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

N E W S O UT H WA LE S

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

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Foreword

I have pleasure in writing the foreword to Guidelines for the Prevention and Management of Workplace Aggression: Case Studies from the NSW Health Industry. This publication and the research that is reported herein demonstrate a willingness by WorkCover NSW and Area Health Services throughout NSW Health to work together to improve workplace safety in health care settings. Workplace safety is an issue of great importance and practices that support hazard identification, risk assessment, risk management and post incident responses relating to workplace violence need to be continually highlighted. The staff who work in health care settings are a valuable resource and we wish to support and protect them by providing safe and healthy workplaces. This publication provides an insight into the current context of care delivery within contemporary health care settings with regard to violence in the workplace and identifies examples of better practice as benchmarks, for all services to consider and incorporate into their risk management strategies. As Chief Executive Officer of Central Sydney Area Health Service (CSAHS) I am most

gratified to be associated with this research project which has been funded under the WorkCover NSW Injury Prevention, Education and Research Grants Scheme. It recognises the need for such work to be undertaken and CSAHSs ability to do so. I am delighted in this confidence and the acknowledgment of the work of CSAHS staff, particularly those such as Mr Jim Delaney who, prior to this project, was actively involved with the CSAHS mental health services, who have over the years gained an Australia wide reputation in the training of critical incident management. I am reassured by the degree of co-operation and collaboration involved in the research and the completion of this project and the commitment demonstrated by large numbers of staff from Area Health Services, the Ambulance Service of NSW, Corrections Health NSW and WorkCover NSW who contributed significantly to this work. I look forward to a continuation of this co-operation.

Dr Diana G. Horvath AO Chief Executive Officer Central Sydney Area Health Service

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

Table of Contents

Foreword _________________________________________________________________ iii Executive Summary __________________________________________________________ ix Acknowledgments ___________________________________________________________ xi

1.

Overview of the Project ___________________________________________________ 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Description of project ________________________________________________ 1 Funding for the project _______________________________________________ 1 Aims of the project __________________________________________________ 1 Project design ______________________________________________________ 2 Advisory group _____________________________________________________ 2 Site visits to Area Health Services and other identified specialty areas within NSW _______________________________ 2 Case studies ________________________________________________________ 3 Nominated staff from NSW Area Health Services and other health related services ________________________________________ 5

2.

Background ____________________________________________________________ 7 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Violence in health care settings _________________________________________ 7 Definition of the problem _____________________________________________ 7 Workplace violence __________________________________________________ 8 Data relating to violence in the workplace _________________________________ 9 Data relating to violence in health care settings _____________________________ 9 The cost of violence in health care _______________________________________ 10 Assessment of violence ________________________________________________ 11 Factors impacting on increased levels of violence in health care _________________ 12

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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 3.2 3.3 3.4 3.5 3.6 3.7 NSW Occupational Health & Safety Act 2000 _____________________________ 19 NSW Occupational Health & Safety Regulation 2001 _______________________ 19 Prosecutions _______________________________________________________ 19 Policy development __________________________________________________ 20 The NSW Health Occupational Health Safety & Rehabilitation (OHS&R) Numerical Profile __________________________________________ 20 WorkCover Authority of NSW _________________________________________ 20 WorkCover NSW reporting ___________________________________________ 21

4.

Risk Management _______________________________________________________ 23 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Australian Standard for Risk Management AS/NZS 4360-1999 ________________ 23 The risk management process __________________________________________ 23 Hazard identification _________________________________________________ 24 Risk assessment _____________________________________________________ 24 Risk control ________________________________________________________ 24 Evaluation _________________________________________________________ 24 Resources and equipment _____________________________________________ 24 Risk management model for workplace aggression __________________________ 25 Case studies from a risk management perspective ___________________________ 26

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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 19972000 _________________________________________ 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

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Executive Summary

This publication is based on a project to develop guidelines for the prevention and management of workplace aggression in the NSW Health Industry, conducted during the period April 1999 to March 2000. This is an initiative of Central Sydney Area Health Service (CSAHS) supported by a grant from WorkCover NSW. It provides guidance material to assist health services within NSW meet their occupational, health, safety and rehabilitation obligations to minimise and manage violence in the workplace. The material adopts a risk management approach to identify, assess and control aggressive incidents in the NSW health industry. An advisory group was established to provide practical and representative direct industry experience to inform the project. Expressions of interest were sought from various professional organisations, the Ambulance Service of NSW, Corrections Health NSW and specialty services within the seventeen Area Health Services in NSW. Both public and private facilities were invited to participate. The project consisted of a series of interviews and discussion groups and involved reviewing materials collected from a number of sources. In addition, the report contains an extensive literature review examining workplace violence. It identifies health service workers as among the worst affected occupational groups and

explores the implications for a number of professional groups such as medical staff, ambulance staff, nurses working in a variety of settings such as Emergency Departments and in remote areas, and health care staff working in both community and inpatient settings. The literature provides many definitions of workplace violence and some of these are included. For example, the definition used by the Worksafe Commission Western Australia (WA) is, any action or incident that physically or psychologically harms another person. It includes such situations where workers and other people are threatened, attacked or physically assaulted at work. The report also includes data relating to violence in health care settings and enumerates some of the costs associated with workplace violence. It provides information on the relevant legislation and highlights some of the complexities associated with workplace violence including a lack of consistency in defining the problem and the variations in reporting which contribute to the confusion that surrounds this phenomenon. The guidelines are based upon experiences from across the NSW health system and describe examples of better practice in the form of case studies. The case studies that best meet the evaluative criteria decided by the advisory group are included in the report. These vary

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from an area wide strategic plan to a peer support program and a notice to deter violence in a specialty area of practice. The recognition of workplace safety as a crucial issue for managers and employees is highlighted and through the provision of case studies, a comprehensive review of available resources and a list of further contacts in the field this publication seeks to inform and empower health care workers.

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Acknowledgements

This research and publication was supported by a WorkCover NSW grant. The author wishes to thank all those colleagues who participated in this study as well as Dr Diana Horvath, Chief Executive Officer of Central Sydney Area Health Service (CSAHS), the NSW Department of Health and the WorkCover NSW advisors for their encouragement and support. The author wishes to acknowledge the contributions of NSW Health and the Chief Executive Officers from Area Health Services, Ambulance Service of NSW and Corrections Health NSW as well as nominated staff from these services. The project team also wishes to thank the members of the Advisory Group and everyone else who contributed to this project.

The Project Steering Committee

Members of the Advisory Group


Ms Trish Butrej, NSW Nurses Association Mr David Cain, Corrections Health NSW Ms Maggie Christensen, Central Coast Area Health 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 Mental Health NSW Mr Mark Haldane, Darlinghurst Community Health Centre Dr Margy Halliday, Project Co-ordinator, Risk Manager, CSAHS

Project Steering Committee


Mr Jim Delaney, Project Officer, CSAHS Ms Aurelia Pompelli, WorkCover Project Adviser (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

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Ms Jenelle Langham, Project Officer, Central Coast Area Health Service Mr Andrew Lillicrap, Health and Research Employees Association Mr Greg Martin, Security Services NSW Mr Dominic McLauglin, Private Hospitals Association NSW Mr Ben Nielsen, Centre for Mental Health NSW Mr Chris Patchett, Project Co-ordinator, Manager Employee Assistance Program CSAHS Ms Carol Pearson, WorkCover NSW Ms Linda Simm, Emergency Nurses Association NSW Ms Cathy Springall, NSW Health Ms Sue Wade, Rural Health Alliance

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 officer on the basis of his skills and experience. Jim has been a Staff Educator with Rozelle Hospital and CSAHS and has held the position of Critical Incident Co-ordinator within CSAHS. He has worked as an educator in the area of aggression management for the past ten years and has updated his knowledge and skills by undertaking advanced training in recognised accredited training programs in the United Kingdom and through networking and familiarity with latest research findings. In addition to conducting workshops, training programs and refresher training he has undertaken extensive needs analyses in a variety of clinical and non-clinical areas in both public and private health sectors in rural and metropolitan locations. Subsequent to conducting needs assessments he has been involved in policy development, service planning and restructuring, clinical practice guidelines, review of critical incidents and development of defusing and debriefing models specific to individual service needs. He has provided specialist training in the management of difficult behaviours for nursing homes, voluntary organisations, day care centres, and Government agencies throughout Australia. Following a national review of nurse education in Tasmania, Jim was invited by the Department of Health, to deliver training programs for staff within mental health facilities.

Other people who assisted with the project


Ms Lisa Carroll, Senior Project Officer, WorkCover NSW (to January 2000) Ms Margaret Coffey, Department of Health NSW Ms Carol Hines, Grants Project Officer, WorkCover NSW (from January 2000) Ms Jan Whalan, Director of Corporate Services, CSAHS

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He completed a Masters in Nursing specialising in education and his major research study examined the impact of educational intervention on anxiety and attitudes of nurses towards aggressive behaviour in a mental health setting. Since then Jim has collaborated on several projects relating to the identification of risk factors in

the area of aggression management receiving research funding as a principal investigator from both the NSW Nurses Association (Cavell Trust) and the Nurses Registration Board of NSW. The Steering Committee is grateful for the depth of experience Jim Delaney was able to bring to the project.

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

Overview of the Project

1.1 Description of project


This project aimed to develop guidance material to assist health services within NSW meet their occupational, health, safety and rehabilitation obligations to minimise and manage violence in the workplace. The material adopts a risk management approach to identify, assess and control aggressive incidents in the NSW health industry. Health Service managers were invited to contribute materials (such as policies, procedures, protocols, flow charts, business plans and educational materials) that they had identified as being helpful in the prevention and management of aggression in their work settings. The guidelines are based upon experiences from across the NSW health system and describe examples of better practice in the form of case studies. The research for this project was conducted during the period April 1999 to March 2000. A project officer was appointed on a full time basis to oversee the project. Ethics approval was obtained from CSAHS Ethics Review Committee.

workplace health and safety, workplace injury management and workers compensation. This is achieved by funding prevention, education and research initiatives, which promote WorkCover NSW objectives and priorities and have practical relevance to industry. Central Sydney Area Health Service (CSAHS) was successful in securing a grant to undertake this project and has benefited enormously from the input, support, encouragement and guidance provided by WorkCover NSW advisers.

1.3 Aims of the project


The aims of the project were as follows: to review the literature relating to the prevention, assessment, management and post incident management of workplace aggression to review policies, procedures, protocols, flow charts and business plans provided by a wide range of NSW and other relevant health services to develop guidelines consistent with a risk management approach for the prevention and management of workplace aggression to identify examples of better practice that can be applied to public and private health care settings

1.2 Funding for the project


This project was funded by the WorkCover NSW Injury Prevention, Education and Research Grants Scheme initiative. The purpose of the WorkCover NSW Grants Scheme is to improve practice in the area of

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

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

to develop case studies from the NSW health care industry with practical examples of successful prevention, management and post-incident management strategies, and to provide information on a range of resources relating to the management of aggression in health care settings.

1.5 Advisory group


An advisory group was established to provide practical and representative direct industry experience to inform the project. Expressions of interest were sought from various relevant professional organisations and specialty services within the seventeen Area Health Services in NSW, the Ambulance Service of NSW, Corrections Health NSW and from the private hospitals of NSW. Information outlining the purpose of the project was provided to promote participation and support for the project. The organisations were asked to seek expressions of interest from their members. It was anticipated that through this consultative process the project would develop comprehensive guidelines for the prevention and management of workplace aggression using case studies from the NSW health industry to support postincident management and the facilitation of rehabilitation and early return to work of affected workers. Members of the advisory group were requested to identify key policies, procedural documents, training approaches and examples of innovative responses in the management of workplace violence.

1.4 Project design


The project consisted of a series of interviews and discussion groups and involved reviewing materials provided. Information was collected from a number of sources, scrutinised and collated into a format that would provide a useful resource for others. A review of the literature relating to the assessment, prevention, management and post incident management of workplace aggression was undertaken. The seventeen Area Health Services in NSW and other selected services were invited to participate, by providing relevant information such as procedures, protocols, flow charts, business plans and educational materials. Consultation occurred with advisory group members in the form of regular meetings, discussion groups and interviews. Comment on draft materials was invited. Data relating to the number and severity of incidents reported by employees and workers compensation claims related to workplace violence and aggression was examined using summary information obtained from WorkCover, Treasury Managed Fund and the NSW Department of Health. Statistics were analysed for trends across the health care field.

1.6 Site visits to Area Health Services and other identified specialty areas within NSW
A letter was a sent to each Area Health Service Chief Executive Officer (CEO) by NSW Health and the CEO from CSAHS requesting their cooperation with the project. Each area was asked to nominate a representative who would liaise with the project officer. The project officer visited each of the seventeen Area Health Services and conducted interviews with the nominated staff. A schedule of questions was prepared to ensure consistency in the methodology. The interviews were

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

Overview of the Project

conducted over a period of several weeks, often necessitating follow-up interviews, phone calls, faxes and e-mails. The positive response to this part of the project was encouraging. Health Service managers were asked to identify issues relating to violence in the work setting, to identify strategies in place to manage workplace violence, to explore training needs and share information relating to current training, policies and procedural guidelines pertaining to their area of work. Staff representatives who were nominated to participate in this part of the project are listed in the appendices (see Table 1 on the next page).

were transferable and flexible satisfied legal requirements as set out under relevant legislation and guidelines (OH&S Act, Mental Health Act, Nurses Act, Health Services Act, Corrections Health Act, Security Act, Ambulance Services Act, Anti Discrimination Act and NSW Health guidelines) adopted a risk management framework demonstrated evidence of consultation with staff demonstrated management commitment were cost effective were informed by the latest developments in the particular area, they were innovative and they demonstrated evidence of efficacy, and were evaluated by the Area Health Service and approval was given to publish.

1.7 Case studies


The guidance material gathered from Area Health Service managers was reviewed and analysed by the advisory group to identify positive better practice in the prevention and management of workplace aggression and develop case studies. Discussion groups and individual interviews were conducted with advisory group members to assist in the selection of case studies for publication. Only some of the examples provided were selected for use as case studies as there were too many to include in the final report. The examples that best met the evaluative criteria decided by the advisory group were included.
Evaluative criteria

Selected case studies

The following case studies were selected as examples of better practice from the NSW health industry. South Western Sydney Area Health Service Security and Minimisation/Management of Aggression (SAMMA) Profile Wentworth Area Health Service Area Wide Strategic Plan 19972000 Central Sydney Area Health Service Critical Incident Management Plan Northern Rivers Area Health Service Notice of Non-Acceptance of Aggression Central Sydney Area Health Service 24 Hour EAP On-Call Service for Critical Incidents in the Workplace

The following criteria were used to evaluate the case studies presented. They: were validated by literature demonstrated evidence of strategic planning based on continued improvement and an outcome focus were considered to be useful and practical

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

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

South Western Sydney Area Health Service Peer Support Program South Eastern Sydney Area Health Service Minimisation of Violence and Aggression: A Self Learning Package Central Sydney Area Health Service Safety Zone Alarm System

requirements and are practical, and while caution is advised in applying solutions and strategies developed in one area of practice without a full and thorough assessment and consideration of local contexts, it is envisaged that these examples will provide direction and guidance for other areas interested in developing similar programs focusing on improving workplace safety. Although it was recognised that there were initiatives in training staff in the prevention and management of workplace aggression, these were not included here as was planned that these be investigated as a future project.

