Professional Documents
Culture Documents
Module 2
AMT002
Aggression minimisation
in high-risk environments
Facilitator manual
This work is copyright. It may be reproduced in whole or in part for study training purposes subject to
the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or
sale. Reproduction for purposes other than those indicated above, requires written permission from the
NSW Department of Health.
July 2003
updated August 2004
MODULE 2
Aggression minimisation in high-risk environments
Contents
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Overview of the manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Modular structure of the aggression minimisation program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
How the manual is set out. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Facilitator preparation before training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Sequence and timing of the modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Other resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Introduction to Module 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
How Module 2 fits into the whole program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Assessment to Module 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . 11
NSW Health preventing and managing aggression in the Health workplace . . . . . . . . . . . .................. . . 11
Assessment conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . 12
Assessment questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . 12
Self assessment checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . 13
Peer assessment checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . 14
Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . 15
Session plan for Module 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 19
Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 19
Equipment required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 19
Participant requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 19
Beginning the training session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 21
1. Welcome participants to the module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 21
2. Housekeeping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 21
3. Outline principles of adult learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 21
Background information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Part 1 Working in high-risk environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
What are high-risk environments? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Why are they high-risk? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Zero tolerance approach to aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Some legal and ethical issues and scenarios in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Part 2 Prevention in high-risk environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Keeping your area secure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Some principles for recognising and dealing with unauthorised visitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Working in the community and outreach environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Working in isolated areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
How to maintain safety when approaching a person with the potential for aggression. . . . . . . . . . . . . . . . . . . . . . . . 54
Ensuring the safety of self and others when interviewing patients or others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Part 3 Understanding aggression in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Triggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Cycles of aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Some possible responses at each stage of the aggression cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Self-control plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Part 4 Managing aggression in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Core values and skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Options when a person has been identified as being high-risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Short-term options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Long-term options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Strategies during hostage or armed hold-up situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
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Acknowledgments
This NSW Health violence prevention training program was developed by Brin FS Grenyer,
Olga Ilkiw-Lavalle and Philip Biro from the Illawarra Institute for Mental Health. Mark Coleman
provided assistance with the facilitator manuals and pilot workshops. The project was coordinated
from the Violence Taskforce, Centre for Mental Health by Frances Waters. The members of the project
contract steering committee who provided extensive guidance during the development of this project were
Frances Waters (Violence Taskforce, Centre for Mental Health), Kathy Baker (Community & Extended Care
Services and Nursing Services, Northern Sydney), Trish Butrej (Occupational Health and Safety, NSW
Nurses’ Association), Maggie Christensen (Learning and Development, Central Coast), Nicole Ducat
(Occupational Health and Safety, South Eastern Sydney), Louise Newman (Royal Australian and
New Zealand College of Psychiatrists), Gemma Summers (Learning and Development,
Northern Sydney) and Choong-Siew Yong (Australian Medical Association, NSW Branch).
A project content reference group also provided input during the development of the project, and the
members were Greg Hugh, Peter Bazzana, Greg Cole, Stephen Allnut, Distan Bach, Liz Cloughessy,
Jim Delaney, Regina McDonald, David Gray, Rajni Chandran, Jennifer Bryant, Terry Tracey and Linda
Sheahan. Consumer input was gratefully provided by Laraine Toms and Robyn Toohey. The NSW Health
Learning and Development Managers forum and others affiliated with the reference group also provided
helpful comment and guidance during the developmental phases of this project, including Jenny Wright,
Earle Durheim, Judy Saba, Brenda Bradbury, John Lain, Bill Wood, Aileen Ferguson, Simon Richards,
Vaughan Bowie, Louise Fullerton, Mira Savich, lain Morriset, Lorraine Hyde, Glenda Hadley, Julie Reid,
Natasha Mooney and Bill Tibben.
The developers would like to thank those staff of the South Western Sydney Area Health Service who
provided useful feedback during the four days of piloting of each of the modules in October 2001.We
also thank the fifteen educators from across the state who provided feedback during the two day trainer
orientation at Western Sydney Area Health Service in November 2002.
The developers would like to give special thanks to Professor Beverley Raphael and Professor Duncan
Chappel from the Violence Taskforce for support, Dr Claire Mayhew for timely insights, Linda Graham for
sharing her wisdom over the years through the development and implementation of the INTACT training
program, Professor Kevin Gournay and Steve Wright from the Institute of Psychiatry, London, for helpful
advice and resources, Dr Nadia Solowij and Jane Middleby-Clements for editorial assistance and to
Professor Frank Deane from the Illawarra Institute for Mental Health for practical support. We also thank
Shane Pifferi, Marie Johnson, Vicky Biro, Tim Coombs, Ralph Stevenson, Dr Alexandra Cockram,
Eugene McGarrell, Samantha Reis and Andrew Phipps for assistance with the project.
This program has incorporated and referred to relevant NSW Health policies and guidelines where
appropriate and a list of these is given at the end of the relevant modules. Modules 1 and 2 of this
program were adapted from a modular aggression minimisation program developed originally by
Austraining (NSW) Pty Ltd for the Central Coast Area Health Service, which was revised by Jenelle
Langham in 2000. Module 3 of this program is a revised version of that developed by Jenelle Langham
for the Central Coast Area Health Service.
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Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
FA C I L I TAT O R M A N U A L
NSW Health is a zero tolerance zone
Introduction
The focus of this training is to provide staff with the most up to date strategies, skills and
techniques to prevent and minimise workplace aggression and violence. It is also based on
relevant task force findings and incorporates key task force initiatives.
The program includes a basic module for all staff identified as being at risk of workplace violence,
a module for staff working in high-risk environments, a module designed specifically for managers
and a refresher module.
All managers of staff identified as being at risk of workplace violence should attend the manager’s
module and all relevant staff should attend the refresher module at least every two years. Health
Services may determine that some groups need to attend the refresher more regularly.
