Mod3 Participant

A safer place to work –
preventing and managing violent

behaviour in the Health workplace
Module 3
90405NSW
Course in aggression minimisation
for managers
Participant manual
NSW Health is a zero tolerance zone

NSW DEPARTMENT OF HEALTH
73 Miller Street
NORTH SYDNEY NSW 2060
Tel. (02) 9391 9000
Fax. (02) 9391 9101
TTY. (02) 9391 9900
www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in part for study training purposes subject to
the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or
sale. Reproduction for purposes other than those indicated above, requires written permission from the
NSW Department of Health.
© NSW Department of Health 2003
SHPN (CMH) 030207

ISBN 0 7347 3591 X
July 2003
updated August 2004
MODULE 3
Course in aggression minimisation for managers
Contents
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Modular structure of preventing and managing aggression in the health workplace . . . . . . . . . . . . . . . . . . . 2
Assessment for Module 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . . . . . . . . . . . 3
Competency standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . . . . . . . . . . . 3
Guidelines for course assessment assignment . . . . . . . . . . . . . . . . . . . . . . .................... . . . . . . . . . . . 5
Assessment specification sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . . . . . . . . . . . 7
Introduction to Module 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Learning outcomes for Module 3 – Aggression minimisation for managers . . . . . . . . . . . . . . . . . . . . . . . . . 10
Part 1 The legal and policy framework for managing aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
A zero tolerance response to aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Legal principles of civil and criminal actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Part 2 Promoting an aggression-free workplace . . . . . . . . . . . . . . . . . . . . . .................. . . . . . . . . 17
Promoting a culture of safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . . . . . . . 17
Occupational health and safety legislation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . . . . . . . 17
Occupational health and safety responsibilities for managers . . . . . . . . . . . . . . . . .................. . . . . . . . . 18
Risk management and the consulting process . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . . . . . . . 19
Designing a safer workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . . . . . . . 21
Regular monitoring, reviewing and evaluating . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . . . . . . . 23
Part 3 Assisting staff when aggression and violence occurs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Dealing with bullying, harassment and discrimination in the workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Response options when confronted with aggression or violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
What is required for the effective management of aggression?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
The duress response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Reporting aggressive incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Investigating aggressive and violent incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Responding to staff stress after an incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Role of managers in supporting staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Appendices
Appendix A Bullying, harassment and discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Appendix B Incident management plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Appendix C Managers’ roles and responsibilities to reduce the incidence and
severity of aggression and violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Appendix D Duress response planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Appendix E Assessment assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
NSW Health A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW
i
Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
MODULE 3
Acknowledgments
This NSW Health violence prevention training program was developed by Brin FS Grenyer,
Olga Ilkiw-Lavalle and Philip Biro from the Illawarra Institute for Mental Health. Mark Coleman
provided assistance with the facilitator manuals and pilot workshops. The project was coordinated
from the Violence Taskforce, Centre for Mental Health by Frances Waters. The members of the project
contract steering committee who provided extensive guidance during the development of this project
were Frances Waters (Violence Taskforce, Centre for Mental Health), Kathy Baker (Community & Extended
Care Services and Nursing Services, Northern Sydney), Trish Butrej (Occupational Health and Safety,
NSW Nurses’ Association), Maggie Christensen (Learning and Development, Central Coast), Nicole Ducat
(Occupational Health and Safety, South Eastern Sydney), Louise Newman (Royal Australian and New
Zealand College of Psychiatrists), Gemma Summers (Learning and Development, Northern Sydney)
and Choong-Siew Yong (Australian Medical Association, NSW Branch).
A project content reference group also provided input during the development of the project, and the
members were Greg Hugh, Peter Bazzana, Greg Cole, Stephen Allnut, Distan Bach, Liz Cloughessy,
Jim Delaney, Regina McDonald, David Gray, Rajni Chandran, Jennifer Bryant, Terry Tracey and
Linda Sheahan. Consumer input was gratefully provided by Laraine Toms and Robyn Toohey. The
NSW Health Learning and Development Managers forum and others affiliated with the reference group
also provided helpful comment and guidance during the developmental phases of this project, including
Jenny Wright, Earle Durheim, Judy Saba, Brenda Bradbury, John Lain, Bill Wood, Aileen Ferguson,
Simon Richards, Vaughan Bowie, Louise Fullerton, Mira Savich, lain Morriset, Lorraine Hyde,
Glenda Hadley, Julie Reid, Natasha Mooney and Bill Tibben.
The developers would like to thank those staff of the South Western Sydney Area Health Service
who provided useful feedback during the four days of piloting of each of the modules in October 2001.
We also thank the fifteen educators from across the state who provided feedback during the two day
trainer orientation at Western Sydney Area Health Service in November 2002.
The developers would like to give special thanks to Professor Beverley Raphael and Professor Duncan
Chappel from the Violence Taskforce for support, Dr Claire Mayhew for timely insights, Linda Graham for
sharing her wisdom over the years through the development and implementation of the INTACT training
program, Professor Kevin Gournay and Steve Wright from the Institute of Psychiatry, London, for helpful
advice and resources, Dr Nadia Solowij and Jane Middleby-Clements for editorial assistance and to
Professor Frank Deane from the Illawarra Institute for Mental Health for practical support. We also
thank Shane Pifferi, Marie Johnson, Vicky Biro, Tim Coombs, Ralph Stevenson, Dr Alexandra Cockram,
Eugene McGarrell, Samantha Reis and Andrew Phipps for assistance with the project.
This program has incorporated and referred to relevant NSW Health policies and guidelines
where appropriate and a list of these is given at the end of the relevant modules. Modules 1 and 2
of this program were adapted from a modular aggression minimisation program developed originally
by Austraining (NSW) Pty Ltd for the Central Coast Area Health Service, which was revised by
Jenelle Langham in 2000. Module 3 of this program is a revised version of that developed by
Jenelle Langham for the Central Coast Area Health Service.
1
PA RT I C I PA N T M A N U A L
Modular structure of preventing

and managing aggression in the
health workplace
HLTCSD6A – Respond effectively to

Module 1 difficult or challenging behaviour
This eight-hour program is designed for all staff identified as being at
risk of workplace violence. It is designed to meet the Health Training
Package competency HLTCSD6A – Respond effectively to difficult
or challenging behaviour. The day is divided into five parts:
1. Understanding difficult or challenging behaviour.

2. Preventing aggression occurring.
3. Preventing aggression escalating.
4. Bullying, harassment and discrimination at work.
5. Reporting and reviewing aggressive incidents.
AMT002 – Aggression minimisation in

Module 2
high-risk environments
This eight-hour program is designed for mental health and other staff working
in high risk areas, eg emergency, security, community, aged care, disability,
dental, midwifery and early childhood, methadone, brain injury, neurology,
admissions and drug and alcohol services. Other staff members identified,
via the risk assessment process, as being at significant risk of aggressive
behaviour should also attend this module.
90405NSW – Course in aggression minimisation

Module 3
for managers
This nationally recognised qualification is a four-hour module designed
for managers. It provides the participant with detailed information, obligations
and practical strategies for promoting a safe workplace environment free of
aggression, assessing and managing risks and types of support to provide
to staff, who have been victims of aggression. Completion of Module 1 is
recommended prior to undertaking this module.
AMT004 – Aggression minimisation refresher training