The eight case studies selected adopt a commitment to a risk management framework and they demonstrate evidence of strategic planning based on continued improvement with an outcome focus. They satisfy legal

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

Overview of the Project

1.8 Nominated staff from NSW Area Health Services and other health related services
Health Service Central Coast AHS Central Sydney AHS Far West AHS Greater Murray AHS Hunter AHS Illawarra AHS Contact Person Martin O'Malley Margy Halliday Chris Patchett Kylie Morton John Lockley Brenda Sim Terry Clout Linda Graham Sue Karpik Genevieve Menzies Damien Eggleton Job Description Human Resource Manager Risk Manager Manager Employee Assistance Program Risk Manager Risk Manager Clinical Nurse Consultant Area Mental Health Services Deputy CEO, Director of Health Service Operations Staff Education /INTACT Pro. Nursing Unit Manager Human Resource Manager Health Service Manager

Macquarie AHS Mid North Coast AHS Mid Western AHS New England AHS

Danny Cameron Human Resource Manager Education Resource Centre Staff Manning Base Hospital Ann-Marie Stranger Craig Hart Steve Beaton Trevor Maunder Trish Blackman David Grey David Dickson Brenda Collier Leonie Morgan Sue Arnold Garvey Geraldine Leslie Ann Costigan Allison Boyle Mari Evans-Rooney Glenda Galvin Tony Homer Roslyn Simpson Dennis Rogers Cathy Crowe John Kilkeary Kevin Gillies Bronwyn Anley Ian Palmer Simon Gould Pam Smith Human Resource Manager Consultant Learning & Development Unit Manager Employee Services Risk Manager Nursing Unit Manager OHS&R Officer Human Resource Manager Risk Manager Training and Education Centre Human Resource Manager OHS Advisor CNC/Liaison Psychiatry CNC/Liaison Psychiatry Human Resource Manager Staff Counsellor Risk Manager OH&S Co-ordinator Nursing Unit Manager Human Resource Manager Dep. Director Human Resource & Risk Management Staff Counsellor Risk Manager Project Officer Risk Manager Clinical Nurse Consultant

Northern Rivers AHS Northern Sydney AHS Southern AHS South Eastern Sydney AHS

South Western Sydney AHS Wentworth AHS

Western Sydney AHS New Children's Hospital Ambulance Service of NSW

Corrections Health NSW David Cain

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

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

Background

2.1 Violence in health care settings


The risk of work related aggression faced by health and social services workers is well recognised1,2 with almost a universal acceptance that violence is a significant problem for managers and practitioners in health care settings.3 The International Council of Nurses reported that health care workers are more likely to be attacked at work than prison officers or police officers.4 Aggression continues to increase and represents a serious health and safety risk for employees of these services. The concern that violence is on the increase in health care is acknowledged by Paterson, McComish & Bradley5 who point out that this trend is not only occurring in the traditional high risk areas of practice such as accident and emergency services, disability services and mental health services but has infiltrated other areas of practice. A study conducted in the United Kingdom (UK) involving human service workers showed that nurses and ambulance personnel were the two occupational groups identified as being most at risk from assault.6,7 Health workers identified as being particularly at risk include ambulance staff, nurses, family practitioners working in lower socio-economic areas, accident and emergency staff, staff in primary health care settings, and health workers caring for psychologically disturbed individuals including people with mental illness, and developmental disability.6,8,9,10

2.2 Definition of the problem


Violence is the unjust or unwarranted use of force or power.11 There is substantial evidence regarding increasing levels of violence in society12,13,14,15 with increasing crime rates reported in Australia and overseas.16,17 The pervasiveness of violence in todays society is indisputable.18 Estimates show that almost one third of all Americans are assaulted each year and that ten to fifteen per cent of these incidents occur in the workplace.19 Crime reports tend to indicate that in addition to the overall increase in violent incidents there is a corresponding increase in the intensity of aggression used.20 However, there are inherent difficulties in over-reliance on statistics due to variations in how crimes are grouped, disparity in reporting systems, variations in reporting tools, dissimilarity in services, and sometimes contradictory reports.17,21 Violence is described by the World Health Organisation (WHO) as a generic term incorporating all types of abuse including behaviour that humiliates, degrades or injures the wellbeing, dignity and worth of an individual.22 Elliott23 highlights that it can range in intensity from verbal threats to physical attacks, brutality and murder and is an individual perceptual experience influenced by a range of factors including culture, context, environment and past experience. Violence in

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

the workplace is perceived as a manifestation of the overall increase in societal aggression20. Statistics in the United States indicate that between 10% to 15% of violence reported occurs in the workplace. Elliott23 suggests that in the USA 25 million people are victimised by fear and violence in the workplace, with workplace homicide occurring on average four times a day, twenty times a week and 1000 times a year. This is in stark contrast to the traditional view of the workplace as a relatively benign and violence free environment where workplace confrontation and conciliatory dialogue occurs as part of the normal milieu.12 There are instances when this course of events fails to have a positive outcome and, according to Gregg & Krause12, the work setting is transformed into a hostile and dangerous environment. Violence in the workplace is defined as incidents where persons are abused, threatened or assaulted in circumstances relating to their work, involving explicit or implicit challenge to their safety.24 The International Labour Organisation (ILO) noted that workplace violence has gone global, crossing borders, work settings and occupational groups and concludes that it is now a public health concern of epidemic proportions.25 Perrone26 fills a void in the Australian literature and provides a valuable insight into the current context of violence in the workplace and in this way achieves the objectives of her study by highlighting factors that impinge on the maintenance of a safe working environment.

psychologically harms another person. It includes such situations where workers and other people are threatened, attacked or physically assaulted at work.27 The Commission also acknowledges the impact of verbal abuse and intimidation on the workers health and well being.27 The definition of work-related violence adopted by the National Health Service (UK) and published in guidance material prepared by Royal College of Nursing (UK) is described as incidents where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well being or health and includes violence from co-workers and other professionals as well as service users.28 In addition to the physical consequences of violence it is important to acknowledge the emotional consequences integral to the spectrum of violence.29 Elliott23 defines workplace violence as any incident in which employers, self-employed people and others are abused, threatened or assaulted in circumstances arising out of, or in the course of, the work undertaken. Estreich1 describes three types of work situations that can produce violence: (a) intra-organisational conflict between employees; (b) client originated violence; and (c) violence from the general public. The main focus of the literature appears to concentrate on client originated violence. However it is important to acknowledge that other situations have the potential to produce violence. The Royal College of Nursing (RCN) in the UK acknowledges intra-organisational conflict where the aggressor is another employee, a supervisor or a manager and provides bullying, harassment and intimidation as examples of incidents encountered.28,30 Such abuses are often systemic and ingrained in the culture of the organisation and their very pervasiveness

2.3 Workplace violence


Workplace violence is defined by the WorkSafe Commission Western Australia (WA) as any action or incident that physically or

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Background

renders them difficult to identify and hence address.26 Inter-group conflict is also described as horizontal violence and is manifested in overt and covert non-physical hostility such as sabotage, infighting, scapegoating, undermining and excessive criticism. It is clearly recognised as a workplace phenomenon and while it is not the major focus of this project it is important to acknowledge its existence.26,31 McClure21 identifies the most likely targets of workplace violence perpetrated by employees as workers and supervisors in the human service industries who are often the people responsible for resolving and mediating workplace disagreements.

homicide were found in the retail and service industries and Kiely, McCafferty, McMahon, & Kraus9 suggest that this may be explained by contact with the public and the handling of money. Libscomb & Love36 suggest that exposure to the public is an important risk factor in determining workplace safety. The risk is further increased when workers are exposed to emotionally charged situations and lack protection, confidence and training when interacting with people affected by a mental illness.37,38,39 It is important to acknowledge that the overwhelming majority of people with mental illness present no such risk.40

2.4 Data relating to violence in the workplace


Several authors acknowledge the difficulty in obtaining definitive data relating to workplace violence5,26,32 and acknowledge that this is compounded by different interpretations of what constitutes violence6,33 as well as the varying perceptions of violence in different contexts and cultures.16 In a study of all occupations in the United States of America (USA) from 1980 to 1988, Jenkins, Layne & Kesner34 reported that homicide was the third leading cause of occupational death among all workers. More recent studies indicate that homicide has become the second leading cause of occupational death.34 Levin, Hewitt & Misner35 reported that for the period 1980 1985 homicide was the leading cause of fatal occupational injury among female workers and this remains unchanged. Grainger18 acknowledges the insidious nature of occupational violence and the fact that it is no longer limited to those occupations where it was considered the norm, such as the police force and those working in areas of accident and emergency and psychiatry. Higher rates of

2.5 Data relating to violence in health care settings


A campaign to stop violence against staff working in the National Health Service (NHS) in the United Kingdom (UK) was launched in late 1999 by the Health Minister and the Lord Chancellor with full support from the government. This was in response to concerns that violence in the NHS was spiralling out of control with workers facing 1.2 million violent incidents a year41. Recent research funded by the Health and Safety Executive in the UK revealed that NHS workers experienced 523,000 physical assaults and 703,000 threats from members of the public in 1997. Workers in health care settings were identified as being a high risk group and the Lord Chancellor emphasised the need for support and respect for dedicated professionals often working in difficult circumstances.41 This initiative was designed to stamp out incidents where staff are assaulted, abused or threatened during the course of their work. The campaign which adopts a zero tolerance slogan has two principal objectives, namely to communicate to members of the public that violence against

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

staff working in the National Health Service is unacceptable and will not be tolerated and to send a clear message to all employees that violence and intimidation is unacceptable and measures are in hand to tackle this problem.42 Statistics available from the National Health Service (UK) regarding the severity of the problem suggest that up to 65,000 incidents of violence against staff occur each year in National Health Service Trusts in England (calculated at seven incidents of violence per thousand staff per month). National Health Service Trusts are urged to have systems in place to record all incidents of violence against staff and have identified strategies in place to reduce incidents by April 2000. National targets aim to reduce the incidents of violence against National Health Service staff by 20% by 2001 and 30% by 2003. Part of this approach is to liaise closely with the police to formulate and implement local crime prevention strategies.42 Workers compensation data for the period July 1995 to June 1998 in Western Australia (WA) indicate that almost half of all workplace assaults resulting in injuries or time lost from work are in health related industries and community services. Specific reference is made to work settings such as hospitals, developmental disability services, aged care facilities and prisons. Staff identified as most frequently injured are nurses and other hospital staff, welfare officers, security personnel, prison officers, childcare workers, teachers and teachers aides. The increased risk of workplace aggression for people who work alone in community settings is also recognised.27 A factor contributing to inadequate data collection is that many workplace violence episodes are not included in national workers

compensation databases. In Australia, as in Canada and the USA, incidents resulting in fewer than five days absence from work are excluded, despite representing forty six per cent of all new claims lodged annually.43,44

2.6 The cost of violence in health care


The cost of workplace violence according to Koch and Hudson43 extends beyond inflicting physical or psychological harm on an individual. It impacts on family, friends, work colleagues and the organisation. Whatever the context of violence it is important to acknowledge that it causes immediate and long-term disruption to interpersonal relationships, the organisation of work and the overall working environment. According to a report prepared by the International Labour Organisation in 199825 employers bear the direct cost of employee time lost from work and are also liable for the cost of improving safety in the workplace. Elliott41 estimates conservatively that in the USA the costs are in excess of US$4.3 billion annually or US$250,000 per incident and cautions that this is not inclusive of the hidden expenses, from the emotional pain victims, witnesses and family members suffer such as depression, isolation and anxiety. Perrone26 suggests that this is a gross underestimation of total expenses involved, and describes indirect or hidden costs as nontangible and cumulative and attempts to catalogue these from the perspective of the individual, the employer and the organisation. Victims are faced with the obvious costs of meeting the immediate and future medical expenses incurred. Other costs include short and long term psychological distress with the possible onset of post traumatic stress disorder (PTSD). Costs are also associated with the onset of substance abuse, stress related physical

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Background

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diseases and mental disorders like anxiety and depression. There are also opportunity costs associated with reduced employment options or loss of promotional prospects, job displacement, fear of crime and a diminished quality of life. Costs associated with the employer identified by Perrone include damage to property or loss of takings through theft or damage, affected employees medical expenses, increased workers compensation insurance premiums, legal expenses defending civil actions, absenteeism, disruption to work performance, increased staff turnover, increased costs associated with recruitment, orientation and training and costs of modifying the environment to create a safer work setting. Other indirect costs identified include reduced efficiency and productivity, loss in quality of products, loss of company image, and a reduction in the number of clients. Costs borne by society in relation to workplace violence include stress, trauma and financial expenses incurred by the victims, family and friends, interpersonal conflict between the victim and family members, elevated workers compensation premiums, lost taxation revenue, increased medicare payments, increased disability claims, retraining and rehabilitation costs, crimes compensation payouts and a loss of confidence in certain areas of business or certain professions leading to shortages in these areas and further recruitment costs. At a fundamental level the provision of a safe working environment is seen as a basic human right and the pervasive, enduring and multifaceted nature of workplace violence seriously threatens this premise. For the victims of violence it is recognised that violence is a cause of stress and a review of occupational stress reports indicates that

related illnesses carry considerable human and economic costs to the individual and their families. In England and Wales 3.3 million work hours were lost due to violence in 1997 with estimates of the cost of work related violence inclusive of medical costs and time off work at around $150 million.45 Human costs have been measured in terms of both psychological and physical ill health. Economic costs have been measured in terms of staff turnover, loss of earnings, absenteeism and impaired functioning.24,46

2.7 Assessment of violence


Predicting aggressive behaviour has been a central issue for mental health professionals during the latter half of the twentieth century.47,48,49 Accuracy in predicting aggression is an issue of concern for clinicians48,50,51,52 and a history of aggression is still considered the best predictor of future aggression.7,48,53 Much of the research focuses on the relationship between specific cues or risk factors and the occurrence of aggressive behaviour.54 Several authors acknowledge the inherent difficulties in researching aggressive behaviour and attribute this in part to difficulties in defining and measuring aggression and to unreliable data collection systems that fail to reflect the complexity of the problem.20,55,56,57,58 The eclectic approach to the use of assessment tools adopted by many facilities and services is criticised by Collins, Robinson & Lange50 who highlight the consequences of relying on inadequate assessments and instruments that lack any developmental or theoretical base. Almik & Woods37 identify the need to undertake validation of assessment tools in current use and acknowledge potential difficulties with inter-rater reliability in the practice setting. Monoghan48 concludes that

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

the most striking characteristic of research in the area of risk assessment is that it is inconclusive. It is however important to acknowledge that a relatively small number of patients is responsible for a high proportion of assaults.59 Distasio60 advocates a more comprehensive approach to assessment that recognises that violence occurs in association with patient, staff, situational and environmental variables and as such is predictable in some instances. There is little doubt that alcohol and drugs, particularly central nervous system stimulants such as amphetamines and cocaine, contribute to violence in the short term.61 The importance of considering situational variables as part of an integrated approach to risk assessment for psychiatric inpatients is well documented.47,62 Identified situational variables that may provoke aggression in inpatient settings include limit setting, conflict with patients, personal space, night time, inactivity and staff characteristics.8,47 In a project conducted in NSW focusing on acute inpatient care increased violent behaviour was noted in situations involving rapid hospitalisation and discharge, overcrowding, poorly defined ward structure, negative ward atmosphere and an unsatisfactory mix of patients with psychiatric disorders and patients with criminal and antisocial behaviour.63 Specific environmental variables included overcrowding, barren and uninteresting surroundings, long periods of unstructured activity leading to boredom, social climate of the unit (how staff and patients interacted) and an expectation of a therapeutic milieu (that there would be no aggression in the unit). Other risk factors associated with assault in health care settings include low levels of staff,

frequent changes in staffing, working in isolation, inadequate security, lack of trained staff and situations where therapeutic activity is at a minimum.7 However despite extensive research and validation studies the general consensus from the literature is that risk assessment in relation to violence is still an equivocal 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 in violence in health related services may be due to changes in service policy, and changes in funding allocations and living arrangements for specific groups. Successful fostering and placement of children in more permanent arrangements may result in an increased concentration of children with behavioural problems remaining in residential care. Davis61 identifies that at a structural level, a shortage of acute inpatient beds and community resources may result in higher numbers of acutely disturbed patients concentrated in inpatient units and also people with higher levels of disability and subjective distress cared for in the community.8 The prevailing economic climate places additional burdens on lower socio-economic groups with greater disparity between the rich and poor and this may trigger resentment, discord and conflict. The emphasis on community based care and mainstreaming of services has placed unprecedented demands on community services, aged care services, accident and emergency services, security services, non-government agencies, disability services, unemployment and welfare agencies, prison and detention services, and often the resources, skills and training of staff are inadequate to effectively respond to the diverse

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needs of consumers8. Elliott23 reports a number of key factors in the health care environment correlating with the increased risk of violence in health care settings. Key factors identified include: twenty-four hour open door policies for patient access decrease in available services for people with a mental illness and for people with substance abuse problems availability of drugs and money in hospital setting the prevalence of weapons amongst patients the current cost-cutting focus and widespread downsizing within the health care industry working alone during the night and early hours of the morning traditional staffing patterns often low staffing levels at times of increased activity, and circumstantial factors, such as unrestricted movement of the public in health care settings, presence of gang members, drug or alcohol abuse, trauma patients, distraught family members, long waiting times and the inability to obtain care or treatment.23

findings indicating that assault victims in hospital settings are most likely to be nurses.10,24,64,65 Rogers66 found that nurses are on average three times more likely to experience workplace violence than other occupational groups. Poster67 found that seventy five per cent of all psychiatric nurses had been assaulted at least once in their careers. Several studies have identified the discrepancies between actual incidents of violence and abuse and reported incidents9,10,68 The difficulties in accurately assessing the extent of the problem is highlighted by several authors who acknowledge that staff often choose not to report incidents of violence and are reluctant to draw attention to themselves21,69,70,71 The American Medical Association (AMA) suggests the development of specific educational materials to assist staff in identifying their legal options13.

