Mod1 Facilitator

A safer place to work –
preventing and managing violent

behaviour in the Health workplace
Module 1
HLTCSD6A
Respond effectively to difficult
or challenging behaviour
Facilitator manual
NSW Health is a zero tolerance zone

NSW DEPARTMENT OF HEALTH
73 Miller Street
NORTH SYDNEY NSW 2060
Tel. (02) 9391 9000
Fax. (02) 9391 9101
TTY. (02) 9391 9900
www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in part for study training purposes subject to
the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or
sale. Reproduction for purposes other than those indicated above, requires written permission from the
NSW Department of Health.
© NSW Department of Health 2004
SHPN (CMH) 030136

ISBN 0 7347 3557 X
July 2003
updated August 2004
MODULE 1
Respond effectively to difficult or challenging behaviour
Contents
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Overview of the manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Modular structure of the aggression minimisation program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
How the manual is set out. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Facilitator preparation before training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Sequence and timing of the modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Other resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Introduction to Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
How Module 1 fits into the whole program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Assessment for Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . 11
Elements of competency and performance criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . 11
Assessor checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . 13
Assessment method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . 14
Assessment conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . 14
Assessment resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . 14
Session plan for Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 15
Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 15
Equipment required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 15
Participant requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . 15
Beginning the training session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1. Welcome participants to the module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2. Housekeeping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3. Outline principles of adult learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4. How Module 1 fits into the whole program
5. Structure of Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Aggression in the workplace – facts and figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Part 1 Understanding difficult or challenging behaviour ....................... ..... . . . . . . . . . . . . . 21
Defining aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....................... ..... . . . . . . . . . . . . . 23
Effects of aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....................... ..... . . . . . . . . . . . . . 24
Zero tolerance response to aggression. . . . . . . . . . . . . . . . . ....................... ..... . . . . . . . . . . . . . 24
Part 2 Preventing aggression occurring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
What you need to know about keeping your workplace safe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Using a risk management approach to prevent aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Eliminating or controlling risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
How the design of your workplace can prevent aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
More ways of keeping your workplace safe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Putting it all together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Caveats and background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Individual risk highlighter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Violence risk awareness checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Violence minimisation checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
What workplace strategies do you have . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Part 3 Preventing aggression escalating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Levels of aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Know your options for action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Deciding to stay or leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
When and who to call for back-up or help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Danger and safety zones when faced with an aggressive or violent person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Self help strategies to remain calm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Verbal and non-verbal de-escalation skills to prevent aggression and violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Attitudes are important . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Your attitudes towards people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Strategies for improving communication with people from a different culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
What governs your actions in responding to aggression? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Some more strategies when faced with a violent person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Response options for repeatedly aggressive people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
NSW Health A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A
i
Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 – updated August 2004
FA C I L I TAT O R M A N U A L
Part 4 Bullying, harassment and discrimination at work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Scope of the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
You have a role to play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Some legal considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
How to confront a person who is bullying, harassing or discriminating against you . . . . . . . . . . . . . . . . . . . . . . . . . . 77
How to formally make a complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Rights of the person making the complaint and the person who is complained against. . . . . . . . . . . . . . . . . . . . . . . 79
Part 5 Reporting and reviewing aggressive incidents ......................... .......... . . . . . . . . 81
Reporting aggressive incidents . . . . . . . . . . . . . . . . . . . . ......................... .......... . . . . . . . . 82
What to expect from an aggressive incident investigation . ......................... .......... . . . . . . . . 84
Support mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . ......................... .......... . . . . . . . . 86
Self care following an aggressive incident . . . . . . . . . . . . . ......................... .......... . . . . . . . . 90
What support can you expect from your manager . . . . . . ......................... .......... . . . . . . . . 93
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......................... .......... . . . . . . . . 94
Related NSW Health policies and guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Module 1 assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Scenario 1: Support staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Scenario 2: Mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Scenario 3: Enrolled nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Scenario 4: Registered nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Scenario 5: Food services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Scenario 6: Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Scenario 7: Community – generalist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Scenario 8: Community mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Scenario 9: Youth worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Scenario 10: Bus driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Scenario 11: Drug and alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Scenario 12: Hospital security staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Scenario 13: Medical officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 113
Scenario 1: Support staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 115
Scenario 2: Mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 117
Scenario 3: Enrolled nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 119
Scenario 4: Registered nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 121
Scenario 5: Food services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 123
Scenario 6: Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 125
Scenario 7: Community – generalist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 127
Scenario 8: Community mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 129
Scenario 9: Youth worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 131
Scenario 10: Bus driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 133
Scenario 11: Drug and alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 135
Scenario 12: Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 137
Scenario 13: Medical officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . . . . . 139
Marking guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 141
Scenario 1: Support staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 141
Scenario 2: Mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 143
Scenario 3: Enrolled nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 145
Scenario 4: Registered nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 147
Scenario 5: Food services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 149
Scenario 6: Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 151
Scenario 7: Community – generalist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 153
Scenario 8: Community mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 155
Scenario 9: Youth worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 157
Scenario 10: Bus driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 159
Scenario 11: Drug and alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 161
Scenario 12: Hospital security staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 163
Scenario 13: Medical officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . 165
ii A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A NSW Health
MODULE 1
Acknowledgments
This NSW Health violence prevention training program was developed by Brin FS Grenyer,
Olga Ilkiw-Lavalle and Philip Biro from the Illawarra Institute for Mental Health. Mark Coleman
provided assistance with the facilitator manuals and pilot workshops. The project was coordinated
from the Violence Taskforce, Centre for Mental Health by Frances Waters. The members of the project
contract steering committee who provided extensive guidance during the development of this project
were Frances Waters (Violence Taskforce, Centre for Mental Health), Kathy Baker (Community & Extended
Care Services and Nursing Services, Northern Sydney), Trish Butrej (Occupational Health and Safety,
NSW Nurses’ Association), Maggie Christensen (Learning and Development, Central Coast), Nicole Ducat
(Occupational Health and Safety, South Eastern Sydney), Louise Newman (Royal Australian and New
Zealand College of Psychiatrists), Gemma Summers (Learning and Development, Northern Sydney)
and Choong-Siew Yong (Australian Medical Association, NSW Branch).
A project content reference group also provided input during the development of the project, and the
members were Greg Hugh, Peter Bazzana, Greg Cole, Stephen Allnut, Distan Bach, Liz Cloughessy,
Jim Delaney, Regina McDonald, David Gray, Rajni Chandran, Jennifer Bryant, Terry Tracey and Linda
Sheahan. Consumer input was gratefully provided by Laraine Toms and Robyn Toohey. The NSW Health
Learning and Development Managers forum and others affiliated with the reference group also provided
helpful comment and guidance during the developmental phases of this project, including Jenny Wright,
Earle Durheim, Judy Saba, Brenda Bradbury, John Lain, Bill Wood, Aileen Ferguson, Simon Richards,
Vaughan Bowie, Louise Fullerton, Mira Savich, lain Morriset, Lorraine Hyde, Glenda Hadley, Julie Reid,
Natasha Mooney and Bill Tibben.
The developers would like to thank those staff of the South Western Sydney Area Health Service
who provided useful feedback during the four days of piloting of each of the modules in October 2001.
We also thank the fifteen educators from across the state who provided feedback during the two day
trainer orientation at Western Sydney Area Health Service in November 2002.
The developers would like to give special thanks to Professor Beverley Raphael and Professor Duncan
Chappel from the Violence Taskforce for support, Dr Claire Mayhew for timely insights, Linda Graham for
sharing her wisdom over the years through the development and implementation of the INTACT training
program, Professor Kevin Gournay and Steve Wright from the Institute of Psychiatry, London, for helpful
advice and resources, Dr Nadia Solowij and Jane Middleby-Clements for editorial assistance and to
Professor Frank Deane from the Illawarra Institute for Mental Health for practical support. We also thank
Shane Pifferi, Marie Johnson, Vicky Biro, Tim Coombs, Ralph Stevenson, Dr Alexandra Cockram,
Eugene McGarrell, Samantha Reis and Andrew Phipps for assistance with the project.
This program has incorporated and referred to relevant NSW Health policies and guidelines where
appropriate and a list of these is given at the end of the relevant modules. Modules 1 and 2 of this program
were adapted from a modular aggression minimisation program developed originally by Austraining (NSW)
Pty Ltd for the Central Coast Area Health Service, which was revised by Jenelle Langham in 2000.
Module 3 of this program is a revised version of that developed by Jenelle Langham for the Central
Coast Area Health Service.
1
Introduction
NSW Health: Preventing and managing aggression in the

