Professional Documents
Culture Documents
Module 1
HLTCSD6A
Respond effectively to difficult
or challenging behaviour
Participant manual
This work is copyright. It may be reproduced in whole or in part for study training purposes subject to
the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or
sale. Reproduction for purposes other than those indicated above, requires written permission from the
NSW Department of Health.
July 2003
updated August 2004
MODULE 1
Respond effectively to difficult or challenging behaviour
Contents
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Modular structure of the aggression minimisation program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Assessment for Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Elements of competency and performance criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Assessment specification sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Learning outcomes for Module 1 – Responding to difficult or challenging behaviour . . . . . . . . . . . . . . . . . . 7
Aggression in the workplace – facts and figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Part 1 – Understanding difficult or challenging behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Defining aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Effects of aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
A zero tolerance response to aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Part 2 – Preventing aggression occurring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
What you need to know about keeping your workplace safe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Using a risk management approach to prevent aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Eliminating or controlling risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
How the design of your workplace can prevent aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
More ways of keeping your workplace safe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Putting it all together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Caveats and background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Individual risk highlighter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Violence risk awareness checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Violence minimisation checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
What workplace strategies do you have . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Part 3 – Preventing aggression escalating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Levels of aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Know your options for action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Deciding to stay or leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
When and who to call for backup or help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Danger and safety zones when faced with an aggressive or violent person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Self help strategies to remain calm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Verbal and non-verbal de-escalation skills to prevent aggression and violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Attitudes are important . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Your attitudes towards people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Strategies for improving communication with people from a different culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
What governs your actions in responding to aggression? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Some more strategies when faced with a violent person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Response options for repeatedly aggressive people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Part 4 – Bullying, harassment and discrimination at work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Scope of the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
You have a role to play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Some legal considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
How to confront a person who is bullying, harassing or discriminating against you . . . . . . . . . . . . . . . . . . . . . . . . . . 37
How to formally make a complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Rights of the person making the complaint and the person who is complained against. . . . . . . . . . . . . . . . . . . . . . . 38
Part 5 – Reporting and reviewing aggressive incidents . . . . . . . . . . . . . . . . . . . . . . . . . ......... . . . . . . . . 41
Reporting aggressive incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... . . . . . . . . 41
What to expect from an aggressive incident investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... . . . . . . . . 42
Support mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... . . . . . . . . 42
Self care following an aggressive incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... . . . . . . . . 43
What support can you expect from your manager . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... . . . . . . . . 45
Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
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Acknowledgments
This NSW Health violence prevention training program was developed by Brin FS Grenyer,
Olga Ilkiw-Lavalle and Philip Biro from the Illawarra Institute for Mental Health. Mark Coleman
provided assistance with the facilitator manuals and pilot workshops. The project was coordinated
from the Violence Taskforce, Centre for Mental Health by Frances Waters. The members of the project
contract steering committee who provided extensive guidance during the development of this project
were Frances Waters (Violence Taskforce, Centre for Mental Health), Kathy Baker (Community & Extended
Care Services and Nursing Services, Northern Sydney), Trish Butrej (Occupational Health and Safety,
NSW Nurses’ Association), Maggie Christensen (Learning and Development, Central Coast), Nicole Ducat
(Occupational Health and Safety, South Eastern Sydney), Louise Newman (Royal Australian and New
Zealand College of Psychiatrists), Gemma Summers (Learning and Development, Northern Sydney)
and Choong-Siew Yong (Australian Medical Association, NSW Branch).
A project content reference group also provided input during the development of the project, and
the members were Greg Hugh, Peter Bazzana, Greg Cole, Stephen Allnut, Distan Bach, Liz Cloughessy,
Jim Delaney, Regina McDonald, David Gray, Rajni Chandran, Jennifer Bryant, Terry Tracey and Linda
Sheahan. Consumer input was gratefully provided by Laraine Toms and Robyn Toohey. The NSW Health
Learning and Development Managers forum and others affiliated with the reference group also provided
helpful comment and guidance during the developmental phases of this project, including Jenny Wright,
Earle Durheim, Judy Saba, Brenda Bradbury, John Lain, Bill Wood, Aileen Ferguson, Simon Richards,
Vaughan Bowie, Louise Fullerton, Mira Savich, lain Morriset, Lorraine Hyde, Glenda Hadley, Julie Reid,
Natasha Mooney and Bill Tibben.