Module 4
This two-hour module is designed for all staff identified as being at risk of
workplace violence, and should be repeated at a minimum of every two
years after completion of Module 1. Depending on the level of risk, some
staff may need to attend more frequently. It is designed to keep staff up
to date with policies and practices, provide refresher training of skills,
and workshop problems.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW NSW Health
2 Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
MODULE 3
Assessment for Module 3
NSW Health a safer place to work – preventing and managing violent behaviour
in the Health Workplace – Module 3 Course in aggression minimisation for managers
(90405NSW).
Competency standards
The competency standards are both from the National frontline management competencies:
● Develop and maintain a safe working environment (Unit 8).
● Establish and maintain effective workplace relationships (Unit 3).
General competencies
General competencies for the program include the ability to:
● collect, analyse and organise information Level 3
● communicate ideas and information Level 3
● plan and organise activities Level 3
● work with others in teams Level 3
● solve problems Level 3
Learning outcomes
1. Demonstrate an understanding of the managers’ roles and responsibilities in preventing
and managing aggression.
2. Demonstrate an understanding of the legal and ethical issues in managing aggression.
3. Promote workplace safety.
4. Assist with the integration of aggression minimisation principles in the workplace.
Assessment criteria
A policy and statement in relation to the minimisation of aggression and bullying:
● Definitions of aggression and bullying.
● An outline of what basic induction and training staff will be offered to support them in
aggression minimisation.
● Specific guidelines as to how, when and by whom risk assessment will be undertaken
to minimise aggression. Address this using the risk management process. Use the
following headings:
Step 1 – Identifying the hazard (workplace aggression).
Step 2 – Assessing the risk (determining how serious the aggression problem is).
Step 3 – Eliminating or controlling the risk (risk controls need to be ranked from the
most effective to the least effective).
Step 4 – Monitoring, reviewing and improving the system.
3
● Indications as to the strategies which will be used to encourage staff in maintaining a positive,
respectful workplace culture.
● Preventative strategies to be taken to minimise risk.
● Specific guidelines in relation to immediate support and ongoing counselling options.
● Specific guidelines to the steps staff should take if feeling bullied.
● Methods to be taken to investigate incidents in a comprehensive manner.
● A list of counselling options available to staff.
● Details of plan implementation.
● Details of evaluation.
Assessment method
Following attendance at the course participants are to develop a workplace plan to minimise
aggression. Guidelines for the development and assessment of the plan will be provided during
the training. Participants are to submit the assessment assignment within three months of
completing the training.
Assessment conditions
The assessment is to occur on an individual basis and be submitted within three months
of completing the training.
Assessment resources
Guidelines for the development and assessment of the plan.
NB. Evidence for the implementation of the plan is required (eg evidence of at least one induction activity and
risk management activity).
4 A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW NSW Health
MODULE 3
Guidelines for course assessment assignment

A strategic plan for aggression minimisation in the workplace
The assessment for this course requires you to develop, document and produce evidence of
initial implementation of a plan for aggression minimisation in your own work area. A report of
this activity should be submitted to the course coordinator within three months of completing
the course.
The assignment report should be documented under the following headings:

1. The aggression minimisation plan.
2. Process of development and implementation of plan.
1. Plan – your plan should cover the following aspects of aggression minimisation:
● A policy that includes a statement in relation to the philosophy of the unit toward
aggression. This may include a statement in relation to workplace bullying or you may
choose to make this a separate policy.
● A clear explanation of what basic induction and training staff will be offered to support them
in aggression minimisation.
● Guidelines as to how, when and by whom risk assessment will be undertaken to minimise
aggression. Use the following headings:
Step 1 – Identifying the hazard (workplace aggression).
Step 2 – Assessing the risk (determining how serious the aggression problem is).
Step 3 – Eliminating or controlling the risk (risk controls need to be ranked from the most
effective to the least effective).
Step 4 – Monitoring, reviewing and improving the system.
● Clear guidelines as to what steps staff should take if they are being bullied.
● Indications as to how staff will be encouraged to maintain a positive workplace culture.
● Clear guidelines on what to do if a violent incident occurs.
● A protocol on safety equipment testing (eg duress alarms).
● Clear guidelines in relation to support. Who is responsible for initiating it, who should receive
it and who should do it?
● Identification of the time schedules and methods of reviewing the plan, in order to evaluate
effectiveness and appropriateness.
2. Process of development and implementation of plan

This section should describe what you did to develop the plan. For example, what activities
did you undertake to identify, assess and control violence risks. Did you do any research,
reading or ask other people in similar positions what they did? Did you consult with your
staff or use some meeting time to develop a plan with team input? If needed, did you
consult with any others outside your workplace?
5
MODULE 3
Aggression minimisation for managers
Assessment specification sheet
Candidate’s name
Work location Telephone (w)
Units of competency to Assessment methods Assessment activities

be assessed
90405NSW Course in aggression Adequate completion of plan Development of workplace
minimisation for managers plan to minimise aggression
in the workplace
Details of special requirements:
Assessor’s name
Signature
/ /
Date of assessment Time
Confirmation of assessment
I confirm that:
● the purpose of this assessment has been clearly explained to me
● the criteria (relevant competency standards) to be used in this assessment have been discussed with me
and I am aware that I will be assessed against this criteria
● I have been given fair notice of the date, time and venue of this assessment
● I am aware of how the assessment will be done and the requirements relating to this assessment
● I am aware of my right to appeal an assessment decision with which I disagree, and the process for
appealing that assessment.
Candidate’s
signature
/ /
Date of assessment
NSW Health A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW 7
MODULE 3
Introduction to Module 3
Aggression in the health industry is a significant problem.1,2,3 The costs of aggression in the
workplace are human4,5,6,7 as well as economic.8,9,10 The economic costs include increased
absenteeism, loss of earnings, compensation claims, impaired functioning and staff turnover.
The human costs include reductions in physical and psychological health.
Managers clearly have a vital role to play in ensuring the safety of the workplace, not only in terms
of organisational responsibilities, but also in terms of leadership. The culture of a workplace is not
solely dependent on managerial style and philosophy, however these are fundamental influencing
factors for which managers need to accept responsibility.
In order to effectively fulfil their role, managers should not only be aware of the aggression
minimisation principles required of their staff, but also their own particular responsibilities.
The aim of this course is to assist managers of health units and facilities to promote a
workplace, which is safe and free from aggression.
The course is intended for managers at all levels. It will provide them with an opportunity to gain
the knowledge and skills necessary to offer leadership, identify, assess and manage violence risks
and provide support for their staff and colleagues in relation to aggression minimisation.
By completing this training and continually improving the way in which you respond to aggression
you may achieve the following:
● Reduced injury to staff, patients and members of the public.
● Reduced levels of stress in the workplace.
● Reduced levels of aggression.
● Fulfilment of your duty of care and responsibility under the NSW Occupational Health and
Safety Act 2000.
Many managers will have first hand experience in encountering aggression and conflict in the
workplace. This course will enable you to draw on those experiences and use them to explore
and develop best practice principles for the prevention and management of aggression.
9
Learning outcomes for Module 3 –

Aggression minimisation for managers
At the conclusion of this module, participants should be able to:

1. demonstrate an understanding of the manager’s roles and responsibilities in preventing
and managing aggression
2. demonstrate an understanding of the legal and ethical issues in managing aggression
3. promote workplace safety
4. assist with the integration of aggression minimisation principles in the workplace.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 3 90405NSW NSW Health
10 Course in aggression minimisation for managers (Version 2) © July 2003 updated August 2004
MODULE 3
Part 1
The legal and policy framework for
managing aggression
This section looks at the NSW Health zero tolerance response to aggression, other policies
and guidelines in relation to aggression and the principles of legal and civil actions.
Legislative,a procedural and ethical laws and guidelines govern:

a. the way in which you manage aggression, and
b. those affected by aggression in the workplace.
You have a responsibility to ensure that:

● you are aware of all NSW Health policies on aggression minimisation and management
● all relevant local policies, procedures and protocols that flow from them are communicated
to your staff
● they are effectively implemented in your area of responsibility.
It is also important to understand the impact of aggression on your staff and your responsibilities
in relation to these impacts.
A zero tolerance response to aggression

NSW Health is committed to the minimisation of violence in the public health system and
the focus should always be on the prevention of violence. However, in the event that a violent
incident does occur, NSW Health, as a result of a key recommendation from the Taskforce
on the Prevention and Management of Violence in the Health Workplace, has adopted a zero
tolerance response to threatening, abusive or violent behaviour by any person towards any
other person on health service premises or towards NSW Health staff working in the community.
What does zero tolerance mean to you?
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11
The zero tolerance responseb means that in all instances of aggression appropriate action will
be taken to protect staff, patients, visitors and health service property from the effects of such
behaviour. It is about keeping health staff, patients and visitors safe.
The zero tolerance response does not take the place of effective risk management, and at all
times the focus must be on prevention. However, in the event of an aggressive incident action will
be taken to minimise the impact on all concerned. Options for action will be discussed in Part 3.
It should be noted that zero tolerance is NOT about taking punitive action against patients
whose violent behaviour is a direct result of a medical condition. In these circumstances the
emphasis is on prompt, effective clinical management and compassionate care of the patient,
while at the same time protecting the safety of the patient, the staff and others who might
be affected by the behaviour.
Underpinning the zero tolerance response is the key message to staff that aggression is NOT
an acceptable part of the job and is not something simply to ‘be put up with’.
For further information see the NSW Health Zero Tolerance Policy and Framework Guidelines.
Zero tolerance attitudes and behaviours

Putting up with aggression and violence in the health workplace IS NOT an acceptable part of
your job (if you don't get the message neither will your staff).
Lead by example (if you don't take aggressive incidents seriously, neither will your staff, patients
or visitors).
Make sure your staff know their options when confronted with violent behaviour (there are options
and it is important that all staff know what they are).
Encourage and support them in utilising these options (staff need to feel confident in the decisions
they make when confronted with violence and that their decisions will be supported, particularly when
police are involved and during any resulting legal process).
Know and exercise your responsibilities as a manager in dealing with violence (both short-term
and long-term).
Ensure that all violent incidents are reported (keep the system simple to encourage a culture
of reporting).
Investigate all violent incidents (this is the only way to ensure that risk management strategies
continue to be effective).
Respond promptly to all reports of bullying (if you don't staff will not take 'zero tolerance' seriously).
Keep 'zero tolerance' on the agenda (discuss in staff meetings the factors that increase violence
risks in the immediate workplace, run debriefs after aggressive incidents, communicate incident
investigation results and remedial actions to your staff, encourage staff to feed back on how
local protocols and procedures are working).
How can you communicate the zero tolerance response to staff, patients, visitors and members of
the public?
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MODULE 3
Legal principles of civil and criminal actions

In general, the law protects an individual’s rights in four main areas. These four main principles
impact on the manner in which staff conduct themselves in the workplace the right:
● to freedom of movement
● to immunity from unwarranted interference from bodily contact by others
● to immunity from conduct by others that would subject the person to unreasonable
risk of injury
● of reputation.
Crimes Act 1900

Under the Crimes Act 1900, persons who commit assaults and other acts of violence can
be charged with criminal offences. The Act also establishes provisions allowing apprehended
personal violence orders to be taken out where a person has reasonable grounds to fear personal
violence, harassment or molestation.b Recent changes to the Act now mean that the occupation
of the victim of an assault will be considered in determining an appropriate sentence. These
changes are designed to allow tougher penalties to be imposed on those who assault health
staff or other ‘essential service workers’ in the course of their work.
Assault
The criminal offence of assault consists of:
i. force applied to another without their consent, or
ii. the actual intent to cause harm to the person, or
iii. a very high degree of reckless indifference to the probability of harm occurring.
These are the conditions for police to prove if they are to successfully secure a prosecution
for assault.
Employers have the responsibility of ensuring that employees are not put at risk of assault.
From an administrative perspective, managers need to ensure that appropriate risk management
initiatives are implemented in their area of responsibility. In particular, communication mechanisms
need to be implemented to ensure that relevant information, relating to patients with a history
of violence, is communicated to staff providing care to these patients. This allows for staff to
be adequately prepared, and to develop patient management plans to reduce the risk of
violent incidents.
Reasonable forceb
Section 418 of the Crimes Act 1900 states that a person may use self-defence if and only if the
person believes the conduct is necessary to:
● defend himself or herself or another person, or
● prevent or terminate the unlawful deprivation of his or her liberty or the liberty of another person, or
● protect property from unlawful taking, destruction, damage or interference, and the conduct is a
reasonable response in the circumstances as he or she perceives them. These provisions were
introduced in February 2002.
This means that a person who assaults another person in self-defence is not criminally
responsible if acting in lawful self-defence. As stated above self-defence is not limited to
the defence of one’s own person, and can be used as a defence for assaults that occur
when protecting property or other people.
In the past the test was whether the perception of a threat was reasonable in the
circumstances, and whether a ‘reasonable person’ in the same circumstances would also
have been able to come to the same conclusion. The defence is now broader and states that as
long as the accused believed that they were under threat, it does not matter that a ‘reasonable
person’ may not have perceived such a threat in the same circumstances.
However, a reasonable response is still required for the law of self-defence to operate.
The law states that there must be some reasonable proportion between the threat perceived
by the accused and his or her response to it. So the key issue is that the person threatened
must be able to persuade a court that they felt threatened, that the threat was real to them
and that their response was appropriate.
Use of restraint
Restraint may be necessary in emergency situations involving aggressive patients, where
there is a foreseeable risk of harm to themselves or others. At all times NSW Health policy
requirements relating to clinical restraint should be adhered to. See NSW Health documents:
Management of Adults with Severe Behavioural Disturbance, May 2002; Mental Health for
Emergency Departments, May 2002; Policies on Seclusion Practices: the Use of Restraint
and the Use of IV Sedation in Psychiatric In-Patient Facilities, December 1994.
When staff restrain a patient they must use only reasonable force in order to be protected from
prosecution for assault.
With regard to the restraint of others in the act of committing a crime, the first consideration for
staff is their own safety and the safety of others. Attempting to restrain in these circumstances
may expose staff to unnecessary risks, and unless there is an immediate and significant threat
to the safety of others, staff should retreat and observe from a safe distance, and police should
be called.
Duty of care
Duty of care requires that a staff member act in the best interests of the patient. However,
it is essential to note that a duty of care does not suggest that staff should remain in dangerous
situations or place themselves at unacceptable risk. At times a staff member’s duty of care to a
patient may justify the use of detainment, restraint or sedation for the patient’s own safety or the
safety of others. In these situations having exercised a duty of care may be a defence for staff
members against claims of false imprisonment or assault. Not exercising a duty of care may
result in a claim of negligence depending on the circumstances.
MODULE 3
What is the role of the manager when:

A staff member seeks to have charges laid against a patient, visitor or a member of the public?
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A patient, visitor or member of the public seeks to have charges laid against a staff member?
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NSW Health Memorandum of Understanding between