Health workplace
What is it?
A number of key projects have flowed from the work of the Violence Taskforce. One of
these is the development of a statewide, appropriately accredited aggression minimisation
training program.
The focus of this training is to provide staff with the most up-to-date strategies, skills and
techniques to prevent and minimise workplace aggression and violence. It is also based on
relevant taskforce findings and incorporates key taskforce initiatives.
The program includes a basic module for all staff identified as being at risk of workplace violence,
a module for staff working in high risk environments, a module designed specifically for managers
and a refresher module.
What materials are provided?

A CD-ROM is available and includes:
● Facilitator manual: Modules 1 through to 4 (in Acrobat PDF format).
● Participant manual: Modules 1 through to 4 (in Acrobat PDF format).
● Powerpoint slides for Modules 1 through to 4.
● Recognition of prior learning forms and assessment of competency forms (as a separate
Acrobat PDF format).
● Assessment scenarios and Question sheets for Module 1 (as a separate Acrobat PDF format).
All of the above are included on the CD.
Who will attend?

Module 1 should be attended by all staff identified as being at risk of workplace violence,
and generally speaking is a prerequisite for all other modules. More detailed advice on the
application of this training is provided in the covering circular. Attendance at additional modules
is recommended for staff determined by the Health Service to be at higher risk of workplace
violence and includes, but is not limited to, security, mental health, Emergency Department,
admissions, drug and alcohol, disability services, brain injury and aged care staff.
All managers of staff identified as being at risk of workplace violence should attend the manager’s
module and all relevant staff should attend the refresher module at least every two years. Health
Services may determine that some groups need to attend the refresher more regularly.
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A NSW Health
2 Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 – updated August 2004
MODULE 1
Overview of the manual
his manual has been developed to provide educational resources for a facilitator to deliver
a comprehensive education program in aggression minimisation.
The manual is divided into four training manuals. Facilitators must have each of the following.
1. Certificate IV in Assessment and Workplace Training.
2. Experience in working in areas of significant violent risk.
3. Experience in effectively managing violent incidents.
4. An ability to relate to staff at all levels of the organisation.
Modular structure of the aggression minimisation program

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

1. Understanding difficult or challenging behaviour.
2. Preventing aggression occurring.
3. Preventing aggression escalating.
4. Bullying, harassment and discrimination at work.
5. Reporting and reviewing aggressive incidents.
Module 2
AMT002 – Aggression minimisation in high-risk environments
This eight-hour program is designed for mental health and other staff working in high risk areas,
eg emergency, security, community, aged care, disability, dental, midwifery and early childhood, methadone,
brain injury, neurology, admissions and drug and alcohol services. Other staff members identified, via the risk
assessment process, as being at significant risk of aggressive behaviour should also attend this module.
The day is divided into four parts:
1. Working in high-risk environments.
2. Prevention in high-risk environments.
3. Understanding aggression in high-risk environments.
4. Managing aggression in high-risk environments.
3
Module 3
90405NSW – Course in aggression minimisation for managers
This four-hour module is designed for managers of health units and facilities. It provides the participant with detailed
information, obligations and practical strategies for promoting a safe workplace environment free of aggression,
assessing and managing risks and types of support to provide to staff, who have been victims of aggression.
Completion of Module 1 is recommended prior to undertaking this module.
The day is divided into three parts:
1. The legal and policy framework for managing aggression.
2. Promoting an aggression-free workplace.
3. Assisting staff when aggression and violence occurs.
Module 4
AMT004 – Aggression minimisation refresher training
This two-hour module is designed for all staff identified as being at risk of workplace violence, and should be
repeated at a minimum of every two years after completion of Module 1. Depending on the level of risk, some staff
may need to attend more frequently. It is designed to keep staff up-to-date with policies and practices, provide
refresher training of skills, and workshop problems.
The day is divided into four parts:

1. The zero tolerance response.
2. New developments in preventing and managing aggression and violence.
3. The prevention of aggression and violence.
4. Managing aggression and violence.
How the manual is set out

The Facilitator manual is divided into the four modules.
All facilitator notes throughout each module look like this.
Basic course content in the Facilitator manual duplicates that found in the Participant manual.
This course content forms the basic syllabus of the training and the trainer needs to know this
material prior to conducting training.
For each module, at the beginning of each section the relevant page number in the
Participant manual is noted.
Relevant slides that should be shown at each point are reproduced throughout this manual.
Layout icons
The following symbols have been used throughout the Facilitator manual to assist in the presentation
of material. In all cases, trainers should use their discretion in the presentation and timing of material
depending on the mix of staff in the training group. Where possible, flexible delivery is encouraged
and specific recommendations are made at the beginning of each module.
4 A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A NSW Health
MODULE 1
Key points
Key points help you to summarise the major themes and information from the section.
Explain and discuss

This icon suggests that you will need some verbal explanation and discussion of this
concept or topic.
Background reading
This icon appears when further background information and reading is supplied
on a topic to assist the facilitator in understanding and delivering the training course.
It should be read before the facilitator conducts any training. The background information
may be verbally summarised by the trainer as the need arises.
Ask the group

Whenever this icon appears in the manual a large group activity is suggested.
Facilitators should ask the suggested question to the group as a whole and elicit
answers or suggestions as appropriate. Participants may choose to write answers
in the space in their manuals.
Small group exercise

This icon represents small group activity. Whenever this icon appears in the manual
a small group activity is suggested. Facilitators may get the group to break into smaller
groups of two to five participants to discuss the question, before reporting back to the
group as a whole. Participants may choose to write answers in the space in their
manuals.
Individual reflection exercise

This icon represents personal reflective activity. Whenever this icon appears in
the manual personal reflection is suggested. Individual participants may complete
this exercise alone. The facilitator may then choose to address the question to the
group as a whole and collect responses from individuals. Participants may choose
to write answers in the space in their manuals.
Answers
Suggested answers to the individual, small and large group activities are provided.
These amplify and reinforce the subject material covered in the Participant manual.
Important training point

Important training points are highlighted with this symbol.
You are on Participant manual page X

These icons assist you to keep the training program in sequence with the
Participant manual. It is suggested that you regularly refer participants to the relevant
page in their Participant manual for further information or to complete an activity.
NSW Health A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A 5
Show overhead slide

Suggested place to present slide.
Facilitator instruction
Specific training hints are given here.
Write responses on board

Suggested place where the trainer may wish to reinforce points or collect
responses from the group on a whiteboard/blackboard/butcher’s paper.
Session time
Suggested times to conduct sessions are given and a session plan is provided
for each module. These are to be used flexibly to meet the needs of trainers
and participants.
Session overview
An overview of the session is given here.
Suggested break time

Suggested breaks are provided. These are flexible.
Readings and resources

Additional readings and resources are highlighted here and should be read prior to
commencing training.
Facilitator preparation before training

Before running this training it is important to be familiar with:
● All NSW Health documents and policies relating to aggression minimisation, prevention and
management (see reference lists at the end of each module).
● All local policies relevant to aggression minimisation. These will include documentation
and emergency responses relating to aggression minimisation, prevention and management,
eg duress response, reporting protocols.
● It is helpful if you have an awareness of recent incidents in your area, where these have
been a particular problem and the outcome. This enables the training to be more relevant
for participants.
● Facilitators need to familiarise themselves with the reference list at the end of the modules.
Sequence and timing of the modules

The individual modules do not need to be taught together as a block. The space between
teaching individual modules may be separated by weeks or months. It is important to consider
the retention of information from previous training and be ready to reinforce previous training
material, particularly from Module 1. Each module contains some common material from other
modules to help reinforce basic concepts, eg zero tolerance. Module 1 forms the prerequisite
for the other modules so needs to be made available to participants prior to offering the
other modules.
MODULE 1
Assessment of competency
Assessment activities accompany Modules 1-4 to facilitate demonstration of competency.
Facilitators should ensure that training outcomes for each participant are appropriately
documented. Recording forms accompany the Facilitator manual.
Flexible delivery
The materials in this training program provide a core recommended syllabus for preventing and
managing aggression in all NSW Health facilities. Each module has a set of learning outcomes
and corresponding assessments. The training is designed in a modular format to allow ease of
delivery, however it is possible that the training may be delivered using flexible delivery methods.
Examples of how the training could be altered include (but are not limited to) the following:
1. Dividing a full day module into two parts, spread over two half days.
2. Emphasising some components of training over others for specific groups. For example,
if the participant training group is non-clinical then the trainer may decide to focus more
on communication strategies and bullying, harassment and discrimination than on some
of
the components that are more relevant for clinical staff.
3. Flexibly incorporating materials from other local training programs that overlap with the
learning outcomes and provide additional training.
4. Shortening a module by providing advance reading materials and exercises to be reviewed
in the participants’ own time and reinforced and assessed in the workshop. However, the
trainer will need to determine that this approach is appropriate for the participant group.
In considering flexible delivery options, it is important to ensure that the learning outcomes are
met as set down in this program.
Recognition of prior learning

Recognition of prior learning can be considered for this training. The relevant forms for recognition
of prior learning accompany the Facilitator manual.
Recognition of prior learning is based on the following:

● Competence – a focus on the competencies an individual has acquired as a result of any
formal or informal training and experience.
● Commitment – to recognise prior learning of individuals, therefore individuals will not have to
duplicate their training unnecessarily.
● Access – every individual may have his or her prior learning recognised.
● Fairness – that the recognition of prior learning process is fair.
● Support – is provided for individuals in applying for recognition of prior learning. Certificate IV
workplace trainers and assessors must provide support so that an efficient and effective service
is maintained.
Portfolio documentation
Appropriate documentation is to be filled in and evidence collected to be submitted with the
application form. All documentation should be submitted as a portfolio. See below for types of
evidence to be collected and included in a portfolio.
Evidence guide
The following is a guide for the evidence to be provided for recognition of prior learning.
For each item of evidence you will need to indicate which part of the item is relevant to which
learning outcomes.
The following types of evidence may be collected:

● Formal accredited certificates of previous training programs attended, or transcripts of
courses of study.
● Authenticated reports on activities participated in, relevant to aggression minimisation.
● Certified evidence of discussions of case studies that shows evidence of having attained
learning outcomes.
● Authenticated reports of work, skills and experience in responding to aggressive behaviour.
Other Resources
Participant manual
A Participant manual is also available and should be used during the training. Participants are
to use the manual during the training session, but also should take it away as a resource. There
is additional information in the Participant manual, and it is not expected that every point can be
covered during the training sessions. The training provides an orientation to the major issues in
aggression minimisation and points the participant to further readings and resources in the area.
Lecture slides
The CD-ROM contains the full set of Powerpoint slides. The Powerpoint slides can also be
printed and transferred to overhead transparencies as needed.
Forms
The CD-ROM contains the recognition of prior learning forms and the assessment of
competency forms.
MODULE 1
Introduction to Module 1
How Module 1 fits into the whole program

Module 1 is the first of four modules dealing with aggression prevention, minimisation
and management. This module is provided for all staff identified as being at risk of
workplace violence, and for some will be all that is required for aggression minimisation
training. Module 1 emphasises the workplace prevention of aggression, basic skills
required to de-escalate an aggressive situation and appropriate reporting procedures
after the incident. Additional modules will address high-risk areas, managerial
responsibilities and refresher training.
Structure of Module 1
HLTCSD6A Responding effectively to difficult or
challenging behaviour
This eight-hour program is designed for all staff identified as being at risk of workplace
violence. It is designed to meet the Health Training Package competency HLTCSD6A
Respond effectively to difficult or challenging behaviour. The day is divided into six parts:
6. Assessment of competency.
The learning outcomes and assessment align with the national training guidelines and the
Health Training Package.
Session times
1. Introduction 10 mins
2. Understanding difficult or challenging behaviour 50 mins
3. Preventing aggression occurring 90 mins
4. Preventing aggression escalating 90 mins
5. Bullying, harassment and discrimination at work 60 mins
6. Reporting and reviewing aggressive incidents 60 mins
7. Assessment of competency 60 mins
Total training time: 7 hours
NB. A session plan is provided at the beginning of Module 1.
9
Training room requirements

The training room should be comfortable with desks for participants so that they can write
in their copy of the Participant manual. Equipment required: projection facilities for Powerpoint
slides (or an overhead projector if the slides have been printed on overheads), a whiteboard
and whiteboard pens (for writing up feedback from participant exercises). Participants will
need pens or pencils for writing in their copy of the Participant manual.
MODULE 1
Assessment for Module 1
Health Training Package Competency: (HLTCSD6A) – Respond Effectively to Difficult or

Challenging Behaviour. The learning outcomes and assessment align with the elements
and performance criteria.
Elements of competency and performance criteria
National code Element name

HLTCSD6A/01 Plan responses
1.1 Planned responses to instances of difficult or challenging behaviour
maximise the availability of other appropriate staff and resources.
1.2 Safety of self and others is given priority in responding to difficult
or challenging behaviour.
HLTCSD6A/02 Apply response

2.1 Responses reflect organisational policies and procedures.
2.2 Assistance is sought as required.
2.3 Difficult or challenging behaviour is dealt with promptly, firmly and
diplomatically in accordance with organisational policy and procedure.
2.4 Communication is used effectively to achieve the desired outcomes
in responding to difficult or challenging behaviour.
2.5 Appropriate strategies are selected to suit particular instances of
difficult or challenging behaviour.
HLTCSD6A/03 Report and review incidents

3.1 Incidents are reported according to organisational policies
and procedures.
3.2 Incidents are reviewed with appropriate staff and suggestions offered
as appropriate to area of responsibility.
3.3 Debriefing mechanisms and other activities are accessed and
participated in.
3.4 Advice and assistance is sought as required.
11
Learning outcome Elements of competency and Assessment

performance criteria question
1. Identify and apply strategies Question 9

for risk management to
prevent aggression.
2. Identify and select Element: Apply response Question 1

appropriate response Performance criteria: 2.1, 2.3, 2.5
options when confronted with
aggressive behaviour.
3. Give priority to the safety of self Element: Plan responses Question 2

and others when confronted with Performance criteria:1.2
aggressive behaviour.
4. Identify when, how and who to Element: Plan responses Question 3

call for assistance. Performance criteria: 1.1
Element: Apply response
Performance criteria: 2.2
5. Use verbal and non-verbal Element: Apply response Question 4

communication strategies to Performance criteria: 2.4
manage aggressive behaviour.
6. Identify appropriate reporting Element: Report and review incidents Question 5

procedures. Performance criteria: 3.1
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
9. Identify how management can Element: Report and review incidents Question 8
support you following an Performance criteria: 3.4
aggressive incident.
MODULE 1
Assessor checklist
(optional to assist in determining competency)
Yes No Unsure How

