar future incidents, and

5. ensure staff are appointed and trained todeliver a skilled and efficient response.

The CIM Plan includes specific informationrelating to the following areas of management:

• role and responsibilities for facilitymanagers

• strategies to improve incidentmanagement

• broad based risk management strategiespertaining to prevention, incidentmanagement, post-incident management,accident/incident investigation and follow-up, training, policies and procedures, andarea wide promulgation, evaluation andreview

• CSAHS needs analysis, and

• appendices, which provide detailedinformation pertaining to key roles,checklists for security and managers,and CIM systems in place and siteco-ordinators.

The CIM Plan defines critical incidents asevents outside the normal experience of aperson which overwhelm their coping skillsand cause them to experience unusually strongemotional reactions at the time or some timelater. These reactions are best described as

Case Study 3

Critical Incident Management Plan

Central Sydney Area Health Service

CSAHS Critical Incident Committee



traumatic stress reactions and interfere with aperson’s ability to function either at the timeof the incident or some period later. Eventsthat precipitate traumatic stress reactionscommonly have one or a number of thefollowing characteristics:

• they are sudden and unexpected

• they are violent and shocking

• they are untimely

• they involve a significant degree ofsuffering and or loss, and

• they involve a high degree of damage.

Rationale for the CIM Plan

CSAHS recognises that the most effective wayto minimise the risks associated with criticalincidents is to identify and assess the potentialfor problems. Once the potential is assessedsystems can be put in place to eliminate orreduce the likelihood of a critical/aggressiveincident. In 1997 NSW Health issued theCritical Incident Manual Policy and Guidelines(Circular 97/97)91 for minimising andmanaging critical incidents in NSW publichealth care facilities. This manual providedinformation on:

• critical incident management and staffresponsibilities

• incident prevention

• response plans

• critical incident response

• incident recovery and review, and

• incidents involving aggression.

In addition, the NSW Health Safety andSecurity Manual identified the responsibilitiesof staff at various levels within the organisationtogether with the actions they are to take in the

event of a particular occurrence, such as fire,bomb threat, assault, or armed hold-up. Thesemanuals also highlighted the need for AreaHealth Services to develop specific guidelinesto cater for local needs. In response to thesedirectives the CSAHS Plan was developed tobe consistent with the NSW Health Circular97/97 and the NSW Health Safety andSecurity Manual.

Statistics

CSAHS maintains statistics relating to incidentsof aggression and workers compensationclaims. For the period July 1995 to June 1996a total of 38 claims were made from allCSAHS facilities related to assaults, 52 in1996/97, 38 in 1997/98 and 16 for the periodJuly to December 1999. The occupationalgroup most affected was nurses, who accountedfor 73% (N=28) of 38 claims in 1995/96, 75%(N=39) of the 52 claims in 1996/97, 84%(N=32) of the 38 claims in 1997/98 and 92%(N=22) of the 24 claims to date in 1998/99.

These statistics do not necessarily reflect theimpact of critical incidents in the organisationbecause not all critical incidents are reportedand of those reported not all lead to workerscompensation claims. It was recognised thatcritical incidents can be particularly distressing(and damaging) on an individual level, andthat particular attention was warranted withregards to the prevention and managementof critical incidents. This necessitated theidentification of high risk areas and thedevelopment of risk assessment approachesand risk control strategies. Within CSAHSthe following areas have been identified ashigh risk:

• mental health services

• dental clinics

Case Studies 41


• emergency departments

• paediatrics at RPAH and CanterburyHospital, and

• neurology at RPAH.


The CIM Plan was launched in June 1999following extensive consultation and rewrites.It was piloted and further modifications weremade. The CIM Plan was then circulated to allfacility managers for implementation.

The strategy

The CIM Plan adopts a broad based riskmanagement approach and provides specificinformation on preventative strategies.Strategies related to risk identification, riskassessment, and risk control are described andguidelines for prevention are provided. TheCIM Plan also contains intervention strategieson incident management and post-incidentmanagement and includes specific informationrelating to CISM. The responsibilities ofmanagers regarding the maintenance of a safeworkplace are outlined and the legal implicationsare also identified. Training requirements,accident/incident investigation, reportingmechanisms and policy and proceduralinformation are included. A committeesupports the CIM Plan with representativesfrom all key areas in CSAHS. This committeemeets bi-monthly to discuss all issues relatingto critical incidents.

Outcomes

Specific measurable objectives/strategies, to becompleted within nominated timeframes, are akey part of the CIM Plan. Action taken underthe guidance of the CIM Plan can then becompared with specific outcomes.

Progress and adherence to the CIM Plan isreviewed as follows:

• an annual review of the CIM Planincluding attainment of nominatedobjectives/strategies

• quarterly reviews of critical incidentstatistics, workers compensation data(de-identified) and Treasury ManagedFund (TMF) performance.

To assist facility managers to comply with theCIM Plan a detailed needs analysis tool wasincluded. This provided information regardingcurrent systems, policies and procedures inplace within CSAHS and categorised these inrelation to broad based risk managementstrategies (prevention, incident management,post-incident management, accidentinvestigation, training, policies, proceduresand evaluation). Subsequent to classifying theexisting policies/procedures, and systems inplace, the CIM Committee identified gaps orspecial needs and developed strategies toaddress these deficits. The CIM Plan includesa monitoring tool to assist facility managers toundertake six-monthly reviews of their servicesin the key areas of critical incident riskmanagement, specify compliance and toprovide evidence of achievements.

Staff issues

Under the NSW Occupational Health &Safety Act employees are required to take thecare of which they are capable, for their ownhealth and safety and the health and safety ofothers in the workplace. They must alsocooperate with the employer where theemployer institutes measures to ensure healthand safety. The CIM Plan reinforces the needto comply with this legislation and specifies therequirements regarding formal reporting,



workers compensation and rehabilitationprocedures.

The CIM Plan highlights the need for CriticalIncident Stress Management (CISM) followingstressful events to reduce the trauma forindividuals who experience distressingincidents and the responsibilities of theorganisation to ensure that prompt andefficient services are readily available.

CSAHS facility managers are required toensure that employee job descriptions includeappropriate information regarding their rolesand responsibilities in the prevention,management, investigation and review ofcritical incident stress management strategies aswell as their training obligations. The CIMPlan specifies roles and responsibilities formanagers, telephone switch operators and staff.

Who else uses this as a strategy?

• South Western Sydney Area HealthService (SAMMA)

• Wentworth Area Health Service (AreaWide Strategic Plan)

• South Eastern Sydney Area Health Service(Critical Incident Management Policy indraft)

• Ambulance Service of NSW (in draft)

For further information contact: Dr MargyHalliday, Risk Manager CSAHS.

Central Sydney Area Health ServiceCritical Incident Management Plan

Contents

1 Central Sydney Area Health Service Statementof Principle

2 Aims of the CSAHS Critical IncidentManagement Plan

3 Roles and Responsibilities4 Broad Based Risk Management Strategies

4.1 Prevention of Critical Incidents4.1.1 Risk (Hazard) Identification4.1.2 Risk Assessment4.1.3 Risk Control

4.2 Incident Management4.3 Post-Incident Management

4.3.1 Access to EAP Services4.3.2 Legal implications

4.4 Accident Investigation4.5 Training4.6 Policies and Procedures4.7 Area-Wide Evaluation and Review

Analysis of CSAHS Systems and Needs (Table)1 Prevention

1.1 Risk Identification and Assessment1.2 Risk Control

2 Incident Management3 Post Incident Management4 Accident Investigation5 Training6 Policies and Procedures7 Area Wide Evaluation and Review

7.1 Performance Indicators

Improving Critical Incident Management (Table)1 Prevention2 Incident Management3 Post-Incident Management4 Accident Investigation5 Training6 Policies and Procedures7 Area-wide Evaluation and Review

Appendix 1Role of SupervisorRole of Telephone Switch OperatorRole of Staff

Appendix 2Critical Incident: Security Checklist

Appendix 3Critical incidents: Post-Incident Check List forSenior Managers

References


Introduction

Staff throughout the Northern Rivers AreaHealth Service (NRAHS) were exposed toverbal abuse and threats with several reportedinstances of physical assault. Staff wereuncertain of what to do, how to respond, andunclear of their legal rights. Mostly staffexpressed feelings of helplessness andpowerlessness. These issues were repeatedlybeing presented at OH&S forums.Management was increasingly concernedregarding the level of verbal abuse directedtowards their staff. It was decided that legalopinion should be obtained to clarify the rightsof staff members in these situations and thatstrategies be explored to assist staff to respondto these situations in a professional manner.