2.10 Medical staff


The American Medical Association (AMA) acknowledges the lack of definitive data relating to the incidence of violent acts against physicians but suggests from anecdotal accounts and media reports that some specialists are more at risk, with psychiatrists and emergency physicians heading the list13. Despite these concerns the AMA suggests that workplace violence against physicians and other health workers is far less frequent than that against other workers in industries such as the retail trade, transportation, public utilities, communications and public administration13. However, statistics collected during the period 19801984 revealed that the leading cause of death from work related injuries in the health care industry overall was homicide (22%). Physicians were more likely to die from work injuries (19%) than other occupational groups

2.9 Inpatient psychiatric facilities


Assault in psychiatric inpatient facilities is a significant problem according to the literature and much of the research literature pertaining to violence in health care focuses on this area of practice.36,51 A number of researchers have found that a small number of patients are responsible for the majority of incidents.59,61 Several studies investigating aggression in psychiatric settings have been conducted with

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

in health care, followed by registered nurses (17%), nurses aides (6%) and dentists (5%). Findings from an annual survey of 160 hospitals undertaken by the International Association of Health Care Security in the USA indicated that 1 homicide, 24 armed robberies, 32 sexual assaults, 703 other assaults and 124 bomb threats were reported in relation to workplace violence in 1990.13 Doctors, like others in the helping profession, are frequently expected to accept workplace violence as an intrinsic feature of the daily risks associated with certain occupations and Perrone26 cautions that by contextualising violence in this way as a permissible, systemic work-related risk, it becomes accepted and is not viewed as an inherently unnecessary violent and harmful activity. More significantly she suggests that it has the effect of deflecting attention away from possibly negligent working environments and practices.26 Doctors, like others, are reviewing traditional roles and work practices. In the UK female doctors are in some instances refusing to make house calls at night71 and in Australia there have been media reports of general practitioners utilising security personnel to facilitate night calls in certain locations.

claims to nurse victims and this has been justified on the grounds that to engage in nursing practice is to accept that nurses are legitimate targets and that violence is part of the job4. Some relevant statistics released by the International Council of Nurses4 include the following: physical assault in health care settings is almost exclusively perpetrated by clients of the service ninety seven per cent of nurses surveyed knew a nurse who had been physically assaulted during the previous year, and seventy two percent of nurses do not feel safe from assault in the workplace.

Norko, Zonana & Philips73 propose guidelines for prosecuting violent patients. These include the following: criteria for pursuing prosecutions should be established as a matter of policy incidents by patients should be reviewed by clinicians not involved in their direct treatment violent incidents should be evaluated against the established criteria for pursuing prosecutions, and when the decision is made to proceed with legal action, the treatment team should not be responsible for initiating the complaint.

2.11 Nurses
The International Council of Nurses4 identifies that nurses are the health care workers most at risk with women considered the most vulnerable. Nursing has been identified as the most dangerous occupation in the UK with one in three nurses verbally or physically abused each year.72 There is an added dimension to the problem due to the widespread acceptance of violence as an unavoidable occupational hazard41. Legal systems have failed to award compensation

2.12 Remote area nurses


The plight of remote area nurses (RANs) is highlighted in a study undertaken by Fisher et al32 who also acknowledge under-reporting of incidents. This is attributed in part to the perception by RANs that except in the case of physical violence there is a tendency to perceive both the frequency and severity of their

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experiences with violence as low and not personally directed. 32 However, anecdotal evidence suggests that violence directed toward RANs is on the increase and the findings of this study support this view. The isolation and particular vulnerabilities of RANs as a group working in small rural communities are identified as significant factors. The study highlights the need to acknowledge RANs as victims, institute supportive measures, develop policies and intervention programs to address the issue of safety, change the culture of underreporting and involve managers and employers in accepting responsibility for the occupational health and safety of RANs. Elliott23 highlights the importance of communicating violent events, and suggests that under-reporting frequently occurs in work environments where the culture discourages reporting, where there is a lack of institutional reporting policy, where employees believe that reporting will not benefit them, or they may fear that employers may perceive assaults resulted from negligence or incompetence.

2.13 Community services


The incidence of aggression toward staff in the community is, according to Beale and Leather74, no higher than for many other health care workers, but what is different is that when community workers are faced with aggression and violence they are frequently alone, in unfamiliar settings and distant from their colleagues and organisational support27. This is compounded by a lack of policies and procedures for emergency action if staff require assistance or fail to check in after a home visit or an appointment with a client. When such policies do exist they are often not backed up with adequate training70. The availability and content of training in aggression management

for community staff is an issue with reports that training programs frequently emphasise physical responses rather than strategies in prevention and defusing techniques74. Cherry and Upston53 suggest some useful protocols to improve staff safety in community settings. These include self awareness, self control, self preservation, responding to actual and potential violence, post incident management and organisational responses. According to a National Health Service report many violent incidents involving community nurses take place on the way to or from the clients home71. The report suggests that training nurses in self defence or providing them with two way radios or alarms will not make any real difference to their safety but acknowledges that some aspects of home visiting can be improved such as visits to risky areas before dark and working in pairs. However it was suggested that the key to reducing the number of violent incidents is in the careful selection of mature, experienced community nurses with good social skills. This should be reinforced by appropriate training in recognising signs of potential violence and how to defuse aggression71. Beale and Leather74 identify some basic steps to be taken to improve safety for community staff if problems are encountered during home visits. These include the following: arrange for the patient to come to the clinic or request other support allow yourself adequate time for the journey, check that you have emergency equipment and that it works make sure somebody knows where you are going and when you are due back remain alert and continually reassess the situation dont go where you dont feel safe

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

if problems do occur, put your own safety first. If you do not feel safe, leave. if you are sure the aggression is letting off steam and not directed at you personally, listen, calm the agitated person and try to help with their problem after an aggressive incident take time to allow yourself to recover and contact your team report the incident through the reporting system be prepared for post trauma reactions following aggressive incidents, even supposedly minor ones. These reactions are entirely normal and usually diminish over time, and do not be afraid or embarrassed to ask for debriefing or counselling if reactions are difficult or persistent.74

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

2.14 The Ambulance Service


Similar to other areas of practice there is no comprehensive database available to track incidents of violence within the Ambulance Service and there are inherent difficulties in obtaining local statistical data both within Australia and overseas.77 Harkins78, in her examination of the effects of critical incident stress on emergency workers within the Metropolitan Ambulance Service (Victoria) for the period 199293, found that of the 73% of staff who had first contact with support services, 11% were solely related to trauma at work, 28% related to work in general, 22% related to personal issues and 39% were attributed to a combination of the above 78. Field77, responding to increasing concerns regarding assaults on Ambulance Officers in NSW, commented on the vulnerability of the position due to lack of prior knowledge of the patients behaviour patterns, the emotional volatility of the situation and the uncertainty of the environment because it is both unknown and uncontrolled. Field administered a questionnaire to 880 Ambulance Officers in the Metropolitan Ambulance Service, Sydney and analysed data obtained from 324 meaningful responses (36% response rate). The average length of service for these officers was 6.9 years. Findings indicated that there is a 22.8% chance that an Ambulance Officer will be attacked in any year (these range from relatively minor attacks to attacks of a more serious nature). Gender differences were recorded with each male officer experiencing 0.22 attacks each year while 0.48 attacks were recorded for female officers. Field acknowledged that these findings

Individuals, teams and organisations have responsibilities to ensure that strategies are in place to increase workplace safety and reduce risks74,75. Some innovations have commenced in this area. WorkCover Victoria76 has established minimum standards for specific areas of practice, such as undertaking community visits, conducting interviews and modifying reception and waiting areas. A best practice model for work in the community has been identified by the Royal District Nursing Services Research Unit as part of a project funded by WorkCover SA43. This model includes features of the work of Cherry and Upston53 and Bowie8 who identified a range of strategies to manage violence in the workplace. The model involves nine awareness and action options for staff to consider. These include, referral and triage, assessment, awareness of options if a violent event is experienced,

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were at variance with other studies that indicated that more males are victims of assault than females and offered the following by way of explanation: there are fewer females in the service than males (sample size small) females have a much shorter average length of service (females 1.9 years; males 7.4 years), and violence in society has increased dramatically in recent times corresponding with a time of increased numbers of females entering the service.

services on the scene. In a review of statistics relating to violent incidents involving Ambulance Officers in the Hunter Area of NSW78 95% of reported incidents from December 1996 to August 1997 related to alcohol and drugs and 36% of these related to call outs as a result of domestic violence. Seventy three per cent of reported incidents from September 1997 to May 1998 related to alcohol and drugs with 39% of call outs in response to domestic violence.79

2.15 Emergency Departments


In a similar project, The California Emergency Nurses Association surveyed 104 hospitals in the state. Findings revealed that injuries to staff, patients or visitors occurred in 58% of hospitals as a result of violence. The high incidence of violence located in Emergency Departments (EDs) was acknowledged with 53% of all hospital assaults occurring in EDs.13 Some of the reasons attributed to the concentration of violence within EDs included the 24-hour accessibility of the service, easy access, a wide range of clientele (including substance users, gang members and the homeless), minimal security, overcrowding, long waiting times, and inadvertent provocation by overworked or insensitive staff.13,80 Other factors included the stressful nature of the environment and the fact that patients are often anxious, in physical pain, experiencing discomfort and distress, confused and under the influence of mind-altering drugs. Gang violence in EDs has also been reported and strategies to counteract the effects of gang violence infiltrating EDs have been identified.81 In a retrospective study conducted by Pane, Winiarski & Salness82 to determine the scope and magnitude of patient and visitor

The most frequently recorded means of attack was with fists, which accounted for almost half of all attacks. A further 20% of attacks involved kicking, 13% were attacks with weapons and 20% were defined as others (eg. walking stick, timber, chairs, cricket bats, hammers). One officer was bitten and 2 officers were attacked with equipment from the ambulance. The majority of assaults occurred when responding to emergency calls (88.9%) rather than on routine calls (11.1%). Field76 categorised the type of emergency call the officers were responding to when assaulted and suggests that this information is important in risk assessment as it highlights the need to obtain additional information from the caller and serves to warn of increased risk in certain situations. Responding to calls relating to alcohol and drug overdose accounted for almost 35% of all assaults with the assailant being male in 80% of instances. Responding to emergency calls resulting from domestic disputes accounted for 20% of all assaults. This information has implications for staff training, the type of information requested from callers, expected responses of ambulance officers and communication with Police services and other

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

aggression directed towards emergency department staff, the findings confirmed that violence is a significant and under-reported problem. The study setting was an emergency unit situated in a medium sized teaching hospital in the USA treating approximately 40,000 patients annually. All violent incidents involving patients and visitors which resulted in a police response were included in the study. A total of 686 incidents were recorded in police logs for the study period. A corresponding review of official incident reports relating to patient and visitor violence completed by ED staff and sent to the risk management section of the hospital revealed that only seven incident forms had been completed.83 Similar studies examining reporting practices have found that all types of aggressive incidents are grossly underreported.83 A study conducted in the UK found that only 35% of incidents involving physical aggression were reported, 31% of incidents involving weapons were reported and that only 18% of incidents involving verbal threats were reported.84 Findings from these and other studies are useful in objectively quantifying the scope of violence in health care settings. They provide a frame of reference and base line data from which appropriate and cost effective strategies can be formulated and implemented.82 The importance of EDs in delivering mental health care within NSW was the focus of a special initiative undertaken by the Centre for

Mental Health reported in 1998.85 Particular concerns were identified in relation to assessment and management of people with mental health problems, accessing appropriate mental health services, co-ordination with other agencies and ensuring appropriate education and training for staff in EDs and Mental Health staff. A number of problems were identified by patients in relation to assessment practices in EDs. These included the lack of recognition that a patient has a psychiatric illness, problems in the management of patients with psychiatric illness and difficulties in safely supervising patients with psychiatric illness. Problems identified in the report by staff included difficulties in recognising some forms of mental illness, difficulties in appropriately triaging patients with mental health problems, difficulties in dealing with disturbed or violent behaviour and difficulties in obtaining adequate and timely access to specialised mental health services.85 The report contains a number of recommendations to address these deficits and a commitment to assist health services meet their obligations by making it a requirement that these recommendations be incorporated into Performance Agreements between NSW Health and Area Health Services.85 While only a small number of people with a mental illness engage in violent or aggressive acts59,61 it is anticipated that assisting staff to develop skills in the assessment, triage, management and appropriate referral will impact on the overall management of violence within EDs.

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

Legislation and Policy

3.1 NSW Occupational Health & Safety Act 2000


Workplace safety has become a crucial issue for managers and employees alike. The NSW Occupational Health and Safety (OH&S) Act 200086 clearly states that employers must ensure the health safety and welfare at work of their employees. Similar legislation in other Australian states and territories as well as overseas has made the responsibilities of employers more explicit, requiring employers to conduct formal risk assessments to plan and implement safe systems of practice.5

managers are obliged to identify and assess the potential for workplace violence. Currently, there is no regulation specific to workplace violence, no Australian code of practice and no standard for the control of workplace violence in NSW.

3.3 Prosecutions
Prosecutions serve as a warning to health, aged care facilities and community services employers that they are not exempt from liability and that WorkCover NSW is serious about enforcing legislation in service industries and the public sector as well as in the more traditional areas of construction and manufacturing. It is now recognised that individual managers who fail to comply with their responsibilities under OH&S legislation may face prosecution.88 In Queensland, a Director in the manufacturing industry was imprisoned for eighteen months for breaches of OH&S legislation. Failure to maintain a brake system to a front loader resulted in an employee being crushed when the machine lost all braking power during a routine loading procedure. In determining the sentence in a Queensland District Court the judge specifically took into account the need for some form of public retribution over the actions of the Director and the need to tangibly convey the message of deterrence to those who commit criminal acts under OH&S Legislation. The judgement in this case is a

3.2 NSW Occupational Health & Safety Regulation 2001


The NSW Occupational Health & Safety Regulation 200187 consolidates requirements for health and safety at work into one document. This regulation replaces all regulations previously made under the OH&S Act 1983, the Factories Shops and Industries Act 1962 and the Construction Safety Act 1912. Some of this legislation being replaced is prescriptive in nature, somewhat dated and may actually limit the employer or self-employed person from using more modern and effective control measures. The main changes to the risk management content are contained in Chapter Two of the Regulation 2001. It is a legal requirement to identify hazards and assess risks in the workplace. This will mean that

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

clear message that the judiciary will not hesitate to use imprisonment to communicate that contravening OH&S legislation is a serious matter.89 The current NSW OH&S legislation contains provision for fines for first offenders and fine and/or prison sentence for repeat offenders. Within health care and community service settings in NSW no imprisonments have resulted to date, however substantial fines have been given. For example, the Department of Community Services was fined $95,000 as a result of a serious assault on an employee and several other prosecutions are currently underway.90

as a valuable tool. It is used in NSW health facilities for monitoring and improving OHS&R performance and includes a specific question on security. It provides a structure for workplace managers to assess their OHS&R performance against set criteria and receive feedback. The integrity of the process relies in part on the ability of profilers to apply the tool consistently and communicate issues clearly with participating workplace managers and staff when conducting Numerical Profile audits. Profilers are accredited to increase inter rater reliability and managers are encouraged to provide feedback on the implementation of the Numerical Profile assessments within their facilities.92

3.4 Policy development


NSW Health issued a circular The Critical Incident Manual: Policy and Guidelines to Assist Public Health Facilities Develop a Planned Response to a Critical Incident Event91 which clearly states the following: It is the policy of NSW Department of Health that every health care facility shall develop a systematic and coordinated Critical Incident Management plan. This plan should identify, establish and promote a range of measures which minimise or eliminate the potential occurrence of a critical incident, identify the action to be taken should a critical incident occur and have protocols in place to reduce the trauma to staff and others who experience distressing incidents. It will also ensure the timely investigation and reporting of the incident.91

3.6 WorkCover Authority of NSW


The general functions of the WorkCover Authority of NSW (WorkCover NSW) as set out in the Workplace Injury Management and Workers Compensation Act 1998, Chapter 2, Part 2, Division 3 are: (a) to be responsible for ensuring compliance with the workers compensation legislation and the occupational health and safety legislation (b) to be responsible for the day to day operational matters relating to the schemes to which any such legislation relates (c) to monitor and report to the Minister on the operation and effectiveness of the workers compensation legislation and the occupational health and safety legislation, and on the performance of the schemes to which that leglislation relates (d) to monitor and review key indicators of financial viability and other aspects of any such schemes, and

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

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(e) to report and make recommendations to the Minister on such matters as the Minister requests or WorkCover Authority considers appropriate. WorkCover NSW has such other functions as are conferred or imposed on it by or under the workers compensation legislation, the occupational health and safety legislation or any other legislation. In exercising its functions, WorkCover Authority must: (a) promote the prevention of injuries and diseases at the workplace and the development of healthy and safe workplaces (b) promote the prompt, efficient and effective management of injuries to persons at work (c) ensure the efficient operation of workers compensation insurance arrangements having regard to policies of the Advisory Council, and (d) ensure the appropriate co-ordination of arrangements for the administration of the schemes to which the workers compensation legislation or the occupational health and safety legislation relates. Specific functions include a range of activities impacting on the prevention and management of occupational injury and rehabilitation and return to work of injured workers. These include the initiation and encouragement of research to identify efficient and effective strategies for the prevention and management of occupational injury and rehabilitation of injured workers.93

3.7 WorkCover NSW reporting


WorkCover NSW is monitoring developments across the state and acknowledges that workplace violence is difficult to quantify due to variations in reporting and coding44. The Health Industry Injury Classification Project94 was initiated as a joint project between NSW Health and WorkCover NSW to review classifications systems used for coding data relating to workers compensation claims. It was recognised that the coding system was not suitable for identifying specific high risk groups, such as occupations, activities, locations and types of accidents. One of the outcomes of this project was the development of an enhanced classification system specific to the health industry. While the project acknowledged that it would not be practical to use such a system on a continuous basis it was suggested that this system would facilitate retrospective audits and other research activities. An examination of workers compensation claims relating to violence during 1995/96 presented by Estreich1 on behalf of a WorkCover NSW working party indicated that work related violence is most prevalent in the following industry groupings shown in Table 1.
Table 1 Worst affected industries by rank order

1. 2. 3. 4. 5. 6. 7. 8.