The developers would like to thank those staff of the South Western Sydney Area Health Service who
provided useful feedback during the four days of piloting of each of the modules in October 2002. We
also thank the fifteen educators from across the state who provided feedback during the two day trainer
orientation at Western Sydney Area Health Service in November 2002.
The developers would like to give special thanks to Professor Beverley Raphael and Professor Duncan
Chappel from the Violence Taskforce for support, Dr Claire Mayhew for timely insights, Linda Graham for
sharing her wisdom over the years through the development and implementation of the INTACT training
program, Professor Kevin Gournay and Steve Wright from the Institute of Psychiatry, London, for helpful
advice and resources, Dr Nadia Solowij and Jane Middleby-Clements for editorial assistance and to
Professor Frank Deane from the Illawarra Institute for Mental Health for practical support. We also thank
Shane Pifferi, Marie Johnson, Vicky Biro, Tim Coombs, Ralph Stevenson, Dr Alexandra Cockram,
Eugene McGarrell, Samantha Reis and Andrew Phipps for assistance with the project.
This program has incorporated and referred to relevant NSW Health policies and guidelines
where appropriate and a list of these is given at the end of the relevant modules. Modules 1 and 2
of this program were adapted from a modular aggression minimisation program developed originally
by Austraining (NSW) Pty Ltd for the Central Coast Area Health Service, which was revised by
Jenelle Langham in 2000. Module 3 of this program is a revised version of that developed by
Jenelle Langham for the Central Coast Area Health Service.
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7. Identify what can be expected Element: Report and review incidents Question 6
from an incident investigation. Performance criteria: 3.2
8. Identify available support services Element: Report and review incidents Question 7
following an aggressive incident. Performance criteria: 3.3
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Candidate’s name
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
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Learning outcomes
At the conclusion of this module, participants should be able to:
1. identify and apply strategies for risk management to prevent aggression
2. identify and select appropriate response options when confronted with aggressive behaviour
3. give priority to the safety of the self and others when confronted with aggressive behaviour
4. identify when, how and who to call for assistance
5. use verbal and non-verbal communication strategies to manage aggressive behaviour
6. identify appropriate reporting procedures
7. identify what can be expected from an incident investigation
8. identify available support services following an aggressive incident
9. identify how management can be supportive following an aggressive incident.
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Aggression in the health industry is a significant problem.1,2,3 In 1999/2000 there were 113
claims made to WorkCover from hospitals and nursing homes in NSW that involved the staff
member being hit and being absent from work for more than five days. The estimated cost of
these claims was $1.3 million. This figure did not include the cost of violent incidents that did
not result in a workers compensation claim or resulted in less than five days absence from
work; this figure is likely to be significantly higher. It also does not include costs associated
with administration of claims, fines, legal costs, absenteeism, staff turnover and recruitment,
or the impact of violence against patients.a
In Australia little research has been conducted on the incidence of aggression. O’Connell,
Young, Brooks, Hutchings and Lofthouse (2000)4 found over a 12-month period that:
● 95% of nurses experienced several episodes of verbal aggression; 80% experienced
several episodes of physical aggression
● 25% experienced verbal aggression; 6.7% encountered physical aggression on
a weekly basis
● 32.4% experienced verbal aggression; 14.4% experienced physical aggression on
a monthly basis
● 37.7% experienced verbal aggression; 59.3% experienced physical aggression between
one and four times per year.
The types of injuries sustained by staff were a result of being grabbed, punched, pushed,
pinched, scratched, kicked and hit with an object.
Barlow, Grenyer and Ilkiw-Lavalle (2000)5 report that during an 18 month study period,
13.7% of patients admitted to inpatient mental health units in the Illawarra Area Health Service
were aggressive. There were on average five aggressive incidents per week in the inpatient units,
and staff injuries accounted for 47.4% of the overall injuries incurred in the mental health units.