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MODULE 2
Aggression minimisation in high-risk environments
This manual has been developed to provide educational resources for a facilitator to
deliver a comprehensive education program in aggression minimisation.
The manual is divided into four training manuals. Facilitators must have each of the following:
1. Certificate IV in Assessment and Workplace Training.
2. Experience in working in areas of significant violent risk.
3. Experience in effectively managing violent incidents.
4. An ability to relate to staff at all levels of the organisation.
Module 2
AMT002 – Aggression minimisation in high-risk environments
This eight-hour program is designed for mental health and other staff working in high risk areas, eg
emergency, security, community, aged care, disability, dental, midwifery and early childhood, methadone,
brain injury, neurology, admissions and drug and alcohol services. Other staff members identified, via the risk
assessment process, as being at significant risk of aggressive behaviour should also attend this module.
The day is divided into four parts:
1. Working in high-risk environments.
2. Prevention in high-risk environments.
3. Understanding aggression in high-risk environments.
4. Managing aggression in high-risk environments.
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Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
FA C I L I TAT O R M A N U A L
NSW Health is a zero tolerance zone
Module 3
90405NSW – Course in aggression minimisation for managers
This four-hour module is designed for managers of health units and facilities. It provides the participant with
detailed information, obligations and practical strategies for promoting a safe workplace environment free of
aggression, assessing and managing risks and types of support to provide to staff, who have been victims
of aggression. Completion of Module 1 is recommended prior to undertaking this module.
The day is divided into three parts:
1. The legal and policy framework for managing aggression.
2. Promoting an aggression-free workplace.
3. Assisting staff when aggression and violence occurs.
Module 4
AMT004 – Aggression minimisation refresher training
This two-hour module is designed for all staff identified as being at risk of workplace violence, and should
be repeated at a minimum of every two years after completion of Module 1. Depending on the level of risk,
some staff may need to attend more frequently. It is designed to keep staff up-to-date with policies and
practices, provide refresher training of skills, and workshop problems.
Basic course content in the Facilitator manual duplicates that found in the Participant manual.
This course content forms the basic syllabus of the training and the trainer needs to know this
material prior to conducting training.
For each module, at the beginning of each section the relevant page number in the
Participant manual is noted.
Relevant slides that should be shown at each point are reproduced throughout this manual.
Layout icons
The following symbols have been used throughout the Facilitator manual to assist in the
presentation of material. In all cases, trainers should use their discretion in the presentation
and timing of material depending on the mix of staff in the training group. Where possible, flexible
delivery is encouraged and specific recommendations are made at the beginning of each module.
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Key points
Key points help you to summarise the major themes and information from the section.
Background reading
This icon appears when further background information and reading is supplied
on a topic to assist the facilitator in understanding and delivering the training course.
It should be read before the facilitator conducts any training. The background information
may be verbally summarised by the trainer as the need arises.
Answers
Suggested answers to the individual, small and large group activities are provided.
These amplify and reinforce the subject material covered in the Participant manual.
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AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
FA C I L I TAT O R M A N U A L
NSW Health is a zero tolerance zone
Facilitator instruction
Specific training hints are given here.
Session time
Suggested times to conduct sessions are given and a session plan is provided
for each module. These are to be used flexibly to meet the needs of trainers
and participants.
Session overview
An overview of the session is given here.
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Aggression minimisation in high-risk environments
Assessment of competency
Assessment activities accompany Modules 1-4 to facilitate demonstration of competency.
Facilitators should ensure that training outcomes for each participant are appropriately
documented. Recording forms accompany the Facilitator manual.
Flexible delivery
The materials in this training program provide a core recommended syllabus for preventing and
managing aggression in all NSW Health facilities. Each module has a set of learning outcomes
and corresponding assessments. The training is designed in a modular format to allow ease of
delivery, however it is possible that the training may be delivered using flexible delivery methods.
Examples of how the training could be altered include (but are not limited to) the following:
1. Dividing a full day module into two parts, spread over two half days.
2. Emphasising some components of training over others for specific groups. For example,
if the participant training group is non-clinical then the trainer may decide to focus more
on communication strategies and bullying, harassment and discrimination than on some
of the components that are more relevant for clinical staff.
3. Flexibly incorporating materials from other local training programs that overlap with the
learning outcomes and provide additional training.
4. Shortening a module by providing advance reading materials and exercises to be reviewed
in the participants’ own time and reinforced and assessed in the workshop. However, the
trainer will need to determine that this approach is appropriate for the participant group.
In considering flexible delivery options, it is important to ensure that the learning outcomes
are met as set down in this program.
Portfolio documentation
Appropriate documentation is to be filled in and evidence collected to be submitted with the
application form. All documentation should be submitted as a portfolio. See below for types
of evidence to be collected and included in a portfolio.
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AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
FA C I L I TAT O R M A N U A L
NSW Health is a zero tolerance zone
Evidence guide
The following is a guide for the evidence to be provided for recognition of prior learning.
For each item of evidence you will need to indicate which part of the item is relevant to which
learning outcomes.
Other resources
Participant manual
A Participant manual is also available and should be used during the training. Participants are
to use the manual during the training session, but also should take it away as a resource. There
is additional information in the Participant manual, and it is not expected that every point can be
covered during the training sessions. The training provides an orientation to the major issues in
aggression minimisation and points the participant to further readings and resources in the area.
Lecture slides
The CD-ROM contains the full set of Powerpoint slides. The Powerpoint slides can also be
printed and transferred to overhead transparencies as needed.
Forms
The CD-ROM contains the recognition of prior learning forms and the assessment of
competency forms.
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Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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Aggression minimisation in high-risk environments
Introduction to Module 2
Structure of Module 2
● Part 1 – Working in high-risk environments – the nature of high-risk and some
legal and ethical issues governing work in these environments.
● Part 2 – Prevention in high-risk environments – including guidelines for improving
safety and security.
● Part 3 – Understanding aggression in high-risk environments – including emotional
and physical responses to escalating incidents.
