The Prevention and Management of
Violence and Aggression at Work
April 2010
DOCUMENT PROFILE |
|
Document Registration HSS-PP-CG-0106-02 |
Document Purpose Policy |
Short Title Violence at Work |
Author Governance Support Team |
Publication Date 2010 |
Target Audience All Staff Working in H&SS |
Circulation List Intranet |
Description The approach that HSS will adopt to prevent and manage violence and aggression in the workplace. |
Linked Policies Harassment & Bullying Policy Management of Serious or Untoward Incidents Incident Reporting Policy |
Approval Route Governance Board |
Review Date |
Contact Details Therapeutic Interventions Officer, Ext 442459 |
CONTENTS LIST:
1. Policy Statement 4
2. Definitions 4
3. Responsibilities 5
4. Measures the Organisation will take against clients who exhibit unacceptable behaviour and the procedures for applying 8
5. Measures the Organisation will take against visitors who exhibit unacceptable behaviour and the procedures for applying 13
6. Staff working alone in the community 14
7. Police Assistance 14
8 Legal advice 15
Appendices
Appendix 1: Template of Level 2 Letter detailing unacceptable behaviour 16
Appendix 2: Template of Level 3 Letter: Warning of exclusion fro HSSD premises 18
Appendix 3: Template of Level 4 Letter - Exclusion from HSSD premises 20
Appendix 4: Template of Letter detailing restrictions to Visitor 22
Appendix 5a-f: General guidance for staff on minimising occurrences of violence, aggression or abuse or dealing with occurrences when they occur.
Appendix 5a: Physical and environmental factors and the minimisation of risk 24
Appendix 5b: General guidance for the management of people exhibiting violent and aggressive behaviour 26
Appendix 5c: Management of Patients/Service Users exhibiting violent and aggressive behaviour in the community and clinics 30
Appendix 5d: Guidance for dealing with incidents of violence and aggression in the community 32
Appendix 5e: De-Escalation 34
Appendix 5f: Physical restraint and available training 36
Appendix 6: Examples of Posters 39
Appendix 7 – Leaflet (to help explain organisational stance on unacceptable behaviour and policy) 43
1. POLICY STATEMENT
The Health & Social Services Department (HSSD) has a duty to provide a safe and secure environment for patients/clients/service users (from hereon in referred to as clients), staff and visitors. Everyone has a duty to behave in an acceptable and appropriate manner. Staff have a right to work, as clients have a right to be treated, in an environment that is properly safe and secure.
This policy is designed to provide support and guidance in order to protect or minimise the impact to HSSD staff and clients from incidents or threats of violence and abuse.
Violent or abusive behaviour will not be tolerated and decisive action will be taken to protect staff, clients and visitors.
This policy relates to incidents of violence, aggression and abuse that are directed at staff who work for the HSSD, those who work on behalf of HSSD or those contracted to provide services to HSSD. It is not limited to incidents that occur on HSSD premises.
The policy will set out how physical and non-physical assaults will be managed including those where the aggressor is a client, service user or member of the public. Where the alleged assault has been carried out by a member of staff or staff working on behalf of or contracted to HSSD; then the States of Jersey Harassment and Bullying Policy documents the processes are to be followed. (Available on intranet)
2. DEFINITIONS
Physical Violence
· “The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort”.
Non Physical Assault Violence or Verbal abuse
· “The use of inappropriate words or behaviour causing distress and/or constituting harassment”.
The following are examples of unacceptable conduct towards HSSD staff:
Non-physical (verbal) abuse:
· Offensive language, verbal abuse or swearing, including racist comments
· Loud and intrusive conversation
· Unwanted abusive remarks; negative, malicious or stereotypical comments
· Offensive sexual remarks, gestures or behaviours.
· Malicious allegations relating to members of staff, other patients or visitors.
· Invasion of personal space
· Brandishing of weapons
· Near misses – unsuccessful physical assaults
· Intimidation or stalking
· Alcohol fuelled abuse
· Incitement of others and/or disruptive behaviour
· Unreasonable behaviour and or non-co-operation such as repeated disregard of hospital visiting hours
· Any of the above linked to destruction of or damage to property
Physical abuse:
· Spitting on/at staff
· Pushing, shoving, poking or jabbing
· Scratching or pinching
· Throwing objects, substances or liquids onto a person
· Punching and kicking; hitting and slapping
· Sexual assaults
· Incidents where reckless behaviour results in physical harm to others
· Incidents where attempts are made to cause physical harm to others and fail
Many staff have duties which involve contact or interactions with clients who are in crisis or on occasions unstable. While recognising the stress and tension inherent in some situations it is not acceptable for staff to be subjected to violent behaviour or behaviour that is intimidating. Such behaviour will result in the assessment of the need to apply appropriate measures.
3. RESPONSIBILITIES
HSSD recognises it’s responsibility under the Health and Safety at Work (Jersey) Law 1989, for providing as far as is reasonably practicable, a safe and secure working environment.
Chief Executive and SMT Governance board
The Chief Executive Officer and members of the SMT Governance Board have overall responsibility for the implementation and adherence to this policy.
They are responsible for ensuring that HSSD provide a system to record all incidents of violence that occur on HSS premises and to HSSD staff working in the community. The chosen system is DATIX. The organisation will monitor the frequency and type of incidents of aggression in order to enhance the safety of its staff. The Therapeutic Interventions Officer, will formulate a report to include collated information for the Governance Board.
The Chief Executive has agreed a zero tolerance to violence against staff and will pursue prosecution in all appropriate cases. This policy will be made known to the public by posting statements in public areas of HSSD premises. Examples of the posters can be found in Appendix 6 Additional copies of notices can be obtained from the Governance Office. Areas should not create their own local statements.
Employee Responsibilities
All employees should comply with this policy.
All employees shall immediately report any acts of violence, aggression or abuse to their manager/supervisor and an incident (DATIX) form must be completed.
If an incident occurs outside of their normal working environment or whilst off duty but is relevant to your employment it should be reported to your line manager, and a Datix report completed.
Staff must ensure their behaviour shows respect for the dignity and rights of clients and their families.
Understand the procedures and guidelines including (local) arrangements; receive instruction in safe systems of working and attend training and refresher training on dealing with violence, aggression and abuse as appropriate
All employees should provide support and take appropriate action in support of colleagues, visitors and clients who are subjected to violence aggression or abuse (but not to take action that may put them at risk of physical harm)
Staff have the right to put their own personal safety before the need to protect the organisation’s property. The primary aim for staff at risk of violent behaviour is avoidance, withdrawal and summoning of assistance
Situations may arise where it is not possible to avoid confrontation and there is a real and imminent risk of injury to staff or others. In such circumstances staff may have to use minimum force to control the situations. Staff who act, within the organisation’s policy and recognised professional guidelines will be supported in such cases. Guidance should be sought from managers on the appropriateness and use of physical restraint.
General guidance for staff on minimising occurrences of violence, aggression or abuse or dealing with occurrence when they occur can be found in Appendix 5a-f.
Managerial Responsibilities
All Directors, Mangers and Line Managers/Supervisors have the responsibility to ensure that this policy and procedure are available to, and understood by staff for which they are managerially responsible.