Fifty-three percent of injuries occurred to patients and visitors.
Aggression is not just experienced from patients. Farrell (1999)6 reports that 30% of nursing
staff experienced aggression from other staff over a six week period. This included experiencing
rudeness, being abused, being humiliated in front of others and peers, being denied access
to opportunities, and having their work excessively scrutinised with threats of disciplinary action.
This program aims to promote a working environment and practice, which minimises and
protects people from aggression. The goals of this training are to improve health care workers’
knowledge in relation to ways of preventing aggression and to gain knowledge and skills in
responding to different instances of aggression.
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Part 1
Understanding difficult or
challenging behaviour
This section looks at what aggression in the workplace is, what the effects of aggression
are and provides an understanding of the ‘zero tolerance’ response to aggression.
Consider the number of interactions that occur between staff and patients, staff and staff,
staff and visitors etc on any day in your area. Consider what proportion of interpersonal
situations result in aggression.
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Defining aggression
NSW Health defines aggression as:
‘Any incident in which employees are abused, threatened or assaulted in circumstances arising out of,
or in the course of, their employment including verbal, physical or psychological abuse, threats or other
intimidating behaviours, intentional physical attacks, aggravated assault, threats with an offensive weapon,
sexual harassment and sexual assault.’
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A key component of the zero tolerance response is to report all aggressive incidents.
What might be some challenges to reporting all incidents in your workplace?
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Key points
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Part 2
Preventing aggression occurring
This section focuses on preventing aggression. It will look at the legal obligations for
preventing aggression, how risk management can prevent or reduce the risk of aggression
and how buildings and workplaces can be designed and redesigned to prevent or reduce
the risk of aggression occurring.
This Act is supported by the Occupational Health and Safety Regulation 2001.
Under the NSW Occupational Health and Safety Act 2000, employers have a responsibility to
ensure the health and safety of any persons who are at their place of work, and who may be
affected by their acts or omissions at work. Employees have a responsibility to take reasonable
care regarding the health and safety of any persons who are at their place of work, and who
may be affected by their acts or omissions at work.
Employers are required to comply with NSW occupational health and safety legislation. 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. Individuals may be
personally liable for fines, and insurance protection does not cover for prosecution or fines.
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The individual staff member has a good perception of the risk of aggression associated with
their workplace. Therefore the individual plays an important role when being consulted about the
risks of aggression, and ways to prevent or control risks. As such, it is important that staff actively
contribute when being consulted.
SAFETY HINT – Report all instances of aggression. If instances are not reported then
they cannot be responded to via the risk management process.
Assessing risk involves estimating the extent of the risk to assist with prioritising and
developing control strategies. The following factors need to be considered when assessing
risks in the workplace. For each factor what aspects would you consider to be associated
with aggression in the workplace?
Factors relating to a specific individual that may be associated with aggression in the workplace?
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The process of monitoring, reviewing and improving policies, procedures and the environment is
a continuous one for all staff. This process enables the identification of areas of further risk, gaps
in systems that could lead to potentially aggressive incidents, failures in any previously identified
preventative measures and the reassessment and monitoring of controls implemented.
Case study
Jim, a new person in your work area, is having trouble adjusting to his new work
environment. You notice Jim increasingly is being isolated at work and is not receiving
the help that others get from the team. He is not invited to a work picnic and people have
put nasty stickers and food scraps into his locker. This culminates early one day when
a patient becomes argumentative and physically violent with him, and staff are slow to
respond to his calls for assistance. Jim is at significant risk of injury, but he manages to
escape. When he walks into the tea-room after this episode all the other staff are smiling.
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What is involved?
1. Territorial reinforcement.
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2. Natural surveillance.
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3. Space management.
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NSW Health has developed a Health Facility Guideline: Safety and Security as part of the
Health Building Design Series, to assist facility planners and designers to reduce risks through
the design of workplaces and the internal physical environment incorporating CPTED principles.