● Part 4 – Managing aggression in high-risk environments – including detailed short
and long-term response options.
● Part 5 – Assessment of competency and review.
Session times
These times are flexible:
Part 1 80 minutes
Part 2 80 minutes
Part 3 80 minutes
Part 4 80 minutes
Part 5 60 minutes
NB. A session plan is provided at the beginning of Module 2.
NSW Health A safer place to work – preventing and managing violent behaviour in the Health workplace Module 2 AMT002
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Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
FA C I L I TAT O R M A N U A L
NSW Health is a zero tolerance zone
Module overview
This eight-hour program is designed for staff working in high-risk areas, eg emergency,
security, mental health, community, aged care, disability, dental, midwifery and early
childhood, methadone, brain injury, neurology, admissions and drug and alcohol services.
Other staff members identified via the risk assessment process as being at significant risk
of aggressive behaviour should also attend this module.
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Assessment method
This assessment is designed to be a learning tool and the learning outcomes are to be
assessed through peer and self assessment. Participants are to work in pairs and each is to
choose a scenario that is different from their partner. Each participant then directs the questions
to their partner and assesses their partner’s responses using the Peer assessment checklist.
The partner is also given the opportunity to assess his or her own responses using the Self
assessment checklist. When this is completed participants are to change roles and repeat the
process for the other member of the pair. Participants may choose to jot down dot point answers
in the column provided in the relevant checklist, though this is not mandatory. On completion of
this task, participants are to discuss what difficulties they may have experienced in answering the
questions relating to their scenario. Following this, the group of participants are to be debriefed
and asked what areas they found difficult. Participants should subsequently be provided with
possible strategies that could be used to overcome such difficulties. Participants who had
problems answering a question should be given an opportunity to answer the question again.
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Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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There are five critical aspects of the assessment relating to four of the assessment
questions. The questions have been designed to align with the critical aspects of the
assessment. Participants are deemed competent if they demonstrate the correct responses
to these questions. The critical aspects of the assessment are identified in the marking
guide (checklists).
Assessment conditions
Participants will be provided with a case scenario and assessment questions at the completion
of training. The facilitator is to inform the participants that they should put themselves in the
place of the health worker in the scenario. Participants are to be informed about how the
assessment should be carried out.
Assessment resources
● Case scenarios
● Assessment questions
● Peer and self assessment checklists
NB. Assessment questions, Peer and Self assessment checklists and Case scenarios are shown below and can also be found
as a separate Acrobat PDF document on the CD-ROM, in order that the assessment questions, checklists and scenarios may
be printed out and handed to participants.
Assessment questions
1. What are the legal issues that need to be taken into account in this scenario?
2. What are the possible triggers for this aggressive incident?
3. At what stage in the cycle of aggression is the person in? What are the behaviours of the
aggressive person that support your choice?
4. How would you ensure the safety of yourself and others in this situation?
5. What communication skills would you use in this situation to attempt to de-escalate the
person’s aggressive behaviour?
6. What might be some short-term options for managing this aggressive incident?
7. What might be some long-term response options that may be used to manage this
aggressive person in the future?
NB. The following issue may not relate to the scenario, however all participants are required to respond to the question.
8. Identify several strategies to ensure your safety when visiting the community or housing
settings for each of the following:
● Prior to leaving the office.
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Identified appropriate
communication skills.
Identified short-term
response options.
Identified long-term
response options.
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AMT002 Aggression minimisation in high-risk environments (Version 1) © July 2003 updated August 2004
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NSW Health is a zero tolerance zone
Identified appropriate
communication skills.
Identified short-term
response options.
Identified long-term
response options.
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Scenarios
Scenario 1 – Leanne Smith, 34 years old and health worker
Leanne has a diagnosis of personality disorder and has a history of self-harming behaviour.
She lives with her abusive boyfriend. Over the past few weeks, Leanne’s mother has been
concerned about her daughter’s behaviour and today Leanne told her mother she was going to
harm herself because her boyfriend threatened her. Leanne’s mother rings you and explains her
concerns to you. When you arrive, Leanne’s boyfriend lets you in. Leanne is in the bedroom and
does not want to speak to you, but does so reluctantly. She shows you some minor cuts on her
arm, stomach and legs. Leanne becomes increasingly agitated and angry and threatens to harm
herself with a knife. You want Leanne to go into hospital, however Leanne tells you that she was
not happy with the way she had been treated in the past when in hospital. As you try to convince
Leanne to come to hospital with you she starts to yell and abuse you, making threats on your
life if you try to make her go into hospital.
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Learning
Time Topic outcomes Content/activity
Materials
The training room should be comfortable with desks for participants so that they can write in
their copy of the Participant manual.
Equipment required
● Projection facilities for Powerpoint slides (or an overhead projector if the slides have been
printed on overheads).
● A whiteboard and whiteboard pens (for writing up feedback from participant exercises).
Participant requirement
Pens or pencils for writing in their copy of the Participant manual.
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Session time
20 minutes
Facilitator instruction
To begin teaching this module you will need to do the following:
2. Housekeeping
Inform participants of the:
● program times
● breaks and meals
● toilets
● mobile phones
● message board
● occupational health and safety (fire escapes).
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Orient participants to how this module fits in with the whole program.
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Background information
Facilitator instruction
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Part 1
Working in high-risk environments
Session time
60 mins
Session overview
This section looks at what high-risk environments are and why they are considered
to be high-risk. It also examines the legal and ethical issues that need to be taken
into account when responding to and managing aggression. These issues include
duty of care, professional negligence, reasonable force, assault, arrest, restraint,
false imprisonment, searching of patients and others, the Guardianship Tribunal,
children and the NSW Mental Health Act 1990.
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Facilitator instruction
Facilitator: Ask participants whether there are any other high-risk environments
to add to the list and the reason for this.