Health Welfare and community services Restaurants hotels and clubs Education Property and business services Retail trade Public administration Road and rail transport

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The worst affected occupational groupings were those providing human services as shown in Table 2. The following nine occupational groupings accounted for 85% of all major violence claims for 1995/96.1
Table 2 Worst affected occupations by rank order

1.

Miscellaneous labourers and related workers (includes guards, security officers and ward helpers) Registered nurses Miscellaneous para-professionals (includes welfare community workers and prison officers) Police Road and rail transport drivers School teachers Miscellaneous salespersons (includes bar attendants waiters and waitresses) Social professional (includes community social workers and social case workers) Managing supervisors (sales and service includes shop, restaurant, hotel, post office, railway station, managers)

2. 3. 4. 5. 6. 7. 8. 9.

(2.2%) and cost $13.1 million, which represented 2.1% of total costs. These injuries involved a total of 19,860 weeks in lost time. The most common injuries in this category were sprains, strains, contusions and fractures. Two hundred and forty incidents recorded involved assault by another person. Thirteen incidents for injury sustained as a result of being hit by a moving object involved another person. It is not possible to determine if these relate to assault with a weapon or to accidental injury.44 Mental Disorders is the category used for occupational stress conditions. This includes depression, anxiety, and other psychological and/or psychiatric conditions, which resulted from workplace stresses. WorkCover NSW has noted a significant increase in the mental disorder category over the last seven years. The introduction of legislative amendments on 1 January 1996 restricted compensation for psychological or psychiatric disorders. To be eligible for compensation, employment must be a substantial cause and injury must not be wholly or predominantly caused by specified reasonable staffing actions. With the introduction of these changes mental disorder cases dropped in 1996/ 97 by 8.7% over the previous year. However in 1997/98 the numbers increased by 20.2%.44 On average mental disorders accounted for 18.8% of all occupational diseases and were most frequently reported in the following industries; finance and insurance (71.6%), education (62%) health and community services (46.4%) and personnel services (45.9%). The total cost of mental disorders for 1997/1998 was $37 million and total time lost as a result of mental disorders was 42,392 weeks. 44

The Statistical Bulletin 19971998 relating to NSW workers compensation data released by WorkCover NSW44 codes injuries relating to workplace violence according to the mechanism of injury. Violence related injury is defined: as an injury where the mechanism of injury is either hit by a person or hit by a moving object and the agency of the injury is coded as other person. Obviously while many of these injuries will involve violence, some will involve accidental injuries. There were a total of 952 injuries during 1997/98 that may be regarded as involving violence. Violence related injuries account for only a small proportion of workplace injuries

WorkCover NSW Injury Prevention, Education and Research Grants Scheme

Risk Management

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


Risk management is an interactive process consisting of clearly defined steps that support improved decision making by contributing a greater insight into risks and their impact. AS/NZS 4360: 199995 is a revision of previous standards established to assist organisations and services to adopt a risk management perspective in their place of work. It provides a framework for establishing the context, identification, analysis, evaluation, treatment, monitoring and communication of risk. It is generic and as such is independent of any specific industry or economic sector. To be most effective risk management needs to be incorporated into the culture of the organisation and become part of the overall philosophy, practices and business plans rather than be viewed as a separate program.

applied at many levels in the organisation. The key elements of a risk management program are to establish the context, identify, analyse, evaluate and treat risks and to monitor review communicate and consult. Risk management can be applied at many levels in the organisation, such as at strategic and operational levels and can also be applied to specific projects to assist with decision making or to manage recognised risks. Risk management involves hazard identification, risk assessment, risk control, developing workplace guidelines, consultation, training, audit review and evaluation.76 The requirements of the NSW OH&S legislation to ensure that the health, safety and welfare of employees and others in the workplace are best met with an appropriate management system, which includes: OH&S policy, codes of practice and programs for implementing and monitoring safe systems of work consultation at all levels of the organisation clearly identified lines of responsibility and accountability training at all levels, and allocation of resources (time, financial and personnel).

4.2 The risk management process


The risk management process can be applied to any situation where an undesired or unexpected outcome could be significant or where opportunities are identified. Decisionmakers are encouraged to be aware of possible adverse outcomes and to take steps to control them. Risk management is an integral part of the management process. It is a multifaceted process of continual improvement and can be

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

The development of an effective OH&S Program requires the identification, assessment and control of workplace hazards. A hazard is a situation with the potential to harm life, health or property. Hazards arise from the workplace environment, use of plant or equipment, use of substances, poor work design, inappropriate management systems and procedures and as a result of human behaviour. The CSAHS Critical Incident Risk Management Plan96 suggests the following to assist in the identification, assessment and control of workplace hazards.

4.5 Risk control


Elimination of hazard (not using a product or designing out a hazard) Substitution (using a safer product or safer equipment) Isolation/enclosure (screens, guards) Ventilation to reduce exposure Policies and procedures Work organisation Training Supervision Personal protective equipment

4.3 Hazard identification


Literature and observation of similar workplaces Workplace inspections Direct observation of the workplace Consultation with employees Complaints Accident and injury reports and statistics Accident investigations OH&S audits

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 risk assessment and costs and complexity of controls

4.4 Risk assessment


Likelihood of exposure (level of risk) Level of exposure (frequency and duration) Severity of resulting injury or illness Human differences (allergies, physical parameters) Contributing factors and their interactions Environmental monitoring Health monitoring

This approach recognises that the prediction of aggression can be very difficult due to a range of causative factors, such as heightened emotions, drug and alcohol induced aggression, various medical conditions (such as head injuries and psychological and psychiatric disorders) pain and frustration.76

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4.8 Risk management model for workplace aggression


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

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4.9 Case studies from a risk management perspective

Risk Identification and Assessment Security and Minimisation/Management of Aggression (SAMMA) Profile South Western Sydney AHS

Risk Control Area Wide Strategic Plan 19972000 Wentworth Area Health Service Critical Incident Management Plan Central Sydney Area Health Service Notice of Non-Acceptance of Aggression Northern Rivers Area Health Service 24 Hour On-Call Service for Critical Incidents in the Workplace Central Sydney Area Health Service Peer Support Program South Western Sydney Area Health Service Minimisation of Violence and Aggression: A Self Learning Package South Eastern Sydney Area Health Service Safety Zone Alarm System Central Sydney Area Health Service

Risk Monitoring and Evaluation Security and Minimisation/Management of Aggression (SAMMA) Profile South Western Sydney AHS

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Case Studies

1.

Security and Minimisation/Management of Aggression (SAMMA) Profile South Western Sydney Area Health Service Area Wide Strategic Plan 19972000 Wentworth Area Health Service Critical Incident Management Plan Central Sydney Area Health Service Notice of Non-Acceptance of Aggression Northern Rivers Area Health Service 24 Hour On-Call EAP Service for Critical Incidents in the Workplace Central Sydney Area Health Service Peer Support Program South Western Sydney Area Health Service Minimisation of Violence and Aggression: A Self-Learning Package South Eastern Sydney Area Health Service Safety Zone Alarm System Central Sydney Area Health Service

2.

3.

4.

5.

6.

7.

8.

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

Introduction
The Security and Minimisation/Management of Aggression (SAMMA) Profile provides facilities with a comprehensive audit tool for assessing their performance in providing security to staff and patients/clients as well as minimising and managing aggression. By conducting these annual assessments South Western Sydney Area Health Service (SWSAHS) is meeting the NSW Health Departments requirement to conduct an annual security audit, as described in the Safety and Security Manual. The profile has been developed as part of the overall SAMMA Program for SWSAHS. The SAMMA program includes training for auditors in the use and application of the tool. The program also incorporates a training package for employees which can be adopted by SWSAHS Health Sectors to provide opportunities for consistent application of local policies and procedures. It has been successfully introduced at SWSAHS.

Background
NSW Health released a document on Policy and Guidelines for the Minimisation and Management of Aggression in NSW Health Care Establishments (Circular 93/53).97 SWSAHS responded by establishing a working party to provide advice and recommendations on how best to deal with aggression in the

workplace in line with policy and guidelines and the Chief Executive Officer (CEO) of SWSAHS was appointed to the NSW Safety and Security Steering Committee. The working party recommended the development of an assessment tool to establish baseline information and to assess and monitor performance of health care facilities in the management of aggression. The intention was to provide information to enable the development of strategies to minimise and manage aggression and security risks. The assessment tool, which was based on the NSW Health Safety and Security Manual, was developed in 1995 and piloted in facilities by sector staff who had received training in the audit process and application of the assessment tool. The intention was to conduct audits annually and provide written reports to sector and area management on performance. Sectors then utilised the reports to develop action plans to address any shortfalls identified by the audits.

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Rationale
A number of factors contributed to the development of this tool. Staff were concerned with the increasing number of reported incidents and breaches of security occurring within SWSAHS. The following table provides an example of this trend within the Liverpool Sector which is SWSAHSs largest Health
Nature of Incident Abduction Aggressive behaviour Arson, threat and attempt Assault, common Assault, sexual Attempted murder Burglary Burglary attempt Damage to property, private Damage to property, health service Dangerous drugs, misuse/theft Disturbance, general Harassment Lost property, private Lost property, health service Missing/wandering patient Patient safety at risk Restraint, patient Robbery Robbery, attempt Road and traffic incident Security breach Theft of property, private Theft of property, health service Threat to person Weapons incident Verbal assault Unsecured area Total 1997 0 4 0 3 0 0 2 6 1 5 0 1 0 0 0 0 0 4 9 2 0 1 64 10 0 0 3 1 116

Service. Managers were requesting assistance in meeting their responsibilities regarding the management of incidents within their facilities in line with NSW Department of Health Circular 93/53. The following statistics are reported security related incidents at the Liverpool Sector.

1998 1 46 1 22 3 1 1 2 9 4 2 7 2 4 1 3 1 7 1 4 3 34 69 23 1 4 3 2 261

1999 (to 31/10) 0 38 0 11 1 0 0 0 5 11 0 0 6 0 0 12 0 7 0 0 0 57 50 26 1 0 1 0 226

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Other contributing factors included: 1. The decision for SWSAHS to develop a SAMMA program including annual audits was taken due to an identified need to maintain a high level of awareness regarding security and aggression issues and to assist in changing the attitudes and culture of staff in thinking about their own safety. An audit process was considered a practical way of achieving such awareness and ensuring continuous improvement in minimising security breaches and aggressive incidents as well as the effects of any breaches and incidents. WorkCover inspected facilities within SWSAHS over the last few years in relation to security of staff and issued a number of Improvement Notices. Sectors were requesting assistance with development and implementation of appropriate policies, procedures, work practices and staff education programs. Staff were expressing concern regarding personal safety and security issues at their workplace. Aggressive incidents and breaches of security had continued to occur (some quite serious), which suggested that managers still required support with implementation of the DOH policy and procedures. The OHS&R numerical profile is a NSW Health Department initiative which was developed to address the broader issues of safety within health care facilities. A review of this profile determined that it should remain as a broad measure and that individual facilities should then develop their own systems to meet the broad standards within the OHS&R profile.

6.

The SAMMA audit tool addresses each policy statement contained in the Health Departments Safety and Security Manual and therefore was considered a very comprehensive way of measuring the performance of each Sector in every aspect of security and aggression. The implementation and maintenance of a SAMMA program was seen as a positive step in developing a better practice approach for measuring and changing work practices

7.

How was it established?


In 1995, an audit tool was developed in response to the NSW Health Department Circular 93/53, Policy and Guidelines for the Minimisation and Management of Aggression in NSW Health Care Establishments.96 This audit tool was reviewed later in 1995 to take into account the policy statements contained in the NSW Health Security and Safety: Minimum Standards for Health Care Facilities.98 An annual audit program was then established to measure performance in SAMMA issues. In response to a need for review of the audit process and to address the ongoing issues described above (Rationale), agreement was sought and provided by General Managers, to hold a workshop with representatives from all facilities, to identify the best way to establish a whole of security approach. A workshop was conducted in 1998 and the following strategies were identified to form part of an action plan. Security officers be accredited in accordance with the requirements of the Security Industry Act.

2.

3.

4.

5.

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The Area Human Resources Development Unit investigate what SAMMA Training Packages are available. The SAMMA assessment tool be reviewed in accordance with the revised Safety and Security Manual. Additional staff be trained in conducting the SAMMA audits. Central co-ordination of the audit program be assigned to Area Commercial Services. 3.

would concentrate on whether a facility achieved an A, B, C or D in each element of the assessment tool. It was considered that this approach would allow facilities to focus on performance for each element rather than an overall score. Consequently, all reference to scores was deleted from the assessment tool and trainee auditors proceeded with the agreed method of reporting performance as outlined above (See attached outline of SAMMA profile summary). Auditor training: a total of twenty-seven staff attended auditor training. The training comprised three major components: 1 day session covering the process for audits and the assessment tool completion of one pilot audit and written report to General Managers review session to discuss issues arising from the application of the new assessment tool and audit process Resources required to undertake surveys: two to three auditors conduct surveys for each Sector, depending on the location and size of units within each Sector. Community Health centres will be surveyed as if they are a facility within their parent Sector. Following is an estimate of time allocation necessary.
Estimated Time Allocation for each Auditor Site Visits Report Writing 1 day 1 day 1 day 1 day 1 day 1 day 1 day 7 days 2.5 days 3 days 2.5 days 3.5 days 2.5 days 1 day 1 day 16 days

The strategy
1. Review of the SAMMA Profile: the 1995 SAMMA assessment profile was reviewed and modified. The review took into account all aspects of the NSW Health Departments Safety and Security Manual. The format of the assessment tool was also adapted to be consistent with the format of the Health Departments OHS&R Numerical Profile. The revised SAMMA was piloted (as part of auditor training) to incorporate feedback from both auditors and staff from the different Sectors within the area. Consideration was given to the scoring aspect of the SAMMA Profile and as part of the pilot the trainee auditors decided against using a numerical score. Instead of a percentage score, performance reporting
Size of Facility (FTE) 1,290.8 2,281.9 615.4 1,130.2 222.5 87.0 164.0 5791.8

4.

2.

Sector Bankstown Liverpool Fairfield Macarthur Wingecarribee Carrington Braeside Total

Number of Auditors 3 3 3 3 2 2 2

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5.

Central co-ordination of the program of surveys takes approximately eight hours and is the responsibility of Area Commercial Services. Result of Pilot Surveys: Facilities were given a rating of A, B, C or D for each element, as opposed to an overall percentage score. It was considered that this approach would allow facilities to concentrate on improving the aspects of SAMMA that are a priority for each facility. A detailed consolidated report was given to Sector Managers indicating results for each element. This provided a basis for networking across Sectors as management could clearly see where better practice was in place. The trainee auditors reported that there was support for the audit and sectors displayed a positive approach to the assessment process. However, auditors and Sectors commented that the survey tool needs to be less detailed and the terminology simplified.

Who else has adopted this as a strategy?


The NSW Health OH&S Advisory Committee, along with the NSW Health Safety and Security Steering Committee, is currently discussing the issue of measuring performance across health for security and management of aggression risks. The alternatives being discussed are: adopting a separate numerical profile for security and management of aggression across all NSW Health facilities expanding on the current OHS&R numerical profile, Standard 2.6, Critical Incidents and Security.

6.

7.

Evaluation of the SAMMA Program


Evaluation of the SAMMA program will be through the following key performance indicators: improvement in levels achieved for each element within the audit tool number and type of reported security related incidents and outcomes, and analysis of evaluations from staff education.