*Identified and selected
appropriate response options.
*Ensured the safety of self

and others.
*Identified when, how and

who to call for help.
Identified appropriate
verbal and non-verbal
communication strategies.
*Identified appropriate
reporting procedures.
Identified what can be

expected from an incident
investigation.
Identified available
support services.
Identified support expected

from management.
Identified and applied

strategies for risk
management.
* Denotes criteria for competence.
Assessment method
The learning outcomes are to be assessed through case scenarios and responses to multiple
choice questions on an answer sheet. The questions have been designed to assess competency
in the learning outcomes of this program (see page 13). Participants are deemed competent if
they provide the correct responses to these questions. The critical aspects of the assessment
are identified in the marking guide. On the answer sheet all items need to be marked as on
the marking guide, however, in the 1-3 range, variance may be accepted (ie 1-3 need not be
in exactly that order). Only the options which appear in the marking guide for the scenario
should be seen as acceptable responses. Question 9 does not link to any of the elements
of competency so can be completed at another time if desired. With a group from one
employment category this could be undertaken as a group exercise.
Assessment conditions
Participants should be notified of the nature of the assessment (case scenarios and assessment
questions) and should sign the standard NSW Health RTO Assessment specification (Participant
manual, page 5), to signify that they understand the assessment process at the commencement
of the training. If the facilitator is unclear on how this should be managed, the facilitator should
contact the AHS Learning and Development Service. At the completion of the module the
facilitator should instruct the participants to complete the front sheet of the assessment
emphasising that it is important to identify the area of employment and to select the appropriate
scenario. The facilitator should explain that, for some questions, answers need to be numbered
in the order in which they should be done, while in others ticks are required in the appropriate
boxes only. Questionnaires should be handed in for marking on completion and certificates
should be issued within a reasonable period of time. Those who are deemed Not Yet Competent
should be given the opportunity to resubmit within a set time.
Flexibility is to be encouraged to meet any language and literacy needs.
Assessment resources
● Case scenarios.
● Assessment question sheets – one set for each scenario.
● Marking guides.
● Sample incident form.
● Local risk management plan format.
NB. Case scenarios, assessment question sheets and marking guides can be found at the end of the Facilitator manual.
Case scenarios and assessment question sheets can also be found as a separate Acrobat PDF document on the CD-ROM,
in order that the scenarios and assessment question sheets may be printed out and handed to participants.
Each participant should be instructed to complete the scenario relevant to the participant’s
position with the organisation. It is important that the location and nature of the participant’s work
is clearly identified on the question sheet. Participants will also be required to complete a sample
incident form on the scenario. Facilitators need to insert a copy of their local incident report form,
and local risk management plan format (or similar) to allow for completion of the relevant section
in the assessment. The coordinator within your organisation may wish to customise some of the
options to meet local conditions.
It is anticipated that the scenarios will be available as trigger videos at a future date to cover all
language and literacy needs.
MODULE 1
Session plan for Module 1
Training session: Module 1 Date:

Respond effectively to difficult Time:
or challenging behaviour
Learning
Time Topic outcomes Content/activity
60 mins ● Introduction. 1 and 2 Small and large group
● Understanding difficult or discussions.
challenging behaviour.
90 mins ● Preventing aggression occurring. 1, 2, 3 and 4 Small and large group

discussions.
90 mins ● Preventing aggression escalating. 2, 4 and 5 Small and large group

discussions.
60 mins ● Bullying, harassment and 4, 5 and 6 Small and large group

discrimination at work. discussions.
60 mins ● Reporting and reviewing 6, 7, 8 and 9 Small and large group

aggressive incidents. discussions.
60 mins ● Assessment of competency. All learning Staff members respond to

outcomes questions in relation to the
scenario they are given.
Materials
The training room should be comfortable with desks for participants so that they can write in
their copy of the Participant manual. `
Equipment required
● Projection facilities for Powerpoint slides (or an overhead projector if the slides have been
printed on overheads).
● A whiteboard and whiteboard pens (for writing up feedback from participant exercises).
Participant requirement
Pens or pencils for writing in their copy of the Participant manual.
15
MODULE 1
Beginning the training session

Session time
10 minutes
To begin teaching this module you will need to do the following:
1. Welcome participants to the module
You may wish to facilitate an introductory activity (ice-breaker).
Example – have participants pair off and:

● introduce themselves and the area they work in
● discuss what they hope to gain from the training.
After a few minutes have passed re-assemble the group and ask each
participant to introduce their partner.
Show overhead slide
2. Housekeeping
Inform participants of the:
● program times
● breaks and meals
● toilets
● mobile phones
● message board
● occupational health and safety (fire escapes).
3. Outline principles of adult learning

● Everyone’s opinion will be respected.
● Participants’ work experience will be valued.
17
4. How Module 1 fits into the whole program
Module 1 is the first of four modules dealing with aggression prevention,

minimisation and management. This module is for all staff identified as being
at risk of workplace violence, and for some will be all that is required for aggression
minimisation training. Module 1 emphasises the workplace prevention of
aggression, basic skills required to de-escalate an aggressive situation and
appropriate reporting procedures after the incident. Additional modules will
address high-risk areas, managerial responsibilities and refresher training.
Show overhead slide
5. Structure of Module 1
HLTCSD6A – Respond effectively to difficult or challenging behaviour

This eight-hour program is designed for all staff. It is designed to meet the
Health Package competency HLTCSD6A – Respond Effectively to Difficult
or Challenging Behaviour. The day is divided into six parts:
6. Assessment of competency.
Show overhead slide
Inform participants that the learning outcomes and assessment align with the
national training guidelines and the Health Training Package.
MODULE 1
Aggression in the workplace –

facts and figures
The following is background information on the problem of aggression.