You may wish to comment that there are other kinds of environments that
are high-risk in general eg poorly lit car parks, exits via dark or narrow lanes
or underpasses, some areas used as shortcuts by the public and isolated areas.
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Certain medical problems that patients experience may be associated with a higher
risk of aggression, such as:
● confusion, eg delirium and acute organic brain syndromes, dementia,
ie Alzheimer’s disease, multiple infarcts or brain dysfunction and trauma
● anxiety associated with their illness and treatment or psychosocial concerns
● mental illness and disorder
● pain
● substance abuse
● dual diagnosis (both mental illness and substance abuse)
● impulsive behaviours (such as those due to personality disorder)
● deafness, blindness and sensory impairment
● developmental disability
● brain impairment resulting from head injury, epilepsy, neurochemical disturbances,
metabolic disturbance (such as hypoglycaemia and limbic system disorder), tumours,
infection and other factors
● neurological disorder such as Huntington’s disease, Parkinson’s disease, Pick’s disease,
Multiple Sclerosis or AIDS dementia.
Facilitator instruction
Emphasise how many of the high-risk environments are those that involve a high
degree of stress and anxiety for patients, staff and visitors.
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Facilitator instruction
The zero tolerance approach to aggression does not mean that aggression
will never be encountered in the workplace. For example, in dementia
and brain injury units aggressive and erratic behaviour can be a part of
the condition encountered. The essential point is to ensure clinical care that
is prompt and appropriate and that protects the safety of the patient, staff
and others involved. The zero tolerance response means that in all instances
of aggression, appropriate action must be taken to protect staff, patients and
visitors from the effects of that aggression. In order for this to be successful,
staff must recognise that aggression is not an acceptable part of the job.
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Case study
A person who is drunk has been brought into the hospital with a head wound
and other cuts received in a fight. The person does not like the treatment being
provided, and starts to become abusive. The individual feels no treatment is
needed and wants to go home.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How might the principles governing ‘duty of care’ versus ‘professional negligence’ be
relevant to a worker’s response to the incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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How might the principles governing ‘reasonable force’ versus ‘assault’ be relevant to
a worker’s response to the incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Background reading
Assault
The criminal offence of assault consists of:
i. force applied to another without their consent, or
ii. the actual intent to cause harm to the person, or
iii. a very high degree of reckless indifference to the probability of harm occurring.
These are the conditions that need to be proven for a successful prosecution.
Under NSW Criminal Law, the term aggravated assault covers the application of physical
force. Such actions include pushing, stabbing, strangling a person, kicking, shooting and
unlawful hitting. The attempted use of physical force that misses or fails to connect is
nevertheless an assault. There must be a belief in the mind of the victim, created by
the offender, that force is going to be used upon him/her.
The law allows the individual the right to defend his/her life against all unlawful attacks.
However:
● no more force than is absolutely necessary to repel the attack can be used
● the force must not be excessive and not out of reasonable proportion to
the attack
● the individual must not use extra blows/strikes by way of revenge.
Any person who on reasonable grounds believes that he/she is likely to be the subject
of an imminent attack can take reasonable measures to protect themselves.
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Reasonable force
Reasonable force is the amount of force considered to be appropriate in proportion
to the perceived danger posed. When a person considers that they or others are under
attack or threat, and self-defence or the defence of others is required, the amount of
force that is used must be considered to be consistent with the perceived threat faced.
Each case is judged considering:
● its unique circumstances
● the threat that was posed
● level of training
● support and options available.
You may wish to refer back to Section 3 of Module 1 relating to assault.
Case study
A fifteen year old boy was in hospital after he fell off his push bike. The boy went
over to the drug trolley with his backpack, put something in his backpack, and ran
out the door.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
Facilitator: Ask the group to consider all the options. These may include doing
nothing (letting him run away) through to seeking to stop the boy.
A suggestion is made that the security officer should run after the boy and
restrain him.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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How might the principles governing ‘citizen’s arrest’ versus ‘restraint’, ‘false imprisonment’
and ‘assault’ be relevant to the worker’s response to the incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Background reading
To arrest someone means to take that person’s liberty or freedom of movement away
from them in order to deliver that person into legal custody, to be dealt with according
to law.
● Individuals are only able to arrest someone if the person is in the act of committing,
or immediately after having committed an offence.
● If restraint is used, reasonable force only must be exercised.
● Security officers have no additional powers of arrest than those of the general public
(unless they are a special constable).
● You have to consider the safety of yourself in making an arrest.
The role of a security officer is one of prevention and protection. They have only the same
power as any other member of the community in relation to arrest.
Restraint should only be used in an aggressive situation where all other measures and
interventions have (if circumstances have allowed) been tried, and there is a foreseeable
risk of harm to any persons.
To be protected from prosecution for assault, when staff restrain a person they must
use only reasonable force. This is the basis for self-defence in court.
You may also wish to refer back to Section 3 of Module 1 regarding clinical and
non-clinical restraint.
Regarding the case study, it is unlikely that it is reasonable to arrest the person.
A better option would be to report the event to the police, who have additional
powers of arrest.
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Consider the case where the boy does not run out of the hospital but after
putting something in his backpack from the drug trolley he sits down on
a nearby chair.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How might the principles governing ‘searching patients’ be relevant to the worker’s
response to the incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Background reading
The power to search clients is restricted to narrow circumstances allowed under
criminal law which are strictly regulated, or when the client consents. Without clear
lawful authority, any search initiated without consent would be a trespass upon the
person and therefore unlawful.
However, under the Inclosed Lands Protection Act 1901 hospitals are entitled to impose
conditions of entry on persons who enter their premises. An example of these conditions,
which would be considered lawful, are:
● Prohibited weapons, fire arms or illegal drugs are not to be bought into the facility.
● The hospital reserves the right to search persons if there is reasonable suspicion that
a person has brought such weapons etc into the facility.
● A person who refuses to be searched when requested will be escorted from
the premises.
However the requirements of entry need to be displayed or communicated to those
entering the premises, so that people are aware that such requirements exist.