NSW Police and NSW Health
The NSW Health Memorandum of Understanding (MOU) between NSW Police and
NSW Health was developed and released in 1998 to establish a clear framework for the
management of situations involving police and health staff, and persons who may have a mental
illness. The objective was to improve the response to and outcomes in the management of mental
health crises that involved responses from multiple services. The MOU clearly defines the roles
of each of the service providers, formalising those roles into a workable and complementary
framework. However, the framework is intentionally broad, to allow for specific protocols to
be developed at the local level utilising local service components and addressing local needs.
The MOU was reviewed in 2000 and resulted in a number of practical tools being developed that
support the MOU and provide more detailed guidance for the development of local protocols.
These documents were released in July 2002.b
Local policies and guidelines

Identify all the local policies and procedures on aggression within your Health Service that are
relevant to your work area of responsibility. How do you ensure that staff are familiar with them?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
MODULE 3
Part 2
Promoting an aggression-free workplace
This section of the course focuses on prevention of aggression in the workplace

and the role of managers in this process. While it is widely acknowledged that not all
aggression in the workplace can be prevented, the focus of all staff including managers
should be to prevent the vast majority of potentially aggressive incidents from occurring.
In this process it is important that managers have a leading role in:
• promoting a culture of safety
• utilising the risk management process.
Promoting a culture of safety

Violence has generally been seen as part of the job in health care,11 with staff expecting to be
physically assaulted at some stage in their careers.12 Feeling unsafe in the workplace can cause:
● additional stress for staff13
● negative attitudes that influence behaviour.14
For detailed information on workplace safety refer to: NSW Health Security Manual and
Workplace Health and Safety: A Better Practice Guide (currently under review).a
As a manager, what are some of the challenges to ensuring safety is a top priority for your staff?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Occupational health and safety legislation

Under the NSW Occupational Health and Safety Act 2000a employers have a duty of care for
the health and safety of all people in the workplace. This requires employers to:
● ensure that premises controlled by the employer where people work are safe and without
risk to health
● ensure that systems of work and the working environment are safe and without risk to health
● ensure that any equipment or substance provided, for use by the employees at work is safe
and without risk to health when properly used
● provide necessary information, instruction, training and supervision for the health and safety
of their employees
This Act is supported by the Occupational Health and Safety Regulation 2001.a
17
Under this regulation employers are responsible for:

● identifying workplace hazards, including violence
● assessing the risks associated with the hazards
● implementing risk control measures
● consulting with their employees during the process
● providing training.
There are various offences and penalties for non-compliance with the Act and Regulation even
if no one has been injured. Penalties can be issued to employers and employees.
Non-compliance with the Act and Regulation includes employers not having done enough to
eliminate or reduce risks even if no one has been injured. If the organisation is in breach of the
Act or Regulation managers may be held liable unless they are able to show that they could not
have influenced the organisation’s conduct in the matter, or that they used ‘due diligence’ to
stop the corporation from contravening the Act.
How can ‘due diligence’ be shown?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Employers need to ensure the health and safety of persons who are at their place of work
and who may be affected by their acts or omissions at work. Employees must cooperate with
employers in complying with OHS requirements.
Occupational health and safety responsibilities for managers

Managers coordinate the overall safety effort within their area of responsibility. This requires
them to understand their duty of care and be familiar with the OHS system in their organisation.
The following are examples of an OHS system in action:a
● Developing safe work practices and procedures.
● Consulting with employees on all safety issues.
● Considering decisions from an OHS perspective.
● Ensuring compliance with safety rules.
● Ensuring line managers do not cut corners, introduce ambiguity or condone unsafe
work practices.
● Raising OHS issues at staff meetings.
MODULE 3
● Encouraging staff to support OHS committee meetings and related activities.

● Reporting back to staff on OHS initiatives and trends.
● Involving staff in all decisions that affect them.
● Enforcing safety policies and procedures.
● Promptly and visibly investigating all significant OHS issues.
● Ensuring effective OHS training and development for employees.
● Developing easy and non-threatening procedures to report accidents, injury, illness
and ‘near misses’.
How do you as a manager ensure that staff are involved in the promotion of workplace safety?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Risk management and the consulting process

Under the OHS Act 2000a employers are required to consult with employees and take into
account their views when decisions are made that affect their health, safety and welfare.
Some examples of when you need to consult staff include:

● whenever examining or reviewing risks to health and safety
● when making decisions about measures taken to eliminate or control risks
● when introducing or altering procedures for identifying and monitoring risks
● whenever changes are being proposed that could affect health and safety in the workplace,
the systems of work or equipment used for work
● whenever decisions are made about consultation arrangements.
Risk management is an interactive process consisting of clearly defined steps.15,16 By following

the steps you can make informed decisions on how best to avoid or control violence risks.
The risk management process

Step 1. Identify the hazard.
Step 2. Assess the risk.
Step 3. Eliminate or control the risk.
Step 4. Monitor, review and improve the system.
The process of identifying risks in your workplace

For the process of identifying risks, some potential sources of information are:
● aggression/violence reports and associated aggregated data
● incident investigation reports and emergency response reviews
● reports of staff and unions
● visual workplace inspections and violence vulnerability audits
● security surveys
● related OHS and workers compensation data
● staff records, eg to identify areas of high staff turnover
● staff grievance records
● patient complaint records
● observations.
Factors to consider when assessing and prioritising risks b

● What is the nature of the risk or hazard, eg is it physical, psychological, chemical?
● What is the degree or severity of harm that the hazard/risk may cause?
● How likely is it that harm will occur as a result of the exposure?
● How often are staff exposed to the risk or hazard?
● How long are the periods of exposure?
● How many staff are exposed to the risk or hazard?
● How many patients are exposed to the risk or hazard?
● What is the level of experience of staff?
● How much training has staff received?
● How effective are the existing control strategies?
Eliminating or controlling risks

Eliminating or controlling risks involves deciding what needs to be done to eliminate or control
the problem. Under the Occupational Health and Safety Regulation 2001 employers are required
to eliminate any ‘reasonably foreseeable’ risks to the health and safety of their employees.
Risk control measures need to be developed and implemented in a manner consistent with the
hierarchy of controls set out in the legislation. The hierarchy ranks control measures from the
most effective to the least effective. In most cases several control measures will be needed.b
MODULE 3
Designing a safer workplace

NSW Health has developed the Design Series (DS) Health Facility Guideline – Security and Safety
2003d to assist facility planners and designers to reduce violence and security risks through the
design and layout of workplaces, by incorporating ‘crime prevention through environmental
design’ (CPTED) principles into the health building process. Considering the design of the
environment can reduce situational crime.
When designingb, 2,17 new facilities or re-furbishingb,2,17 it is important to reduce the opportunity
for criminal activity. This can be achieved through:
● increasing the risk for offenders
● reducing the opportunity for the offender to make an excuse to trespass
● reducing the likely rewards for criminal behaviour.
Target hardening and territorial reinforcementb,2