These guidelines will also assist user groups and staff involved in the consultation process for
the design of new and refurbished health buildings or facilities.
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Use the Violence risk awareness checklist to help identify all the different risks in your workplace
and encourage problem solving.
Use the Violence minimisation checklist for a comprehensive list of strategies to reduce risk.
1. Accurate risk prediction for an individual patient at a particular time is very difficult.
2. The Individual risk highlighter is to be used in considering the risk of immediate triggers for
aggression in individual patients.
3. The Individual risk highlighter does not provide a statistical likelihood of aggression. It serves
only to remind staff of factors that increase the likelihood of aggression.
4. The Individual risk highlighter is not intended to be used for all patients – only for that subset
for which there are some preliminary indications that the patient has a potential to be violent.
5. Risk is a dynamic concept – it can change rapidly, and requires frequent reassessment.
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Risk
What to do
• Take precautions.
• Alert others.
• Follow hospital procedure.
• Have clear patient
management plans.
• Apply ‘Individual risk highlighter’.
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How does your employer ensure that you have read and are up to date with current policies
and procedures on managing aggression?
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Part 3
Preventing aggression escalating
This section reviews the levels of aggression, what options you have in responding to
aggressive behaviour and the legal issues you need to be aware of when choosing your
options. It reviews options when faced with a physically aggressive or violent person and
strategies to remain calm. Understanding the role of attitudes and cultural diversity in
minimising aggression are reviewed. Effective verbal and non-verbal de-escalation
skills to prevent aggression escalating are practised.
Levels of aggression
If an aggressive person confronts you, it can help to identify what level of aggression they
are displaying:
You have many options when confronted with an aggressive person. Knowing what level the
person is displaying will help you decide the best way to try and prevent the aggression escalating.
When considering your options you always need to keep in mind the following:
● Whether the person has an underlying physical or mental condition that is contributing to
the person’s aggressive or violent behaviour.
● Always remain calm and assess the level of threat and the different levels of aggression
displayed as this will help you to make a decision on the appropriate response to take.
● Regardless of the response option you choose, de-escalating and containing the situation
should be considered where possible.
● If at any time you feel unsafe you need to call for support and/or leave.
● At all times your priority is for the safety of yourself and others including preventing injury
to yourself and others around you.
● Be aware of the potential for violence, look for contributing factors or warning signs.
● You can use more than one option.
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Response options...
● 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 duress alarm or unit emergency response as relevant.
● Initiate team restraint response.
● Initiate external emergency response, eg security, police.
● Charging of the perpetrator with assault.
If possible, a person’s potential for aggression should be identified early. Potential factors to
be aware of include the person having a past history of aggression, the presence of any current
threats of harm and the likely availability of weapons. This also assists in making the decision
regarding whether to stay or leave.
SAFETY HINT – In all situations that are getting out of control you should immediately
seek help, regardless of whether you decide to stay or leave.
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Consider some instances where you were confronted with an aggressive person.
What factors influenced your decision to stay or leave?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Consider all of the above response options. Which would be suitable for the differing levels
of aggression?
Low ______________________________________________________________________________
____________________________________________________________________________________
Moderate __________________________________________________________________________
____________________________________________________________________________________
High ______________________________________________________________________________
____________________________________________________________________________________
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Controlling feelings of fear, anxiety and apprehension can be done by pausing, breathing
(deep breaths), positive self-talk (thinking) and/or counting to three. While interacting with an
aggressive person be aware of your breathing rate and keep it slow and deep. This is one of
the most effective tools for maintaining a state of calm.
Non-verbal skills
Presenting yourself as being calm and in control is a powerful de-escalation skill. Your behaviour
will calm the person as much, if not more, than the words you say.
Here are some important points to consider when endeavouring to display a calm,
controlled disposition:
● Do not mirror (copy) the aggressive behaviour or postures back to the person.
● If possible, give the person more rather than less personal space. Do not invade their personal
space. Avoid touching the person.
● Do not hide your hands or move them too much. Have them in a non-threatening relaxed
position that reveals your open palms if possible. Avoid folding your arms across your chest,
having your hands on your hips or in your pockets.