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Facilitator instruction
Background reading
The situation is somewhat different in relation to persons involuntarily detained
under the Mental Health Act, which provides for the involuntary detention of persons
suffering from a mental illness that place themselves or others at risk of serious harm.
The objects of the Act include facilitating treatment and care, and section 31 (2)
specifically allows a detained person to be given such treatment as the medical
superintendent ‘thinks fit’. This combination of provisions may authorise searching
involuntary patients, where the search was directed towards care and/or treatment
or prevention of harm to the patient or others. All of this information needs to be
considered by health care facilities when developing policies and procedures in
relation to searching.
Case study
An involuntary patient decides she wants to leave the hospital and becomes
excited and angry when told that she cannot leave the hospital. A staff member
considers her ‘at risk’ and tells her she will give her something to calm her down.
The drug injected has the effect of making the patient unconscious.
Could the patient claim false imprisonment? How might the principles governing the
Mental Health Act be relevant to the worker’s response to the incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
Facilitator note: An example of a drug that may have this effect is Midazolam.
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Overview the Mental Health Act and the issues of false imprisonment.
Background reading
Mental Health Act 1990
● Under the NSW Mental Health Act, mentally ill persons are those who have
a mental illness and as a result of the illness there are reasonable grounds for
assuming that care, treatment or control is necessary to protect the person or
others from serious harm.
● Within the Act, mentally disordered persons are defined as those persons whose
behaviour is so irrational that there are reasonable grounds for assuming that care,
treatment or control is necessary to protect the person or others from serious
physical harm.
The most common behaviours requiring containment for the protection of self or
others include:
● deliberate self harm
● delirium
● acute distress
● confusion
● aggressive behaviour.
Being detained under the Mental Health Act does not automatically mean that the patient
may be sedated as treatment must be the least restrictive, allowing for effective care and
treatment. The clinical situation must warrant the use of involuntary sedation.
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How might the principles governing the Guardianship Tribunal be relevant to the worker’s
response to the incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Background reading
Guardianship Tribunal
A person may be under the Guardianship Tribunal for either financial or medical
orders or both. If staff want to give additional or non-prescribed treatment to a patient
whose order is for medical treatment they must contact the Tribunal first. However, in an
emergency, the Tribunal should be contacted immediately after the person has been given
their medical treatment.
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Background reading
General principles in relation to child and adolescent care
● Parents have a general right to determine a child’s upbringing and education,
including the right to discipline a child. Of course, this right is limited by laws
concerning child abuse and neglect and by the fact that any punishment inflicted
must be moderate and reasonable.
● Parents are entitled to ‘delegate’ this authority to other persons who stand in
‘loco parentis’ to the children.
● The right to decide on medical treatment arises independently of any right or control
of a parent over a child. Thus, as a rule, medical treatment for a child under 14 can
only occur with parent/guardian approval. Between 14-16 is the ‘grey’ area and when
16 and over the child can determine treatment independently. This point becomes
relevant with regard to the issue of medication.
● In NSW law, the only grounds to detain persons against their will outside of criminal law
are found in the statutory provisions of the Mental Health Act and the Public Health Act.
Recognition of parental or guardian authority is given with respect to voluntary
admissions to psychiatric hospitals, but not with respect to involuntary admissions.
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‘Grey areas’
● If any force is required, it should be minimum force only. Clearly, if a situation is
escalating, evasion and seeking additional support is the best option. In this regard,
if a matter of assault did come before a court, it would be unlikely to conclude that
any parental authority would authorise the use of excessive force.
Case study
In the evening two youths were noticed hanging around a health facility building.
There is no one in the premises after hours. Staff working in another building
noticed that the youths had driven their car and parked it outside the front door.
One of the youths threw a rock at a window and no alarm was set off. They
then proceeded to try to break into the building.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Facilitator instruction
Facilitator instruction
Facilitator: Add to the scenario by considering a case where two staff ran
to stop the offenders. The staff were seriously assaulted by the youths.
Facilitator instruction
Organisation:
● Need to reinforce self protection and safety with regard to staff behaviour.
● Document incident.
● Perform a risk assessment.
● Instigate changes to improve security and surveillance.
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Key points
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Part 2
Prevention in high-risk environments
Session time
80 minutes
Session overview
This part looks at safety strategies in high-risk environments. It considers
circumstances where unauthorised persons have entered restricted and
unauthorised areas, safety when working in the community, how to approach an
aggressive person and safety strategies when interviewing patients and others.
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Case study
You notice a stranger is in the staff room with the door to a locker open and hanging
on one hinge. The person is going through the locker of a staff member you know
and you suspect this person is stealing.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
Note the appearance of the person, note what they are doing and where they
go afterwards. Ring security and report the incident formally.
You might ask the group: ‘Should you approach the person?’
The safest strategy is not to approach the person, however, depending on the
circumstances, saying something like, ‘can I help you?’ while maintaining a safe
distance and not blocking the exit, may be appropriate.
Case study
An elderly gentleman came to the receptionist’s desk. He was of non-English
speaking background. He was speaking loudly, and abruptly said, “I want to see
my wife, where is Ward 14”. Ward 14 is a high dependency unit with restricted
admission. The staff member is worried that the gentleman is going to become
aggressive and asks him in a quiet, polite manner what his wife’s name is. He
answers loudly, “Where is Ward 14?” and puts his hand in his pocket as if he is
about to take something out. At the same time he notices a sign with an arrow
pointing toward Ward 14. He walks briskly toward the ward and pushes open
the doors, entering the ward. The staff member panics, picks up the phone and
calls security. Several security staff arrive and escort the gentleman, shouting
and struggling, off the premises.
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Discuss the incident and the worker’s response. What strategies should be used
when dealing with unauthorised access?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What might be the socio-cultural issues that might have contributed to this
incident escalating?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
Facilitator instruction
Recognise that de-escalation communication skills may no longer be
appropriate because the person has moved into a restricted area.