Preliminary discussions have indicated that the issue of security and personal safety of health service employees is of high enough importance to warrant a separate audit. In addition to this, the current standard 2.6 requires, for a B level, the completion of an annual security survey. However, it is also considered desirable to have a simple but effective assessment tool, in which case the SWSAHS audit may be used as the basis for the development of an appropriate assessment mechanism. Not withstanding the above comments and possible direction of NSW Health, the SAMMA tool will now be refined to incorporate, where appropriate, suggested changes as a result of the comments received from Sector Management and auditors. In addition, the number of elements within the tool will be reviewed with a view to amalgamating elements where appropriate, or deletion of elements where there is significant overlap with the OHS&R Numerical Profile. For further information contact: Mr Craig Turner, Manager Commercial Services, SWSAHS.

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SAMMA profile performance level summary


1 Standard A 1.0 Organisation and Administration 1.1 Policies 1.2 Employee Recruitment and Selection 1.3 Evaluation / Review of SAMMA Performance 1.4 Identification of Risks 1.5 Assessment and Control of Identified Risks 2.0 Physical Environment 2.1 External Environment 2.2 Internal Environment 2.3 Security Services 2.4 Control of Theft 2.5 Access Control 2.6 Security and Storage of Information 2.7 Security and Storage of Pharmaceuticals 2.8 Security and Storage of Medical Gases 2.9 Security and Storage of Radioactive Substances 3.0 Incident Management, Education and Training 3.1 Identification and Control of Aggressive People 3.2 Induction and Orientation 3.3 Incident prevention training 3.4 Critical Incident Stress Management (CISM) 4.0 Special Circumstances 4.1 Field Workers 4.2 Emergency Situations 4.3 Clients in Custody 4.4 Batons and Handcuffs Total number of A Levels: Total number of B Levels: Total number of C Levels: Total number of D Levels: Standard Achieved B C D

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Case Study 2
Area Wide Strategic Plan 19972000 Wentworth Area Health Service

Introduction
The Wentworth Area Health Service (WAHS) has adopted a comprehensive approach to ensuring the health, safety and welfare at work of all employees in accordance with the NSW Occupational Health & Safety Act 1983 (OH&S Act). An area wide strategic plan was developed to assist the organisation to meet its responsibilities regarding OH&S legislation. The goals of the strategic plan are to promote an injury free and healthy workforce, to facilitate a consistent and effective OH&S infrastructure across WAHS, to reduce and appropriately manage the impact of workplace accidents and injuries and to return injured or ill employees to full health as safely as possible. The strategic plan encompasses the development, promotion and implementation of specific prevention programs to reduce workplace illness and injury. One section of the strategic plan relates specifically to minimising the risk of violence and aggression in the workplace, (and provides detailed information regarding the prevention, minimisation and post incident management of aggression in the work setting). The plan is continually being updated and adapted in response to the changing needs and demands of the work setting and also in response to changes in NSW Health policy, procedural guidelines and relevant legislation.

Rationale
The plan was established following the appointment of an area OH&S Co-ordinator and as part of the WAHS commitment to adhere to the requirements of the NSW Health policy and procedural guidelines, Circular 97/97 and the NSW Health Safety and Security Manual.

How was it established?


A working party was established comprising twelve senior staff and OH&S representatives from the WAHS. The brief of this working party was to address the issue of health and safety in the workplace. Workshops were conducted to facilitate the development of the strategic plan and involved as many staff as possible in identifying key issues impacting on health and safety in the workplace. Outline proposals of the plan were presented to workshop participants to seek feedback and encourage involvement in the development of a comprehensive strategic approach to reduce workplace illness and injury. Some of the issues identified in the workshops related to manual handling, slips trips and falls, and anecdotal information regarding the increasing amount of violent and aggressive behaviour directed towards health care workers. Following this feedback the working party began developing the area wide strategic plan with an emphasis on a risk management approach.

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The strategy
The strategic plan describes goals and objectives required to meet OH&S requirements regarding the provision of a safe workplace. Each objective has identified strategies, specific actions required, performance indicators and inbuilt accountability by identifying individuals or groups responsible, expected dates for completion, and outcome or achievements to date (see attachment). Topics included in the strategic plan are as follows: 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.

requirements for all health facilities within the area are in place. The WAHS Security Policy has recently been updated in response to current practice issues. The indicated Security Manager is also responsible for convening an Area Security Committee to assist facilities with implementing security policies. This committee meets bi-monthly and reviews a number of issues relating to safety and security at work. High risk areas are currently being identified and statistical reports are issued to all facilities on a regular basis. Actions to control risks are progressively implemented as risks are identified. Security is a standing agenda item at OH&S committees. A review of all violence/aggression management training for staff has been undertaken. Staff working in identified high risk areas are given priority access to training. Training programs are conducted throughout the year to increase staff access to training. Regular updates on the implementation of the strategic plan are provided to the WAHS executive to ensure performance indicators are monitored and that identified outcomes are completed by the due dates.

Outcomes
As a result of adopting a strategic approach to minimise the risk of aggression in the workplace a number of initiatives have been undertaken, or are in the process of being implemented. This process has been assisted by the appointment of a facility Security Manager, who has area wide responsibilities include the ongoing development and dissemination of security policies for WAHS, setting minimum standards for safety and security in accordance with policy and legislation and ensuring safety and security

Patient/staff issues
Staff were provided with the opportunity to be involved in the development, implementation and ongoing evaluation of the strategic plan. A number of issues have been identified for staff and patients.

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The strategic plan provides direction for staff and reinforces the need to adopt a preventative approach to ensure safety in the workplace. The expansion of the Security Managers role and a regular security and OH&S committee structure provides staff with access to a forum to further explore incidents of concern and identify future management options. Statistics relating to accidents/incidents are disseminated and reviewed on a regular basis by identified persons/teams and this enables the service to identify trends, monitor areas of high risk and institute appropriate preventative measures.

Staff in identified high risk areas are given priority access to training and this increases individual responsibility in the maintenance of a safe workplace and increases staff awareness of the need to undertake assessment and develop skills in responding and appropriate referral.

Conclusion
The strategic plan reinforces the commitment of WAHS to ensure the health, safety and welfare of all employees in the workplace. It is a comprehensive approach and includes operational details to ensure that specific strategies are in place and provides inbuilt accountability and target dates for delivery of outcomes. For further information contact: Ms Roslyn Simpson, Risk Manager, WAHS.

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Case Study 3
Critical Incident Management Plan Central Sydney Area Health Service

Introduction
Central Sydney Area Health Service (CSAHS) has adopted a systematic and coordinated approach to critical incident management through the development of a comprehensive Critical Incident Management (CIM) Plan. The purpose of the CIM Plan is to develop a risk management approach to critical incidents and standardise this across the Area Health Service. The specific aims of the CIM Plan are to: 1. develop an operational environment that reduces, minimises or prevents the occurrence of critical incidents implement systems to facilitate timely and effective responses to critical incidents identify and facilitate the provision of resources necessary to ensure recovery from critical incidents review, investigate and report on incidents with the purpose of reducing the potential for similar future incidents, and ensure staff are appointed and trained to deliver a skilled and efficient response.

CSAHS Critical Incident Committee

2. 3.

broad based risk management strategies pertaining to prevention, incident management, post-incident management, accident/incident investigation and followup, training, policies and procedures, and area wide promulgation, evaluation and review CSAHS needs analysis, and appendices, which provide detailed information pertaining to key roles, checklists for security and managers, and CIM systems in place and site co-ordinators.

4.

5.

The CIM Plan includes specific information relating to the following areas of management: role and responsibilities for facility managers strategies to improve incident management

The CIM Plan defines critical incidents as events outside the normal experience of a person which overwhelm their coping skills and cause them to experience unusually strong emotional reactions at the time or some time later. These reactions are best described as

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traumatic stress reactions and interfere with a persons ability to function either at the time of the incident or some period later. Events that precipitate traumatic stress reactions commonly have one or a number of the following characteristics: they are sudden and unexpected they are violent and shocking they are untimely they involve a significant degree of suffering and or loss, and they involve a high degree of damage.

event of a particular occurrence, such as fire, bomb threat, assault, or armed hold-up. These manuals also highlighted the need for Area Health Services to develop specific guidelines to cater for local needs. In response to these directives the CSAHS Plan was developed to be consistent with the NSW Health Circular 97/97 and the NSW Health Safety and Security Manual.

Statistics
CSAHS maintains statistics relating to incidents of aggression and workers compensation claims. For the period July 1995 to June 1996 a total of 38 claims were made from all CSAHS facilities related to assaults, 52 in 1996/97, 38 in 1997/98 and 16 for the period July to December 1999. The occupational group most affected was nurses, who accounted for 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 the impact of critical incidents in the organisation because not all critical incidents are reported and of those reported not all lead to workers compensation claims. It was recognised that critical incidents can be particularly distressing (and damaging) on an individual level, and that particular attention was warranted with regards to the prevention and management of critical incidents. This necessitated the identification of high risk areas and the development of risk assessment approaches and risk control strategies. Within CSAHS the following areas have been identified as high risk: mental health services dental clinics

Rationale for the CIM Plan


CSAHS recognises that the most effective way to minimise the risks associated with critical incidents is to identify and assess the potential for problems. Once the potential is assessed systems can be put in place to eliminate or reduce the likelihood of a critical/aggressive incident. In 1997 NSW Health issued the Critical Incident Manual Policy and Guidelines (Circular 97/97)91 for minimising and managing critical incidents in NSW public health care facilities. This manual provided information on: critical incident management and staff responsibilities incident prevention response plans critical incident response incident recovery and review, and incidents involving aggression.

In addition, the NSW Health Safety and Security Manual identified the responsibilities of staff at various levels within the organisation together with the actions they are to take in the

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emergency departments paediatrics at RPAH and Canterbury Hospital, and neurology at RPAH.

Progress and adherence to the CIM Plan is reviewed as follows: an annual review of the CIM Plan including attainment of nominated objectives/strategies quarterly reviews of critical incident statistics, workers compensation data (de-identified) and Treasury Managed Fund (TMF) performance.

How was it established?


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

The strategy
The CIM Plan adopts a broad based risk management approach and provides specific information on preventative strategies. Strategies related to risk identification, risk assessment, and risk control are described and guidelines for prevention are provided. The CIM Plan also contains intervention strategies on incident management and post-incident management and includes specific information relating to CISM. The responsibilities of managers regarding the maintenance of a safe workplace are outlined and the legal implications are also identified. Training requirements, accident/incident investigation, reporting mechanisms and policy and procedural information are included. A committee supports the CIM Plan with representatives from all key areas in CSAHS. This committee meets bi-monthly to discuss all issues relating to critical incidents.

To assist facility managers to comply with the CIM Plan a detailed needs analysis tool was included. This provided information regarding current systems, policies and procedures in place within CSAHS and categorised these in relation to broad based risk management strategies (prevention, incident management, post-incident management, accident investigation, training, policies, procedures and evaluation). Subsequent to classifying the existing policies/procedures, and systems in place, the CIM Committee identified gaps or special needs and developed strategies to address these deficits. The CIM Plan includes a monitoring tool to assist facility managers to undertake six-monthly reviews of their services in the key areas of critical incident risk management, specify compliance and to provide evidence of achievements.

Staff issues
Under the NSW Occupational Health & Safety Act employees are required to take the care of which they are capable, for their own health and safety and the health and safety of others in the workplace. They must also cooperate with the employer where the employer institutes measures to ensure health and safety. The CIM Plan reinforces the need to comply with this legislation and specifies the requirements regarding formal reporting,

Outcomes
Specific measurable objectives/strategies, to be completed within nominated timeframes, are a key part of the CIM Plan. Action taken under the guidance of the CIM Plan can then be compared with specific outcomes.

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workers compensation and rehabilitation procedures. The CIM Plan highlights the need for Critical Incident Stress Management (CISM) following stressful events to reduce the trauma for individuals who experience distressing incidents and the responsibilities of the organisation to ensure that prompt and efficient services are readily available. CSAHS facility managers are required to ensure that employee job descriptions include appropriate information regarding their roles and responsibilities in the prevention, management, investigation and review of critical incident stress management strategies as well as their training obligations. The CIM Plan specifies roles and responsibilities for managers, telephone switch operators and staff.

Central Sydney Area Health Service Critical Incident Management Plan Contents 1 2 3 4 Central Sydney Area Health Service Statement of Principle Aims of the CSAHS Critical Incident Management Plan Roles and Responsibilities Broad Based Risk Management Strategies 4.1 Prevention of Critical Incidents 4.1.1 Risk (Hazard) Identification 4.1.2 Risk Assessment 4.1.3 Risk Control 4.2 Incident Management 4.3 Post-Incident Management 4.3.1 Access to EAP Services 4.3.2 Legal implications 4.4 Accident Investigation 4.5 Training 4.6 Policies and Procedures 4.7 Area-Wide Evaluation and Review

Who else uses this as a strategy?


South Western Sydney Area Health Service (SAMMA) Wentworth Area Health Service (Area Wide Strategic Plan) South Eastern Sydney Area Health Service (Critical Incident Management Policy in draft) Ambulance Service of NSW (in draft)

Analysis of CSAHS Systems and Needs (Table) 1 Prevention 1.1 Risk Identification and Assessment 1.2 Risk Control 2 Incident Management 3 Post Incident Management 4 Accident Investigation 5 Training 6 Policies and Procedures 7 Area Wide Evaluation and Review 7.1 Performance Indicators Improving Critical Incident Management (Table) 1 Prevention 2 Incident Management 3 Post-Incident Management 4 Accident Investigation 5 Training 6 Policies and Procedures 7 Area-wide Evaluation and Review Appendix 1 Role of Supervisor Role of Telephone Switch Operator Role of Staff Appendix 2 Critical Incident: Security Checklist Appendix 3 Critical incidents: Post-Incident Check List for Senior Managers References

For further information contact: Dr Margy Halliday, Risk Manager CSAHS.

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Case Study 4
Notice of Non-acceptance of Aggression Northern Rivers Area Health Service

Introduction
Staff throughout the Northern Rivers Area Health Service (NRAHS) were exposed to verbal abuse and threats with several reported instances of physical assault. Staff were uncertain of what to do, how to respond, and unclear of their legal rights. Mostly staff expressed feelings of helplessness and powerlessness. These issues were repeatedly being presented at OH&S forums. Management was increasingly concerned regarding the level of verbal abuse directed towards their staff. It was decided that legal opinion should be obtained to clarify the rights of staff members in these situations and that strategies be explored to assist staff to respond to these situations in a professional manner.

increased incidence of verbal abuse/ aggression from patients, visitors and others statistics did not reflect the increase in incidents of verbal abuse as staff tended not to report incidents of verbal abuse staff reported feeling increasingly powerless and helpless when confronted with verbal abuse staff wanted clarification of their legal rights in these situations perceived need to seek legal advice to clarify rights of all involved serious attempt by management to acknowledge staff distress and focus on a preventative strategy management wanted to demonstrate their support for staff in a tangible manner, and as part of a comprehensive approach to dealing with verbal abuse as a precursor to aggression.

Statistics
Many staff members stated that there had been a major increase in verbal abuse and verbal threats particularly in the preceding two years. Only the more serious threats or aggressive incidents tended to be reported. Verbal abuse was not always officially reported so this information was not accurately reflected in the statistical data relating to aggression.

How was it established?


Following extensive multidisciplinary consultation with clinical and non-clinical staff it was decided to convey a clear message of non-acceptance of aggression (both verbal and physical) in the workplace. This approach was to be communicated to service users via a notice displayed in a prominent place. Legal

Rationale
A number of factors contributed to the development of this tool as is evidenced by the following:

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advice was sought from a number of different sources to inform the development of a notice. There was no opposition from staff to displaying the notice in the work setting. The fundamental understanding that needed to be conveyed was that everybody has rights and that there are legal consequences for individuals who display aggressive behaviours. Health care workers have the same legal rights and recourse to the law as clients and service users. This was the focus of the notice and was conveyed in clear language to the client groups. The initial implementation phase involved a trial of the notice in identified high-risk areas.

The patients most likely to respond positively to the notices were patients with a behavioural disorder who would understand that there were consequences for acting out their aggression. While it is acknowledged that there are some difficulties bringing charges against patients with a psychiatric disorder this should not prevent staff from being supported in exercising their legal rights when they encounter aggression in the workplace.

Outcomes
The introductory strategy was met with staff approval. The Area Health Service noted how effective this strategy had been. The effect had been much greater than anticipated at the outset. There was a major decrease in verbal abuse. Some areas, particularly dental clinics, reported an almost 90% decrease in verbal abuse. Reception staff reported a dramatic decrease in verbal abuse. Staff reported increased confidence in dealing with verbal abuse. There has been a consistent team approach in the management of aggression. It has encouraged further discussion and prompted staff to consider a range of strategies to manage aggression in their workplace.

The strategy
Once agreement was reached regarding the format for the notice it was referred to the Area CEO for approval. Following receipt of approval early in 1998 the notice was displayed throughout Lismore Base Hospital including the Psychiatric Unit. The notice was initially displayed in prominent positions in reception areas, above counter areas, in nurses stations and in patient areas and was aimed at patients and visitors. Notices were also displayed in community centres, dental clinics, and other health care facilities. Areas that did not have any notices began requesting them. The plan was to use the statement of intent to pursue legal action as a deterrent for workplace aggression (both physical and verbal). There was some discussion regarding the feasibility of pressing charges against patients with a psychiatric disorder, particularly if they were actively psychotic at the time of the incident. It was generally felt that these patients were usually identified and for the most part effective management strategies were instituted.