Managers must carry out and record risk assessments within their area of responsibility. These should take account of the risk of violence; prioritise the defects in the environment or work systems, take action to minimise these risks and make appropriate recommendations to their senior manager if they can not resolve the risks themselves. Advice regarding this may be sought from the Health and Safety Manager and the Therapeutic Interventions Officer.
Assess their staffs’ need for appropriate training related to violence, aggression and abuse and ensure their staff are trained appropriately.
Safeguard the welfare of their staff by devising appropriate safety procedures for their service and bringing them to the attention of staff.
Ensure that Posters displaying the organisations ‘zero tolerance to violence against staff policy’ are displayed their areas of responsibility.
Immediately following an incident in the organisation’s facilities, steps must be taken by manager available, to ensure that staff are no longer at risk of further violence. Necessary medical treatment is sought and that practical assistance is available in the aftermath of an incident.
Line managers must provide effective follow up. This includes reviewing the incident with those involved in order to learn from the experience, offering support and assistance to staff, e.g. accessing other sources of support including occupational health staff, staff counsellor and trade unions / professional bodies. The Therapeutic Interventions Officer is available to assist with these debrief sessions.
Creating and maintaining a culture within your work area which affirms that:
o Aggressive behaviour towards staff is unacceptable.
o Being involved in an aggressive incident is not evidence of professional failure.
o It is acceptable to ask for and receive help.
o Withdrawing from a situation may be a sensible decision and is not a sign of weakness.
o Fear is a natural response often arising from an accurate assessment of the situation.
o All staff share a responsibility to deal with aggression irrespective of their age or gender.
General guidance for staff on minimising occurrences of violence, aggression or abuse or dealing with occurrence when they occur can be found in Appendix 5a-f.
Therapeutic Interventions Officer
Provide support and advice to individuals who have being involved in incidents of violence, aggression or abuse
Review Datix forms to identify areas of concerns and provide support and guidance
Assist in risk assessments and debriefs as necessary
Identify the training needs of the organisation in relation to violence and aggression, and facilitate appropriate training for the organisations needs. Ensure adequate records of training are kept.
Formulate a report to include collated information for the Governance Board.
Responsible for the addition of ‘safety and security risk alert due to potential violence’ alerts against clients records on TrakCare (once implemented). These should have a review date of 1 year, and the Therapeutic Interventions Officer is responsible for reviewing these after this period. The Therapeutic Interventions Officer is responsible for removal or continuation of this alert after consideration with relevant individuals. The flag may remain as long as the client is considered a risk to staff however should be reviewed 1 yearly.
4. MEASURES THE ORGANISATION WILL TAKE AGAINST CLIENTS WHO EXHIBIT UNACCEPTABLE BEHAVIOUR AND THE PROCEDURES FOR APPLYING
Health and Social Services have adopted four levels of measures for dealing with clients who demonstrate unacceptable behaviour
Level 1: Verbal warning
Level 2: Letter detailing unacceptable behaviour
Level 3: Warning of Exclusion from HSSD premises if Unacceptable Behaviour Persists
Level 4: Exclusion from HSSD premises
The four levels recognise the varying degrees of unacceptable behaviour, and the associated impact on staff. It is not necessary to go through each level in succession, eg. a client may have a number of verbal warnings, and not progress to an ‘letter detailing unacceptable behaviour’. Alternatively, a client’s behaviour may be so extreme that it is appropriate to instigate a ‘warning of exclusion’ or ‘exclusion from HSSD premises’ immediately.
The varying implication of the levels, is recognised and to ensure measures applied are appropriate as the levels increase so do the amount and seniority of individuals who must be involved in the decision to apply a measure. Measures will only be applied after full consideration of the incident, precipitating and causative factors.
When an incident of violence, aggression or abuse occurs the preliminary action is to stop the unacceptable behaviour occurring, and the associated risk to staff.
Following de-escalation of the unacceptable behaviour, HSSD may undertake any of the 4 measures, in order to ensure the client understands their behaviour was unacceptable, and to endeavour to prevent it occurring again.
The following diagram explains the four measures that can be taken, and who must be involved in the decision to apply the measure.
Level 1: Verbal Warning
If a client’s unacceptable behaviour has improved following discussion with staff, a verbal warning may be given by the line manager.
This should include an explanation of the specific behaviour that was unacceptable, the standards of behaviour that is expected by HSSD and our policy
A record of this verbal warning should be documented in the client’s notes.
A leaflet (appendix 7) is available to help explain what is considered unacceptable behaviour and our policy.
Level 2: Letter detailing unacceptable behaviour
If a client demonstrates ‘unacceptable behaviour’ that does not desist following initial request or ‘actual, threatened or anticipated violence’ for which further action beyond a verbal warning is felt necessary, the line manager should discuss the incident with the Directorate Manager.
The Directorate Manager may send a Level 2 letter, if they feel the incident warrants it.
A template of this letter can be found in appendix 1.
Copies should be sent as follows
· Two copies of this letter should be sent to the client.
· A copy to the Therapeutics Intervention Officer
· A copy to the Clients notes
If appropriate the Therapeutic Interventions Officer to place a ‘safety and security risk alert due to potential violence’ on TrakCare.
If the client chooses to appeal against the decision to send a letter, they may appeal to the Head of Risk Management, who will determine whether the sending of a letter was appropriate or not. If upon review they do not consider it was appropriate the letter will be removed from the notes.
Level 3: Warning of Exclusion from HSSD premises if Unacceptable Behaviour Persists
A Level 3 letter is issued when behaviour is of such an unacceptable nature or persistent nature that HSSD are considering excluding the individual from HSSD premises (Level 4), this is an official pre-warning stage to Level 4. The imposition of level 3 has no impact on the provision of care – however a flag is placed on PAS (as a warning to staff that this client has received a level 3 letter, and thus to contact their Line Manager and Directorate Manager should unacceptable behaviour occur again) A further incident of unacceptable behaviour will result in strong consideration of imposing an exclusion from HSSD premises (level 4).
If the client’s behaviour potentially warrants a level 3 response, the Directorate Manager should discuss the incident with the relevant Consultant , Therapeutic Interventions Officer, Head of Risk Management and Director of Governance. If they are all in agreement the client’s behaviour warrants it, the Director of Governance may send a Level 3 letter.
A template of this letter can be found in appendix 2.
Copies should be sent as follows
· Two copies of this letter should be sent to the patient. (along with a copy of the Policy)
· A copy to the Therapeutics Intervention Officer
· A copy to the Clients notes
· A copy to the GP
The Therapeutic Interventions Officer will place a ‘safety and security risk alert due to potential violence’ on PAS/TrakCare and additionally ensure a ‘Level 3’ flag is placed against the pateints record on TrakCare (once implemented).
The Therapeutic Interventions Officer is responsible for ensuring the Level 3 flag is reviewed and removed if appropriate after 1 year.
The Therapeutic Interventions Officer is responsible for writing to the client at the end of the year to confirm the outcome of the review.
If the client chooses to appeal against the decision to implement a level 3 measure, they may appeal to the Deputy Chief executive Officer, who will determine whether the level 3 measure was appropriate or not. If upon review they do not consider it was appropriate the letter will be removed from the notes.
A detailed record of the rationale for instigation of the level 3 measure should be kept in the client’s health and social care record.