Ask participants: ‘What risk control measures can be put in place for
restricted areas?’
Facilitator instruction
Review issues to do with:
● safety barriers around reception areas
● signage
● locked doors to unit with video intercom for communication with staff.
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Unauthorised access
● Know your escape route.
● Know your emergency numbers.
● Know your local emergency procedures.
● Know location of duress alarms.
● Remain calm.
● Know that your safety is the first priority.
● Know how to contact security or police.
● Know your rights.
● Use non-confrontational methods.
● Use open hand gestures.
● Note clothing or distinguishing features.
● Complete an incident report.
● Seek counselling if appropriate.
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
Facilitator:
● Discuss if there are any local procedures, policies or risk assessment forms prior
to the visit.
● Highlight importance of recognising that there is a risk of aggression from those
around the patient, eg family members, friends, flatmates, etc.
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Facilitator note: Discuss local policies and procedures on risk assessment prior
to the first visit.
SAFETY HINT: Recognise that the busier you are, the more at risk you may be.
Being busy may lead you to:
● being less likely to notice early warning signs of aggression
● taking less time to clarify a person’s problem before acting
● being more vulnerable to taking unnecessary risks.
Facilitator note: For this exercise allocate a particular section to each group
(see page 49 of this manual, page 14 of Participant’s manual) and then have
each group give its response.
Case study
Jane works in a small community health centre. She is leaving her office to visit
a well known client, John, in his home. When Jane arrived at the house, John’s
parents welcomed Jane in. When Jane walked in she realised she left her mobile
phone in the car but did not go back outside to get it. John was in his bedroom
with a friend Bill who Jane recognised and knew had a history of aggression. John
closed the door behind Jane and when Jane started talking to John his friend Bill
became abusive to Jane and started yelling and shouting at her. Jane immediately
left the room and Bill started to follow her. Jane ran for the front door and tried to
open it. John’s parents came to see what was going on but Bill pushed them
aside. Jane eventually opened the door and ran to her car and was trying to
find her keys in her bag. Meanwhile Bill grabbed Jane but let her go when
John stopped him. Jane eventually got in her car and drove off.
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Consider the scenario. Discuss what you can do to ensure your safety in the community.
Fill in the relevant issues to consider in the boxes provided.
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Answers
Prior to leaving the office
● Ensure that your base knows where you are going and who you are going to see,
and leave the following information:
– The name, address and phone number of persons being visited.
– Expected time of appointment.
– Expected length of appointment.
– Any changes to the schedule of visits.
– The proposed route.
● Take any personal protective equipment that is provided.
● Ensure your mobile phone is working and 000 and your base number are
keyed in.
● Do not make a home visit alone:
– If you suspect or know a person has the potential for aggression (this includes
other persons who may be in the home).
– If you believe you are at risk.
– If there is not enough information to establish a person’s potential
for aggression.
● At times it may be appropriate for the police to go on the visit (consider using
police if you are concerned about your own and/or another’s safety).
● Ring to see if the client is there.
● Perform a risk assessment.
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On arrival
● Park the car facing the way you will be exiting and make sure you cannot be
blocked in (this stops you from being trapped or wasting time trying to turn).
● Do not attempt to enter premises if there are any potentially aggressive animals
and they are not restrained.
● When entering buildings, check lighting and stairwells where no lift is available.
● If entering a lift, look first and do not enter if you are concerned about safety.
● Stay near the door and control panel in lifts, and be observant of others.
● Do not search for patients by unnecessarily knocking on doors.
● Do not remain in the parked car for long periods of time before and after visits.
● If you are concerned about location or access to premises, ask a family member
to meet you and escort you to the patient.
● If no one is home and you are leaving a card, slip it under the door or put it in
their letterbox if it is locked (so other people cannot find it).
● Always check the locking mechanism on the gate so you won’t be impeded if
you need to leave quickly.
● Before knocking at the door and ringing the bell, listen for any arguments,
unexpected voices or anything that may make the situation unsafe (these are
reasons to reassess the situation).
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● Keep your keys handy so that you do not waste time searching for them
at the bottom of the bag.
● Only take in what you need.
● Leave immediately if you are verbally or physically threatened by anyone.
Facilitator note: Discuss local procedures when mobile phones do not work in
specific geographical areas.
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● Always ensure you have as much information as possible about the location and person
being visited.
● Ensure patients are aware of the visit and purpose.
● Under no circumstances should you knowingly place yourself or co-workers at risk. This
also applies to those in an inspectorial role. Where the threat of violence presents itself, you
should leave and/or seek further assistance, eg police. If you are unable to escape, evasive
self-defence may be necessary.
● Always contact police if you are concerned about your own or another's security.
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Facilitator instruction
SAFETY TIP
Do Don’t
● Always remove any personal items that ● Use any sudden or violent gestures.
could be used by the patient to grab a ● Have prolonged eye contact.
hold of you, eg tie, necklace, earrings,
● Address the patient in a
stethoscope, etc, prior to approaching
confrontational manner.
the person and not in view of the person.
● Corner or tower over the patient.
● Be calm and confident.
● Turn your back on the patient until
● Give the patient ample space.
you are well clear of the situation.
● Be empathic and emphasise your desire
to help.
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Facilitator instruction
Facilitator:
● Note the importance of having an exit strategy.
● Where possible, use rooms with two doors or exits.
● Do not situate yourself in a position where you cannot get to the door first.
● Don’t have things on your desk or in the room that can be used as a weapon
(elicit examples from group).
● Emphasise the importance of always being polite (even if a person is
disrespectful or abusive to you).
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Key points
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Part 3
Understanding aggression
in high-risk environments
Show overhead slide
Session time
80 minutes
Session overview
This section aims to extend your knowledge of aggression through discussing
common triggers for aggression in the health care industry and the cycle of
aggression. The aggressive person’s and the recipient’s responses are both
outlined and discussed. It is the recipient’s response that can give control
back to the recipient in an aggressive situation.