Patient issues
Now a well established AHS response to situations.

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Word gets out that the AHS is addressing the issue of abuse/aggression towards staff members and that there are consequences for patients. This in itself is a further deterrent. There were six prosecutions in the 16 months after the strategy was implemented.

Staff acknowledge the efforts of AHS management to reduce aggression and support 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 similar strategies as part of a comprehensive approach to managing verbal and physical abuse. This approach has been endorsed by health services overseas where there is an international move towards an environment of zero tolerance particularly in the U.K. (Issues Statement, 19 October 1999, Department of Health UK).

Examples of action against aggressors


An AVO was taken out against a patient who attended the hospital with a weapon in their possession; this patient had a well-documented psychiatric disorder. A patient was charged with damaging property in the Emergency Department. An inpatient who was verbally abusive and threatening towards staff, and continued to abuse staff, was assessed and subsequently discharged.

Conclusion
This strategy supports an approach being adopted by health services and other agencies in Australia and overseas. It conveys a clear message to service users that individuals have to accept responsibility for their own behaviour and that there are consequences when this is not the case. It is part of an overall risk management approach and its effectiveness appears to be linked to a total risk management approach rather than relying on it as a single strategy to resolve all kinds of workplace aggression. It is a clear message of support from managers and the consultative nature of its development and implementation increases the likelihood of staff support and staff consistency in implementation. It is cost effective, can be modified to meet local needs and can be linked to outcome measures. For further information contact: Mr David Grey, OH&S Manager, NRAHS.

Staff issues
Staff report a heightened awareness of their legal rights and of issues relating to abuse/aggression at work. Staff are more focused on identifying strategies for responding to abuse/ aggression at work. The notice conveys a clear message regarding service expectations and management support. It increases staff confidence when responding to incidents of verbal abuse and provides a consistent approach for staff.

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Case Study 5
24 Hour On-call EAP Service for Critical Incidents in the Workplace Central Sydney Area Health Services

Introduction
As part of the Critical Incident Management Plan, CSAHS established a 24 hour, 7 days per week on-call service for staff and managers involved in critical incidents in the workplace. This service was established as an additional component of the Employee Assistance Program (EAP) within the CSAHS in September 1997. The primary activities of the service involve post incident support and consultation, once the immediate incident has been addressed and managed. Services may be provided over the telephone, or on site when required. This may be immediately post-incident, within 2472 hours after the incident, or later on some occasions as required. The types of incidents regarded as critical incidents follow the NSW Health Policy and Guidelines (97/97) page 2.1.91 Critical incidents especially related to health care facilities could include: assaults on staff by patients or others unexplained or suspicious deaths or significant bad outcomes due to possible poor hospital or service administration suicides or attempted suicides by a patient or staff member.

Employee Assistance Program staff

services during office hours as part of their core duties. The service is activated by the Manager of the area where the critical incident occurs. The Manager may initiate this directly, or do so via their own Senior Manager. The philosophy of the service is to support the relevant levels of management in their critical incident response, rather than taking over the post incident management. This collaborative approach has a number of benefits, including: greater development of managers in their post incident skills; reinforcing the team approach and natural peer support activities, and a positive acceptance of the EAP role. CISM Services include: consultation with managers; individual or group defusing; one-to-one support on site, or via telephone; practical assistance with escorts to medical services; acute follow-up, family support and group debriefing.

This service is provided by members of the EAP staff counselling service, who offer Critical Incident Stress Management (CISM)

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Statistics
Table 1 On-call activations and on site call outs

Period Sept 1997August 1998 Sept 1998August 99 Sept 1999Feb 2000 Total

Activations 36 26 14 76

Call Outs 17 9 4 30

Table 2 On-call occasions of service

Period Sept 1997Aug 1998 Sept 1998Aug 1999 Sept 1999Feb 2000 Total

Manager Consults 42 46 24 112

On-Site Services 38 32 8 78

Phone Support 29 20 7 56

Total Occassions of Service 109 98 39 246

The activations have been in response to a range of critical incidents, including: staff assaulted by patients, visitors or intruders patient suicides, serious attempts and completed staff suicides, and sudden, unexpected deaths of staff members traumatic, unsuccessful resuscitations of patients, and particularly gruesome emergency patient presentations.

The challenge to Senior Management is to determine when such exposure has taken place and the potential has become actual critical incident stress. Management need to ensure an appropriate response occurs which acknowledges that psychological harm may have been done and to provide intervention and support to those affected NSW Health Policy and Guidelines (97/97: p2.2). 91 Individual responses to potential critical incidents vary enormously, both from person to person, and at times, with the same person on different occasions. Effective CISM involves the implementation of a system that identifies the hazards and risks in the workplace and establishes controls to enhance the prevention of serious incidents occurring and to minimise the impact on people affected when incidents occur. In line with the NSW Health Policy and Guidelines (97/97) Post Incident strategies are only effective within the framework of a CISM Plan which encompasses prevention, preparation, response and recovery.

Rationale
The vast majority of health care staff have the potential to encounter critical incidents in the course of their work, and many staff who work in high risk areas such as: emergency departments; acute mental health services; psychogeriatric areas; frontline reception staff, security and drug clinics encounter high risk of exposure to critical incidents.

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In facilitating an appropriate, early response a number of positive effects can be maximised: effective assessment of acute state and immediate needs of staff exposed to trauma more efficient access to medical services when needed strong message of acknowledgment and support to affected staff key information provided regarding support services for post-acute stage .ore effective separation of staff support strategies and clinical/medico-legal investigative requirements.

Management training programs provided for managers and staff within CSAHS. Tailored education and inservice CISM programs have also been provided for high risk and specialised areas. These training programs are scheduled throughout 2000, and they are mandatory components of training for managers.

Outcomes
Feedback from senior managers, after hours supervisors and staff has been very positive. Comments have focussed on the supportive, professional and accessible service provided by EAP staff. Rapport has been quickly established and the 24 hour service functions quite naturally as an extension of the existing core EAP service. Statistics are maintained on non-identifying data, number of call outs, telephone support provided, occasions of service and on-site services among others. Manager and staff feedback has been provided through discussions and regular contact with service managers and site managers. It is planned to undertake satisfaction surveys and integrate these into the service provision.

How was it established?


In 1997, CSAHS Senior Management reviewed the full range of prevention, preparation, response and recovery CISM strategies that had been implemented. While there were many positive strategies that were applied, the post incident responses needed to be more systematic, and more effectively coordinated. An Area Committee was formed to develop an Area CISM Plan, to be adapted by every CSAHS facility and service, and oversee the implementation of all aspects of the plan at a local level.

Who else uses this strategy?


Within the public and private health industry of NSW, a number of models have been utilised, from the use of internal staff counsellors to external, specialised CISM providers, and a combination of both. Economic factors, accessibility, response times, efficiencies, staff resources, confidentiality concerns, knowledge of and sensitivity to health cultures and settings are all important in considering appropriate, effective strategies.

The strategy
All service areas are aware of the 24 hour number to activate the on-call service for work related critical incidents. This information is disseminated through flyers, pamphlets and inserts in orientation and induction packages throughout the CSAHS. EAP staff conduct regular sessions in the Critical Incident

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Conclusion
The service has been well utilised since its launch two and a half years ago. The clear trend has been more effective utilisation of existing on site resources, and telephone support rather than the higher percentage of call outs provided in the first year. A culture of support and caring is reinforced and early involvement in supporting affected workers improves individual outcomes. Managers have also developed a greater awareness of a broader range of potential critical incidents, and activated support accordingly. For further information contact: Mr Chris Patchett Manager EAP, CSAHS.

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Attachment 1. Critical incidents: Post Incident Check List for Senior Managers
Central Sydney Area Health Service 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 or staff members 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 patients 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&S Co-ordinator or equivalent Patient debriefing completed if required. Consider inviting patient representatives/advocates or consumer consultants 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 and identification 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 with rehabilitation co-ordinator and EAP staff counsellor

September 2000

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Attachment 2. Critical Incidents: EAP Staff Counsellors Checklist


Central Sydney Area Health Service
Immediately After Notification Liaise with managers, map out list of staff involved, including witnesses, medical officers, support staff etc, not just 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 and updated Initial diffusing organised if required, ensure staff are offered this support proactively, as a normal aspect of post incident management. Staff support activities are not mandatory. All staff should at least be given a copy of the CISM handout Make a list with contact details of staff affected by critical incident. Double check details, and ensure extra copy is 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 provide preparation for careful driving or pedestrian strategies Notify other counsellors regarding the critical incident. Organise other work commitments reschedule appointments etc with assistance from other EAP team members, as required. Arrange time for own debriefing with 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 2448 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 4872 Hours Post Incident Appropriate follow-up with affected staff and managers Review important developments, including: management and location of client(s) involved in incident; police action; 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 stress management materials, and key contacts list EAP manager; senior health service managers; acute care teams, and EAP colleagues home and work numbers

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Case Study 6
Peer Support Program South Western Sydney Area Health Service

Introduction
A peer support program has been developed and implemented for clinical and non-clinical staff who work in the Critical Care Division of Liverpool Hospital as part of a pilot project. The purpose of the program is to provide support for staff who work in stressful areas of practice through a facilitative process with staff of the same or similar rank. The program has been operational since July 1999 and preliminary evaluation is encouraging with plans to extend this model into other areas of practice in the future.

positive outcomes. This provided the impetus to explore support options utilising the resources and expertise available.

How was it established?


A group of staff approached the Staff Counsellor to assist with the development of a peer support program that met the needs of staff who worked in the very busy critical care areas, which included the emergency department, intensive care unit and operating theatres. A steering committee was established to examine the structure of a program, develop policy and procedural information, address training and selection of peer supporters and appoint a group to direct the development of the program. A code of conduct was established and privacy, confidentiality and boundary issues were addressed. A two-day training program, developed by the Staff Counsellor, was run with representatives from management, clinical staff and the union, invited to participate. The program was well received and it was decided to undertake a pilot program. Inservices about the program were run in the units of the division identifying the members of the Peer Support Team, a contact report sheet was developed (see attached) and information about the program was disseminated through the Critical Care Newsletter.

Rationale
The program was developed in response to identified needs of staff who work in busy, demanding, stressful areas of practice. Nurses working in critical care units such as emergency departments, intensive care units and operating theatres perceived a need to have some form of formal support structures to assist staff cope with the demands of their roles. The process of conferring or consulting with a peer in a supportive setting to resolve issues impacting on practice was accepted and the value of formalising these arrangements was recognised. Some of the staff had been involved in the development of similar programs in other employment areas or had participated in similar programs and reported

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The strategy
A peer support program is an informal process where one staff member discusses issues of importance with an identified peer support member on a one-to-one basis. The sessions are not time limited but vary depending on work commitments, time constraints and the needs of the staff member. There are no restrictions on the content of the sessions and topics discussed are usually related to some of the following: dealing with critical incidents/needlestick injuries demands of shiftwork stress/burnout home/family/financial issues interpersonal relationships/conflict/role identification workload/work environment/competing demands, and resources/equipment.

This program relies on the work not only of the peer-support team members but also on the on-going commitment of committee members in this program an anaesthetist plays a key role.

Outcomes
Finding a model that has some degree of accountability, can be linked to enhanced clinical practice and improved consumer outcomes while at the same time providing staff with the support they need, is difficult. The inherent difficulties in evaluating a peer support program and attributing specific outcomes to a single program are recognised. Initial evaluation is focusing on numbers of staff accessing the program and subjective reports regarding the usefulness of the program. Examples of comments received are as follows: very valuable experience very approachable people providing much needed support to busy areas, and a great program.

The confidential nature of the sessions is acknowledged with no formal records maintained on the content of individual sessions or any information relating to the person accessing the program. Peer supporters maintain data on the number of sessions they facilitate and some of the main topics explored to assist with evaluating the program. The Staff Counsellor provides ongoing supervision and support for the supporters and acts as a referral destination when problems encountered are too severe or complex. Administration is very supportive of the program and sessions are conducted in work time to enable staff to access the program.

Staff issues
Staff report positive experiences with the program to date and use the sessions to reflect on their practice and identify positive coping strategies. There is a general recognition of the stressful areas of practice and that this is a process of providing staff who work in these areas with much needed support. Other clinical areas, for example the psychiatric unit, maternity unit and community staff have requested information about the program and expressed a willingness to implement similar programs in their teams.

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Who else uses this as a strategy?


Peer support programs are well recognised in Australia in the emergency services such as the Police, Fire and Ambulance and models of peer support have been established as an integral part of professional practice in professional groups (psychiatrists, nurses, social work) overseas. There are developing models in many

of the helping services within Australia, particularly associated with clinical internship programs, however it has been slow to permeate mainstream practice. There is a lot of interest in the provision of a peer support program that is practical, acceptable to staff and possible within existing resources. For further information contact: Mr Tony Homer, Staff Counsellor, SWSAHS.

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SOUTH EAST HEALTH


South Eastern Sydney Area Health Service

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

Introduction
This self-learning package has been developed by the Consultation and Liaison Nurse Consultancy Clinical Nurse Consultant (CNC) at the Prince of Wales Hospital (POW), a large Sydney teaching hospital. The package was primarily developed for general nursing staff who work at POW Hospital but can be successfully transferred and adapted for use in other areas. The self-learning package focuses on the minimisation and management of aggression in health care settings and encourages the learner to identify their own learning needs. The package contains a pre and post test questionnaire to provide feedback on knowledge and skills gained and includes information, trigger questions and reference material pertaining to minimisation, management and post incident management of aggression. Prior to completing the package participants are encouraged to attend a one-hour introductory education session presented by the Nurse Consultants. A self-learning package was deemed to be an effective initial strategy and a resource for staff who were experiencing an increasing level of abuse and aggressive behaviour in a variety of settings throughout the Hospital. There were various educational programs on offer but due to the large number of staff employed access to

these programs was on a priority basis. The package was based on the Department of Health Guidelines on the Minimisation and Management of Critical Incidents in Health Care Facilities (Circular 97/97)90 and was not intended as a stand-alone package but as an adjunct to education and skill-based training. The package was completed and distributed to all areas early in 1999.

Rationale
In the months June to September 1997 an increase in the number of aggressive incidents in POW Hospital was noted. This was evidenced by the frequency of calls to Consultation and Liaison Nurse Consultancy Clinical Nurse Consultants for assistance in the behavioural management of such patients,

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and an increase in requests and the number of referrals for Critical Incident Stress Debriefing (CISD) following aggressive incidents. Anecdotal evidence presented during in-service education suggested that an increasing number of staff were being threatened with assault, verbally or physically abused and intimidated in the workplace. In response to the above, a brief to develop a self-learning package titled The Minimisation of Violence and Aggression was undertaken after discussion with the Principal Director of Nursing.

special interest topics addressed were aggression in the elderly and horizontal violence. A video entitled What if it turns nasty is part of the package and is accessed from a central location. Once the package was completed in 1998 a pilot study was conducted in five clinical areas yielding the following results: 18 nursing staff participated it took staff an average of three and a half hours in total to complete the package most staff worked on the package at the same time as others 100% thought the layout of the package was user friendly 100% stated that the content was easy to understand, and pre- and post-test assessments were reviewed.

How was it established?


The package was developed as one of a number of strategies to deal with the increasing amount of aggression in the workplace. Other strategies included participation in specific training, development of policies and procedures and an Area wide mediation team to assist staff to deal with conflict in the workplace.

The strategy
The first step in preparing the package involved the development of guidelines for the management of aggressive incidents and these guidelines were also presented in the form of a poster. A laminated version was circulated to all clinical areas just prior to the circulation of the package. This acted as a prompt to staff when dealing with an incident and contained telephone numbers of key personnel. The package contained information sections on theories of aggression, communication strategies to de-escalate situations, crisis communication and strategies to assist with limit setting. Other areas covered included legal issues, guidelines for management, post incident management, handling complaints and strategies for minimising aggression in open areas and various other references. Two

Some corrections and editing took place as a result of the study and the packages were then circulated to Nursing Unit Managers (NUMs), Clinical Nurse Specialists (CNCs) and all clinical staff. Fifty packages were distributed to all clinical areas in March 1999 and three hundred staff have attended the one-hour accompanying in-service.

Outcomes
Formal evaluation of the package was due to commence in early 2000. Staff complete a self-evaluation pre and post test quiz to test their knowledge level both before and after completion of the package. The packages are freely available and can be accessed for regular refreshers. Formal evaluation forms are also included and the reader is encouraged to complete them and return them to the CNCs.