Facilitators may wish to draw out some key points from this and refer
to any local issues or data relevant to the problem of aggression and
aggression management.
Show overhead slide
Explain and discuss
Background reading
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 1 and 4 times per year.
19
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.
53% 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.
MODULE 1
Part 1
Understanding difficult or
challenging behaviour
Session time
50 mins
Session overview
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.
You are on Participant manual page 9
To teach this part you will need to have a copy of the NSW Health Zero
Tolerance Policy and Framework Guidelines to show the participants, and
enough copies of the zero tolerance brochure for all attendees. You will need
to be familiar with the contents of both.
The purpose of the introductory questions are:

1. to begin a process where participants actively own the responsibility for
aggression minimisation
2. to encourage a facilitative, active adult learning experience.
The aim of this part is to provide participants with an understanding of:

● the extent of aggression in the workplace
● the responsibility of all staff to manage aggression and its outcomes.
It is important to link the material in this module with local policies and procedures
at all times, and generate discussion of local issues relevant to the particular
participant group attending the training on the day.
21
Show overhead slide
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.
Show overhead slide
Ask the group

How many times are you exposed to aggression in your workplace?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
You would expect the answers to indicate that aggression is encountered on
a frequent basis, particularly bullying and verbal abuse. For some people it can
be encountered daily.
Whose problem is aggression in the workplace?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
It is expected that people acknowledge that aggression in the workplace is
everyone’s problem, including their own.
MODULE 1
Explain and discuss
Show overhead slide
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.’
Workplace aggression can be Targets of aggression include:

encountered from: ● you
● patients ● others
● relatives and friends of patients ● property.
● staff members
● members of the public
● intruders.
Explain and discuss
Show overhead slide
Effects of aggression
The effects of aggression4,7,8,9 on an individual can include:
● physical injury ● insomnia
● anxiety ● depression
● distress ● impaired decision making
● anger ● loss of self-confidence
● irritability ● severe fatigue
● self-blame ● fear of patients
● apathy ● difficulty returning to work.
Show overhead slide
The effects of aggression on the workplace10, 11,12 include:

● poor morale, erosion of worker loyalty and commitment
● reduced efficiency, productivity and public image
● costs associated with counselling, employee assistance, management time,
rehabilitation, recruitment and training of new staff
● increased sick leave, absenteeism and staff turnover
● costs associated with compensation, prosecution and penalties imposed on
the organisation.
A zero tolerance response to aggression

The zero tolerance approach to aggression does not mean that aggression
will never be encountered in the workplace. For example, in dementia and
brain injury units, aggressive and erratic behaviour can be a part of the condition
encountered. The zero tolerance approach to aggression highlights that no amount
of aggression in the workplace is acceptable, therefore all incidents of aggression
should be reported and managed utilising the principles covered in this module.
Facilitators need to be aware of the local zero tolerance policy and procedures.
MODULE 1
Show overhead slide
Explain and discuss
Outline the major components of zero tolerance.
Background reading
NSW Health is committed to the minimisation of violence in the public health system
and the focus should always be on the prevention of violence. However, in the event that
a violent incident does occur, NSW Health, as a result of a key recommendation from the
Taskforce on the Prevention and Management of Violence in the Health Workplace, has
adopted a zero tolerance response to threatening, abusive or violent behaviour by any
person towards any other person on health service premises, or towards NSW Health
staff working in the community.
The zero tolerance response means that in all instances of aggression, appropriate action
will be taken to protect staff, patients and visitors, and health service property from the
effects of such behaviour. It is about keeping staff, patients and visitors safe.
The zero tolerance response does not take the place of effective risk management,
and at all times the focus must be on prevention. However, in the event of an aggressive
incident, consistent action must be taken to minimise the impact on all concerned.
Options for action will be discussed in Part 3.
It should be noted that zero tolerance is NOT about taking punitive action against
patients whose violent behaviour is a direct result of a medical condition. In these
circumstances the emphasis is on prompt, effective clinical management and
compassionate care of the patient. At the same time the safety of the patient,
staff and others who may be affected by the aggressive behaviour is paramount.

Underpinning the zero tolerance response is the key message to staff that aggression
is NOT an acceptable part of the job, and is not something simply to ‘be put up with’.
For further information see the NSW Health Zero Tolerance Policy and Framework
Guidelines and supporting brochure.
The zero tolerance approach is crucial to this training. Refer participants to

the following table in their workbooks and explain and discuss each point.
Zero tolerance attitudes and behaviours

Putting up with violence in the health workplace IS NOT an acceptable part of your job
(if you don’t get the message, neither will patients and visitors).
Know your options when confronted with violent behaviour and exercise them consistently
(the most effective way of protecting yourself AND getting the message to patients and visitors).
Management will support you in utilising these options (this is part of their responsibility).
Report all violent incidents (problems that don’t get reported don’t get fixed).
Be aware of violence as an occupational risk (it is just as real as other more recognised
OHS risks eg manual handling, exposure to hazardous substances, etc).
Be vigilant of factors contributing to the risk of violence (prevention is better than cure).
Show overhead slide
Ask the group

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?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
It is expected that the answers here reflect the attitudes and behaviours
outlined on the previous page.
MODULE 1
Emphasise the following:

● Being aware of your local zero tolerance policy.
● Reinforcing attitudes and behaviours which indicate that violence is not an
acceptable part of the job.
● Actively contributing to aggression and violence risk management discussions
at meetings.
● Making sure that the zero tolerance approach is communicated to patients and
visitors, ie by making sure they have access to pamphlets that outline their rights
and what behaviour is expected when they are in the facility.
● Making sure that all related materials are provided for patients in their bedside
lockers and patient information kit.
● Keeping supplies in waiting areas, etc.
● Making sure key phone numbers and response codes are clearly displayed in
high-risk areas eg reception areas, nurse stations, in consulting rooms, etc.
Show overhead slide
Reinforce the key points.
Key points
● Aggression may be encountered in the workplace.