Level 4: Exclusion from HSSD premises
A Level 4 measure is issued for behaviour which is of such an unacceptable nature or persistent nature that HSSD consider the client presents an unacceptable risk to staff from their behaviour, and as such will only provide emergency care. The client is not entitled to enter HSSD premises for any other purposes (including visiting other clients) and will be removed.
A level 4 flag is placed on PAS (as a warning to staff that this client is under a level 4 measure, and thus is not eligible for any treatment but emergency treatment).
If the client’s behaviour potentially warrants a level 4 response, or a further example of unacceptable behaviour occur for a client currently under a level 3 measure, the Directorate Manager should discuss the incident with the relevant Consultant, Risk Manager, Therapeutic Interventions Officer, Director of Governance and Deputy Chief Executive Officer. If they are all in agreement the client’s behaviour warrants it, the Deputy Chief Executive Officer may send a Level 4 letter.
A template of this letter can be found in appendix 3.
Copies should be sent as follows
· Two copies of this letter should be sent to the client. (along with a copy of the Policy)
· A copy to the Therapeutic Interventions Officer
· A copy to the Clients notes
· A copy to the GP
· A copy to the Security Manager
The Therapeutic Interventions Officer to place a ‘safety and security risk alert due to potential violence’ on PAS and additionally ensure a ‘Level 4’ flag is placed against the pateints record on TrakCare (once implemented). They are responsible for ensuring this is reviewed and removed after 1 year.
The Therapeutic Interventions Officer is responsible for writing to the client at the end of the year to confirm the outcome of the review.
If the client chooses to appeal against the decision to implement a level 4 measure, they may appeal to the Chief Executive who will determine whether the level 4 measure was appropriate or not.
Arrangements for Care: HSSD maintain a duty of care to pateints issued with level 4 measures, therefore pateints will always be able to access emergency treatment. The relevant Consultant is included in the decision over whether to issue a level 4 measure or not, so consideration can be given to any existing medical conditions the clients have, and alternative arrangements made to provide care for conditions that need care.
A detailed record of the rationale for exclusion and the alternate arrangements for care should be kept in the client’s health and social care record. These should also be explained to the Clients GP, and the Client.
The issuing of a level 4 measure does not affect the duty of HSSD to fully investigate all valid concerns raised by a client
Such exclusion will last one year, subject to alternative care arrangements being made; the provision of such arrangements will be pursued with vigour by the relevant Clinician. In the event of an excluded individual entering the Accident and Emergency Department for emergency treatment, that individual will be treated and stabilised with, if necessary, appropriate staff in attendance. If the client is not fit for discharge and continuing treatment is required and therefore admission is unavoidable, arrangements will be made to have supporting staff in attendance.
Where individuals have been excluded, the process of reviewing that exclusion will begin at 6 months following the issue of the letter of exclusion from HSSD. This process will be undertaken by the Therapeutic Interventions Officer. The outcome of that review, which will coincide with the exclusion of one year, and will be notified to the client concerned.
Upon notification to the client that the exclusion is being withdrawn they would be advised of the requirements to comply with the expected standards of behaviour as a consequence of the exclusion being lifted.
The issuing of a level 4 measure does not affect the right of HSSD to report any client behaving unlawfully to the police or prosecute perpetrators of crime on or against HSSD property, assets and staff.
Flags
The Master Index of Clients used by HSSD (soon to be implemented – TrakCare) has the facility to record Alerts against clients.
If assessed as warranted responsibility for the addition of ‘safety and security risk alert due to potential violence’ lies with the Therapeutic Interventions Officer. These alerts should have a review date of 1 year, and the Therapeutic Interventions Officer is responsible for reviewing these after this period. The Therapeutic Interventions Officer is responsible for removal or continuation of this alert after consideration with relevant individuals. The flag may remain as long as the client is considered a risk to staff however should be reviewed 1 yearly.
Level 3 and Level 4 flags indicate to staff that the client is on a Level 3 or Level 4 measure of this policy. The responsibility of addition, review and removal of Level 3 and Level 4 flags are the responsibility of the Therapeutic Interventions Officer. These flags must be reviewed 1 year after issue. They must not stay on a clients record once a level 3 or level 4 warning has being removed.
5. MEASURES THE ORGANISATION WILL TAKE AGAINST VISITORS WHO EXHIBIT UNACCEPTABLE BEHAVIOUR AND THE PROCEDURES FOR APPLYING
A visitor in this policy is defined as anyone who is not a client, volunteer or a member of staff
Visitors who display any of the unacceptable behaviours will be asked to desist and offered the opportunity to explain their action
Continued failure to comply with the required standard of behaviour will result in the line manager, security and duty manager (if appropriate) being bleeped and the removal of the offending individual from the HSSD property.
A Datix form must be completed
Any visitor behaving in an unlawful manner will be reported to the police and HSSD will seek application of the maximum penalties available in law. HSSD will prosecute all perpetrators of crime on or against HSSD property, assets and staff.
The relevant line manager in conjunction with the Directorate Manager may decide to continue to exclude an individual, or restrict visiting to specific times, and if necessary, under escort. The Directorate Manger is responsible for writing to the visitor with details of these restrictions if felt appropriate.
A template letter from the Directorate Manger is included in Appendix 4
The visitor may appeal to the Head of Risk Management if they feel the restrictions are inappropriate.
6. STAFF WORKING ALONE IN THE COMMUNITY
A major concern for the safety of employees working in the community is that they can be contacted should a problem occurs.
All mangers of areas with lone workers should identify, communicate and enforce a system that ensures their staff can be located easily; examples include shared electronic diaries, regularly updated whiteboard system, procedures around checking in and out at end of day or visit, and procedures to follow should a staff member fail to check in after a specified time.
A simple risk assessment should be carried out before any home visit, and any identified risks addressed or minimised.
Further guidance can be found in appendix 5
7. POLICE ASSISTANCE
If you feel a situation is getting out of control and there is danger of violence you should consider involving the police. Normally the police should only be called after consulting your line manager; however, in exceptional circumstances where help is needed urgently you should ring the police immediately and avoid unnecessary delay.
If you are working away from your area and are unable to contact your manager you have the right to decide whether or not to call the police or ask someone else to do so for assistance.
If you have been subjected to violence or serious threat of violence, you and your manager should consider whether to inform the police. Any decision not to do so should only be made with the agreement of all staff concerned. The organisation reserves the right to call the police even if the person involved does not agree.
When an offence is reported to the police the matter will be investigated. If the police or their legal advisors decide not to prosecute, it may be possible for a member of staff to take a private prosecution. The organisation cannot do this on your behalf.
If you are asked to attend a Police Station to give a statement, you may ask your manager and / or trade union representative to accompany you.
You should be aware that if physical restraint is used, you must be prepared to justify your actions on the basis of the situation at the time and the perceived risks in it. Legally restraint is trespass to the person and if exercised without cause may be construed as assault.
When a decision is made to report the incident to the police, the accused (i.e. the perpetrator) will be informed, that the action being taken is by the organisation rather than the victim. However the staff members may be required to make a statement to the police or attend court.
8. LEGAL ADVICE
All staff members are entitled to make a formal complaint to the Police, where a criminal prosecution is pursued by the Crown, support will be provided (however HSSD are unable to pay individuals legal fees)
Staff may prefer to seek legal advice from their staff side organisation or another source and in some circumstances, staff may be advised to retain their own independent legal advice.