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Anecdotally there are less frequent calls from some areas to assist with the management of aggression and there are increasing requests for consultation on how to prevent incidents and improve personal management strategies. Staff report an increased awareness of the importance of maintaining vigilance in this area and the influence of their personal style of intervention in achieving a positive outcome for all involved. Another observation noted as a result of introducing this package is that other departments/disciplines have started to request consultation regarding the minimisation of aggression, eg pharmacy, community centres, clerical staff and reception staff. Feedback has been positive and comments include: now I am more aware of my own body language when talking to aggressive clients I enjoyed the package, it is easy to read an excellent guide to self control and common sense I feel this package is a bonus for all staff as getting to courses can be difficult.

within the package and this will be considered when the package is next reviewed.

Patient issues and staff issues


Current staffing levels, increased number of vacancies and staff turnover have all affected the number of nursing staff who have completed the package. The package has been implemented at the Royal Hospital for Women and will be implemented at Sydney Childrens Hospital, Randwick in early 2000.

Conclusion
This approach to the minimisation and management of aggression provides staff with quick access to specific information regarding the safety of the work environment in which they are working while staff are waiting to participate in centre based training programs. It encourages staff to take some responsibility for their own safety and learning needs in partnership with the AHS and directs staff to reading materials, policies and highlights specific local protocols. For further information contact: Ms Allison Boyle CNC, Liaison Psychiatry, Prince of Wales Hospital, SESAHS. Ms Mari Evans-Rooney CNC, Liaison Psychiatry, Prince of Wales Hospital, SESAHS.

All staff reported that the package was relevant and easy to understand. Some staff have commented that there is some repetition

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Case Study 8
Safety Zone Alarm System Central Sydney Area Health Service

Introduction
The Safety Zone Alarm System was installed throughout the grounds of Royal Prince Alfred Hospital (RPAH) in Central Sydney Area Health Service (CSAHS) in 1997. The NSW Minister for Health launched the system marking RPAH as the first hospital in NSW to use this technology as part of an overall approach to the provision of safety within the work setting.

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

The strategy
The Safety Zone Alarm System consists of a network of beacons, which are strategically located within the 15 hectare campus at RPAH, including car parks, nurses residence and walkways between the many buildings. There are 25 beacons scattered throughout the campus. Each beacon is about 100 meters apart and is individually zone numbered. A small hand held transmitter activates the beacons. Each hand held transmitter is individually programmed with a personal identification number (PIN) which identifies the remote control user. Once the signal is triggered, sirens sound, lights flash and loudspeakers send verbal warnings that security staff have been alerted and are approaching the area. Security staff are electronically notified of the staff members identity and alarm location. Staff are advised to activate the system if they feel threatened, if they see another person or property at risk or if they see something security should be notified of immediately. Safety Zone remote control units are available to all RPAH employees for a small refundable deposit. Staff members who work shift work or who are on call mainly accesses the units. The

Rationale
The Safety Zone Alarm System was installed following consultation with staff and representation to the General Manager regarding the safety and security of staff who were employed at RPAH. The hospital campus at RPAH covers approximately 15 hectares and staff were becoming increasingly concerned regarding safety issues, particularly at night.

How was it established?


The Area security manager was asked to investigate available security alarm systems used in Australia with a view to suitability for installation at RPAH. The Safety Zone Alarm System was the preferred system having been in use in several hospitals in Australia with positive results. The system is solar powered which means that it can be easily relocated. The system can also be powered from a main

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remote control units are small, compact and easy to activate. The system can be used externally or internally as a silent duress alarm by using the same hand held transmitter. The beacon and remote control units (hand held transmitter) are shown in the following photograph.

Staff issues
Staff express a sense of protection and reduction in fear and anxiety as a result of the Safety Zone Alarm System being installed. They report that they feel safe when walking throughout the grounds. Staff members have had occasions to activate the Safety Zone remote alarm and reported satisfaction with the response provided.

Who else uses this as a strategy?


The Safety Zone Alarm System is widely used in other states within Australia and also overseas. While some services have maintained statistics on incidents pre and post installation of the system and report positive findings these are not currently available.

Conclusion
The Safety Zone Alarm System demonstrates the commitment of the managers at RPAH to ensure the health, safety and welfare of all employees in the workplace. The safety zone system provides a visual proactive policing role to reassure members of the public who have need to traverse the campus that RPAH is safety and security conscious. In addition safety zone beacons and signs act as a deterrent to would be perpetrators. It is part of a comprehensive approach to risk management and the system provides security staff with immediate access to information about the location of attacks, assaults and other incidents and the identity of the staff member activating the alarm. For further information contact: Director, Engineering Services, Royal Prince Alfred Hospital, CSAHS.

Safety Zone alarm beacon and handheld transmitter

Outcomes
Notices are clearly displayed throughout the RPAH campus informing the public that a Safety Zone Alarm System is in operation. These notices also act as a deterrent. There has only been one confrontation by offenders and the system protected the staff member immediately. The system was installed in 1997 and on the few occasions that the alarm has been activated the voice recordings have frightened away would be attackers.

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Literature Sources

A number of documents are available to provide information and direction for health service managers in meeting their occupational health and safety responsibilities in the area of aggression management and to assist in the development of policy and guidelines within specific settings. Clinical practice guidelines have also been developed to inform clinical decision making and to assist in co-ordinating a planned response to the identification, prevention, management and post incident management of aggression and violence in the workplace. Some of these guidelines are generic and identify common risk factors and describe strategic responses75,99,100,101 while others focus on particular areas of practice or specific roles.2,12,46,101 The following is an overview of available resources for staff in the area of aggression risk management. 6.1 Management of imminent violence: clinical practice guidelines to support mental health services, Royal College of Psychiatrists, London (1998) Occasional Paper OP 41, London: Royal College of Psychiatrists.9 Clinical Practice Guidelines consist of systematically developed statements to assist consumers and practitioners in making decisions about appropriate health care in specified clinical circumstances. This is a comprehensive evidence based approach to determining the most effective strategies to

assist health practitioners and health service workers manage violence in mental health care settings. It addresses such areas of practice as the design and organisation of the environment of care, activities undertaken and treatments including use of restraint, seclusion, rapid tranquillisation and use of other medications. It explains the process of guideline development and the rigour involved and includes many informative references. Information is prioritised in boxes to facilitate retrieval. An example of this relates to the identification of key features required to identify a caring or effective clinical environment, these are: collaboration with service users in planning clinical environments, policies and practices adequate hand-over between clinical teams for continuity clear management policies and leadership open communication between management and staff at all levels ward/unit size and design appropriate to patient population staff training and development with regular updating critical reviews of any incident carried out adequate staff ratios, well supervised, trained and experienced staff

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gender and ethnic mix of staff appropriate to patient population multidisciplinary consensus on clinical care, and structured timetable and activities as part of program.

The use of restraint is investigated with specific guidelines relating to the rationale for considering using restraint, methods of physical restraint, use of seclusion and policy issues relating to restraint and seclusion. Reasons for using restraint include the following: serious degree or urgency of danger significant physical attacks significant threats or attempts at self injury seriously destructive of property prolonged and serious verbal abuse, threats or disruption of clinical environment prolonged over-activity or risk of exhaustion risk of serious accident to self or others, and attempts to abscond (if detained as an involuntary person).

references. It is limited to publications issued after 1987. It is arranged in alphabetical order according to author and a brief description of the content of each reference is provided. The materials address a wide range of topics such as contributing causes to violence, intervention strategies, and specific contexts of violence in the workplace such as health care workers, social workers, and other occupational groups who have contact with members of the public. Recommended measures for intervention include redesigning the work, improving recruitment procedures, staff training and counselling services, and improving security systems. 6.3 Guidelines for preventing workplace violence for health care and social service workers (1996) US Department of Labour, Occupational Safety and Health Administration (OSHA).99 The Occupational Safety and Health Administration (OSHA) guidelines are advisory in nature and are intended for use by employers seeking to provide a safe and healthy workplace through the implementation of effective workplace violence prevention programs. They emphasise the need to consider local contexts and adapt to the specific requirements of each place of employment. The guidelines include policy recommendations and practical corrective methods to help prevent and alleviate the effects of workplace violence. In addition the following sample documents are included; Workplace Violence Checklist, Staff Assault Survey and Violence Incident Report Form. These guidelines cover a broad spectrum of workers who provide health care and social services in hospital emergency departments, community mental health clinics, inpatient

6.2 Annotated bibliography on violence at work, International Labour Organisation (2000) Geneva, ILO.103 This bibliography provides a wide range of references on the subject of violence at work in the form of an annotated bibliography. It draws upon books, journal articles, monographs, reports, surveys and conference proceedings using the International Labour Organisations extensive database as a primary source of

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mental health facilities, drug abuse treatment clinics, pharmacies, ambulance services and emergency care facilities, community care facilities, forensic and long term care facilities. The guidelines identify four components of an effective safety and health program that also apply to preventing workplace violence, (a) management commitment and employee involvement, (b) worksite analysis, (c) hazard prevention and control, and (d) safety and health training. (a) Management Commitment and Employee Involvement Management commitment and employee involvement are complementary and essential elements of a comprehensive approach to violence management in the workplace. To ensure an effective program, management and front line employees must work together through a consultative approach. Management commitment and the visible involvement of senior management, provide the motivation and resources to deal effectively with workplace violence and should include the following: designated responsibility for the various aspects of workplace violence prevention programs to ensure that all managers, supervisors, and employees understand their obligations appropriate allocation of authority and resources to all responsible parties a system of accountability for managers, supervisors and employees demonstrated organisational concern for employee emotional and physical safety and health equal commitment to worker safety and health and client safety and health

a comprehensive program including medical and psychological support for employees experiencing or witnessing assaults and other violent incidents, and commitment to support and implement recommendations from safety and health committees.

Strategies to encourage employee involvement and feedback are suggested and include the following: dissemination of information to all employees regarding workplace violence prevention programs and other safety and security measures checking that employees have knowledge of and comply with workplace violence prevention programs and other safety and security measures provision of opportunities for employees to participate in an employee complaint or suggestion procedure relating to safety and security concerns prompt response to employee concerns employee involvement on safety and health committees or other forums that receive reports of violent incidents or security problems, undertake facility inspections and make recommendations to enhance workplace safety and health prompt and accurate reporting of violent incidents, and participation in a continuing education program that includes the identification of escalating agitation, assaultive behaviour or criminal intent and includes deescalation techniques and appropriate responses.

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(b) Worksite Analysis Worksite analysis involves a systematic examination of existing or potential hazards for workplace violence. This includes a review of policies, procedures and operations that contribute to hazards and specific locations where hazards may develop. The recommended program for worksite analysis includes, but is not limited to, analysing and tracking records, monitoring trends, analysing incidents, distributing employee questionnaires or surveys and analysing workplace security. A worksite examination would incorporate the following: analysis of incidents including the characteristics of assailants and victims, an account of what happened prior to and during the incident and the relevant details of the situation and outcome identification of locations or roles with the greatest risk of violence and the processes and procedures that place employees at risk of assault, including frequency and timing of incidents identification of high risk factors such as types of clients (eg. those with psychiatric conditions, clients disoriented by drugs, alcohol or stress); physical risk factors of the building; isolated locations; specific activities; lighting problems; lack of phones and other communication devices; areas of easy access; areas with previous safety and security problems; and evaluation of the effectiveness of security measures in place.

removal of the hazard from the area or creating a barrier between the worker and the hazard. Changes in work practices and administrative procedures can also help to prevent violence. For example, a clear statement to employees and clients that violence is not tolerated, liaison with local police, focused training programs for staff in selected areas, and the establishment of a system to chart clients with assaultive behaviour problems. (d) Safety and Health Training Training and education increase awareness of potential security hazards and assist staff to identify ways in which they can protect themselves and their co-workers and clients through established policies and procedures. Training should include the following topics: workplace violence prevention policy risk factors that cause or contribute to assaults early recognition of escalating behaviour and the recognition of warning signs/ situations that may lead to assaults strategies to prevent or defuse volatile situations, managing anger and the appropriate use of medication information on cultural diversity to develop sensitive responses to racial and ethnic issues and differences a standard response action plan for violent situations including availability of assistance, response to alarms, and communication procedures strategies to respond to hostile relatives or visitors progressive behaviour control methods and safe methods of restraint application and escape

(c) Hazard Prevention and Control Once hazards have been identified it is necessary to develop strategies to prevent or control them. This can be achieved by engineering controls and workplace adaptation such as the

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location and operation of safety devices strategies to protect oneself including use of the buddy system policies and procedures for reporting and record keeping, and policies and procedures for obtaining medical care, counselling, compensation or legal assistance post incident.

(A) The identification of risks faced by staff through an examination of the job, involving physical location, task being performed, staff performance, organisational policy and expectations, features or characteristics of the customer group, and management demands/attitudes. (B) The assessment of the identified risks. For each identified it is necessary to assess if the risk is acceptable or unacceptable. (C) The recommendation of action that will reduce unacceptable risks to an acceptable level. It identifies the importance of checklists and includes examples of checklists with trigger questions to assist workers to clarify issues surrounding their safety. One such example is a checklist to assist in locating risk in the workplace. More suggests that in order to locate or identify risks it is useful to compile a list of the responses to the following questions. Tasks What tasks are likely to upset or annoy? People Are there groups or individuals with behaviours that are unpredictable? Places Are some of the places where you work inherently unsafe? Times Are there times when you feel more unsafe than others?

6.4 Taking safety seriously improving workplace safety management in the NSW public sectors policy and guidelines (1999) NSW Premiers Department.100 Policy and guidelines have been developed to assist agencies to ensure their occupational health and safety (OHS) and injury management systems are appropriate to their needs, are meeting legislative requirements and are being continuously improved. They will assist agencies to review major cost drivers in workers compensation, and develop and implement integrated and effective OHS, injury management and workers compensation practices. 6.5 The A-B-C of handling aggression, W More (1993) PEPAR Publications, Birmingham, UK.104 This booklet provides a user friendly approach to the management of aggression and includes chapters on fear and anger, risk assessment, supports available and a section specifically dealing with safety when undertaking home visits. It provides many useful insights into safety management and personal awareness before, during and after incidents of aggression. More suggests that knowledge of the work setting is an essential prerequisite to maintaining safety and that assessing the hotspots on the job accurately is basically a three step process of A-B-C.

He suggests that most of the items on such a list would fit into the following categories: telling customers things they dont want to hear asking customers to do what they dont want to do unpredictable behaviour working alone or in isolation with no access to support

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being alone and untraceable outside your base, travelling to work in other peoples premises or homes, and where physical force is being used.

sought out riskier situations, challenged or confronted clients unnecessarily, were more demanding or less flexible and were less able to detect potentially violent situations or to handle them once they occurred. 6.7 Violence at work, D Chappel & C Di Martino (1998) International Labour Office Publications, Geneva.16 This ILO report addresses workplace violence and presents international coverage of the problem as a basis for understanding the nature of workplace violence. The authors highlight better practice and effective methods of prevention, illustrating the positive lessons derived from such experiences. The report provides useful insights on a range of topics including analysis of data displaying patterns and trends in violence, areas and occupations most affected, social and economic costs of violence, causative factors, types of responses, analysis of policies and guidelines and a range of successful specific and practical action based experiences. 6.8 Guidelines for coping with violence in the workplace (1999) International Council of Nurses, ICN Publications, Geneva.4 These guidelines were written in response to increasing incidents of abuse and violence in health care settings and the concern that increasing levels of violence are interfering with the provision of quality care and jeopardising the personal dignity and self value of health professionals. The objectives of the guidelines are: to review prevalence, incidence and impact of abuse and violence against nursing personnel to recognise nurses responses to incidents of violence

6.6 Coping with violence: a guide for the human services, V Bowie (1996) (2nd Ed) Whiting & Birch Ltd. London.8 This book is an updated version of an earlier publication by Vaughan Bowie who has been instrumental in increasing awareness of the problems facing human service workers in dealing with violence in work settings. The book suggests that human service workers are considered a high-risk occupational group due to constant and often stressful contact with members of the public. Several theories on the causes of violence are presented as well as strategies to prevent and manage incidents of violence. Bowie provides useful insights into adjusting negative staff attitudes, common sense approaches to the prevention and defusion of violence and identifies strategies to implement appropriate post trauma support for assaulted workers. Crisis communication and the principles of physical intervention are also included with the judicious use of diagrams and pictures to illustrate examples and enhance the understanding of the reader. Overall this book is a valuable tool for health care workers and it demystifies many of the myths surrounding violence against workers. In the chapter on the Hurting Helper Bowie refers to research conducted around the stereotyping of the assaulted worker and challenges some of these stereotypes. He quotes that peers frequently represent the assaulted worker as being more provocative, incompetent, authoritarian and inexperienced. Assaulted workers are often characterised as those who

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to determine the major security factors acting on the workplace, and to present strategies that aim to confront and reduce/eliminate violence in the workplace.