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Triggers
A trigger is a specific occurrence that precipitates the escalation of a person’s aggressive
behaviour. Triggers may be grouped under the following headings:
• Environmental
• Personal
• Cultural
• Workplace practices
Facilitator instruction
Name triggers you have witnessed or experienced under the following headings.
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator – some issues might include:
● confined spaces and overcrowding
● environments that are too hot or too cold
● poorly designed rooms
● inadequate lighting
● uncomfortable spaces
● inadequate or poorly maintained facilities, eg no water dispensers, phone not
working, inadequate toilet facilities.
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Personal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Cultural
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
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Workplace practices
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
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Cycle of aggression
Facilitator instruction
Facilitator: Discuss each stage, how aggressive incidents may escalate rapidly
and the post incident effects.
Facilitator instruction
Facilitator: Use the next table as a discussion point. Consider each component
of the cycle of aggression and discuss what the aggressive person and the
recipient may be feeling at each stage. Then go through and review possible
strategies to help minimise the aggression.
3 5
2
1
Baseline 6
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1 Baseline ● Calm and relaxed. ● Calm and relaxed. ● Observe for verbal
and non-verbal cues.
● Apologetic. ● Questioning.
NB. Staff may call for back-up at any time. Back-up can include a more senior experienced member of staff.
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Sometimes these responses can prevent you from responding in a way that
you would desire. You may under or over react to a situation possibly:
Self-control plan
You need to have a self-control plan in place so that when you are confronted with an
aggressive incident, your response acts to calm the aggressive person and not to further
escalate the individual.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Answers
Facilitator: Elicit examples from the group. Some strategies might include:
● deep breathing
● controlled breathing
● inner dialogues
● focus on empathy
● count to three.
This is the first step in a crisis. It slows you down and lets you think about
responding in a controlled manner, rather than just reacting. It is a tool for
putting on the brakes.
● Deep breathing
Focus on your breathing. Deep breathing is essential to preparing yourself
physically to deal with an aggressive situation. There are a number of different
breathing techniques which may be used.
● Inner dialogues
Inner dialogues are the conversations we have with ourselves which determine
the way we approach a particular event, or the way we deal with a particular
person. Inner dialogues influence our attitude and strongly influence
the outcome.
When we think things won’t go well, because of our negative inner dialogues,
they probably won’t. Conversely, when we think things will go well, so long as it
is not based on blind optimism, they usually do. Inner dialogues are also useful
for monitoring the crises and your own reactions as you go along.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Facilitator instruction
Facilitator: Elicit examples from the group. Some strategies may not work when:
● strategies do not suit the individual
● the person is being physically assaulted
● taken by surprise
● personal issues or triggers intrude
● you are physically unwell
● you feel helpless and hopeless about the situation
● your own family, children, or people that you know are involved.
Facilitator note: It is useful to point out that everyone may have a self-control
plan but that it may not always be able to be drawn upon.
Key points
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Part 4
Managing aggression in
high-risk environments
Session time
80 minutes
Session overview
This part discusses the core values and skills required to manage aggressive
people. Short and long-term strategies are discussed to both prevent and manage
aggression in high-risk environments. Finally, the protective factors involved in an
armed hold-up or hostage situation are identified.
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Facilitator instruction
Facilitator: Emphasise respect and politeness. Good social skills are highly
effective in preventing and minimising aggression. De-escalation communication
skills are really basic commonsense.
● Be honest – don’t pretend you know what is going on if you do not. Tell the truth
but do it in a way that is sensitive – be truthful but not brutal.
● Communication depends on having your undivided attention. Listen to the person’s
need. De-escalation does not necessarily mean you are talking – listening is a key
communication strategy.
Ask the group: Identify three key factors that may be associated with an
individual’s escalation toward frustration and aggression.
Answers
Examples:
● Indifference of staff.
● Waiting times.
● Not having issues adequately explained.
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● eliminate risk
or
● reduce the risk to the lowest possible level.
It is important that all staff be aware that a range of options exist when faced with
aggressive or violent individuals. These responses will depend on a number of factors
including the nature and severity of the event, whether it is a patient, visitor or intruder
and the skills, experience and confidence of the staff members involved. This may
include calling for back-up, security or local police.
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Short-term options
Some short-term options for dealing with aggression may include the following.
The order in which they are used or the appropriateness of the strategy depends
on the specific situation.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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The key issue is trying to meet the needs of a person. Recognise that you
cannot always meet their needs.
Remember that the majority of people don’t reach crisis. If they are verbally
abusing you, generally they are angry at the system.
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Medication management
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
Facilitator note: Ask participants about the duress alarm in their area.
Explain that duress alarms do not reduce the incidence of aggression. However,
they may reduce the likelihood or severity of injury when appropriately used.
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Back-up
Depending on the level of perceived threat, imminence or actuality of violence,
effects of the behaviour on others, availability of support and local protocols,
back-up may include:
● calling on a more senior staff member or clinician – in some circumstances,
this may be enough to calm an aggressive patient and also allow for a clinical
assessment if warranted
● contacting security staff – the presence of security staff may act as a deterrent
and/or assist in the protection of staff and visitors
● using the duress alarm or initiating the duress response
● calling police or other external security services
● withdrawing to a safer location.
6. Defending self
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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Case study
A seventy-eight year old patient is in intensive care after suffering a cardiac
arrest. He has been in for two days and has improved only slightly. He begins
to become agitated, and as the morning progresses he becomes louder, calling
for the doctor and his wife, saying he wants to go home because he will be better
off there. Attempts by the staff to calm him are not successful and he begins to
lash out at staff as they approach him. He tries to climb out of bed saying that
his taxi is out the front waiting for him. He is pulling at his IV line and repeats
that he will miss his taxi if staff don’t get out of the way.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
It is useful to re-cap each of the short-term options and discuss how they may
or may not apply to this case.