Statistics

Many staff members stated that there had beena major increase in verbal abuse and verbalthreats particularly in the preceding two years.Only the more serious threats or aggressiveincidents tended to be reported. Verbal abusewas not always officially reported so thisinformation was not accurately reflected in thestatistical data relating to aggression.

Rationale

A number of factors contributed to thedevelopment of this tool as is evidenced bythe following:

• increased incidence of verbal abuse/aggression from patients, visitors andothers

• statistics did not reflect the increase inincidents of verbal abuse as staff tendednot to report incidents of verbal abuse

• staff reported feeling increasinglypowerless and helpless when confrontedwith verbal abuse

• staff wanted clarification of their legalrights in these situations

• perceived need to seek legal advice toclarify rights of all involved

• serious attempt by management toacknowledge staff distress and focus ona preventative strategy

• management wanted to demonstrate theirsupport for staff in a tangible manner, and

• as part of a comprehensive approach todealing with verbal abuse as a precursor toaggression.


Following extensive multidisciplinaryconsultation with clinical and non-clinical staffit was decided to convey a clear message ofnon-acceptance of aggression (both verbal andphysical) in the workplace. This approach wasto be communicated to service users via anotice displayed in a prominent place. Legal

Case Study 4

Notice of Non-acceptance of Aggression

Northern Rivers Area Health Service



advice was sought from a number of differentsources to inform the development of a notice.There was no opposition from staff todisplaying the notice in the work setting. Thefundamental understanding that needed to beconveyed was that everybody has rights andthat there are legal consequences forindividuals who display aggressive behaviours.Health care workers have the same legal rightsand recourse to the law as clients and serviceusers. This was the focus of the notice and wasconveyed in clear language to the client groups.The initial implementation phase involved atrial of the notice in identified high-risk areas.

The strategy

Once agreement was reached regarding theformat for the notice it was referred to theArea CEO for approval. Following receipt ofapproval early in 1998 the notice was displayedthroughout Lismore Base Hospital includingthe Psychiatric Unit. The notice was initiallydisplayed in prominent positions in receptionareas, above counter areas, in nurses’ stationsand in patient areas and was aimed at patientsand visitors. Notices were also displayed incommunity centres, dental clinics, and otherhealth care facilities. Areas that did not haveany notices began requesting them. The planwas to use the statement of intent to pursuelegal action as a deterrent for workplaceaggression (both physical and verbal). Therewas some discussion regarding the feasibilityof pressing charges against patients with apsychiatric disorder, particularly if they wereactively psychotic at the time of the incident.It was generally felt that these patients wereusually identified and for the most parteffective management strategies were instituted.

The patients most likely to respond positivelyto the notices were patients with a behaviouraldisorder who would understand that therewere consequences for acting out theiraggression. While it is acknowledged that thereare some difficulties bringing charges againstpatients with a psychiatric disorder this shouldnot prevent staff from being supported inexercising their legal rights when theyencounter aggression in the workplace.

Outcomes

• The introductory strategy was met withstaff approval.

• The Area Health Service noted howeffective this strategy had been.

• The effect had been much greater thananticipated at the outset.

• There was a major decrease in verbalabuse. Some areas, particularly dentalclinics, reported an almost 90% decreasein verbal abuse.

• Reception staff reported a dramaticdecrease in verbal abuse.

• Staff reported increased confidence indealing with verbal abuse.

• There has been a consistent teamapproach in the management ofaggression.

• It has encouraged further discussion andprompted staff to consider a range ofstrategies to manage aggression in theirworkplace.

Patient issues

• Now a well established AHS response tosituations.

Case Studies 45


• Word gets out that the AHS is addressingthe issue of abuse/aggression towards staffmembers and that there are consequencesfor patients.

• This in itself is a further deterrent.

• There were six prosecutions in the 16months after the strategy was implemented.

Examples of action against aggressors

• An AVO was taken out against a patientwho attended the hospital with a weaponin their possession; this patient had awell-documented psychiatric disorder.

• A patient was charged with damagingproperty in the Emergency Department.

• An inpatient who was verbally abusiveand threatening towards staff, andcontinued to abuse staff, was assessed andsubsequently discharged.

Staff issues

• Staff report a heightened awareness oftheir legal rights and of issues relating toabuse/aggression at work.

• Staff are more focused on identifyingstrategies for responding to abuse/aggression at work.

• The notice conveys a clear messageregarding service expectations andmanagement support.

• It increases staff confidence whenresponding to incidents of verbal abuseand provides a consistent approach forstaff.

• Staff acknowledge the efforts of AHSmanagement to reduce aggression andsupport staff who are abused.

• It has a positive impact on staff morale.

Who else has adopted this as

a strategy?

Several other Area Health Services have similarstrategies as part of a comprehensive approachto managing verbal and physical abuse. Thisapproach has been endorsed by health servicesoverseas where there is an international movetowards an environment of “zero tolerance”particularly in the U.K. (Issues Statement, 19October 1999, Department of Health UK).

Conclusion

This strategy supports an approach beingadopted by health services and other agenciesin Australia and overseas. It conveys a clearmessage to service users that individuals haveto accept responsibility for their own behaviourand that there are consequences when this isnot the case. It is part of an overall riskmanagement approach and its effectivenessappears to be linked to a total risk managementapproach rather than relying on it as a singlestrategy to resolve all kinds of workplaceaggression. It is a clear message of supportfrom managers and the consultative nature ofits development and implementation increasesthe likelihood of staff support and staffconsistency in implementation. It is costeffective, can be modified to meet local needsand can be linked to outcome measures.

For further information contact: Mr DavidGrey, OH&S Manager, NRAHS.




Introduction

As part of the Critical Incident ManagementPlan, CSAHS established a 24 hour, 7 days perweek on-call service for staff and managersinvolved in critical incidents in the workplace.This service was established as an additionalcomponent of the Employee Assistance Program(EAP) within the CSAHS in September 1997.The primary activities of the service involvepost incident support and consultation, oncethe immediate incident has been addressedand managed. Services may be provided overthe telephone, or on site when required. Thismay be immediately post-incident, within24–72 hours after the incident, or later onsome occasions as required.

The types of incidents regarded as criticalincidents follow the NSW Health Policy andGuidelines (97/97) page 2.1.91

“Critical incidents especially related to healthcare facilities could include:

• assaults on staff by patients or others

• unexplained or suspicious deaths orsignificant bad outcomes due to possiblepoor hospital or service administration

• suicides or attempted suicides by a patientor staff member”.

This service is provided by members of theEAP staff counselling service, who offerCritical Incident Stress Management (CISM)

Case Study 5

24 Hour On-call EAP Service for Critical Incidents in the Workplace

Central Sydney Area Health Services

services during office hours as part of theircore duties.

The service is activated by the Manager of thearea where the critical incident occurs. TheManager may initiate this directly, or do so viatheir own Senior Manager. The philosophy ofthe service is to support the relevant levels ofmanagement in their critical incident response,rather than “taking over” the post incidentmanagement. This collaborative approach hasa number of benefits, including: greaterdevelopment of managers in their post incidentskills; reinforcing the team approach and“natural” peer support activities, and a positiveacceptance of the EAP role.

CISM Services include: consultation withmanagers; individual or group defusing;one-to-one support on site, or via telephone;practical assistance with escorts to medicalservices; acute follow-up, family support andgroup debriefing.

Employee Assistance Program staff



Statistics

“The challenge to Senior Management is todetermine when such exposure has taken placeand the potential has become actual criticalincident stress. Management need to ensure anappropriate response occurs which acknowledgesthat psychological harm may have been done andto provide intervention and support to thoseaffected” NSW Health Policy and Guidelines(97/97: p2.2). 91

Individual responses to potential criticalincidents vary enormously, both from personto person, and at times, with the same personon different occasions. Effective CISM involvesthe implementation of a system that identifiesthe hazards and risks in the workplace andestablishes controls to enhance the preventionof serious incidents occurring and to minimisethe impact on people affected when incidentsoccur. In line with the NSW Health Policyand Guidelines (97/97) Post Incident strategiesare only effective within the framework of aCISM Plan which encompasses prevention,preparation, response and recovery.

The activations have been in response to arange of critical incidents, including:

• staff assaulted by patients, visitors orintruders

• patient suicides, serious attempts andcompleted

• staff suicides, and sudden, unexpecteddeaths of staff members

• traumatic, unsuccessful resuscitations ofpatients, and particularly gruesomeemergency patient presentations.