● Maintain eye contact, however do not be threatening, ie do not stare, instead use broken
eye contact.
● Be attentive to the individual rather than concerned with something else that is happening
in the area.
Verbal skills
Using the following verbal skills can help de-escalate aggression. Many instances of aggression
occur because a person’s needs are not being met. Understanding the person’s expectations,
and trying to ‘put yourself in their shoes’, can help you understand what is troubling them.
Communicating back to them that you understand something about their expectations and
feelings can be a powerful de-escalation tool. Helping to negotiate a solution will in most
cases reduce their aggression.
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Tone of voice
When speaking to an aggressive person your tone of voice should be calm and low, though
loud enough for them to hear if they are shouting over the top of you. Endeavour to speak
slowly and clearly so that you will be easily understood. Remember that you are modelling
appropriate behaviour. You are also encouraging the other person to think about and re-focus
on the situation rather than to act out their anger. Remember that raised voices are likely to
escalate aggression.
Explanations
A person who is emotionally aroused cannot absorb as much information as a calm person.
It is therefore helpful to :
● keep sentences short
● keep words simple.
Humour
Be very careful with the use of humour. If you believe the use of humour may help to de-escalate
the person ensure:
● you use mainstream humour
● the aggressive person is not the butt of the joke.
Setting limits
Sometimes you need to set limits on a person’s behaviour for the safety of themselves or
others, and to enforce unit rules. Examples can include: not allowing smoking; not allowing
access to patients during certain hours or when undergoing medical procedures; preventing
a person from entering or leaving a restricted area.
Using assertion skills may help you in such situations. An assertive response would be to set
the limit and then explain to the person the reason for the limit. Being assertive can help ensure
that the needs of both parties are satisfied with the settlement negotiated. Whilst it is important
to be firm when setting limits, a person who becomes very aggressive may not accept these
limits. Remember the first rule is to maintain your safety. Therefore, if the situation deteriorates
you may need to back down and seek assistance.
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Do Don’t
● Introduce yourself (first name only). ● Mirror (copy) the aggressive person’s behaviour.
● Be calm and in control. ● Touch the person.
● Give the person more personal space. ● Hide or move your hands too much.
● Maintain eye contact in a non-threatening way. ● Fold your arms across your chest.
● Be attentive and listen actively. ● Raise your voice.
● Communicate back that you understand.
● Acknowledge the person’s emotions.
● Help to negotiate a solution.
● Model appropriate behaviour.
● Speak slowly and clearly.
● Keep sentences short and simple.
● Help the person as much as possible to have
their needs met.
● Set limits where appropriate.
Case study
1. When told of the waiting list for elective surgery, a patient became irate about the
public health system. The patient yelled loudly and cursed the government and said
something should be done about it.
2. A patient in pain and suffering from the effects of alcohol, swore violently
at a staff member and threatened to punch the staff member if help wasn’t
immediately provided.
Work in pairs to create a situation where one person acts out aggressively (both verbally
and non-verbally). The other person is to play the role of a staff member aiming to de-escalate
the situation, and should practise using both verbal and non-verbal de-escalation responses.
Remember the staff member should practise keeping calm and in control.
Following the role-play discuss the de-escalation strategies used and the effect this had on
the aggressive person and the staff member. Then change roles and repeat.
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Do not assume that because someone speaks with an accent they have poor English skills.
In addition, do not assume a person with limited grammar skills has intellectual deficits.
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Some verbal and non-verbal ways of communication used by people can be misinterpreted
as the person being angry or aggressive. Consider the role of tone and pitch in communication.
Often what is difficult to master is the translation of tone. Many languages use tone in ways
distinctly different to English. For example, when a person ‘sounds’ angry it may be that they
are angry, or it may be that the tone of their first language applied to English causes the listener
to assume that they are angry. Do not raise your voice to someone with an accent, unless you
know they are deaf. The same words said in a number of different tones can evoke totally
different meanings. To understand these you can use the following strategies:
● If others from a similar cultural background are around ask them for help.