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Long-term options
Important training point
1. Written warnings
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Background reading
Document must have the signature of the unit manager, facility manager or
area health service chief executive officer as most appropriate.
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Background reading
Such circumstances may include where the patient has a history of repeatedly:
● presenting for treatment under the influence of alcohol or other drugs, leading
to aggressive, violent or disruptive behaviour
● being accompanied by groups of friends/relatives significantly disrupting the
treating environment
● being accompanied by persons with a history of aggressive behaviour towards
staff or others
● presenting in an aggressive manner late at night or at change of shift times
and disrupting the treating environment
● regularly threatening, attempting or perpetrating violence against staff or
other patients.
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____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Facilitator instruction
These usually apply to relatives or other visitors to a health facility and may be
considered as a long-term option for repeated problem behaviours.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Facilitator instruction
These usually apply to relatives or other visitors to a health facility and may be
considered as a long-term option for repeated problem behaviours.
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Background reading
File flagging
● Used to identify patients who pose a risk to the health and safety of staff
and other patients. Enables staff to be aware of the patient’s tendency to
become violent.
● The criteria to meet the need for a flag needs to be linked to violence and safety
issues because of the person’s behaviour, not simply because of the person’s
medical diagnosis.
● The flagging of a file may result in the person being provided with service in
a different manner than other patients. This may even, in extraordinary cases,
include an inability to supply the service in certain circumstances.
Relevant legislation
Anti-Discrimination Act 1977
The Anti-Discrimination Act provides for the making, conciliation and/or determining of
complaints about ‘unlawful discrimination’. Under the Act, it is unlawful to discriminate
on the grounds of race, sexual preference, transgender status, marital status or
disability. Disability includes mental illness and infectious disease status.
The Act states that it is unlawful for a person to refuse to provide goods and
services to another person on the grounds of a disability, or to place terms on
provision of those goods and services on the grounds of disability.
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Under the Privacy and Personal Information Protection Act 1998 (PPIPA), disclosure
of personal information is permissible provided it is necessary ‘to prevent or lessen
a serious and imminent threat to the life or health of the individual to whom the
information relates, or another person’. Any patient-alert system must therefore
incorporate these criteria.
Under both PPIPA and the Freedom of Information Act, patients have the right to
know what is on their file and can request to view their file. There are exceptions to
this, generally limited to circumstances where giving access to the information may
have an adverse effect on the physical or mental health of the person concerned.
Patients also have the right to request that their file be amended and this would
apply to a flag inserted into a file. If the request is refused, the patient can seek that
a notation be placed on their file outlining their concern, without erasing the flag
information completely.
Retention of a flag that is no longer accurate will have implications under PPIPA
and possibly the Anti-Discrimination Act. Thus, an active flag should not remain
on a file once the risk is no longer current. A process to review and remove flags
as appropriate is critical to any flagging system.
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Facilitator instruction
Discuss local policies and procedures on file flagging.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
These will set out who is treating the patient, what the crisis care strategies are,
identified goals and methods for achieving these goals. These plans are often
used for suicidal or parasuicidal patients.
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7. Inability to treat
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Background reading
Despite the options available for managing violent patients, there may be,
on rare occasions, and usually as a temporary measure, a situation where it
is almost impossible to treat a patient without significant, unacceptable risks
to those involved.
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Background reading
Where a staff member fears that there may be future violence, harassment
or intimidation from someone they have been exposed to in the workplace or
in the course of their work, regardless of whether charges of assault are being
laid against the person, the staff member may seek to take out an Apprehended
Violence Order (AVO).
An AVO is an order made by the court to protect people from abuse, violence
or threats of violence. They can also be applied for if someone is being stalked,
intimidated or harassed, or has reason to fear that they may be in the future.
The AVO is an agreement between the defendant and the court that the
defendant will not engage in certain behaviours. It usually states that the
defendant cannot assault, harass, threaten, stalk or intimidate the person
seeking the order (the complainant), or go within a certain distance of
their home or workplace. Other orders can be included if necessary.
There are two types of AVO. An Apprehended Domestic Violence Order (ADVO)
is made where those involved are related, have lived or are still living together or
are in an intimate relationship. An Apprehended Personal Violence Order (APVO)
is an AVO made where the people involved are not related and is the one most
likely to apply in workplace violence situations.
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9. Laying charges
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
It is helpful to reinforce this as an option. You may wish to elicit recent local
examples of patients or visitors being charged.
Case study
Jan, a community nurse, was on a routine visit to check up on a six-month-old
baby. The baby’s father sells drugs and when Jan arrives on one of her visits a
group of young, intoxicated males comes out of the kitchen, traps her and begins
to threaten her. At this point, the baby’s mother comes out and intervenes and
Jan runs out shaking and drives back to the community health centre.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
It can be useful to review all the long-term options and consider which ones
may be used in this case.
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Case study
A person brought in her hurt five-year-old child with a head injury. She was
very agitated and one of the staff noticed that an alert was flagged on her file
with regard to a risk for aggression. The staff called security and the child was
removed from the care of the person because they suspected the person caused
the injury. The person then became very aggressive and assaulted security.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator instruction
It can be useful to review all the short-term options and consider which ones
may be used in this case.
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Hostage negotiators will typically not mention or refer to the people taken
hostage in order not to raise their importance in the aggressor’s eyes.
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Key points
Facilitator instruction
Facilitator note:
● Recap the importance of safety.
● Recap the impact of aggression on the individual.
● Recap self-care: monitor intake of caffeine, cigarettes, alcohol
(remember their impact on the immune system).
● Reinforce mindfulness and stress reduction strategies.
Facilitator note: to conclude the session reinforce the zero tolerance attitudes
and behaviours.
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References
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3. Chaplin E, Allison G (1998). The prevention and management of violence in the community.
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4. Claravall L (1996). Health care violence: a nursing administration perspective.
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15. NSW Interagency guidelines for child protection intervention, 2000. (online).
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