● Anyone can be a target.
● It affects both the individual and the organisation.
● NSW Health is committed to a ZERO TOLERANCE response to aggression in
the workplace.
MODULE 1
Part 2
Preventing aggression occurring
Session time
90 minutes
Session overview
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; how buildings and workplaces can be designed and redesigned to
prevent or reduce the risk of aggression occurring.
The most important aspect of this part is to emphasise that

preventing aggression is a far more effective strategy than focusing
on management of an aggressive incident. Prevention is the cornerstone
of aggression minimisation.
To lead this part the facilitator will need to be familiar with:

● NSW Occupational Health & Safety Act, 2000
● NSW Occupational Health & Safety Regulation, 2001
● WorkCover NSW Risk Management at Work Guide, 2001
● Crime Prevention through Environmental Design (CPTED) principles
● WorkCover Risk Assessment Code of Practice, 2001
● NSW Health Security Manual
NB. The NSW Health Design Series publication Health Facility Guideline – Security and Safety, released in
February 2003 provides useful information on CPTED principles.
There is a need to emphasise that everyone has a role in risk management and
aggression prevention.
29
Show overhead slide
Show overhead slide
Explain and discuss

What you need to know about keeping your
workplace safe
Under the NSW Occupational Health and Safety Act 2000 employers have a duty
of care for the health and safety of all people in the work place.b This requires
employers to:
● ensure that premises controlled by the employer where people work are safe and
without risk to health
● ensure that systems of work and the working environment are safe and without risk
to health
● ensure that any equipment or substance provided for use by the employees at work,
is safe and without risk to health when properly used
● provide necessary information, instruction, training and supervision for the health and
safety of their employees.
Show overhead slide
MODULE 1
Explain and discuss
Outline the major responsibilities of the act and regulation.
Background reading
This Act is supported by the Occupational Health and Safety Regulation 2001.
Employers under this regulation are required to:

● identify workplace hazards, including violence
● assess the risks associated with the hazards
● eliminate risks where possible
● implement risk control measures
● consult with employees, and their representatives throughout the process
● provide training.
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.
Show overhead slide
Explain and discuss
Outline the major points in risk management.
Background reading
Using a risk management approach to prevent aggression

Risk management is the process of identifying situations that are likely to cause
harm to people or property. The aim is to avert or diminish the chances of harm
by being proactive in seeking to prevent, or reduce, injury to people or property.15
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.
Risk management is an interactive process of clearly designed steps.15 By following the

steps outlined staff members can assist their managers to make better decisions on how
best to eliminate or control a risk by reducing it to its lowest possible level.16
Explain and discuss
The risk management process

Step 1. Identifying the problem (hazard identification) eg workplace aggression.
Step 2. Assessing the risk (determining how serious the aggression problem is).
Step 3. Eliminating or controlling the risk of workplace aggression by deciding what needs
to be done to solve the problem and in what order (risk control measures need to
be ranked from the most effective to the least effective).
Step 4. Monitoring, reviewing and improving the system.
SAFETY HINT – Report all instances of aggression. If instances are not reported
then they cannot be responded to via the risk management process.
Show overhead slide
MODULE 1
Ask the group

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?
Individual factors relating to an individual that may be associated with aggression

in the workplace.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Participant responses should include:
● clinical (patient factors)
● substance abuse/intoxication
● history of violence
● medical illness (eg dementia, delirium, psychosis)
● history of poor impulse control
● confusion
● anxiety/fear
● pain/grief
● head injury
● rejection and humiliation
● concerns or requests being ignored.
Physical environment associated with aggression in the workplace.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
● facility/unit location – is it near a hotel or club, in or near a high crime area or
used by locals as a short cut
● facility design and layout – location and layout of Emergency Departments,
reception and waiting areas, treatment and interview rooms, location of access,
public telephones, lighting, access to refreshments and toilets, air conditioning
● alarm systems and general security
● high-risk activities undertaken in the workplace, eg on-site storage of drugs
● parking areas – away from the workplace, poorly lit, dark spots and
hiding places
● entries and exits – multiple public access, lack of staff escape routes, doors
propped open for fresh air, exit doors that provide easy access to staff and
clinical areas
● Emergency Departments – poor separation of public and treatment or staff areas,
easy access to staff areas
● reception/waiting areas – poor staff view, easy access to staff areas, reduced
personal space, inadequate seating, lack of public facilities eg phones, toilets,
lack of privacy
● treatment/interview rooms – single access/egress point, inability to separate
patients from distraught, intoxicated or noisy family or friends.
Work systems and practices associated with aggression in the workplace.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
• working alone or in isolation
• having long waiting times
• working late at night
• patients not being given explanations regarding the reasons for long waiting times.
MODULE 1
Staff factors associated with aggression in the workplace.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers

● staff shortages
● lack of trained and experienced staff
● busy workloads
● personal issues (tiredness, stress, illness)
● ignoring patients
● not being polite.
Community work associated with aggression in the workplace.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers

● obtaining as much information as possible about the patient/client/business
prior to the first visit
● obtaining relevant information about other members of the household and
likely visitors when making home visits
● gathering information about the geographical location of the premises,
eg is it in a high crime area, geographically isolated, does it have reduced
accessibility to/availability of police
● acquiring specific information about the premises, eg is there security access,
stairs, external lighting, hiding places, are the premises modern, in good repair,
is phone connected, etc
● speaking to other staff who may have provided the services or inspected the
premises in the past
● where possible, speaking to the patient/client by phone prior to the first visit
to confirm the appointment, as this can also provide insights
● using as broad a range possible of information/resources eg point of referral,
relevant patient/client records, other staff, local GPs, local police.
How would you prioritise risks?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Inform participants that to identify and put in place effective risk
control strategies it is necessary to identify the level of threat posed by the
various risks and hazards. This provides information about those risks that
most urgently need action and helps prioritise others for future management.
Factors to consider when prioritising risks for remedial action include:

● the nature of the risk or hazard, eg physical, psychological, chemical
● the degree or severity of harm that the hazard/risk may cause
● how likely it is that harm will occur as a result of the exposure
● how often staff are exposed to the risk or hazard
● how long the periods of exposure are
● how many staff are exposed to the risk or hazard?
Show overhead slide
Explain and discuss
Eliminating or controlling risks