Staff injured as a result of a violent incident may be entitled to make a claim for compensation under the Criminal Injuries Board and / or through the organisation’s employer’s liability injury insurance scheme. The member of staff should seek advice in the first instance from the Human Resources Department. Staff may wish to seek advice from their union representative / staff association regarding a claim.
Appendix 1: Template of Level 2 Letter detailing unacceptable behaviour
Sections in Italics should be amended as appropriate – areas not in italics should not generally be altered.
Dear Mr/s
Re: Unacceptable Behaviour On Date
Details of the event leading to this action, such as: We are aware of the frustration and anxiety that can be caused by an illness or long term condition and we will often make allowances for such behaviour.
However as a result of this interaction (Further details of interaction can be placed here if necessary) our staff member was made to feel physically/non-physically/verbally threatened by you and was distressed and upset. Such behaviour will not be tolerated.
As an employer, the Health and Social Services Department, amongst other things, has a legal responsibility to protect its staff from incidents of threatening behaviour or verbal abuse. Just as the Health and Social Services Department has a responsibility to you, I would remind you that you have a responsibility to use Health and Social Services Department services in a fair and appropriate way that does not cause harassment, alarm or distress to staff that are providing services to you.
This department is firmly of the view that all those who work in or provide services to the Health and Social Services Department have the right to do so without fear of violence or abuse.
Our staff strive to deliver high standards of health and social care to our patients and clients. In the future I would urge you to consider your behaviour when you are attended by any Health and Social Services Department member of staff and that you treat them with the respect and dignity that you, yourself, would wish to be treated with and to refrain from unacceptable behaviour. Examples of behaviour/conduct we consider unacceptable are below:
Non-physical (verbal) abuse:
· Offensive language, verbal abuse or swearing, including racist comments
· Loud and intrusive conversation
· Unwanted abusive remarks; negative, malicious or stereotypical comments
· Offensive sexual remarks, gestures or behaviours. Malicious allegations relating to members of staff, other patients/clients or visitors.
· Invasion of personal space
· Brandishing of weapons
· Near misses – unsuccessful physical assaults
· Intimidation or stalking
· Alcohol fuelled abuse
· Incitement of others and/or disruptive behaviour
· Unreasonable behaviour and or non-co-operation such as repeated disregard of hospital visiting hours
· Any of the above inked to destruction of or damage to property
Physical abuse:
· Spitting on/at staff
· Pushing; shoving, poking or jabbing
· Scratching or pinching
· Throwing objects; substances or liquids onto a person
· Punching and kicking; hitting and slapping
· Sexual assaults
· Incidents where reckless behaviour results in physical harm to others
· Incidents where attempts are made to cause physical harm to others and fail
If you fail to act in accordance and continue to demonstrate what we consider to be unacceptable behaviour, the department will have no choice but to take the matter further and potentially inform the police and instigate the next stages of our ‘The Prevention and Management of Violence and Aggression at Work’ policy.
A copy of this letter is attached. Please sign the second copy and return it to me to indicate that you have read and understood the above warning and agree to act in a responsible and appropriate manner towards our staff.
If you do not respond within 14 days, I shall assume tacit agreement.
A full copy of our ‘The Prevention and Management of Violence and Aggression at Work’ policy can be found on our website at www.gov.je.
I have sent a copy of this letter to our Therapeutic Interventions Officer for his records and also placed a copy in your medical notes.
If you do not feel the sending of this letter is appropriate you may appeal to the Head of Risk Management, Governance Support Team, General Hospital, St Helier within 14 days of the date of this letter.
Yours sincerely,
Directorate manager
I, (name) accept the conditions listed above and agree to abide by them accordingly.
Signed:
Date:
Appendix 2: Template of Level 3 Letter: Warning of exclusion for HSSD premises
Sections in Italics should be amended as appropriate – areas not in italics should not generally be altered.
A copy of this policy must be sent with this letter
Dear Mr/s
Re: Unacceptable Behaviour On Date –Level 3 Measures
Details of the event leading to this action, such as: We are aware of the frustration and anxiety that can be caused by an illness or long term condition and we will often make allowances for such behaviour.
However as a result of this interaction (Further details of interaction can be placed here if necessary) our staff member was made to feel physically/non-physically/verbally threatened by you and was distressed and upset. Such behaviour will not be tolerated.
As an employer, the Health and Social Services Department, amongst other things, has a legal responsibility to protect its staff from incidents of threatening behaviour or verbal abuse. Just as the Health and Social Services Department has a responsibility to you, I would remind you that you have a responsibility to use Health and Social Services Department services in a fair and appropriate way that does not cause harassment, alarm or distress to staff that are providing services to you.
This department is firmly of the view that all those who work in or provide services to the Health and Social Services Department have the right to do so without fear of violence or abuse.
The department has ‘The Prevention and Management of Violence and Aggression at Work’ policy’ (attached) that sets out different sanctions for pateints/clients that fail to meet acceptable standards of behaviour towards our staff. Unfortunately your behaviour has fallen below the acceptable standard to such an extent that we have instigated a level 3 measure towards you.
The issuing of a level 3 measure does not affect your clinical care, however if your behaviour was to fail to meet the required standard a further time, while the measure is in place, the department would strongly consider implementing level 4 measure. A level 4 measure means that you would not be able to enter HSSD premises for any treatment apart from emergency care, and alternative arrangements for any care will be made as necessary.
The level 3 measure will remain in place for a year, after which point if your behaviour has being acceptable it will be removed.
Examples of behaviour/conduct we consider unacceptable are below:
Non-physical (verbal) abuse:
· Offensive language, verbal abuse or swearing, including racist comments
· Loud and intrusive conversation
· Unwanted abusive remarks; negative, malicious or stereotypical comments
· Offensive sexual remarks, gestures or behaviours. Malicious allegations relating to members of staff, other patients or visitors.
· Invasion of personal space
· Brandishing of weapons
· Near misses – unsuccessful physical assaults
· Intimidation or stalking
· Alcohol fuelled abuse
· Incitement of others and/or disruptive behaviour
· Unreasonable behaviour and or non-co-operation such as repeated disregard of hospital visiting hours
· Any of the above linked to destruction of or damage to property
Physical abuse:
· Spitting on/at staff
· Pushing; shoving, poking or jabbing
· Scratching or pinching
· Throwing objects; substances or liquids onto a person
· Punching and kicking; hitting and slapping
· Sexual assaults
· Incidents where reckless behaviour results in physical harm to others
· Incidents where attempts are made to cause physical harm to others and fail
A copy of this letter is attached. Please sign the second copy and return it to me to indicate that you have read and understood the above detailing the issuance of the level 3 measure and that you agree to act in a responsible and appropriate manner towards our staff.
If you do not respond within 14 days, I shall assume tacit agreement.
A full copy of our ‘The Prevention and Management of Violence and Aggression at Work’ policy is attached
I have sent a copy of this letter to the Therapeutics Intervention Officer, a copy to your GP and also placed a copy in your medical notes.
If you do not feel the imposition of level 3 measures are appropriate you may appeal to the Deputy Chief Executive Officer, 4th Floor Peter Crill House, Gloucester Street, St Helier within 14 days of the date of this letter.
Yours sincerely,
Director of Governance
I, (name) understand that I ahev being issued with a level 3 measure and accept the conditions listed above and agree to abide by them accordingly.