Rationale

The vast majority of health care staff have thepotential to encounter critical incidents in thecourse of their work, and many staff who workin high risk areas such as: emergencydepartments; acute mental health services;psychogeriatric areas; frontline reception staff,security and drug clinics encounter high risk ofexposure to critical incidents.

doireP snoitavitcA stuOllaC

8991tsuguA–7991tpeS 63 71

99tsuguA–8991tpeS 62 9

0002beF–9991tpeS 41 4

latoT 67 03

Table 1 On-call activations and on site call outs

Table 2 On-call occasions of service

doireP stlusnoCreganaM secivreSetiS-nO troppuSenohP snoissaccOlatoTecivreSfo

8991guA–7991tpeS 24 83 92 901

9991guA–8991tpeS 64 23 02 89

0002beF–9991tpeS 42 8 7 93

latoT 211 87 65 642

Case Studies 49


In facilitating an appropriate, early response anumber of positive effects can be maximised:

• effective assessment of acute state andimmediate needs of staff exposed totrauma

• more efficient access to medical serviceswhen needed

• strong message of acknowledgment andsupport to affected staff

• key information provided regardingsupport services for post-acute stage

• .ore effective separation of staff supportstrategies and clinical/medico-legalinvestigative requirements.


In 1997, CSAHS Senior Management reviewedthe full range of prevention, preparation,response and recovery CISM strategies thathad been implemented. While there weremany positive strategies that were applied, thepost incident responses needed to be moresystematic, and more effectively coordinated.An Area Committee was formed to developan Area CISM Plan, to be adapted by everyCSAHS facility and service, and oversee theimplementation of all aspects of the plan ata local level.

The strategy

All service areas are aware of the 24 hournumber to activate the on-call service for workrelated critical incidents. This information isdisseminated through flyers, pamphlets andinserts in orientation and induction packagesthroughout the CSAHS. EAP staff conductregular sessions in the Critical Incident

Management training programs provided formanagers and staff within CSAHS. Tailorededucation and inservice CISM programs havealso been provided for high risk and specialisedareas. These training programs are scheduledthroughout 2000, and they are mandatorycomponents of training for managers.

Outcomes

Feedback from senior managers, after hourssupervisors and staff has been very positive.Comments have focussed on the supportive,professional and accessible service provided byEAP staff. Rapport has been quicklyestablished and the 24 hour service functionsquite naturally as an extension of the existingcore EAP service.

Statistics are maintained on non-identifyingdata, number of call outs, telephone supportprovided, occasions of service and on-siteservices among others. Manager and stafffeedback has been provided throughdiscussions and regular contact with servicemanagers and site managers. It is planned toundertake satisfaction surveys and integratethese into the service provision.

Who else uses this strategy?

Within the public and private health industryof NSW, a number of models have beenutilised, from the use of internal staffcounsellors to external, specialised CISMproviders, and a combination of both.Economic factors, accessibility, response times,efficiencies, staff resources, confidentialityconcerns, knowledge of and sensitivity tohealth cultures and settings are all important inconsidering appropriate, effective strategies.



Conclusion

The service has been well utilised since itslaunch two and a half years ago. The cleartrend has been more effective utilisation ofexisting on site resources, and telephonesupport rather than the higher percentage ofcall outs provided in the first year. A cultureof support and caring is reinforced and earlyinvolvement in supporting affected workersimproves individual outcomes. Managers havealso developed a greater awareness of a broaderrange of potential critical incidents, andactivated support accordingly.

For further information contact: Mr ChrisPatchett Manager EAP, CSAHS.

Case Studies 51


Attachment 1. Critical incidents: Post Incident Check List for Senior Managers


Note: Senior Manager to record all steps taken. Time frame described is optimal.

1. Immediately after incident: Staff and patient injuries

Medical officer, where available, to assess injuries – staff should go to Emergency Dept or may choose own MO

If further medical assessment/treatment is indicated, notify Emergency Department Nursing Team Leader orstaff member’s own MO and outline incident and injuries

Organise transport and brief driver and/or escort, as required

Notify on call EAP Staff Counsellor that a staff member(s) is attending Emergency Department

List all staff involved in incident and their contact numbers, and ensure this includes any senior managers,supervisors, relief and assisting staff of all disciplines, where relevant

Hold/organise defusing, note time held and staff who attended

Ensure all staff involved in the incident are offered ongoing support

Ensure the unit/department has appropriate staffing to complete shift

Ensure notification of relatives of staff, and refer them to the relevant Emergency Department – provide phone number

Ensure patient safety and modify clinical management if required

2. Within two hours of Incident

If during office hours inform Director of Nursing, or appropriate senior manager

If after hours, follow usual protocols to inform senior management

Contact EAP Staff Counsellor-on-call via RPA Hospital switch 9515 6111, and outline incident and injuries

Ensure staff accident/incident forms are completed and returned.

Ensure Workers Compensation and Rehabilitation information is provided to injured staff

Check documentation has been completed in the patient’s file, if appropriate

Check that patient/client incident form(s) has been completed, if appropriate

Begin department manager briefing note

Ensure that protocols are followed regarding communication with Police and/or media

3. Within 24 Hours of incident

Ensure incident investigation and possible WorkCover reporting requirements are discussed with OH&SCo-ordinator or equivalent

Patient debriefing completed if required. Consider inviting patient representatives/advocates or consumerconsultants or patient support

Ensure that injured staff are contacted at home by management representative and EAP Counsellor for follow-up

Ensure that staff support is planned with EAP staff counsellor including: provision of full list of staff affected andidentification of staff support co-ordinator

4. Further Follow-up

Follow-up staff support co-ordinated as required

Personal acknowledgment by senior management of staff involved in incident

Multidisciplinary clinical review of patient related incident undertaken

Post incident management review co-ordinated

Keep contact with staff involved in incident and facilitate return to work, including appropriate liaison withrehabilitation co-ordinator and EAP staff counsellor

September 2000



Attachment 2. Critical Incidents: EAP Staff Counsellor’s Checklist


Immediately After Notification

Liaise with managers, map out list of staff involved, including witnesses, medical officers, support staff etc, notjust those directly injured or threatened. Organise progress feedback for manager

Identify who is co-ordinating staff support response. This co-ordinator should ensure response plan is made andupdated

Initial diffusing organised if required, ensure staff are offered this support proactively, as a normal aspect of postincident management. Staff support activities are not mandatory. All staff should at least be given a copy of theCISM handout

Make a list with contact details of staff affected by critical incident. Double check details, and ensure extra copyis made

Contact all staff on list to offer support services

Ensure all affected staff have safe means of transport home. Assist with organising lifts, cabcharge or providepreparation for careful driving or pedestrian strategies

Notify other counsellors regarding the critical incident. Organise other work commitments – rescheduleappointments etc with assistance from other EAP team members, as required. Arrange time for own debriefingwith colleague after acute stage completed

Check for any hospitalised staff (including Emergency Department), organise personal support, ensure relatives/close friends are notified and supported. Liaise with Social Work service to clarify roles and specific responsibilities.

Staff Health notified, if relevant.

Liaise with management regarding latest information regarding client or visitor who caused critical incident –status, whereabouts, plan for management over next 24–48 hours, police action etc.

Establish a plan with senior management for informing other staff of incident as they come onto later shifts.Carefully assess process of informing other key staff who may not return to work for some days, eg Allied Health

Access EAP colleague for own debriefing

48–72 Hours Post Incident

Appropriate follow-up with affected staff and managers

Review important developments, including: management and location of client(s) involved in incident; policeaction; funeral details, and clinical review timing

Assess need for further group or individual support. Organise appropriately

Ensure staff are given assistance, if required, with OH&S forms, police processes, etc

Resources Required

Mobile phone, charged and prepared

Home kit plus stock in EAP offices comprising: handouts and EAP information; Cabcharge; personal stressmanagement materials, and key contacts list – EAP manager; senior health service managers; acute careteams, and EAP colleagues home and work numbers


Introduction

A peer support program has been developedand implemented for clinical and non-clinicalstaff who work in the Critical Care Divisionof Liverpool Hospital as part of a pilot project.The purpose of the program is to providesupport for staff who work in stressful areasof practice through a facilitative process withstaff of the same or similar rank. The programhas been operational since July 1999 andpreliminary evaluation is encouraging withplans to extend this model into other areas ofpractice in the future.

Rationale

The program was developed in response toidentified needs of staff who work in busy,demanding, stressful areas of practice. Nursesworking in critical care units such asemergency departments, intensive care unitsand operating theatres perceived a need to havesome form of formal support structures toassist staff cope with the demands of theirroles. The process of conferring or consultingwith a peer in a supportive setting to resolveissues impacting on practice was accepted andthe value of formalising these arrangementswas recognised. Some of the staff had beeninvolved in the development of similarprograms in other employment areas or hadparticipated in similar programs and reported

positive outcomes. This provided the impetusto explore support options utilising theresources and expertise available.