The following steps are recommended as an approach to be used to confront increasing incidents of abuse and violence experienced by staff in their work settings: identify risk behaviours and environmental triggers take preventative measures to reduce/ eliminate risk factors apply incident management mechanisms if and when violence occurs guarantee access of all involved to effective support structures maintain reliable records evaluate violent incidents and their management, and develop appropriate recommendations on the basis of findings.

within the work setting. In addition to defining violence and exploring types of violence it explores factors relating to the identification, assessment and reduction of violence and post incident management. Procedures that may be adopted to reduce the number and severity of violent incidents and make the workplace a safer and healthier place for employees, employers and visitors include: avoiding or reducing working in isolation to minimise the threat of external violence setting up a system for alerting co-workers that urgent assistance is required selecting a sufficient number of staff so that delays that may raise stress are minimised and support is available when needed giving staff clear guidelines to follow, such as how to deal with aggressive clients addressing the potential for violence at employee induction training training and developing interpersonal and communication skills to improve staff ability to detect signs of imminent aggression and defuse potentially violent situations training in recognising normal reactions and ways of coping following violent incidents to lessen their effects providing personal protection such as duress alarms, mobile phones or other systems for calling assistance providing self defence training ensuring staff know how to access first aid and medical help, deal with emergency services staff and police, complete medical and legal reports and provide transport for the victims

6.9 Violence at work: a workplace health and safety guide, Workplace Health & Safety (1993) Department of Employment, Vocational Education, Training and Industrial Relations, QLD.11 This booklet was written in response to concern regarding escalating violence within health care settings. It provides an overview of workplace violence, a framework for managing potential workplace violence and contains a useful list of sources of additional information pertaining to the management of violence. It is very simply and succinctly written and is a useful guide to assist health care workers navigate the morass surrounding violence

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accessing support services for the people involved in a violent incident at work to reduce the impact of such events and to develop skills for handling violent incidents in the future, for example by debriefing and counselling setting up a reporting system for employees, so that employers can take the necessary follow-up action and identify changes that may prevent a similar event develop random work patterns (particularly when handling monies or drugs) provide procedures for working in unfamiliar environments, for example home visits provide access to health and safety professionals for expert consultation services consult with employee representatives, unions and associations, and develop procedures to follow during and after an incident, which are relevant to the workplace.

who to go to for help (staff counselling services, OH&S officer, Unions, support people), and recording and reporting requirements.

6.10 Human services minimum standards for the prevention and management of occupational assault (1995) Human Services Promotion, WorkCover Unit, Victoria.76 This publication arose from recognition within the Department of Human Services (DHS) of the need to have a co-ordinated response to the issue of occupational assault within work settings. The DHS acknowledged that the staff of Human Services are its greatest resource and wished to protect and support this resource by providing safe and healthy places of work. To this end minimum standards in this area were developed as part of an overall improvement process. A clear definition of assault is provided: Occupational assault is any incident in which employees are abused, threatened or assaulted in circumstances arising out of or in the course of their employment. The Standards provide specific information regarding legal roles and responsibilities affecting employers and employees including the requirements of Occupational Health and Safety legislation. They provide comprehensive information regarding the Human Services Risk Management Program and establish minimum standards for specific areas of practice, for example undertaking community visits and conducting interviews. They also recognise the need to develop minimum standards in relation to the physical environment, for example the design and layout of reception rooms and waiting areas, parking areas, entries and exits. The legislative responsibility for ensuring appropriate

A simple checklist outlines the essential elements of a comprehensive approach to post incident management: first aid relieve the staff involved communication (staff involved should be protected from media intrusion) debrief the staff involved immediate support counselling rehabilitation follow-up support investigation and subsequent action

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education and training for all staff is acknowledged with minimum standards established in relation to orientation, timing of training, program content, priority training needs and access to ongoing refresher programs. A complete section is devoted to critical incident management and includes identification, assessment, control, crisis communication, self care and post incident counselling and support. 6.11 Aggression and violence: approaches to effective management (1999) edited by J Turnbull & B Paterson, Macmillan, Suffolk, UK.101 This timely book contains an introduction by the editors which sets the scene for subsequent chapters. It describes the contributors as having a shared interest in exploring how violence and aggression towards staff in public service can be managed more successfully. It catalogues the emotional distress and range of emotions generated by a violent incident in the workplace and draws upon social, occupational and organisational contexts to explain violence and aggression. The nine subsequent chapters written by acknowledged experts in the field of aggression management encompass the identification of staff at risk, theoretical approaches to violence and aggression and some of the legal and ethical implications associated with this topic. An interesting chapter on verbal abuse by Rob Wondrak explores this concept in a range of contexts including nursing and examines verbal abuse in the context of gender differences in nursing. Brodie Paterson and David Leadbetter draw upon evidence based practice to inform de-escalation and the management of violence including physical violence. Vaughan Bowie focuses on pre and post-incident strategies to

support staff who have experienced violence at work. Colin Beacock explores training requirements. The final chapter is devoted to the role of the manager and describes a five stage framework for risk management that includes identification of the values, beliefs and principles of staff, the need to assess sources of information and how this is managed, an analysis of the risks involved, the formulation of an action plan and finally the implementation of the action plan in partnership with staff. 6.12 Personal safety for health care workers (1995) P Bibby, Arena Ashgate Publishing Co. England.75 This book contains a foreword by D Lamplugh OBE. She provides a moving account of the disappearance of her daughter in broad daylight in London in 1986. This experience inspired her to establish the Suzy Lamplugh Trust to raise awareness of violence in society, and in particular at work, and to help provide appropriate training facilities to raise self awareness and avoid personal vulnerability. The message contained in this book is that prevention is better than cure and that preventative action can protect staff while providing sensitive high quality care. It provides background information relating to the prevalence of violence at work and endeavours to put this into some perspective. It specifically addresses safety issues relating to home visits undertaken by health care workers and staff working in nursing homes and day care settings including interviewing techniques, travel guidelines, developing assertiveness and non verbal communication. In addition, there is an examination of the roles and responsibilities of employers/managers and of employees and also of the mechanisms in place to facilitate policy development and data gathering.

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6.13 Dealing with violence against nursing staff, an RCN guide for nurses and managers (1998) Royal College of Nursing, London.46 This fifteen page booklet tackles the challenge of workplace violence in a novel manner. The first section identifies key recommendations that are required at organisational level, at departmental, team or unit level and at the individual level. The guide acknowledges the difficulty in defining workplace violence but recognises the need to have some shared understanding of the phenomenon in order that incidents can be recognised, reported, recorded and reviewed systematically. The recognition of nursing as a high risk profession is acknowledged and it is suggested that this is intensified because interactions take place where access to care, services, treatment or facilities can be granted, denied or delayed. The evidence relating to higher incidence of violence at work being associated with the following variables is highlighted: dealing with the public providing care or advice working with confused older people working with those who have mental health problems working with those who have alcohol or other drug problems working alone handling valuables or medication, and working with people under stress.

individual concerned and the organisation for which they work. The expenditure involved can 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 early retirement pursuing legal action against an assailant treatment of injured staff provision of counselling services and ongoing support loss of resources that went into training if victim retires/leaves the profession due to assault criminal injury compensation payments effect of negative publicity on morale, productivity and corporate image, and management time in dealing with the investigation and the administration of issues relating to the incident.

The importance of adopting a risk management approach is emphasised with the use of case studies to reinforce this strategy. 6.14 Managing violent and potentially violent situations: a guide for workers and organisation (1997) D Cherry & B Upston, Centre for Social Health, Taverner Printing Services, Victoria.53 This document is divided into two sections. Section one is a guide for workers and addresses theoretical and practical ideas to assist in managing violence in the work setting. Section two focuses on the responsibility of the organisation in planning and policy development to assist staff to manage violence in the workplace. A sample violence policy

Other contributing factors identified include inadequate resources, low staffing levels and inappropriate skill mix. A number of possible consequences of a violent incident are outlined. Every violent incident incurs a cost, either in direct and immediate financial terms or in longer term indirect costs suffered by both the

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document is included in the appendix as a guide. This document is ideal for anyone developing a training program as it utilises principles and theoretical approaches frequently incorporated into training modules. 6.15 Violence in the medical workplace; prevention strategies (1995) JJ Robertson, American Medical Association, Department of Young Physicians Services, USA.13 This document was developed in response to growing concern by the American medical profession regarding the frequency and intensity of workplace violence encountered by medical staff and other health care workers within the USA. The spectrum of violence is explored and statistics relating to specific occupational groups and work settings are provided. Specific examples of health care personnel who were victims of extreme violence in the work setting are provided as a chilling reminder of the reality of violence and personal devastation associated with these incidents. The emphasis on prevention and staff training is reinforced throughout the document. Specific attention is given to training staff to identify a potentially violent situation, how to recognise impairment due to drugs, alcohol or mental instability, how to respond to these situations and the need to include information on specific cultures and be sensitive to cultural diversity. Predictors for violence are provided in a list and while it is not intended to be exhaustive it has been drawn from many sources and covers key predictors. It is suggested that individuals or groups of individuals identified in this document who have been shown to have a higher potential for violence should receive

special attention. These include: males adolescents individuals with dementia those with tattoos (may indicate gang involvement or prison experience) homeless persons individuals traumatised from a recent conflict systems abusers (recidivists, drug seekers), and previously violent individuals.

6.16 Safer working in the community: a guide for NHS managers and staff on reducing the risks from violence and aggression (1998) National Health Service Publication UK.105 These guidelines are structured to (i) emphasise the legal imperatives resting with employers to protect the health and safety of their employees; (ii) provide a framework for an integrated organisation approach involving a partnership between the organisation, the work team and the individual; and (iii) suggest actions 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 introduction to the problem of violence for National Health Service staff working in community settings and describes an integrated organisational approach to the management of violence Section Two describes the responsibility of the organisation in establishing policies and systems to manage risk before, during and after incidents of violence

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Section Three describes the responsibility of the work team before, during and after incidents of violence Section Four describes the responsibility of the individual before, during and after incidents of violence, and Section Five considers training in place for NHS staff regarding reducing the risk of violent incidents.

Detailed information is provided and case studies are incorporated into the document to enhance understanding. There are comprehensive guidelines on how to conduct home visits and reduce risks associated with violence in these situations. 6.17 Violence in health care: institutional strategies to cope with the phenomenon (1994) CA Distasio, Health Care Supervisor, 12(4) 134.60 This article explores violence in health care work settings and presents interesting insights into the problem by way of case studies and scenarios. It emphasises the need to develop appropriate health care organisational responses and the recognition that violence is associated with patient, staff, situational and environmental variables. This article suggests that accurate prediction is possible in most situations and that effective management of violent patients requires comprehensive organisational policies, procedures and protocols in addition to a staff training program. 6.18 Risky business: managing employee violence in the workplace (1996) LF McClure, The Haworth Press, New York.21 This book is somewhat different in that the subject matter relates to workplace violence as a consequence of employee precipitated

violence. It deals with issues surrounding bullying, harassment and intimidation in the workplace and suggests strategies for managers in recognising and responding to this phenomenon of enquiry. The emphasis is on the identification of high-risk employees and includes profiling, grouping according to dominant characteristics and numerous references to specific places of work, work practices, policies and statistics relating to workplace violence. 6.19 Workplace bullying: a secure workplace for young Australians (1999) WorkCover Authority of NSW, Sydney.30 This is a joint initiative of WorkCover NSW and the National Childrens and Youth Law Centre to address the problem of workplace bullying, particularly involving young trainees and apprentices. It included a set of fact sheets relating to a range of topics pertaining to workplace bullying and workplace violence. Examples include the following: awareness provides information on what constitutes workplace violence/bullying legal consequences states the legal consequences for employers and employees who carry out workplace violence or who fail to prevent workplace violence intervention this fact sheet lists a range of steps that must be taken when workplace violence, bullying or harassment are identified or suspected intervention strategies for your business provides assistance in developing a workplace violence policy prevention this fact sheet lists some practical steps you can take to prevent workplace violence, bullying or harassment, and

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prevention strategies for your business provides assistance in developing a workplace violence policy.

World Wide Web sources


http://www.workcover.nsw.gov.au WorkCover NSW site provides information on WorkCover NSW including health and safety notes, backwatch, OH&S documents, hazardous substances and rehabilitation guidelines. http://www.health.gov.au Australian Department of Health and Aged Care site provides access to all current and non-current press release papers. Seminar and meeting papers on health related issues are also available. http://www.aic.gov.au Australian Institute of Criminology, has a section Occupational Violence in Australia: An Annotated Bibliography of Prevention Policies, Strategies and Guidance Materials compiled by Dr Claire Mayhew.

http://www.osha-slc.gov/SLTC/ workplaceviolence/guideline.html Occupational Safety and Health Administration (USA) has a document Guidelines for Preventing Workplace Violence for Health Care and Social Services Workers. http://www.noworkviolence.com Workplace Violence Research Institute (USA). http://iahss.org/links.htm This index is arranged alphabetically and is designed to act as an exhaustive list of sites that can aid security and safety managers in the performance of their duties (USA). http://www.ashrm.org The American Society for Health Care Risk Management of the American Hospital Association lists resources and publications. http://www.alltheweb.com This is a very fast search engine which has over 1,000 references to workplace violence. http://www.nurseadvocate.org Website of nurse advocate organisation (Carrie Lybecker) has a section on nurses and workplace violence.

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Conclusion

This publication is based on a project to develop guidelines for the prevention and management of workplace aggression in the NSW health industry, conducted during the period April 1999 to March 2000. The material adopts a risk management approach to identify, assess and control aggressive incidents in the NSW health industry. There is an extensive literature review examining workplace violence. It identifies health service workers as among the worst affected occupational groups and explores the implications for a number of professional groups such as medical staff, ambulance staff, nurses working in a variety of settings such as Emergency Departments and in remote areas, and health care staff working in both community and inpatient settings. The literature provides many definitions of workplace violence and some of these are included, for example the definition used by the WorkSafe Commission Western Australia (WA), any action or incident that physically or psychologically harms another person. It includes such situations where workers and other people are threatened, attacked or physically assaulted at work. The report also includes data relating to violence in health care settings and enumerates some of the costs associated with workplace violence. It provides information on the relevant legislation and highlights some of the

complexities associated with workplace violence including a lack of consistency in defining the problem and the variations in reporting which are highlighted as contributing to the confusion that surrounds this phenomenon. The guidelines are based upon experiences from across the NSW health system and describe examples of better practice in the form of case studies. The case studies that best meet the evaluative criteria decided by the advisory group are included in the report. These vary from an area wide strategic plan to a peer support program and a notice to deter violence in a specialty area of practice. Although there were initiatives in training staff in the prevention and management of workplace aggression, these were not included here as it was planned that these be investigated as a future part of this project. Strategies for the prevention and management of workplace aggression continue to be developed and implemented. Since the completion of this project the Northern Sydney Area Health Service Mental Health Service has received recognition by way of a NSW Public Sector Risk Management Award for an Aggression Monitoring Tool. This tool provides a system for recording, monitoring and evaluating aggressive incidents which has facilitated significant changes to the work environment and processes.

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The recognition of workplace safety as a crucial issue for managers and employees is highlighted and through the provision of case studies, a comprehensive review of available resources and a list of further contacts in the field this publication seeks to inform and empower health care workers.

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49. Resnick, PJ (1999) Violence risk assessment, Audio-Digest Psychiatry, Vol 28 (8). 50. Collins, J, Robinson, D & Lange, A (1999) Using self assessment to gauge aggression in psychiatric populations. Mental Health Practice, Vol 2 (10): 2229. 51. Haller, RM & Deluty, RH (1988) Assaults on staff by psychiatric in-patients: a critical review, British Journal of Psychiatry, Vol 15 (2): 174179. 52. Palmstierna, T & Wistedt, B (1989) Risk factors for aggressive behaviour are of limited value in predicting the violent behaviour of acute involuntary admitted patients. Acta Psychaitra Scand, Vol 81: 152155. 53. Cherry D & Upston, B (1997), Managing Violent and Potentially Violent Situations: A Guide for Workers and Organisation, Centre for Social Health, Taverner Printing Services, Melbourne. 54. Monoghan, J & Steadman, HJ (1994) Violence and Mental Disorder Developments in Risk Assessment, The University of Chicago Press, Chicago. 55. Lidz, CW, Mulvey, EP & Gardner, W (1993) The accuracy of predictions of violence to others, Journal of American Medical Association, 269 (8): 10071011. 56. Monoghan, J (1984) The prediction of violent behaviour: Toward a second generation of theory and policy, American Journal of Psychiatry, Vol 141: 1015. 57. Palmstierna, T (1992) Aggressive behaviour from institutionalised psychiatric patients: A methodological study with clinical applications. Danderyd Hospital: Department of Psychiatry Karolinska Institute. 58. Wykes, T (1994) Violence and health care professionals, Chapman & Hall, London.

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WorkCover NSW Injury Prevention, Education and Research Grants Scheme