Signed:
Date:
Appendix 3: Template of Level 4 Letter - Exclusion from HSSD premises
Sections in Italics should be amended as appropriate – areas not in italics should not generally be altered.
A copy of this policy must be sent with this letter
Dear Mr/s
Re: Unacceptable Behaviour On Date – Instigation of Level 4 measures
Details of the event leading to this action, such as: We are aware of the frustration and anxiety that can be caused by an illness or long term condition and we will often make allowances for such behaviour.
However as a result of this interaction (Further details of interaction can be placed here if necessary) our staff member was made to feel physically/non-physically/verbally threatened by you and was distressed and upset. Such behaviour will not be tolerated.
As an employer, the Health and Social Services Department, amongst other things, has a legal responsibility to protect its staff from incidents of threatening behaviour or verbal abuse. Just as the Health and Social Services Department has a responsibility to you, I would remind you that you have a responsibility to use Health and Social Services Department services in a fair and appropriate way that does not cause harassment, alarm or distress to staff that are providing services to you.
This department is firmly of the view that all those who work in or provide services to the Health and Social Services Department have the right to do so without fear of violence or abuse.
The department has a ‘The Prevention and Management of Violence and Aggression at Work’ policy’ (attached) that sets out different sanctions for pateints/clients that fail to meet acceptable standards of behaviour towards our staff. Unfortunately your behaviour has fallen below the acceptable standard to such an extent that we have instigated level 4 measures towards you.
The issuing of level 4 measures means that you are not permitted to enter HSSD premises for any purpose apart from emergency care. This includes visiting other patients. Please be aware if you do enter the HSSD premises, you will be asked to leave and the Police may be called.
Your relevant Consultant in conjunction with you GP where necessary will make alternative arrangements for any essential treatment you require, and you will be informed of this in due course if appropriate.
The level 4 measure will remain in place for a year, after which point if your behaviour has being acceptable it will be removed.
A copy of this letter is attached. Please sign the second copy and return it to me to indicate that you have read and understood the above detailing the issuance of the level 4 measures and the associated conditions.
If you do not respond within 14 days, I shall assume tacit agreement.
A full copy of our Violence and Aggression policy is attached
I have sent a copy of this letter to our Therapeutic Interventions Officer for his records, a copy to your GP, a copy to our Security Manager and also placed a copy in your medical notes.
If you do not feel the imposition of the level 4 measures is appropriate you may appeal to the Chief Executive 4th Floor Peter Crill House, Gloucester Street, St Helier within 14 days of the date of this letter.
Yours sincerely,
Deputy Chief Executive Officer
I, (name) understand that I ahev being issued with a level 4 measure and accept the conditions listed above and agree to abide by them accordingly.
Signed:
Date:
Appendix 4: Template of Letter detailing restrictions to Visitor
Sections in Italics should be amended as appropriate – areas not in italics should not generally be altered.
Dear Mr/s
Re: Unacceptable Behaviour On Date
Details of the event leading to this action, such as: We are aware of the frustration and anxiety that can be caused by friends or relatives illness or long term condition and we will often make allowances for such behaviour.
However as a result of this interaction (Further details of interaction can be placed here if necessary) our staff member was made to feel physically/non-physically/verbally threatened by you and was distressed and upset. Such behaviour will not be tolerated.
As an employer, the Health and Social Services Department, amongst other things, has a legal responsibility to protect its staff and patients from incidents of threatening behaviour or verbal abuse. Just as the Health and Social Services Department has a responsibility to you, I would remind you that you have a responsibility to use Health and Social Services Department services in a fair and appropriate way that does not cause harassment, alarm or distress to staff that are providing services to you or other patients .
This department is firmly of the view that all those who work in or provide services to the Health and Social Services Department have the right to do so without fear of violence or abuse.
I have discussed the recent interaction with the ward staff, and while I am mindful of your need to visit your friend / relative, I am also mindful of the need to protect our staff and patients.
As such I am afraid I have to ask you to not visit the hospital anymore. If you do visit the hospital you will be asked to leave, and the police may be called.
As such I am afraid I have to ask you to only visit the hospital at visiting times. If you do visit the hospital at other times you will be asked to leave, and the police may be called.
As such I am afraid I have to ask you to only visit the hospital, at pre-arranged times with the ward manager and that a member of the security team will remain with you at all times.
These retractions will remain in place until insert date.
Please note these restrictions do not prevent you from attending the hospital for any treatment you require yourself.
Our staff strive to deliver high standards of health and social care to our patients and clients, and assist their visitors wherever possible. In the future I would urge you to consider your behaviour when you are dealing with any Health and Social Services Department member of staff and that you treat them with the respect and dignity that you, yourself, would wish to be treated with and to refrain from unacceptable behaviour. Examples of behaviour/conduct we consider unacceptable are below:
Non-physical (verbal) abuse:
· Offensive language, verbal abuse or swearing, including racist comments
· Loud and intrusive conversation
· Unwanted abusive remarks; negative, malicious or stereotypical comments
· Offensive sexual remarks, gestures or behaviours. Malicious allegations relating to members of staff, other patients or visitors.
· Invasion of personal space
· Brandishing of weapons
· Near misses – unsuccessful physical assaults
· Intimidation or stalking
· Alcohol fuelled abuse
· Incitement of others and/or disruptive behaviour
· Unreasonable behaviour and or non-co-operation such as repeated disregard of hospital visiting hours
· Any of the above linked to destruction of or damage to property
Physical abuse:
· Spitting on/at staff
· Pushing; shoving, poking or jabbing
· Scratching or pinching
· Throwing objects; substances or liquids onto a person
· Punching and kicking; hitting and slapping
· Sexual assaults
· Incidents where reckless behaviour results in physical harm to others
· Incidents where attempts are made to cause physical harm to others and fail
A copy of this letter is attached. Please sign the second copy and return it to me to indicate that you have read and understood the above warning and agree to act in a responsible and appropriate manner towards our staff.
If you do not respond within 14 days, I shall assume tacit agreement.
A full copy of our Violence and Aggression policy can be found on our website at www.gov.je/health.
If you do not feel the sending of this letter is appropriate you may appeal to the Head of Risk Management, Governance Support Team, General Hospital, St Helier within 14 days of the date of this letter.
Yours sincerely,
Directorate Manager
I, (name) accept the conditions listed above and agree to abide by them accordingly.
Signed:
Date:
Appendix 5: General Guidance for Staff on minimising occurrences of Violence, Aggression or Abuse or dealing with occurrences when they occur.
Appendix 5a
PHYSICAL AND ENVIRONMENTAL FACTORS AND THE MINIMISATION OF RISK
The physical environment may affect the likelihood of violent incidents and the ease with which people can respond to them.
In carrying out area risk assessments the following factors should be considered in determining risk, and whether adequate controls are in place.
Reception areas
· Reception areas should be easily identifiable, accessible and properly staffed.
· Clear signs should be in place to indicate where patients/service users and others should report (this is especially important if a system of triage is in operation).
· If a significant risk of violence exists consider if there should be security grade glass screens.
· Where security screens exist do these impede communication?
· Is the reception desk wide enough to prevent easy ‘grabbing’ across the desk?
· Are areas kept clean and hospitable?
Waiting areas
· Is there sufficient room to avoid crowding for people waiting for treatment? (Invasion of ‘personal space’ can be intimidating and heighten stress levels).