A group of staff approached the StaffCounsellor to assist with the development of apeer support program that met the needs ofstaff who worked in the very busy critical careareas, which included the emergencydepartment, intensive care unit and operatingtheatres. A steering committee was establishedto examine the structure of a program, developpolicy and procedural information, addresstraining and selection of peer supporters andappoint a group to direct the development ofthe program. A code of conduct wasestablished and privacy, confidentiality andboundary issues were addressed. A two-daytraining program, developed by the StaffCounsellor, was run with representatives frommanagement, clinical staff and the union,invited to participate. The program was wellreceived and it was decided to undertake apilot program. Inservices about the programwere run in the units of the divisionidentifying the members of the Peer SupportTeam, a contact report sheet was developed(see attached) and information about theprogram was disseminated through the CriticalCare Newsletter.

Case Study 6

Peer Support Program

South Western Sydney Area Health Service



The strategy

A peer support program is an informal processwhere one staff member discusses issues ofimportance with an identified peer supportmember on a one-to-one basis. The sessionsare not time limited but vary depending onwork commitments, time constraints and theneeds of the staff member. There are norestrictions on the content of the sessions andtopics discussed are usually related to some ofthe following:

• dealing with critical incidents/needlestickinjuries

• demands of shiftwork

• stress/burnout

• home/family/financial issues

• interpersonal relationships/conflict/roleidentification

• workload/work environment/competingdemands, and

• resources/equipment.

The confidential nature of the sessions isacknowledged with no formal recordsmaintained on the content of individualsessions or any information relating to theperson accessing the program. Peer supportersmaintain data on the number of sessions theyfacilitate and some of the main topics exploredto assist with evaluating the program. TheStaff Counsellor provides ongoing supervisionand support for the supporters and acts as areferral destination when problems encounteredare too severe or complex. Administration isvery supportive of the program and sessionsare conducted in work time to enable staff toaccess the program.

This program relies on the work not only ofthe peer-support team members but also onthe on-going commitment of committeemembers – in this program an anaesthetistplays a key role.

Outcomes

Finding a model that has some degree ofaccountability, can be linked to enhancedclinical practice and improved consumeroutcomes while at the same time providingstaff with the support they need, is difficult.The inherent difficulties in evaluating a peersupport program and attributing specificoutcomes to a single program are recognised.Initial evaluation is focusing on numbers ofstaff accessing the program and subjectivereports regarding the usefulness of theprogram. Examples of comments received areas follows:

• very valuable experience

• very approachable people

• providing much needed support to busyareas, and

• a great program.

Staff issues

Staff report positive experiences with theprogram to date and use the sessions to reflecton their practice and identify positive copingstrategies. There is a general recognition of thestressful areas of practice and that this is aprocess of providing staff who work in theseareas with much needed support. Otherclinical areas, for example the psychiatric unit,maternity unit and community staff haverequested information about the program andexpressed a willingness to implement similarprograms in their teams.

Case Studies 55



Peer support programs are well recognised inAustralia in the emergency services such as thePolice, Fire and Ambulance and models of peersupport have been established as an integralpart of professional practice in professionalgroups (psychiatrists, nurses, social work)overseas. There are developing models in many

of the helping services within Australia,particularly associated with clinical internshipprograms, however it has been slow topermeate mainstream practice. There is a lot ofinterest in the provision of a peer supportprogram that is practical, acceptable to staffand possible within existing resources.

For further information contact: Mr TonyHomer, Staff Counsellor, SWSAHS.




Introduction

This self-learning package has been developedby the Consultation and Liaison NurseConsultancy – Clinical Nurse Consultant(CNC) at the Prince of Wales Hospital(POW), a large Sydney teaching hospital.The package was primarily developed forgeneral nursing staff who work at POWHospital but can be successfully transferredand adapted for use in other areas.

The self-learning package focuses on theminimisation and management of aggressionin health care settings and encourages thelearner to identify their own learning needs.The package contains a pre and post testquestionnaire to provide feedback on knowledgeand skills gained and includes information,trigger questions and reference materialpertaining to minimisation, management andpost incident management of aggression. Priorto completing the package participants areencouraged to attend a one-hour introductoryeducation session presented by the NurseConsultants.

A self-learning package was deemed to be aneffective initial strategy and a resource for staffwho were experiencing an increasing level ofabuse and aggressive behaviour in a variety ofsettings throughout the Hospital. There werevarious educational programs on offer but dueto the large number of staff employed access to

these programs was on a priority basis. Thepackage was based on the Department ofHealth Guidelines on the Minimisation andManagement of Critical Incidents in HealthCare Facilities (Circular 97/97)90 and was notintended as a stand-alone package but as anadjunct to education and skill-based training.The package was completed and distributed toall areas early in 1999.

Rationale

In the months June to September 1997 anincrease in the number of aggressive incidentsin POW Hospital was noted. This wasevidenced by the frequency of calls toConsultation and Liaison Nurse ConsultancyClinical Nurse Consultants for assistance inthe behavioural management of such patients,

Case Study 7

Minimisation of Violence and Aggression: A Self-learning Package

South Eastern Sydney Area Health Service

SOUTH EAST HEALTHSouth Eastern Sydney Area Health Service



and an increase in requests and the number ofreferrals for Critical Incident Stress Debriefing(CISD) following aggressive incidents.Anecdotal evidence presented during in-serviceeducation suggested that an increasing numberof staff were being threatened with assault,verbally or physically abused and intimidatedin the workplace. In response to the above, abrief to develop a self-learning package titled‘The Minimisation of Violence andAggression’ was undertaken after discussionwith the Principal Director of Nursing.


The package was developed as one of a numberof strategies to deal with the increasing amountof aggression in the workplace. Other strategiesincluded participation in specific training,development of policies and procedures and anArea wide mediation team to assist staff to dealwith conflict in the workplace.

The strategy

The first step in preparing the packageinvolved the development of guidelines for themanagement of aggressive incidents and theseguidelines were also presented in the form of aposter. A laminated version was circulated toall clinical areas just prior to the circulation ofthe package. This acted as a prompt to staffwhen dealing with an incident and containedtelephone numbers of key personnel. Thepackage contained information sections ontheories of aggression, communicationstrategies to de-escalate situations, crisiscommunication and strategies to assist withlimit setting. Other areas covered includedlegal issues, guidelines for management, postincident management, handling complaintsand strategies for minimising aggression inopen areas and various other references. Two

special interest topics addressed wereaggression in the elderly and horizontalviolence. A video entitled “What if it turnsnasty” is part of the package and is accessedfrom a central location.

Once the package was completed in 1998 apilot study was conducted in five clinical areasyielding the following results:

• 18 nursing staff participated

• it took staff an average of three and a halfhours in total to complete the package

• most staff worked on the package at thesame time as others

• 100% thought the layout of the packagewas user friendly

• 100% stated that the content was easy tounderstand, and

• pre- and post-test assessments werereviewed.

Some corrections and editing took place as aresult of the study and the packages were thencirculated to Nursing Unit Managers (NUMs),Clinical Nurse Specialists (CNCs) and allclinical staff. Fifty packages were distributedto all clinical areas in March 1999 and threehundred staff have attended the one-houraccompanying in-service.

Outcomes

Formal evaluation of the package was due tocommence in early 2000. Staff complete aself-evaluation pre and post test quiz to testtheir knowledge level both before and aftercompletion of the package. The packages arefreely available and can be accessed for regularrefreshers. Formal evaluation forms are alsoincluded and the reader is encouraged tocomplete them and return them to the CNCs.

Case Studies 59


Anecdotally there are less frequent calls fromsome areas to assist with the management ofaggression and there are increasing requests forconsultation on how to prevent incidents andimprove personal management strategies. Staffreport an increased awareness of theimportance of maintaining vigilance in thisarea and the influence of their personal styleof intervention in achieving a positive outcomefor all involved. Another observation noted asa result of introducing this package is thatother departments/disciplines have started torequest consultation regarding theminimisation of aggression, eg pharmacy,community centres, clerical staff and receptionstaff.

Feedback has been positive and commentsinclude:

• “now I am more aware of my own bodylanguage when talking to aggressiveclients”

• “I enjoyed the package, it is easy to read”

• “an excellent guide to self control andcommon sense”

• “I feel this package is a bonus for all staffas getting to courses can be difficult”.

All staff reported that the package was relevantand easy to understand. Some staff havecommented that there is some repetition

within the package and this will be consideredwhen the package is next reviewed.

Patient issues and staff issues

Current staffing levels, increased number ofvacancies and staff turnover have all affectedthe number of nursing staff who havecompleted the package. The package has beenimplemented at the Royal Hospital forWomen and will be implemented at SydneyChildren’s Hospital, Randwick in early 2000.

Conclusion

This approach to the minimisation andmanagement of aggression provides staff withquick access to specific information regardingthe safety of the work environment in whichthey are working while staff are waiting toparticipate in centre based training programs.It encourages staff to take some responsibilityfor their own safety and learning needs inpartnership with the AHS and directs staff toreading materials, policies and highlightsspecific local protocols.