‘Target hardening’ refers to reducing access to specific high-risk areas through architectural or
engineering designs or redesigns. Target hardening strategies include:
● access controls
● barriers and grates
● deadlocks on drug cabinets.
‘Territorial reinforcement’ refers to ensuring that ‘staff-only’ areas are clearly identified and
separated from other areas so that staff are more likely to notice an intruder. Staff can be
encouraged to view the health care setting as something that is theirs. A sense of protectiveness
of the facility by staff is an important aspect of safety. Staff are more likely to pay attention to
areas where ‘staff only’ are permitted. Strategies for territorial reinforcement include:
● encouraging staff to be responsible for the facility and its use
● designing facilities that have clear transitions and boundaries between the health facility and
the general community and between ‘staff only’ areas and other areas
● establishing clearly visible signs on who is to use a space and its purpose.
Natural surveillanceb,2
Increasing visibility in the workplace discourages offenders as it improves the chance of others
witnessing and reporting the offenders. Examples include:
● having clear sightlines between public and staff areas
● effective lighting for visibility
● ensuring that areas that are landscaped are not places where offenders have an opportunity
to hide or entrap victims
● designing pathways to car parks to be in full view of passers-by and/or overlooked
by windows.
Space managementb,2
The types of fittings and furniture used in the workplace can reduce the risk of aggression
by making it more difficult for perpetrators to commit a crime and cause injury to others.
Some strategies include:
● keeping sites clean
● keeping all furniture, fittings and facilities in good repair
● attending quickly to the repair of vandalism and graffiti
● replacing any burned out external lighting
● removing or refurbishing any decayed physical surroundings.
Discuss what environmental control measures you have in your workplace and what
environmental control measures need to be implemented for each of the following to
reduce the risk of aggression and violence:
Target hardening
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Surveillance and lighting
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Fittings and furniture
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
For further information on making your workplace safe and on risk management, refer to
Workplace Health and Safety: A Better Practice Guide (currently under review).a When making
decisions about the appropriate purchasing and acquiring of equipment such as alarms,
communication systems, security lighting, locks, key controls etc, refer to NSW Health
Security Manual.c The police can also provide advice about security issues.
MODULE 3
Regular monitoring, reviewing and evaluating

A key component of aggression prevention and management is the need to regularly monitor
the work area for hazards and risks. The violence prevention and management system also
needs to be regularly monitored, reviewed and evaluated. The following are examples of
possible monitoring, review and evaluation activities.
Consider who should be involved in carrying out each of the following and tick the
appropriate boxes.
Managers Staff
Regular security and violence vulnerability audits.
Implementing and monitoring recommendations from the audits.
Reviewing local policies, procedures and protocols for continuing relevance

and effectiveness.
Testing and maintaining safety equipment such as duress alarms and

communication devices.
Ensuring safety equipment continues to effectively meet the needs/purposes

for which it was initially provided.
Monitoring the incident reporting system/procedures and compliance.
Investigating incidents and ensuring recommendations from the investigation

are implemented in a timely manner.
Ensuring that appropriate post-incident support is provided to those involved

in aggressive or violent incidents.
Reviewing responses to the aggressive and/or violent incidents,

including the duress response.
Implementing and monitoring recommended modifications to the

response protocols.
Ensuring staff are appropriately trained, including induction/orientation of

new staff.
Ensuring that training meets the needs of the target staff.
Ensuring that all related legal requirements are met.
Identifying and regularly reviewing system performance indicators.
What are the risks of trying to do all on the previous page yourself?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
To determine whether the prevention and management systems are effective in

preventing and reducing aggression, managers need to look at whether there is
a reduction in the frequency and severity of aggressive and violent incidents.
1. Discuss what information can be used to evaluate whether there is a reduction in the
frequency and severity of aggressive and violent incidents.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. As part of the evaluation process managers should also be looking at and monitoring the
degree of implementation of key violence prevention initiatives. What indicators could be
used to evaluate this?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
MODULE 3
Part 3
Assisting staff when
aggression and violence occurs
This section looks at bullying, harassment and discrimination, response options

when confronted with violence, the duress response, reporting and investigating
aggressive incidents, responding to staff stress after an incident and the role of
managers in supporting staff.
Dealing with bullying, harassment and discrimination

in the workplace
NSW Health is committed to providing safe and equitable working conditions for all employees.
It seeks to eliminate bullying, harassment and discrimination from the workplace and ensure that
employees are not subjected to treatment that is hostile and unprofessional. See C2002/50
Joint Management and Employee Association Policy Statement on Bullying, Harassment
and Discrimination.e
Bullying, harassment and discrimination can be defined as the repeated, unfavourable

treatment of a person in the workplace, which may be considered unreasonable and
an inappropriate workplace practice. It can involve employees, managers, contractors,
visitors or patients.e See Appendix A for further information on bullying, harassment
and discrimination.
What types of behaviours represent bullying, harassment and discrimination?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Managers are responsible for fostering a work environment which is free from bullying,
harassment and discrimination and they must not themselves be perpetrators of bullying,
harassment and discrimination.e
How can managers promote a workplace that is free from bullying, harassment
and discrimination?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
25
Response options when confronted with aggression or violence

You need to ensure that your staff are aware that there are always options when confronted with
an aggressive or violent incident. These options can be applied both in the short and long-term,
and more than one type of response may be used.
Short term response options

The type of response staff choose will depend on the nature and severity of the incident and
whether the perpetrator is a patient, visitor or intruder, and the skill, experience and confidence
of the staff member involved. For guidelines on managing patients who are violent refer to NSW
Health Mental Health for Emergency Departments (red book) and NSW Health Management
of Adults with Severe Behavioural Disturbance (green book).
Some short term response optionsb (in no particular order):

● Issue a verbal warning.
● Seek support from other staff.
● Request that the person behaving aggressively leave.
● Request that the patient be reviewed by a clinician.
● Negotiate treatment.
● Use verbal de-escalation and distraction techniques.
● Stay and call for help.
● Leave and seek help.
● Utilise the emergency duress response.
● Initiate external emergency response, eg police.
Longer term response options

The following options should be considered for the management of repeated aggressive
behaviour. For further information, refer to the NSW Health Zero Tolerance Policy and
Framework Guidelines.
Some long-term response options (in no particular order) include:

● written warnings
● formal patient management plans
● conditional treatment agreements
● exclusion from visits
● conditional visiting rights
● patient alerts in conjunction with support management plan
● Recognition of inability to treat in certain circumstances
● taking out an AVO to protect staff
● having charges laid.
Both short and long-term options are discussed in some detail in the NSW Health Zero Tolerance
Policy and Framework Guidelines.
MODULE 3
How do you ensure that your staff have been trained in violence minimisation, and how can you
ensure that staff are aware of their response options?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What is required for the effective management of aggression?

Managers have an administrative responsibility to ensure that their workplace areas of
responsibility have processes in place to ensure that:
● staff are able to effectively manage violent behaviour
● the risk of harm to themselves and others is minimised as far as possible.
See Appendix B for managers’ roles and responsibilities for a facility’s incident management plan
and Appendix C for managers’ roles and responsibilities to reduce the frequency and severity of
violent behaviour in their area of responsibility.
Processes need to be in place to manage all forms of violence in the workplace, regardless of
the source of violence, or the target. This includes:
● violence from members of the public to staff
● patient violence to staff
● patient violence to other patients
● staff violence to other staff
● staff violence to patients or members of the public
● violence from members of the public to other members of the public.
Response options will vary depending on the circumstances.
The duress response

All staff need access to assistance in an emergency, and all areas should have in place an
emergency response. In particular, all high-risk areas need a well planned, defined and clearly
articulated duress response. Duress response plans should identify, establish and promote a
range of procedures that aim to contain and control a violent or potentially violent incident, and
that minimise or eliminate the risk of injury in a violent incident. Staff need to be aware of when
to activate the duress response and should not be blamed or judged for activating the duress
responseb if they feel it is necessary.
See Appendix D for managers’ responsibilities for the duress response.
Principles of the duress response in