· Consider whether seating could be arranged in clusters rather than rows.
· Are there separate rooms where private conversations may be held, or where sensitive matters can be discussed? Separate rooms can also be useful to segregate people who are disruptive or could be a risk to others?
· Consider whether “traffic flow” through waiting areas could be diverted or modified to minimise disturbance.
· Is the temperature controlled to maintain an environment that is comfortable?
· Is there a supply of up-to-date reading material?
· Consider if the provision of a television set would contribute to a more relaxed atmosphere.
· Consider if there is a need to identify if a dedicated smoking area is available?
· Is there a Payphone in the area so that patients/service users and visitors can communicate with relations etc.?
Lighting, decoration and furnishings
· Are lighting conditions such that all areas can be seen by staff so that people cannot hide or move unseen?
· Is the lighting diffuse, without glare and free from flicker so that it contributes to a relaxed environment?
· Consider the external environment e.g. lighting in car parks, concealed areas and pedestrian routes.
· Consider whether wall coverings, pictures and plants etc could be provided to contribute to a more relaxed environment.
· Is there sufficient comfortable seating for people waiting, and is it and other furniture heavy enough or fixed to prevent it being used as a weapon?
Noise
· Consider whether noise sources and levels could be reduced to reduce stress levels. This could include noisy equipment, public address systems, banging doors etc. The type and quality of floor and wall coverings will play a part in this. Visual display systems rather than audio systems may be less intrusive in providing information.
· Children can be a source of annoyance to some people under stressful situations. Consider whether play equipment or separate areas could be provided for them.
Provision of information
· Is clear information provided for patients/service users and visitors? Consider if better signage would improve the situation (clear, simple and visible to direct people to the appropriate location e.g. treatment rooms, toilets and other facilities) and whether some form of information concerning waiting times could be provided.
· Consider whether improvements could be made to the way in which staff deal directly with people who seem vulnerable or irritated.
Treatment rooms, Wards etc.
Consider whether, in treatment rooms, wards etc:
· There is any furniture or equipment that could be used as a weapon.
· There are sufficient, and identified, escape routes for staff in the event of aggression or violence.
· A suitable alarm system and an agreed protocol for raising the alarm or warning of a developing situation exists. This may include personal alarms or coded messages that need to be understood by all staff.
· There is a means for easy communication, including visual contact, between staff and patients/service users, while retaining privacy for patients/service users
· Adequate staffing levels exist to provide an adequate response in the event of a violent situation arising.
· There is appropriate supervision of entrance and exits to wards etc. depending on the particular circumstances of the area under consideration.
· There is adequate secure storage provided for potentially dangerous items which could be used for self-harm or harm to others.
· The potential risk of theft has been minimised through the provision of adequate secure storage
· Secure, lockable, doors are provided where patient/service user and visitor access is restricted.
· The applicability of the above factors will depend on the area under consideration, and in many cases some of them may not be relevant. Also, the list is not exhaustive, and risk assessors should be alert to other specific features of an area that may be contributing to stress levels, which could lead to violence and aggression.
Appendix 5b
GENERAL GUIDANCE FOR THE MANAGEMENT OF PEOPLE
EXHIBITING VIOLENT AND AGGRESSIVE BEHAVIOUR
Throughout this section "people” or “person” includes “patients /service users/relatives/visitors/staff”.
Introduction
Experience shows that often violence is minor and in the majority of cases skilled action can resolve the incident quickly and satisfactorily without serious confrontation or restraint becoming necessary. A violent attack seldom occurs but when it does it is usually over quickly. It is important that the staff member at the scene notifies other staff, the appropriate medical staff and manager if a person shows signs of potential violence.
The distress, which is associated with physical and mental illness, often reveals itself in fear, turmoil and agitation in people. A mood of suspicion and irritability may escalate into apparent hostility, which is a symptom of the underlying desperation felt by the individual, and usually does not lead to violence, provided the response is not antagonistic.
Recognition of potential violence
Violent behaviour cannot always be prevented, as it is sometimes impulsive. However, it is possible to recognise someone who may be potentially violent and what situations are likely to precipitate such violence. It follows therefore, that most incidents of violent behaviour should not take staff by surprise but should be planned for in advance.
Some of the factors, which may indicate that violence might occur, include:
· The persons maybe noisy, abusive or impulsive
· The person may appear to be having disturbed relationships
· The person may appear to be deluded or hallucinating
Causative factors include:
· drug dependency
· alcoholism
· alcohol consumption
· metabolic disturbance
· dementia
· cerebral lesions
· mania
· depression
· Suicidal tendencies.
Knowledge and understanding of a particular person may reveal signs of impending
violence.
Warning Signs:
These will differ according to the individual concerned; therefore it is not possible to give a comprehensive list. The following is a sample of responses, which may suggest an increase in tension.
Body Language e.g. tense muscles, restlessness / agitation, sweating, sudden jerky movements, clenching hands.
Eyes staring or break in eye contact, enlarged pupils, tears.
Facial loss of colour or facial flushing, grinning or grimacing or other gestures.
Speech abrupt responses, voice which is unusually loud / quiet for the person or situation or a sudden change in tone, volume or content.
It may be known that the person has a history of violence or aggressive behaviour. Staff
may be aware of emotional instability, anxiety, frustration or hostile feelings in a person.
There may be environmental factors (see Appendix 5a) or a conflict between people.
If there is a history of aggressive incidents involving the same service user, the multi-disciplinary team must review the way in which services are delivered to that person.
Summoning assistance
Remember being involved in an aggressive incident is not evidence of professional failure.
It should never be assumed that people will automatically give assistance. They should be asked to help, as otherwise they may not be aware that help is needed. Staff can develop local coded responses to use to alert colleagues that help is required.
The senior member of staff is responsible for contacting the police if it becomes necessary. The Senior or Head of Department will arrange for additional help to safeguard other people and maintain the rest of the service. They will also liaise with medical staff, administrative staff and police as appropriate.
Prevention of violence and dealing with aggression and verbal abuse.
Aggression should not be confused with healthy self-assertion. Too tight a control on an individual or a group of people may provoke aggression.
Treat the person as a responsible adult, even if they are not behaving as one.
Aggression is more likely if people are uncertain of what is happening, or what is expected of them. Explain what is going on and ask for permission for any procedure that you are about to perform. Try to find out why the person feels as they do. Sometimes the causative factor is simple to solve.
Ensure your tone of voice is appropriate. Loud noises can stimulate aggression and will pass on aggressive cues to the patient/service user.
Hostility may be defused by diverting a person’s aggressive impulses to activities, which interest and satisfy. Stand just out of arm’s length so you are not invading their personal space, and cannot be grabbed.
Aggressive outbursts tend to increase, affecting others in the vicinity, unless prompt action is taken to deal with the situation.
Voice and body posture can be threatening. Sometimes angry people may become less aggressive after being spoken to calmly and quietly. The more skilfully people are approached the less likely is an occurrence of violent behaviour. Avoid a confrontational pose — stand sideways to the person with your arms by your side, not folded. Establish and maintain relaxed eye contact. Do not point your finger.
Having a number of staff together, near to a violent person, may be sufficient to prevent a worsening situation.
When there is obvious disagreement about the correct approach, anxiety and tension may be transmitted to people and this may lead to violence.