For further information contact:

Ms Allison Boyle CNC, Liaison Psychiatry,Prince of Wales Hospital, SESAHS.

Ms Mari Evans-Rooney CNC, LiaisonPsychiatry, Prince of Wales Hospital,SESAHS.




Introduction

The Safety Zone Alarm System was installedthroughout the grounds of Royal Prince AlfredHospital (RPAH) in Central Sydney AreaHealth Service (CSAHS) in 1997. The NSWMinister for Health launched the systemmarking RPAH as the first hospital in NSWto use this technology as part of an overallapproach to the provision of safety within thework setting.

Rationale

The Safety Zone Alarm System was installedfollowing consultation with staff andrepresentation to the General Managerregarding the safety and security of staff whowere employed at RPAH. The hospital campusat RPAH covers approximately 15 hectares andstaff were becoming increasingly concernedregarding safety issues, particularly at night.


The Area security manager was asked toinvestigate available security alarm systemsused in Australia with a view to suitability forinstallation at RPAH. The Safety Zone AlarmSystem was the preferred system having beenin use in several hospitals in Australia withpositive results. The system is solar poweredwhich means that it can be easily relocated.The system can also be powered from a main

source, can be interactive with CCTV camerasor have fixed panic buttons.

The strategy

The Safety Zone Alarm System consists of anetwork of beacons, which are strategicallylocated within the 15 hectare campus atRPAH, including car parks, nurses’ residenceand walkways between the many buildings.There are 25 beacons scattered throughout thecampus. Each beacon is about 100 metersapart and is individually zone numbered. Asmall hand held transmitter activates thebeacons. Each hand held transmitter isindividually programmed with a personalidentification number (PIN) which identifiesthe remote control user. Once the signal istriggered, sirens sound, lights flash andloudspeakers send verbal warnings that securitystaff have been alerted and are approaching thearea.

Security staff are electronically notified of thestaff member’s identity and alarm location.Staff are advised to activate the system if theyfeel threatened, if they see another person orproperty at risk or if they see somethingsecurity should be notified of immediately.Safety Zone remote control units are availableto all RPAH employees for a small refundabledeposit. Staff members who work shift work orwho are on call mainly accesses the units. The

Case Study 8

Safety Zone Alarm System




remote control units are small, compact andeasy to activate. The system can be usedexternally or internally as a silent duress alarmby using the same hand held transmitter. Thebeacon and remote control units (hand heldtransmitter) are shown in the followingphotograph.

Staff issues

Staff express a sense of protection andreduction in fear and anxiety as a result of theSafety Zone Alarm System being installed.They report that they feel safe when walkingthroughout the grounds. Staff members havehad occasions to activate the Safety Zoneremote alarm and reported satisfaction withthe response provided.


The Safety Zone Alarm System is widely usedin other states within Australia and alsooverseas. While some services have maintainedstatistics on incidents pre and post installationof the system and report positive findings theseare not currently available.

Conclusion

The Safety Zone Alarm System demonstratesthe commitment of the managers at RPAH toensure the health, safety and welfare of allemployees in the workplace. The safety zonesystem provides a visual proactive policing roleto reassure members of the public who haveneed to traverse the campus that RPAH issafety and security conscious. In addition safetyzone beacons and signs act as a deterrent towould be perpetrators. It is part of acomprehensive approach to risk managementand the system provides security staff withimmediate access to information about thelocation of attacks, assaults and other incidentsand the identity of the staff member activatingthe alarm.

For further information contact: Director,Engineering Services, Royal Prince AlfredHospital, CSAHS.

Outcomes

Notices are clearly displayed throughout theRPAH campus informing the public that aSafety Zone Alarm System is in operation.These notices also act as a deterrent. There hasonly been one confrontation by offenders andthe system protected the staff memberimmediately. The system was installed in 1997and on the few occasions that the alarm hasbeen activated the voice recordings havefrightened away would be attackers.

Safety Zone alarm beacon and handheld transmitter


A number of documents are available toprovide information and direction for healthservice managers in meeting their occupationalhealth and safety responsibilities in the area ofaggression management and to assist in thedevelopment of policy and guidelines withinspecific settings. Clinical practice guidelineshave also been developed to inform clinicaldecision making and to assist in co-ordinatinga planned response to the identification,prevention, management and post incidentmanagement of aggression and violence in theworkplace. Some of these guidelines are genericand identify common risk factors and describestrategic responses75,99,100,101 while others focuson particular areas of practice or specificroles.2,12,46,101 The following is an overview ofavailable resources for staff in the area ofaggression risk management.

6.1 Management of imminent violence:clinical practice guidelines to support mentalhealth services, Royal College of Psychiatrists,London (1998) Occasional Paper OP 41,London: Royal College of Psychiatrists.9

Clinical Practice Guidelines consist ofsystematically developed statements to assistconsumers and practitioners in makingdecisions about appropriate health care inspecified clinical circumstances. This is acomprehensive evidence based approach todetermining the most effective strategies to

assist health practitioners and health serviceworkers manage violence in mental health caresettings. It addresses such areas of practice asthe design and organisation of theenvironment of care, activities undertaken andtreatments including use of restraint, seclusion,rapid tranquillisation and use of othermedications. It explains the process ofguideline development and the rigour involvedand includes many informative references.Information is prioritised in boxes to facilitateretrieval. An example of this relates to theidentification of key features required to identifya caring or effective clinical environment,these are:

• collaboration with service users inplanning clinical environments, policiesand practices

• adequate hand-over between clinical teamsfor continuity

• clear management policies and leadership

• open communication betweenmanagement and staff at all levels

• ward/unit size and design appropriate topatient population

• staff training and development withregular updating

• critical reviews of any incident carried out

• adequate staff ratios, well supervised,trained and experienced staff

Literature Sources



• gender and ethnic mix of staff appropriateto patient population

• multidisciplinary consensus on clinicalcare, and

• structured timetable and activities as partof program.

The use of restraint is investigated withspecific guidelines relating to the rationale forconsidering using restraint, methods ofphysical restraint, use of seclusion and policyissues relating to restraint and seclusion.Reasons for using restraint include thefollowing:

• serious degree or urgency of danger

• significant physical attacks

• significant threats or attempts at selfinjury

• seriously destructive of property

• prolonged and serious verbal abuse,threats or disruption of clinicalenvironment

• prolonged over-activity or risk ofexhaustion

• risk of serious accident to self or others,and

• attempts to abscond (if detained as aninvoluntary person).

6.2 Annotated bibliography on violence atwork, International Labour Organisation(2000) Geneva, ILO.103

This bibliography provides a wide range ofreferences on the subject of violence at work inthe form of an annotated bibliography. Itdraws upon books, journal articles, monographs,reports, surveys and conference proceedingsusing the International Labour Organisation’sextensive database as a primary source of

references. It is limited to publications issuedafter 1987. It is arranged in alphabetical orderaccording to author and a brief description ofthe content of each reference is provided.The materials address a wide range of topicssuch as contributing causes to violence,intervention strategies, and specific contextsof violence in the workplace such as health careworkers, social workers, and other occupationalgroups who have contact with members of thepublic. Recommended measures for interventioninclude redesigning the work, improvingrecruitment procedures, staff training andcounselling services, and improving securitysystems.

6.3 Guidelines for preventing workplaceviolence for health care and social serviceworkers (1996) US Department of Labour,Occupational Safety and HealthAdministration (OSHA).99

The Occupational Safety and HealthAdministration (OSHA) guidelines areadvisory in nature and are intended for use byemployers seeking to provide a safe and healthyworkplace through the implementation ofeffective workplace violence preventionprograms. They emphasise the need to considerlocal contexts and adapt to the specificrequirements of each place of employment.The guidelines include policyrecommendations and practical correctivemethods to help prevent and alleviate theeffects of workplace violence. In addition thefollowing sample documents are included;Workplace Violence Checklist, Staff AssaultSurvey and Violence Incident Report Form.

These guidelines cover a broad spectrum ofworkers who provide health care and socialservices in hospital emergency departments,community mental health clinics, inpatient

Literature Sources 65


mental health facilities, drug abuse treatmentclinics, pharmacies, ambulance services andemergency care facilities, community carefacilities, forensic and long term care facilities.The guidelines identify four components of aneffective safety and health program that alsoapply to preventing workplace violence, (a)management commitment and employeeinvolvement, (b) worksite analysis, (c) hazardprevention and control, and (d) safety andhealth training.