● Acknowledge your unfamiliarity with their culture. The person will value your interest in
their culture.
● Clarify communication styles you are not sure about with the person. For example,
if someone is talking loudly say, ‘You are speaking loudly, so I have the impression you
might be angry’. This will allow the person to explain themselves. It may be that they
have hearing difficulties.
● Ask questions when necessary to help assess the person’s coping strategies during stressful
situations. For example, ‘How do you handle? or ‘Some people find that when this happens
it is best to ... what would be better for you?’.
● Clarify, interpret and re-label the person’s behaviour.
● Apologise for any mistakes.
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Assault
The criminal offence of assault consists of:
i. force applied to another without their consent, or
ii. the actual intent to cause harm to the person, or
iii. a very high degree of reckless indifference to the probability of harm occurring.
These are the conditions that must be proved if there is to be a successful assault prosecution
on behalf of a staff member or any member of the public.
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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.
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.
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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.
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For further information, consult the following document: NSW Health Zero Tolerance Policy and
Framework Guidelines.
Key points
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Part 4
Bullying, harassment and
discrimination at work
This section looks at the behaviours, effects and legal issues surrounding bullying,
discrimination and harassment, making a formal complaint, and how to confront a
person who is bullying, harassing or discriminating against you.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
The effects of bullying,25,26 harassment and discrimination on the individual can include:
● distress
● poor work performance
● perceived poor career prospects
● lack of trust between staff
● emotional reactions and stress including loss of self-confidence and self-esteem
● poor concentration
● poor relationships with family and friends
● unwanted transfer, resignation, early retirement or even dismissal therefore resulting in loss
of income
● development of anxiety disorders and/or depression.
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For further information, consult the Joint Management and Employee Association Policy
Statement on Bullying Harassment and Discrimination.
There are some circumstances that may not be considered defamation, such as:
● statements that would lead to the conviction of a crime
● statements of disease process, eg medical notes
● statements that would lead to a person being judged to be unfit for a profession.
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It is strongly suggested that you gain the services of an advocate in this process. The most
obvious would be a representative from your industrial or professional organisation. Ensure you
are familiar with local bullying reporting procedures.
Rights of the person making the complaint and the person who
is complained against
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.
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Discuss the obstacles to overcoming bullying, harassment and discrimination in your own
workplace and some possible solutions.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Key points
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Part 5
Reporting and reviewing
aggressive incidents
This section reviews the processes and procedures of reporting and reviewing
aggressive incidents, including the kind of support you should expect if you are involved
in an incident. A key resource is NSW Health circular 2002/19 Effective Incident Response:
A Framework for Prevention and Management in the Health Workplace.
Consider your local policies and procedures for reporting and documenting aggressive incidents.
Discuss the requirements for writing incident reports following an aggressive incident?
(How much time do you have? Who is responsible for writing the report? Who is the report
given to? Who signs the report?)
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____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
For further information on aggressive incident investigations, consult Effective Incident Response:
A Framework for Prevention and Management in the Health Workplace.
Think of an aggressive incident that you have been involved in or know occurred.
Discuss what happened during the investigation of the incident. How was it conducted?
What did you or others think would happen during the investigation? How did you feel during
and after the investigation?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Support mechanisms
All people react to stress differently, therefore your reactions after an aggressive incident are a
normal response to an abnormal event. Even if you are a witness to an aggressive incident you
can also experience similar emotional reactions.29 For many people, depending on the type of
aggressive incident, the emotional reactions will decrease over a period of a few weeks.
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Depending on your reactions the following types of support should be available to you:b
● Psychological first aid – immediate social and practical help.
● Employee assistance programs.
● Peer support programs.
● Supportive or specialised counselling.
● Supportive group discussion.
● Operational debriefing.
● Mental health care.
● Other practical help.
The following strategies can help you to deal with these reactions:h
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Work on your own and fill in the spaces below for things that you do for yourself, and what
you would like to try to do for yourself to manage stress.
____________________________________________________________________________________
____________________________________________________________________________________
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____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Key points
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References
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