● The call or trigger should be earlier rather than later.
● Only one call or alarm trigger should be required.
● Response should be appropriate, timely and effective.
● Response should be standardised to reduce any confusion between team members.
● Staff in the duress response team need to be clearly aware of their roles and responsibilities
and have formal training in the procedures, particularly those relating to restraint and sedation.
● All shifts need to be covered and there needs to be processes in place to cover unexpected
staff shortages, eg due to sick leave, etc.
● Post-incident support is to be provided.
● Operational review and debriefings are to be conducted following the duress response.
● The duress response is to be regularly evaluated and updated.
What policies and procedures are in place in your area for the duress response? How is the
effectiveness of the duress response evaluated?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Reporting aggressive incidents

Many aggressive incidents remain unreported.1,11,18 All aggressive incidents need to be reported
and documented on the appropriate forms. This includes verbal threats, bullying, ‘near miss’
events, workers’ compensation claims, property damage insurance claims and security incidents.
In addition to local reporting requirements, there are mandatory requirements for reporting a
range of incidents to the NSW WorkCover Authority and NSW Health.b
For further information see NSW Health circular 2003/88 Reportable Incident Briefs to the
NSW Department of Health,g circular 2002/19 Effective Incident Response: A Framework for
Prevention and Management in the Health Workplace and circular 2003/75 NSW Health Policy
and Procedures for Injury Management and Return-to-Work.
Why do you think many aggressive incidents remain unreported?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
How can you encourage staff to report all aggressive incidents?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
MODULE 3
Investigating aggressive and violent incidents

When interviewing staff and other witnesses, the aim is not to look at who was to blame for
the incident occurring but to identify the cause(s) and what measures are needed to prevent
similar or more serious incidents.h
Key points to remember during the interview

● Approach – be supportive.
● Tone and attitude – be empathic and acknowledge the person’s experience and distress.
Your tone and attitude should not be harsh or judgmental.
Establishing the facts

● What happened?
● Who was involved?
● Where did it happen?
● When did it happen?
● How did it happen?
● Why did it happen?
All contributing factors should be considered:

● Work environment.
● Status of the perpetrator/s, eg patient, intruder, visitor etc
● Equipment.
● Work practices.
● Supervision.
● Staff skill.
● Education and training.
An investigation is complete when the following questions can be answered:

● Do you have all the facts and details on the causes and contributors to the incident?
● Who was or should have been involved in the response and management of the incident
(this should have been gleaned in part from the operational review/debrief)?
● What systems were in place to minimise the risk of the incident occurring?
● What were the identified system gaps or failures, ie why didn’t the system work?
● What were the achievements/positive actions and outcomes from the incident?
● Were all policy/legislative requirements met concerning pre and post-incident management?
● How could this or similar incidents be prevented?
● What are the recommendations for changes to policies, procedures, equipment,
environment, staffing or competencies? The recommendations should be followed by
budgetary requirements if any, who is responsible for their implementation and time
frames for completion.
● Who is responsible for monitoring and evaluating the changes?
Responding to staff stress after an incident

People react to stress differently and their reactions are a normal response to an abnormal event.
The level of fear a person feels and the way they respond during and after an aggressive incident
relates to their own experiences, skills and personality. One of the major outcomes of aggression
against workers, apart from physical injury, is the resulting anxiety and stress experienced by that
person.h,7 Although many aggressive incidents may be minor in nature, on a continuing basis they
may produce severe psychological consequences including post traumatic stress disorder and
substance abuse. It is important to remember that witnesses to violence may also suffer similar
emotional reactions.19
For many people these stress reactions will be managed with the person’s own coping
mechanisms, support networks and material resources and will diminish over a period of
a few weeks.h
Type of stress reactions

● Emotional – shock, anger, irritability, helplessness, loss of control.
● Physical – fatigue, sleep disturbance, hyperarousal, eg hypervigilance, somatic complaints
(psychological disorders with physical symptoms).
● Cognitive – poor concentration and memory, worry, intrusive thoughts.
● Interpersonal – social withdrawal, relationship difficulties.
Immediate managers need to support staff returning to their normal work duties; this ongoing
support is important for the staff member’s overall well being. Due to the fact that victims of
aggression manage the trauma and stress of their experience differently, the type of support
offered will depend on this factor as well as the nature and severity of the aggressive incident.
All staff involved in aggressive incidents need to be followed up to identify the employees
who may require further support services or time away from their department/unit. Two weeks
following the incident all staff should be contacted even if they had initially declined support or
assistance. If staff continue to decline support or assistance, further follow-up is advisable
four weeks after the incident.h
For further information refer to NSW Health Effective Incident Response: A framework for
Prevention and Management in the Health Workplaceh.
The following types of support can be offered:h

● Psychological first aid – Immediate social and practical help.
● Employee assistance programs and peer support programs.
● Supportive counselling.
● Supportive group discussion.
● Operational debriefing.
● Specialised counselling.
● Mental health care.
NB. NSW Health does not recommend compulsory critical incident debriefing as a structured post-incident intervention.
MODULE 3
Discuss the following:

What staff support mechanisms do you have in place in your own workplace and how are staff
aware of these?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Role of managers in supporting staff

Staff have generally perceived that they are not always supported by management following
aggressive incidents.13 Staff who are victims of aggression and violence are entitled to have
the aggressive incidents dealt with through the legal system.20,21
Managers need to provide support to staff in the following waysa,b:

● Through assistance with appropriate support mechanisms.
● Not forcing staff to provide care for a patient who has injured them.
● Supporting staff when they return to work.
● Providing access to injury management programs, eg return to work programs, retraining.
● Helping with compensation issues.
● When required, requesting police take out apprehended violence orders on behalf of staff.
● When required, requesting police press charges.
● Providing practical and legal support for staff who have to give evidence in court, eg educating
staff on what to expect.
● Providing support, eg a support person during court hearings, or when staff attend the police
station to make a statement.
Employers under the Workplace Injury Management and Workers Compensation Act 1998a
are required to:
● participate in the insurer’s injury management program
● provide early notification of workplace injuries to the insurer
● provide suitable work if practical for injured employees
● cooperate with the insurer’s injury management plan
● establish a return-to-work program for the organisation and a return-to-work program for the
injured employees.
For more information refer to your Risk Management Unit or Return to Work Coordinator and see
circular 2003/75 NSW Health Policy and Procedures for Injury management and Return-to-Work.
Roles and responsibilities to assist managers in preventing and managing

workplace aggression and violence
● Prevent workplace aggression and violence in consultation with staff through the risk
management process.
● Encourage and support staff to report all aggressive and violent incidents.
● Investigate incidents promptly and efficiently and implement the resulting recommendations.
● Be aware of all relevant policies, procedures and protocols for aggression and violence prevention.
● Be aware of all the short and long-term options for preventing and managing violence.
● Ensure that staff are trained in violence prevention strategies, procedures and protocols.
● Ensure staff are aware of their options when confronted with violence.
● Implement all violence prevention and management policies, protocols and procedures in their
area of responsibility.
● Ensure that relevant post-incident management policies, procedures and protocols are implemented
following a violent incident.
● Always keep violence as an agenda item at relevant staff meetings.
MODULE 3
Related NSW Health policies

and guidelines
a. C2001/22 Workplace Health and safety: A Better Practice Guide (currently under review).
b. NSW Health Zero Tolerance Policy and Framework Guidelines.
c. NSW Health Security Manual.
d. Design Series (DS) Health Facility Guideline – Security and Safety 2003.
e. C2002/50 Joint Management and Employee Association Policy Statement on
Bullying, Harassment and Discrimination.
f. Management of Adults with Severe Behavioural Disturbance, May 2002 (green book) and
Mental Health for Emergency Departments, May 2002 (red book).
g. C2003/88 Reportable Incident Briefs to the NSW Department of Health.
h. C2002/19 Effective Incident Response: A Framework for Prevention and
Management in the Health Workplace.
i. C94/127 Policies on Seclusion Practices: the Use of Restraint and the Use of IV Sedation
in Psychiatric In-Patient Facilities (currently under review).
j. C2003/75 NSW Health Policy and Procedures for Injury Management and Return-to-Work.
33
MODULE 3
References
1. Mayhew C, Chappell D (2001a). Occupational violence: types, reporting patterns, and