(a) Management Commitment andEmployee InvolvementManagement commitment and employeeinvolvement are complementary and essentialelements of a comprehensive approach toviolence management in the workplace. Toensure an effective program, management andfront line employees must work togetherthrough a consultative approach. Managementcommitment and the visible involvement ofsenior management, provide the motivationand resources to deal effectively with workplaceviolence and should include the following:

• designated responsibility for the variousaspects of workplace violence preventionprograms to ensure that all managers,supervisors, and employees understandtheir obligations

• appropriate allocation of authority andresources to all responsible parties

• a system of accountability for managers,supervisors and employees

• demonstrated organisational concern foremployee emotional and physical safetyand health

• equal commitment to worker safety andhealth and client safety and health

• a comprehensive program includingmedical and psychological support foremployees experiencing or witnessingassaults and other violent incidents, and

• commitment to support and implementrecommendations from safety and healthcommittees.

Strategies to encourage employee involvementand feedback are suggested and include thefollowing:

• dissemination of information to allemployees regarding workplace violenceprevention programs and other safety andsecurity measures

• checking that employees have knowledgeof and comply with workplace violenceprevention programs and other safety andsecurity measures

• provision of opportunities for employeesto participate in an employee complaint orsuggestion procedure relating to safety andsecurity concerns

• prompt response to employee concerns

• employee involvement on safety andhealth committees or other forums thatreceive reports of violent incidents orsecurity problems, undertake facilityinspections and make recommendationsto enhance workplace safety and health

• prompt and accurate reporting of violentincidents, and

• participation in a continuing educationprogram that includes the identification ofescalating agitation, assaultive behaviouror criminal intent and includes de-escalation techniques and appropriateresponses.



(b) Worksite AnalysisWorksite analysis involves a systematicexamination of existing or potential hazardsfor workplace violence. This includes a reviewof policies, procedures and operations thatcontribute to hazards and specific locationswhere hazards may develop. The recommendedprogram for worksite analysis includes, but isnot limited to, analysing and tracking records,monitoring trends, analysing incidents,distributing employee questionnaires or surveysand analysing workplace security. A worksiteexamination would incorporate the following:

• analysis of incidents including thecharacteristics of assailants and victims, anaccount of what happened prior to andduring the incident and the relevantdetails of the situation and outcome

• identification of locations or roles with thegreatest risk of violence and the processesand procedures that place employees atrisk of assault, including frequency andtiming of incidents

• identification of high risk factors such astypes of clients (eg. those with psychiatricconditions, clients disoriented by drugs,alcohol or stress); physical risk factors ofthe building; isolated locations; specificactivities; lighting problems; lack ofphones and other communication devices;areas of easy access; areas with previoussafety and security problems; and

• evaluation of the effectiveness of securitymeasures in place.

(c) Hazard Prevention and ControlOnce hazards have been identified it is necessaryto develop strategies to prevent or controlthem. This can be achieved by engineeringcontrols and workplace adaptation such as the

removal of the hazard from the area or creatinga barrier between the worker and the hazard.Changes in work practices and administrativeprocedures can also help to prevent violence.For example, a clear statement to employeesand clients that violence is not tolerated,liaison with local police, focused trainingprograms for staff in selected areas, and theestablishment of a system to chart clients withassaultive behaviour problems.

(d) Safety and Health TrainingTraining and education increase awarenessof potential security hazards and assist staffto identify ways in which they can protectthemselves and their co-workers and clientsthrough established policies and procedures.Training should include the following topics:

• workplace violence prevention policy

• risk factors that cause or contribute toassaults

• early recognition of escalating behaviourand the recognition of warning signs/situations that may lead to assaults

• strategies to prevent or defuse volatilesituations, managing anger and theappropriate use of medication

• information on cultural diversity todevelop sensitive responses to racial andethnic issues and differences

• a standard response action plan for violentsituations including availability ofassistance, response to alarms, andcommunication procedures

• strategies to respond to hostile relatives orvisitors

• progressive behaviour control methodsand safe methods of restraint applicationand escape



• location and operation of safety devices

• strategies to protect oneself including useof the “buddy system”

• policies and procedures for reporting andrecord keeping, and

• policies and procedures for obtainingmedical care, counselling, compensationor legal assistance post incident.

6.4 Taking safety seriously – improvingworkplace safety management in the NSWpublic sectors’ policy and guidelines (1999)NSW Premier’s Department.100

Policy and guidelines have been developed toassist agencies to ensure their occupational healthand safety (OHS) and injury managementsystems are appropriate to their needs, aremeeting legislative requirements and are beingcontinuously improved. They will assist agenciesto review major cost drivers in workerscompensation, and develop and implementintegrated and effective OHS, injurymanagement and workers compensationpractices.

6.5 The A-B-C of handling aggression,W More (1993) PEPAR Publications,Birmingham, UK.104

This booklet provides a user friendly approachto the management of aggression and includeschapters on fear and anger, risk assessment,supports available and a section specificallydealing with safety when undertaking homevisits. It provides many useful insights intosafety management and personal awarenessbefore, during and after incidents ofaggression. More suggests that knowledge ofthe work setting is an essential prerequisite tomaintaining safety and that assessing the “hot-spots” on the job accurately is basically a threestep process of A-B-C.

(A) The identification of risks faced by staffthrough an examination of the job,involving physical location, task beingperformed, staff performance,organisational policy and expectations,features or characteristics of the customergroup, and management demands/attitudes.

(B) The assessment of the identified risks. Foreach identified it is necessary to assess ifthe risk is acceptable or unacceptable.

(C) The recommendation of action that willreduce unacceptable risks to an acceptablelevel.

It identifies the importance of checklists andincludes examples of checklists with triggerquestions to assist workers to clarify issuessurrounding their safety. One such example isa checklist to assist in locating risk in theworkplace. More suggests that in order tolocate or identify risks it is useful to compile alist of the responses to the following questions.

• Tasks – What tasks are likely to upset orannoy?

• People – Are there groups or individualswith behaviours that are unpredictable?

• Places – Are some of the places where youwork inherently unsafe?

• Times – Are there times when you feelmore unsafe than others?

He suggests that most of the items on such alist would fit into the following categories:

• telling customers things they don’t wantto hear

• asking customers to do what they don’twant to do

• unpredictable behaviour

• working alone or in isolation with noaccess to support



• being alone and untraceable

• outside your base, travelling to work

• in other people’s premises or homes, and

• where physical force is being used.

6.6 Coping with violence: a guide for thehuman services, V Bowie (1996) (2nd Ed)Whiting & Birch Ltd. London.8

This book is an updated version of an earlierpublication by Vaughan Bowie who has beeninstrumental in increasing awareness of theproblems facing human service workers indealing with violence in work settings. Thebook suggests that human service workers areconsidered a high-risk occupational group dueto constant and often stressful contact withmembers of the public. Several theories onthe causes of violence are presented as wellas strategies to prevent and manage incidentsof violence. Bowie provides useful insights intoadjusting negative staff attitudes, commonsense approaches to the prevention anddefusion of violence and identifies strategiesto implement appropriate post trauma supportfor assaulted workers. Crisis communicationand the principles of physical intervention arealso included with the judicious use of diagramsand pictures to illustrate examples and enhancethe understanding of the reader. Overall thisbook is a valuable tool for health care workersand it demystifies many of the mythssurrounding violence against workers. In thechapter on the ‘Hurting Helper’ Bowie refersto research conducted around the stereotypingof the assaulted worker and challenges someof these stereotypes. He quotes that peersfrequently represent the assaulted worker asbeing more provocative, incompetent,authoritarian and inexperienced. Assaultedworkers are often characterised as those who

sought out riskier situations, challenged orconfronted clients unnecessarily, were moredemanding or less flexible and were less ableto detect potentially violent situations or tohandle them once they occurred.

6.7 Violence at work, D Chappel & C DiMartino (1998) International Labour OfficePublications, Geneva.16

This ILO report addresses workplace violenceand presents international coverage of theproblem as a basis for understanding thenature of workplace violence. The authorshighlight better practice and effective methodsof prevention, illustrating the positive lessonsderived from such experiences. The reportprovides useful insights on a range of topicsincluding analysis of data displaying patternsand trends in violence, areas and occupationsmost affected, social and economic costs ofviolence, causative factors, types of responses,analysis of policies and guidelines and a rangeof successful specific and practical action basedexperiences.

6.8 Guidelines for coping with violence inthe workplace (1999) International Councilof Nurses, ICN Publications, Geneva.4

These guidelines were written in response toincreasing incidents of abuse and violence inhealth care settings and the concern thatincreasing levels of violence are interferingwith the provision of quality care andjeopardising the personal dignity and self valueof health professionals. The objectives of theguidelines are:

• to review prevalence, incidence andimpact of abuse and violence againstnursing personnel

• to recognise nurses’ responses to incidentsof violence



• to determine the major security factorsacting on the workplace, and

• to present strategies that aim to confrontand reduce/eliminate violence in theworkplace.