If a person’s disturbed behaviour is directed towards staff they too may react by being angry, annoyed or impatient. Unless staff are aware of these feelings there may be a violent episode.
Should a relative/patient/service user direct verbal anger it is important for the member of staff to appear outwardly calm and respond in an empathetic, sensitive manner. Above all, do not be defensive or respond angrily.
Approach patients/service users/relatives who have a history of violence with care. When interviewing, advise colleagues where you will conduct the interview and always sit nearest the exit. If the person wishes to leave the room at any stage, get out of their way and let them go.
Where possible do not interview a client who is drunk or under the influence of drugs and acting irresponsibly, particularly when you are unaccompanied. Try to conduct the interview at a later stage, and if applicable persuade the client to leave as quietly as possible.
Alleviate patient’s/service user's/relatives’ fear by offering explanations of their illness, condition, treatment, etc. in terms which they can comprehend. Avoid the use of medical ‘jargon’ where possible.
Avoid the use of open confrontation and never confront someone on your own if violence is anticipated.
Dealing with episodes of violence
Restraint and the laying of hands upon another person is technically common assault. Within HSSD there are a number of staff trained in various intervention techniques. Outside this group of staff these techniques should not be used. However, if assessments identify a high risk of assault and staff feel the need to be trained, the appropriateness of this training must be discussed with, and agreed by, the appropriate manager.
General guidelines
· Always call for assistance.
· Ask other people to summon help
· All staff should be appropriately dressed when on duty and before dealing with a potentially violent incident. They should remove any objects that could be potentially dangerous from their clothing (even a stethoscope could be in this category).
· Try to appear calm; talk to the person continually and quietly.
· Vacate the area of all other personnel, if possible until assistance arrives. Withdrawing from a situation may be a sensible decision and is not a sign of weakness
Reporting incidents
All incidents of violence, aggression or abuse should be reported on Datix in accordance with the Incident reporting Policy.
The following deals with some broader issues of reporting:
In the case of violence involving patients/service users, relatives should only be contacted after discussions with medical and management staff.
Statements may be required from participants or witnesses. The lead/head nurse, department head, senior manager or police will decide this matter. The statements should be written as soon as possible whilst events are fresh in everyone’s mind. In any case, it is recommended that individuals make a personal written note as their own record and have their signature witnessed by a manager or other independent person. The countersignature must be dated and timed.
Appendix 5c
MANAGEMENT OF PATIENTS/SERVICE USERS EXHIBITING VIOLENT AND
AGGRESSIVE BEHAVIOUR IN THE COMMUNITY AND CLINICS
Principle of Prevention
The best way to deal with violence is to prevent it, always in a professional manner. The following guidance, which is intended for use by any member of staff when their work takes them out into the community, is intended to highlight some of the preventative measures that can be taken.
Members of staff should consider the issues raised, and develop their own plan to ensure that their work can be carried out as safely as possible.
Risk assessors and managers should also consider the following guidance, when deciding control measures and safe systems of work for HSSD activities taking place in the community.
Every member of the staff in contact with patients/service users in the Community should have a regular opportunity to discuss problems and methods of dealing with them, with colleagues, their manager and medical staff.
Checklists for home visits
Before leaving
· Make appointments with the patient/client/service user prior to the visit and avoid self– referrals wherever possible.
· Contact a colleague, or your manager, if you are unhappy about making a visit alone.
· Check records and risk assessment forms for any known difficulties. If you are deputising for another member of staff make sure that they brief you on any foreseeable difficulties.
· It is important to know patients/service users well, where appropriate, prior to discharge from hospital. Be knowledgeable of a patient’s/service user's biography, e.g. any likes and dislikes, associated disorders, perception, difficulties or psychological problems
· Check the destination, and make sure that the route to be taken is as safe as possible (consider the possibility of mechanical breakdown).
· Check that the vehicle is regularly serviced, and that fluid and fuel levels are satisfactory.
· Let others know where you are going and when you expect to return.
· Be aware that wearing jewellery may make you vulnerable, e.g. a necklace could be tightened around your neck or non-stud earrings ripped out during an attack. Jewellery that is noticeable may also increase the risk of mugging.
En Route
· Consider the time, location and route you are taking.
· Lock your vehicle whilst travelling.
· Do not leave any medical bags, drugs etc on view.
· Check that you are not being followed. If you feel uneasy or uncertain remain with your vehicle and drive to a place of safety. Contact the police if necessary.
· Be alert at all times when walking in the streets and if your bag is snatched, let it go.
On arrival
· Park your car safely, and in such a position that you could drive off easily in an emergency (quick getaway), and if possible in a well-lit area. This may mean turning the car around before parking it. Park as close to your destination as you can, without compromising safety.
· Before leaving the car ensure that all medical equipment, medicines or prescription pads are out of view, preferably locked in the boot.
· Close all windows, and lock the car
· Do not advertise doctor or nurse on call unnecessarily.
· Be alert and aware of your surroundings.
· Use your judgement before entering lifts – could other occupants become violent or someone enter the lift at another level?
· If you are in any doubt about the premises you are visiting, do not enter them but seek advice and assistance. If this is not feasible abort the visit and return to your work base.
During the visit
· Watch out for hazards in a home, such as poor lighting, trailing flexes, narrow or steep staircases, alert any colleagues who may also be visiting.
· Try to avoid examining patients/service user with a dog present. Request politely that it be removed, if not report to your manager.
· Never force your way into a patient’s/service user's home. Always ask permission to enter if you have not been invited in.
· Always explain clearly the purpose of your visit/and/or any procedure to be carried out.
After the visit
· Confirm that you have completed the visit with the appropriate person so that they are aware that you have returned.
· Debrief your manager, team leader etc. of any problems encountered on the visit. Ensure that any information which could be useful to staff making visits in the future is recorded.
Appendix 5d
GUIDANCE FOR DEALING WITH INCIDENTS OF VIOLENCE AND AGGRESSION IN
THE COMMUNITY
Dealing with a violent incident in a patient’s/service user's home
Staff should make every effort to calm the person; they should speak firmly but quietly to them. In rare circumstances where the presence of another individual is making the situation worse, it is sometimes best to seek a way of separating the patient/service user from the other person. This might be done by suggesting that you move elsewhere with the patient/service user, or by steering the other person to another part of the house. Be tactful.
Extra help should be called if it seems that it may be needed. At this point, when violence is only a possibility, other people should not burst upon the scene; this could easily precipitate violence. They should either stay just outside the room where the disturbed patient/service user is, or if any of the relatives are on particularly good terms with her, that person could help talk the patient/service user through the crisis.
Staff talking to the patient/service user should consider if it is necessary to stand between them and the door, so as to reduce the possibility of them rushing to another part of the home if this seems likely, and it is not in the patient’s/service user's best interest to do so. If violence is directed to a member of the family and they are sustaining injury, attempt to reason with the patient/service user. Help should be summoned if available in the house. Don’t forget your mobile telephone.
When violence is directed to a child in the family, then the Child Protection Policy must be implemented.
If violence is directed to yourself when no help is available, and you are unable to manage the patient/service user, turn and break free, leave immediately and inform the your Manager and the Police via the emergency 999 service if appropriate.
Dealing with a violent incident in the Clinic
The protection of other patients as well as yourself, is your responsibility. At the first sign of trouble call for assistance.