variations between health sectors. Working Paper Series no. 139, School of Industrial
Relations and Organisational Behaviour and the Industrial Relations Research Centre,
paper written for the Taskforce on the Prevention and Management of Violence in
the Health Workplace, University of New South Wales, Sydney.
2. Mayhew C, Chappell D (2001b). Prevention of occupational violence in the health workplace.
Working Paper Series no. 140, School of Industrial Relations and Organisational Behaviour
and the Industrial Relations Research Centre, paper written for the Taskforce on the
Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney.
3. Mayhew C, Chappell D (2001c). Internal violence (or bullying) and the health workforce.
Working Paper Series no. 141, School of Industrial Relations and Organisational Behaviour
and the Industrial Relations Research Centre, paper written for the Taskforce on the
Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney.
4. O’Connell B, Young J, Brooks J, Hutchings J, Lofthouse J (2000). Nurses’ perceptions of the
nature and frequency of aggression in general ward settings and high dependency areas.
Journal of Clinical Nursing, 9 (4), 602-610.
5. Everley GS, Lasting JM (1995). Psychotraumatology: key papers and care concepts in post
traumatic stress. New York: Plenum Press.
6. Ilkiw-Lavalle O, Grenyer B (2003). Differences between patient and staff perceptions of
aggression in mental health units. Psychiatric Services, 54, 389-393.
7. Perrone S (1999). Violence in the workplace. Research and Public Policy Series no. 22,
Australian Institute of Criminology, Canberra.
8. Baron SA (1996). Organisational factors in workplace violence: developing effective
programs to reduce workplace violence. Occupational Medicine: State of the Art Reviews,
11 (2), 335-348.
9. Fletcher TA, Brakel SM, Cavanaugh JL (2000). Violence in the workplace: new perspectives
in forensic mental health services in the USA. British Journal of Psychiatry, 176, 339-344.
10. Smith-Pittman MH, McKoy D (1999). Workplace violence in healthcare environments. Nursing
Forum, 34 (3), 5-13.
11. Jones J, Lyneham J (2000). Violence: part of the job for Australian nurses? Australian
Journal of Advanced Nursing, 18 (2), 27-32.
12. Erickson L, Williams-Evans SA (2000). Attitudes of emergency nurses regarding patient
assaults. Journal of Emergency Nursing, 26 (3), 210-215.
13. Jackson D, Clare J, Mannix J (2002). Who would want to be a nurse? Violence in
the workplace – a factor in recruitment and retention. Journal of Nursing Management,
0 (1), 13-20.
35
14. Poster EC, Ryan JA (1989). Nurses’ attitudes toward physical assaults by patients.
Archives of Psychiatric Nursing, 3 (6), 315-332.
15. WorkCover NSW Health and Safety Guide. (2001). Risk management at work
(on-line). Available www.workcover.nsw.gov.au/.
16. WorkCover NSW. HAZPAK. Making your workplace safer: A practical guide to basic
risk management.
17. Bowie V (2000). Preventing and managing violence by intruders in the workplace:
a situational, organisational and societal response. Journal of Occupational Health and Safety:
Australia and New Zealand, (16) 5, 443-448.
18. Macdonald G, Sirotich F (2001). Reporting client violence. Social Work, 46 (2), 107-114.
19. Rees C, Lehane P (1996). Witnessing violence to staff: a study of nurses’ experiences.
Nursing Standard, 11 (13-15), 45-47.
20. Coyne A (2002). Should patients who assault staff be prosecuted? Journal of Psychiatric
and Mental Health Nursing, 8, 139-145.
21. Till U (1998). The prosecution of psychiatric inpatients for assault: benefits and ethics.
Psychiatric Care, 5 (6), 219-224.
22. WorkCover NSW. The New Simple Way to Notify Work-Related Incidents (2003) (on-line).
Available www.workcover.nsw.gov.au
MODULE 3
Appendix A
Bullying, harassment and discrimination
The person making the complaint and the person who is being complained against have rights
that need to be considered and observed. These rights are consistent with the principles of:
● natural justice
● equal opportunity
● workplace awards and conditions.
Rights of the person making the complaint

The person who believes he/she is a victim of bullying, harassment or discrimination at work
has the right to:
● making a complaint
● being free from victimisation having made this complaint
● accessing advice and support from either the Human Resources Unit or a professional or
industrial body.
Rights of the person that is being complained against

The person who is being complained against has the following rights:
● Being informed of the complaint.
● Being able to respond to the complaint.
● Having the complaint kept confidential.
Grievance procedure
The person allegedly being bullied could do the following:
● Approach the contact person for advice, support and assistance.
● Inform their immediate supervisor and together attempt to resolve the problem (If this does
not work, or the immediate supervisor is part of the problem, approach the next in line).
● Seek mediation, eg from the Dispute Resolution Centre.
The person being allegedly bullied may lodge a written complaint where the other approaches
are unsuccessful, or the allegations are so serious that other approaches are inappropriate.
The procedure for lodging a written complaint should include when and how a written complaint
is to be lodged.
The grievance procedure should include methods for ensuring people are not victimised as a
result of using the grievance procedure.
37
The investigation
Bullying, harassment and discrimination usually follow a predictable pattern. If you are
investigating the incident, try to determine such patterns. You should encourage workers
who experience workplace bullying, harassment or discrimination to keep a diary of the
alleged behaviours.
The procedure for carrying out an investigation should address:

● when an investigation is to occur (usually if a complaint is received or you become aware
of the bullying)
● who will carry out the investigation (the person must be seen to be competent to conduct the
investigation, impartial and be given an appropriate amount of time to enable them to carry out
the investigation effectively)
● how the complaint will be investigated, eg through interviews with:
– the person making the complaint
– the alleged bully
– witnesses
● whether and on what basis the alleged bully will be suspended pending the investigation
● the need for each party to receive a report on the outcome of the investigation.
Possible outcomes of the investigation could include:

● dismissal of the complaint where it is not upheld
● finding that bullying, harassment or discrimination occurred.
Disciplinary action for the perpetrator could include one or a combination of:
● an apology and an undertaking that the behaviour will not occur again
● a formal warning
● counselling
● transferring the perpetrator to another work area away from the complainant, or vice versa
if the complainant is agreeable
● a suspension from the workplace
● dismissal as a final resort.
Follow-up
Procedures should be outlined for following-up on the actions taken to stop the bullying,
harassment or discrimination in order to determine if the actions are effective.
Appeal
Mechanisms should be set out for appealing against a decision (internally and externally).
For example, where the dispute is between a worker and their employer, a person may apply
to the Industrial Relations Commission.
MODULE 3
Access to counselling and training