The following steps are recommended as anapproach to be used to confront increasingincidents of abuse and violence experienced bystaff in their work settings:

• identify risk behaviours and environmentaltriggers

• take preventative measures to reduce/eliminate risk factors

• apply incident management mechanismsif and when violence occurs

• guarantee access of all involved to effectivesupport structures

• maintain reliable records

• evaluate violent incidents and theirmanagement, and

• develop appropriate recommendations onthe basis of findings.

6.9 Violence at work: a workplace health andsafety guide, Workplace Health & Safety(1993) Department of Employment,Vocational Education, Training andIndustrial Relations, QLD.11

This booklet was written in response toconcern regarding escalating violence withinhealth care settings. It provides an overview ofworkplace violence, a framework for managingpotential workplace violence and contains auseful list of sources of additional informationpertaining to the management of violence. It isvery simply and succinctly written and is auseful guide to assist health care workersnavigate the morass surrounding violence

within the work setting. In addition todefining violence and exploring types ofviolence it explores factors relating to theidentification, assessment and reduction ofviolence and post incident management.Procedures that may be adopted to reduce thenumber and severity of violent incidents andmake the workplace a safer and healthier placefor employees, employers and visitors include:

• avoiding or reducing working in isolationto minimise the threat of external violence

• setting up a system for alerting co-workersthat urgent assistance is required

• selecting a sufficient number of staff sothat delays that may raise stress areminimised and support is available whenneeded

• giving staff clear guidelines to follow, suchas how to deal with aggressive clients

• addressing the potential for violence atemployee induction training

• training and developing interpersonal andcommunication skills to improve staffability to detect signs of imminentaggression and defuse potentially violentsituations

• training in recognising normal reactionsand ways of coping following violentincidents to lessen their effects

• providing personal protection such asduress alarms, mobile phones or othersystems for calling assistance

• providing self defence training

• ensuring staff know how to access first aidand medical help, deal with emergencyservices staff and police, complete medicaland legal reports and provide transport forthe victims



• accessing support services for the peopleinvolved in a violent incident at work toreduce the impact of such events and todevelop skills for handling violentincidents in the future, for example by de-briefing and counselling

• setting up a reporting system foremployees, so that employers can take thenecessary follow-up action and identifychanges that may prevent a similar event

• develop random work patterns (particularlywhen handling monies or drugs)

• provide procedures for working inunfamiliar environments, for examplehome visits

• provide access to health and safetyprofessionals for expert consultationservices

• consult with employee representatives,unions and associations, and

• develop procedures to follow during andafter an incident, which are relevant to theworkplace.

A simple checklist outlines the essentialelements of a comprehensive approach to postincident management:

• first aid

• relieve the staff involved

• communication (staff involved should beprotected from media intrusion)

• debrief the staff involved

• immediate support

• counselling

• rehabilitation

• follow-up support

• investigation and subsequent action

• who to go to for help (staff counsellingservices, OH&S officer, Unions, supportpeople), and

• recording and reporting requirements.

6.10 Human services minimum standards forthe prevention and management ofoccupational assault (1995) Human ServicesPromotion, WorkCover Unit, Victoria.76

This publication arose from recognition withinthe Department of Human Services (DHS) ofthe need to have a co-ordinated response to theissue of occupational assault within worksettings. The DHS acknowledged that the staffof Human Services are its greatest resource andwished to protect and support this resource byproviding safe and healthy places of work. Tothis end minimum standards in this area weredeveloped as part of an overall improvementprocess. A clear definition of assault isprovided:

“Occupational assault is any incident in whichemployees are abused, threatened or assaulted incircumstances arising out of or in the course oftheir employment”.

The Standards provide specific informationregarding legal roles and responsibilitiesaffecting employers and employees includingthe requirements of Occupational Health andSafety legislation. They provide comprehensiveinformation regarding the Human ServicesRisk Management Program and establishminimum standards for specific areas ofpractice, for example undertaking communityvisits and conducting interviews. They alsorecognise the need to develop minimumstandards in relation to the physicalenvironment, for example the design andlayout of reception rooms and waiting areas,parking areas, entries and exits. The legislativeresponsibility for ensuring appropriate



education and training for all staff isacknowledged with minimum standardsestablished in relation to orientation, timingof training, program content, priority trainingneeds and access to ongoing refresherprograms. A complete section is devoted tocritical incident management and includesidentification, assessment, control, crisiscommunication, self care and post incidentcounselling and support.

6.11 Aggression and violence: approachesto effective management (1999) edited byJ Turnbull & B Paterson, Macmillan,Suffolk, UK.101

This timely book contains an introduction bythe editors which sets the scene for subsequentchapters. It describes the contributors ashaving a shared interest in exploring howviolence and aggression towards staff in publicservice can be managed more successfully. Itcatalogues the emotional distress and range ofemotions generated by a violent incident in theworkplace and draws upon social, occupationaland organisational contexts to explain violenceand aggression. The nine subsequent chapterswritten by acknowledged experts in the field ofaggression management encompass theidentification of staff at risk, theoreticalapproaches to violence and aggression andsome of the legal and ethical implicationsassociated with this topic. An interestingchapter on verbal abuse by Rob Wondrakexplores this concept in a range of contextsincluding nursing and examines verbal abusein the context of gender differences in nursing.Brodie Paterson and David Leadbetter drawupon evidence based practice to informde-escalation and the management of violenceincluding physical violence. Vaughan Bowiefocuses on pre and post-incident strategies to

support staff who have experienced violence atwork. Colin Beacock explores trainingrequirements. The final chapter is devoted tothe role of the manager and describes a fivestage framework for risk management thatincludes identification of the values, beliefs andprinciples of staff, the need to assess sources ofinformation and how this is managed, ananalysis of the risks involved, the formulationof an action plan and finally theimplementation of the action plan inpartnership with staff.

6.12 Personal safety for health care workers(1995) P Bibby, Arena Ashgate PublishingCo. England.75

This book contains a foreword by D LamplughOBE. She provides a moving account of thedisappearance of her daughter in broaddaylight in London in 1986. This experienceinspired her to establish the Suzy LamplughTrust to raise awareness of violence in society,and in particular at work, and to help provideappropriate training facilities to raise selfawareness and avoid personal vulnerability.The message contained in this book is thatprevention is better than cure and thatpreventative action can protect staff whileproviding sensitive high quality care. Itprovides background information relating tothe prevalence of violence at work andendeavours to put this into some perspective.It specifically addresses safety issues relating tohome visits undertaken by health care workersand staff working in nursing homes and daycare settings including interviewing techniques,travel guidelines, developing assertiveness andnon verbal communication. In addition, thereis an examination of the roles and responsibilitiesof employers/managers and of employees andalso of the mechanisms in place to facilitatepolicy development and data gathering.



6.13 Dealing with violence against nursingstaff, an RCN guide for nurses and managers(1998) Royal College of Nursing, London.46

This fifteen page booklet tackles the challengeof workplace violence in a novel manner. Thefirst section identifies key recommendationsthat are required at organisational level, atdepartmental, team or unit level and at theindividual level. The guide acknowledges thedifficulty in defining workplace violence butrecognises the need to have some sharedunderstanding of the phenomenon in orderthat incidents can be recognised, reported,recorded and reviewed systematically.

The recognition of nursing as a high riskprofession is acknowledged and it is suggestedthat this is intensified because interactions takeplace where access to care, services, treatmentor facilities can be granted, denied or delayed.The evidence relating to higher incidence ofviolence at work being associated with thefollowing variables is highlighted:

• dealing with the public

• providing care or advice

• working with confused older people

• working with those who have mentalhealth problems

• working with those who have alcoholor other drug problems

• working alone

• handling valuables or medication, and

• working with people under stress.

Other contributing factors identified includeinadequate resources, low staffing levels andinappropriate skill mix. A number of possibleconsequences of a violent incident are outlined.Every violent incident incurs a cost, either indirect and immediate financial terms or inlonger term indirect costs suffered by both the

individual concerned and the organisation forwhich they work. The expenditure involvedcan be attributed to the following:

• sick pay for the individual

• arranging and paying for replacement staff

• injury benefits payment

• increased cost of pension caused by earlyretirement

• pursuing legal action against an assailant

• treatment of injured staff

• provision of counselling services andongoing support

• loss of resources that went into training ifvictim retires/leaves the profession due toassault

• criminal injury compensation payments

• effect of negative publicity on morale,productivity and corporate image, and

• management time in dealing with theinvestigation and the administration ofissues relating to the incident.

The importance of adopting a risk managementapproach is emphasised with the use of casestudies to reinforce this strategy.