People matter more than property. If a patient is damaging property, move other patients away. If however, the patient is breaking windows in such a way to cause injury to themselves, then staff must try to prevent them causing further injury.
If another patient is being attacked staff should go to that patient’s assistance. If a member of staff is attacked they should try to move away and keep a large piece of furniture, such as a table, between themselves and the violent patient.
Follow-up management
As soon as possible after the incident, a case conference with any other agency involved with the welfare of the patient must be convened, and a decision reached as to the future care of the client.
The Manager, Nurse and team members should consider the advisability of further visits to the client’s home being made unaccompanied.
N.B. The above is not exhaustive and should be read alongside the detailed guidance
given in Appendix 5a
Appendix 5e
DE-ESCALATION
Sometimes despite our best efforts aggression and violence still occurs, the following guidelines may help you deal with such situations.
· Always try to keep a clear exit, so you can remove yourself from the area.
· Try not to panic or switch too quickly into alarm-mode.
· Concentrate on slow, deliberate breathing to help you remain calm and release any rigidity in your body.
· If possible your approach should be calm and fair.
· Let the person know you recognise how they may be feeling.
· Encourage the person to express verbally their feelings.
· If a person is getting angry try to keep the option open to allow them to back down without losing face.
· Do not be provoked by abuse. Remain polite, never use words that could be perceived as threatening or challenging.
· Do not get caught up in trying to win an argument. Use simple, clear language and avoid appearing condescending or superior.
· Maintain relaxed eye contact similar to that during normal conversation. Prolonged direct eye contact should be avoided as it may be interpreted as provocative, and avoidance of eye contact may be viewed as submissive or fearful.
· Use the person's first name (if appropriate) as frequently as possible.
· Remove any potential weapons (e.g. ashtrays, scarf) if possible.
· If the person has a weapon (or an object which could be used one) remove yourself from the situation and seek help. If you are unable to remove yourself from the immediate area, ask the person to put down the weapon - not hand it over to you.
· If possible, position yourself so that you and the other person both have a clear exit from the immediate area.
· If a situation becomes violent having a barrier between you and the person e.g. table / desk can be helpful since violent impulses can be momentary and fleeting.
· Self preservation is your first priority when a situation gets out of control. If possible back out, run away or shout for help.
· Do not try to resolve the situation physically unless absolutely necessary. Your own safety and that of others is of greater importance than damage to property. Avoid physical contact (if possible).
· Do not personalise abusive language.
· Onlookers can increase the tension in such situations so try to disperse the audience or if possible move away from them.
· Other staff, not directly involved, should stay in the background but be ready to assist if necessary.
· If you are going to stand up, walk away or leave the room, let the person know what you are doing so your actions are not seen as hostile or disrespectful. However if a situation is threatening to become violent you should try to get out of it.
Note: Sometimes people use threats of violence to gain concessions. Getting caught up in such negotiations can prolong the situation and increase the danger. Other staff may have to deal with the repercussions and therefore be placed at risk. Be firm but friendly and do not confuse concern and empathy with concessions.
Appendix 5f
PHYSICAL RESTRAINT (ADULTS only) AND AVAILABLE TRAINING
Physical restraint is not a short cut to talking with the person. However occasionally a situation may arise when it is important to protect yourself or another person. The Royal College of Psychiatrists give the following advice as regards when restraint may be applicable:
· Serious degree of urgency and danger
· Significant physical attacks
· Significant threats or attempts at self injury
· Seriously destructive of property
· Prolonged and serious verbal abuse, threats, disruption of ward
· Prolonged over-activity, risk of exhaustion
· Risk of serious accident to self and others
· Attempts to abscond (if detained under article and in an open ward).
As far as possible in the circumstances, the reasons for restraint should be explained to the client and the likely outcome specified. The explanation should be repeated later.
Should restraint be required, then The Royal College of Psychiatrists recommends that the system adopted should:
· Include allocation of responsibilities to team members for co-ordinating team response.
· Allocate responsibility to an identified team member for clear, direct, uncomplicated communication throughout the procedure.
· Be appropriate to the age, size and gender of the client.
· Not be dependent on height or weight of staff members or client.
· Not involve neck compression
· Offer a hierarchy of physical responses.
· Use secure grips.
· Minimise pain.
· Maintain dignity.
· Protect the clients head during descent.
· Protect the clients’ air supply.
· Use controlled descents.
· Avoid unnecessary pressure on the clients back or chest.
· Therapeutic Physical Interventions
· High Level Interventions – Control and Restraint
Control and Restraint training
This training involves the use of three person teams, and covers the theory/management of challenging behaviour and physical de-escalation and/or the administration of essential interventions in severely disturbed adults. It conforms with the above, and is available as a five day course. Once trained, staff are required to attend a refresher course once every twelve months. Control and Restraint training is recommended for those staff that work in an area where there is an increased likelihood of aggression and need for restraint. As mentioned above the techniques involve three person teams, so would not be suitable for areas where three people would not usually be available e.g. the ambulance department.
Medium Level Interventions
This training is suitable for the physical de-escalation of adults and/or the administration of essential interventions in adults resistive to treatment.
Low Level interventions
This training was developed in partnership with Northampton Health Services and ratified by Northampton University. It conforms with the above and is a two and a half day course covering theory/management of challenging behaviour and physical de-escalation and/or the administration of essential interventions in older adults using two/three person teams. Once trained, staff are required to attend a refresher course once every year.
De-escalation and Breakaways
This training is available as two separate half day course or in combination as a one day course. De-escalation instructs staff in techniques to diffuse a potentially aggressive situation and Breakaways cover physical techniques to enable staff to disengage themselves from a physical assault to enable them to remove themselves from the danger.
Therapeutic Crisis Interventions
This is a five day course developed by Cornell University New York, which trains staff in therapeutic interventions for distressed children, including breakaway techniques and restraints. Depending on the size/strength of the young person the restraints are performed by one, two or three people. Once trained staff are required to attend a refresher course every six months.
The above training offers staff a hierarchy of responses and/or enables staff to be instructed in interventions suitable to their work area. All of the above can be accessed by contacting the Therapeutic Interventions Officer.
Training packages to cater for the individual needs of an area, or in response to current problems can be devised by the Therapeutic Interventions Officer, and if required delivered in the place of work.
It should be noted that these techniques are for the restraint of an unarmed individual, and that a visual check should be made beforehand to ascertain as far as is possible, that the person is not in the possession of a weapon. Should the person be in the possession of a weapon, then people trained in restraint techniques involving the restraint of armed individuals should be contacted i.e. the police.
It should be noted that the law only sanctions the use of reasonable force for self protection. Action even if purely defensive, which was deemed excessive may constitute an assault. In view of this the following general guidelines are provided for those staff that are not trained in therapeutic interventions
· You must use minimum force and avoid injury.
· Your hold on a person must avoid interfering with breathing or primary blood flows or contact with sexual areas.
· Continued calm reassurance should be given by one allocated person. More than one voice can confuse the client.
· If it is necessary to restrain arms or legs, they should be held above and below the major joint.
Appendix 6 – Examples of Posters (available from Governance Office)
Appendix 7 – Leaflet (to help explain organisational stance on unacceptable behaviour and policy) Copies available from Therapeutic Intervention Officer
HSS-PP-CG-0106-02
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