You should provide access to counselling and training where appropriate for:
● the person making the complaint, eg for coping strategies to deal with the bullying while
the problem is being resolved, assertiveness training
● the alleged bully, to enable him/her to recognise and change their behaviour
● others who may have been witness to the events and may have been affected by them.
MODULE 3
Appendix B
Incident management plan
Role of managers
● Implement the facility’s incident management program and procedures and promote this
to all staff.
● Ensure that staff attend relevant training.
● Ensure that a preventative and risk management approach is used.
● Ensure incidents are reported in accordance with the health facility protocols and legislative
requirements. All aggressive incidents need to be reported and documented on the appropriate
forms. This includes verbal threats, bullying, ‘near miss’ events, workers’ compensation
claims, property damage insurance claims and security incidents. There are also mandatory
requirements for reporting significant incidents to the NSW WorkCover Authority and NSW
Health. For further information see Circular 2003/88 Reportable Incident Briefs to the NSW
Department of Health,g The New Simple Way to Notify Work-Related Incidents22 and Circular
2003/75 NSW Health Policy and Procedures for Injury Management and Return-to-Work.
● Ensure staff involved in violent incidents receive appropriate support and necessary
medical treatment.
● Ensure that the consequences of the incident’s impact on the service provided are identified,
assessed and managed effectively and efficiently.
● Attend the appropriate training so that any psychological reactions and symptoms can be
identified that may follow an incident.
● Ensure that counselling and access to other professional assistance is arranged and
accessible to staff as the need arises.
● Participate in post-incident review/investigation and initiate any recommended
preventative action.
● Coordinate and provide legal and practical support for any legal proceedings.
For further information on the incident management plan refer to NSW Health Effective
Incident Response: A Framework for Prevention and Management in the Health Workplace
and NSW Health Security Manual.c
41
MODULE 3
Appendix C
Managers’ roles and responsibilities
to reduce the incidence and severity
of aggression and violence
Managers have administrative responsibilities to ensure the safety of staff and others under their
control. For further detailed information, see NSW Health Security Manual.c
In general, managers are responsible for ensuring, in their area of responsibility, that:
● general security measures are established
● areas of risk to staff, patients and visitors are identified, assessed, eliminated where reasonably
practicable and controlled
● work systems and procedures minimise the risk of violence
● procedures are in place for identifying those who have a potential for violent behaviour, and that
appropriate, clearly documented patient plans, including actions to be implemented to reduce
the risk of violent behaviour, are developed
● local violence prevention policies and procedures are in place and that staff are aware of them
● their staff receive appropriate training and that ongoing training needs are identified
● staff working in isolated facilities/units are rostered with a minimum of two staff on each shift.
If this cannot be achieved then staff must be provided with adequate security eg access
controls, communication mechanisms, duress alarms, prompt access to back-up and
assistance etc
● adequate security is provided in all circumstances, including community health, based
on the level of risk determined by the risk management process, eg CCTV, duress alarms,
duress response, video intercoms, access control and adequate lighting etc.
43
MODULE 3
Appendix D
Duress response planning
Responsibilities of managers
● Ensuring a duress response exists in their area of responsibility – this includes
community services.
● Consulting with staff on the development and review of duress response plans.
● Respecting the rights of staff to call for a duress response if and when they identify a need.
Staff should be encouraged to call the duress response team at any time when they feel at risk.
● Ensuring staff and response team partners, eg other government, non-government and/or
community respondents attend relevant training.
● Ensuring that operational review/debrief occurs after a duress response event.
For further information on duress response, planning and principles see NSW Health
Security Manual.c
45
MODULE 3
Appendix E
Assessment assignment
Guidelines for course assessment assignment

A strategic plan for aggression minimisation in the workplace
The assessment for this course requires you to develop, document and produce evidence
of initial implementation of a plan for aggression minimisation in your own work area. A report
of this activity should be submitted to the course coordinator within three months of completing
the course.
The assignment report should be documented under the following headings:

1. The aggression minimisation plan.
2. Process of development and implementation of plan.
1. Plan
Your plan should cover the following aspects of aggression minimisation:
● A policy that includes a statement in relation to the philosophy of the unit toward
aggression. This may include a statement in relation to workplace bullying, or you may
choose to make this a separate policy.
● A clear explanation of what basic induction and training staff will be offered to support them
in aggression minimisation.
● Guidelines as to how, when and by whom risk assessment will be undertaken to minimise
aggression. Address this using the risk management process. Use the following headings:
– Step 1 – Identifying the hazard (workplace aggression).
– Step 2 – Assessing the risk (determining how serious the aggression problem is).
– Step 3 – Eliminating or controlling the risk (risk controls need to be ranked from the most
effective to the least effective).
– Step 4 – Monitoring, reviewing and improving the system.
● Clear guidelines as to what steps staff should take if they are being bullied.
● Indications as to how staff will be encouraged to maintain a positive workplace culture.
● Clear guidelines on what to do in a violent incident.
● A protocol on safety equipment testing, eg duress alarms, other communication devices.
● Clear guidelines in relation to support – who is responsible for initiating it, who should get it
and who should do it?
● Identification of the time schedules and methods of reviewing the plan in order to evaluate
effectiveness and appropriateness.
47
2. Process of development and implementation of plan

This section should describe what you did to develop the plan. For example, what activities
did you undertake to identify, assess and control violence risks. Did you do any research,
reading or ask other people in similar positions what they did? Did you consult with your
staff or use some meeting time to develop a plan from team input? If needed, did you
consult with any others outside your workplace?
NB. Evidence for the implementation of the plan is required, eg evidence of at least one induction activity and risk
management activity.

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A safer place to work –

preventing and managing violent

NSW Health is a zero tolerance zone

© NSW Department of Health 2003

SHPN (CMH) 030207

Modular structure of preventing

HLTCSD6A – Respond effectively to

1. Understanding difficult or challenging behaviour.

AMT002 – Aggression minimisation in

90405NSW – Course in aggression minimisation

AMT004 – Aggression minimisation refresher training

Assessment for Module 3

Guidelines for course assessment assignment

The assignment report should be documented under the following headings:

2. Process of development and implementation of plan

Assessment specification sheet

Work location Telephone (w)

Units of competency to Assessment methods Assessment activities

Details of special requirements:

Learning outcomes for Module 3 –

At the conclusion of this module, participants should be able to:

Legislative,a procedural and ethical laws and guidelines govern:

You have a responsibility to ensure that:

A zero tolerance response to aggression

What does zero tolerance mean to you?

Zero tolerance attitudes and behaviours

Legal principles of civil and criminal actions

Crimes Act 1900

What is the role of the manager when:

NSW Health Memorandum of Understanding between

Local policies and guidelines

This section of the course focuses on prevention of aggression in the workplace

Promoting a culture of safety

Occupational health and safety legislation

Under this regulation employers are responsible for:

How can ‘due diligence’ be shown?

Occupational health and safety responsibilities for managers

● Encouraging staff to support OHS committee meetings and related activities.

Risk management and the consulting process

Some examples of when you need to consult staff include:

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

The risk management process

The process of identifying risks in your workplace

Factors to consider when assessing and prioritising risks b

Eliminating or controlling risks

Designing a safer workplace

Target hardening and territorial reinforcementb,2

Surveillance and lighting

Fittings and furniture

Regular monitoring, reviewing and evaluating

Regular security and violence vulnerability audits.

Implementing and monitoring recommendations from the audits.

Reviewing local policies, procedures and protocols for continuing relevance

Testing and maintaining safety equipment such as duress alarms and

Ensuring safety equipment continues to effectively meet the needs/purposes

Monitoring the incident reporting system/procedures and compliance.

Investigating incidents and ensuring recommendations from the investigation

Ensuring that appropriate post-incident support is provided to those involved

Reviewing responses to the aggressive and/or violent incidents,

Implementing and monitoring recommended modifications to the

Ensuring staff are appropriately trained, including induction/orientation of

Ensuring that training meets the needs of the target staff.

Ensuring that all related legal requirements are met.