6.14 Managing violent and potentiallyviolent situations: a guide for workers andorganisation (1997) D Cherry & B Upston,Centre for Social Health, Taverner PrintingServices, Victoria.53

This document is divided into two sections.Section one is a guide for workers andaddresses theoretical and practical ideas toassist in managing violence in the work setting.Section two focuses on the responsibility of theorganisation in planning and policydevelopment to assist staff to manage violencein the workplace. A sample violence policy



document is included in the appendix as aguide. This document is ideal for anyonedeveloping a training program as it utilisesprinciples and theoretical approachesfrequently incorporated into training modules.

6.15 Violence in the medical workplace;prevention strategies (1995) JJ Robertson,American Medical Association, Departmentof Young Physicians Services, USA.13

This document was developed in response togrowing concern by the American medicalprofession regarding the frequency andintensity of workplace violence encounteredby medical staff and other health care workerswithin the USA. The spectrum of violence isexplored and statistics relating to specificoccupational groups and work settings areprovided. Specific examples of health carepersonnel who were victims of extremeviolence in the work setting are provided as achilling reminder of the reality of violence andpersonal devastation associated with theseincidents. The emphasis on prevention andstaff training is reinforced throughout thedocument. Specific attention is given totraining staff to identify a potentially violentsituation, how to recognise impairment dueto drugs, alcohol or mental instability, howto respond to these situations and the needto include information on specific culturesand be sensitive to cultural diversity.

Predictors for violence are provided in a listand while it is not intended to be exhaustive ithas been drawn from many sources and coverskey predictors. It is suggested that individualsor groups of individuals identified in thisdocument who have been shown to have ahigher potential for violence should receive

special attention. These include:

• males

• adolescents

• individuals with dementia

• those with tattoos (may indicate ganginvolvement or prison experience)

• homeless persons

• individuals traumatised from a recentconflict

• systems abusers (recidivists, drug seekers),and

• previously violent individuals.

6.16 Safer working in the community:a guide for NHS managers and staff onreducing the risks from violence andaggression (1998) National Health ServicePublication UK.105

These guidelines are structured to (i)emphasise the legal imperatives resting withemployers to protect the health and safety oftheir employees; (ii) provide a framework foran integrated organisation approach involvinga partnership between the organisation, thework team and the individual; and (iii) suggestactions that can be taken at each level before,during and after violent incidents.

The guidelines are set out in five sections.

• Section One provides a brief introductionto the problem of violence for NationalHealth Service staff working incommunity settings and describes anintegrated organisational approach to themanagement of violence

• Section Two describes the responsibilityof the organisation in establishing policiesand systems to manage risk before, duringand after incidents of violence



• Section Three describes the responsibilityof the work team before, during and afterincidents of violence

• Section Four describes the responsibilityof the individual before, during and afterincidents of violence, and

• Section Five considers training in place forNHS staff regarding reducing the risk ofviolent incidents.

Detailed information is provided and casestudies are incorporated into the document toenhance understanding. There are comprehensiveguidelines on how to conduct home visits andreduce risks associated with violence in thesesituations.

6.17 Violence in health care: institutionalstrategies to cope with the phenomenon(1994) CA Distasio, Health Care Supervisor,12(4) 1–34.60

This article explores violence in health carework settings and presents interesting insightsinto the problem by way of case studies andscenarios. It emphasises the need to developappropriate health care organisationalresponses and the recognition that violence isassociated with patient, staff, situational andenvironmental variables. This article suggeststhat accurate prediction is possible in mostsituations and that effective management ofviolent patients requires comprehensiveorganisational policies, procedures andprotocols in addition to a staff trainingprogram.

6.18 Risky business: managing employeeviolence in the workplace (1996) LFMcClure, The Haworth Press, New York.21

This book is somewhat different in that thesubject matter relates to workplace violence asa consequence of employee precipitated

violence. It deals with issues surroundingbullying, harassment and intimidation in theworkplace and suggests strategies for managersin recognising and responding to thisphenomenon of enquiry. The emphasis is onthe identification of “high-risk employees”and includes profiling, grouping according todominant characteristics and numerousreferences to specific places of work, workpractices, policies and statistics relating toworkplace violence.

6.19 Workplace bullying: a secure workplacefor young Australians (1999) WorkCoverAuthority of NSW, Sydney.30

This is a joint initiative of WorkCover NSWand the National Children’s and Youth LawCentre to address the problem of workplacebullying, particularly involving young traineesand apprentices. It included a set of fact sheetsrelating to a range of topics pertaining toworkplace bullying and workplace violence.Examples include the following:

• awareness – provides information on whatconstitutes workplace violence/bullying

• legal consequences – states the legalconsequences for employers andemployees who carry out workplaceviolence or who fail to prevent workplaceviolence

• intervention – this fact sheet lists a rangeof steps that must be taken when workplaceviolence, bullying or harassment areidentified or suspected

• intervention strategies for your business –provides assistance in developing aworkplace violence policy

• prevention – this fact sheet lists somepractical steps you can take to preventworkplace violence, bullying orharassment, and



• prevention strategies for your business –provides assistance in developing aworkplace violence policy.

World Wide Web sources

http://www.workcover.nsw.gov.auWorkCover NSW site provides informationon WorkCover NSW including health andsafety notes, backwatch, OH&S documents,hazardous substances and rehabilitationguidelines.

http://www.health.gov.auAustralian Department of Health and AgedCare site provides access to all current andnon-current press release papers. Seminar andmeeting papers on health related issues are alsoavailable.

http://www.aic.gov.auAustralian Institute of Criminology, has asection “Occupational Violence in Australia:An Annotated Bibliography of PreventionPolicies, Strategies and Guidance Materialscompiled by Dr Claire Mayhew.

http://www.osha-slc.gov/SLTC/workplaceviolence/guideline.htmlOccupational Safety and Health Administration(USA) has a document “Guidelines forPreventing Workplace Violence for HealthCare and Social Services Workers.”

http://www.noworkviolence.comWorkplace Violence Research Institute (USA).

http://iahss.org/links.htmThis index is arranged alphabetically and isdesigned to act as an exhaustive list of sites thatcan aid security and safety managers in theperformance of their duties (USA).

http://www.ashrm.orgThe American Society for Health Care RiskManagement of the American HospitalAssociation lists resources and publications.

http://www.alltheweb.comThis is a very fast search engine which has over1,000 references to workplace violence.

http://www.nurseadvocate.orgWebsite of nurse advocate organisation(Carrie Lybecker) has a section on nurses andworkplace violence.




This publication is based on a project todevelop guidelines for the prevention andmanagement of workplace aggression in theNSW health industry, conducted during theperiod April 1999 to March 2000. The materialadopts a risk management approach to identify,assess and control aggressive incidents in theNSW health industry.

There is an extensive literature reviewexamining workplace violence. It identifieshealth service workers as among the worstaffected occupational groups and explores theimplications for a number of professionalgroups such as medical staff, ambulance staff,nurses working in a variety of settings such asEmergency Departments and in remote areas,and health care staff working in both communityand inpatient settings. The literature providesmany definitions of workplace violence andsome of these are included, for example thedefinition used by the WorkSafe CommissionWestern Australia (WA), “any action orincident that physically or psychologically harmsanother person. It includes such situations whereworkers and other people are threatened, attackedor physically assaulted at work”.

The report also includes data relating toviolence in health care settings and enumeratessome of the costs associated with workplaceviolence. It provides information on therelevant legislation and highlights some of the

complexities associated with workplace violenceincluding a lack of consistency in defining theproblem and the variations in reporting whichare highlighted as contributing to theconfusion that surrounds this phenomenon.

The guidelines are based upon experiencesfrom across the NSW health system anddescribe examples of better practice in the formof case studies. The case studies that best meetthe evaluative criteria decided by the advisorygroup are included in the report. These varyfrom an area wide strategic plan to a peersupport program and a notice to deter violencein a specialty area of practice. Although therewere initiatives in training staff in theprevention and management of workplaceaggression, these were not included here as itwas planned that these be investigated as afuture part of this project.

Strategies for the prevention and managementof workplace aggression continue to bedeveloped and implemented. Since thecompletion of this project the NorthernSydney Area Health Service Mental HealthService has received recognition by way of aNSW Public Sector Risk Management Awardfor an “Aggression Monitoring Tool”. Thistool provides a system for recording, monitoringand evaluating aggressive incidents which hasfacilitated significant changes to the workenvironment and processes.

Conclusion



The recognition of workplace safety as a crucialissue for managers and employees is highlightedand through the provision of case studies, acomprehensive review of available resourcesand a list of further contacts in the field thispublication seeks to inform and empowerhealth care workers.


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Documents

Guidelines for Prevention and Mangement of Workplace Aggression 4358