Eliminating or controlling risks involves deciding what needs to be done to eliminate
or control the problem of aggression and lessen the risk to the lowest possible level.
Under the Occupational Health and Safety Regulation 2001 employers are required to
eliminate any ‘reasonably foreseeable’ risks to the health and safety of their employees.
However this is not possible in all circumstances, therefore risk control measures need
to be implemented according to the hierarchy set out in the legislation.16 Prior to any
implementation of controls, the controls need to be ranked from the most effective
to the least effective. In most cases several control measures will be needed.
MODULE 1
Facilitator: Inform participants that not all risks can be eliminated, eg

to eliminate the risk of aggression in Emergency Departments very few
patients would be accepted. In this situation, controlling the risk rather
than eliminating the risk is the appropriate course of action. Other examples
of controlling the risk include:
● providing comfortable waiting areas with well maintained facilities
● providing regular updates to patients and visitors on waiting times and causes
for delay etc
● the use of duress alarms (personal and fixed)
● closed circuit television systems
● access controls
● security personnel
● effective triage systems
● aggression prevention and minimisation training for staff.
It needs to be ensured that risk control measures do not introduce new hazards
to the workplace. For example a post-operative patient not fully recovered, may
in a very busy ward get out of bed and therefore be at risk of sustaining an injury.
An example of a measure that could possibly be used to control this risk is the
introduction of bed rails. However, even with this safety measure there is the
potential for a confused post-operative patient to try and climb over the bed
rails and consequently be at risk of injury. Therefore, when selecting control
strategies, it is important to be mindful of not introducing new or more serious
risks. The above is an example only and other examples may be used.
Explain and discuss
Regulatory hierarchy for controlling risk16

1. Substituting a hazard giving rise to the risk with a hazard that gives rise to a lesser risk.
2. Isolating the hazard from the person put at risk.
3. Minimising the risk by engineering means.
4. Minimising the risk by administrative means (eg by adopting safe working practices or
providing appropriate training, instruction or information).
5. Using personal protective equipment.
Facilitator: For hierarchy of risk controls (examples the facilitator can mention)
Examples of engineering controls

● Designing out the risk or hazard when planning new premises, equipment
and work systems.
● Redesigning existing work environments, equipment and work systems to
eliminate the risks.
● Isolating the risk or hazard from staff.
Examples of administrative controls

● Rotating staff to reduce frequency and duration of exposure to the risk.
● Maintenance programs and housekeeping.
● Providing information and training.
● Developing procedures and protocols for hazardous activities.
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.
Facilitator needs to emphasise that this process is an active and ongoing one
with an emphasis on consultation between managers and staff.
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.
MODULE 1
Apply the four steps of risk management to this scenario.
1. Identify the hazard.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Assess the risk (how serious the problem is).
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3. Eliminate or control the risk (decide what needs to be done).
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
4. Monitor, review and improve the system.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Answers
Facilitator: These four steps are from the previous two pages and participants
should be able to break down the process – the hazard is bullying, the risk is
serious, steps need to be put in place to report, investigate and manage the
bullying with management, and this needs to be monitored. Staff may need
additional training. Jim may need counselling and assistance.
Show overhead slide
How the design of your workplace can prevent aggression

Explain and discuss
Crime prevention through environmental design (CPTED)2,17 and situational crime
prevention2,17 are approaches that can be applied to enhance building design.
These approaches decrease the possibility of crime occurring in the workplace by:
● increasing the risk for offenders
● making it harder for offenders to make up an excuse for the trespass
● reducing the likely rewards for criminal behaviour.
Ask the group

What is involved?
1. Territorial reinforcement.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Inform participants that ‘territorial reinforcement’ includes the idea
that people can be encouraged to view the health care setting as something
that is theirs. A sense of protectiveness of the facility by staff is an important
aspect of safety. In areas where staff only are permitted, staff are more likely
to pay attention to the area. Strategies include:
● being responsible for the facility and its use
● ensuring facilities have clear transitions and boundaries between the health
facility and the general community, and between staff only areas and other areas
● establishing clear visible signs on who is to use a space and its purpose.
2. Natural surveillance.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
MODULE 1
Answers
Facilitator: Inform participants that the surveillance principle refers to the

way in which work facilities are designed so that high risk sections can be
overlooked and watched by other staff going about in their normal day to day
tasks. Therefore good surveillance means that people within the health setting
can see what others are doing. Facilities designed with good surveillance
opportunities are less likely to be targeted by criminals as an area to
commit an offence. Strategies include:
● having clear sight lines between public and staff places
● good lighting for visibility
● ensuring that the areas that are landscaped are not places where offenders
have an opportunity to hide or entrap victims
● designing pathways to car-parks to be in full view of all passers-by and
overlooked by windows.
Improve surveillance
Facilitator: Inform participants that increasing visibility in the workplace

discourages offenders as it improves the chance of others witnessing and
reporting the offenders. Examples of strategies are in the list below:
● Adequate lighting in car parks, corridors and storage areas.
● Safety glass windows in interview rooms so patient/staff interactions can
be seen by outsiders while at the same time providing reasonable privacy
for patients and others.
● Closed circuit television.
● Large signs indicating that the workplace is being monitored continuously.
3. Space management.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Inform participants that space management refers to ensuring
that surrounding spaces around buildings are well maintained and cared for
and used appropriately. These include:
● keeping sites clean
● attending quickly to the repair of vandalism and graffiti
● replacing any burned out lighting
● removing or refurbishing decayed physical surroundings.
Improve fittings and furniture
Facilitator: Inform participants that the types of fittings and furniture used in
the workplace can reduce the risk of aggression by making it more difficult for
perpetrators to commit the crime and injure others. Examples of strategies are
in the list below:
● Ensure comfortable waiting areas.
● Have clear signage and give explanations for any delays.
● To ensure protection enquiry desks may be fitted with well designed,
clear screens with appropriately placed slits for communications and
passage of documents.
● Have duress alarms in discreet places.
● Ensure where possible that interview rooms have two doors.
● Ensure that furniture is comfortable but kept to a minimum.
● Provide easy access to food and drinks in waiting areas.
MODULE 1
More ways of keeping your workplace safe

Facilitator: Inform participants that controlling access to specific high risk

areas in the work environment through architectural or engineering designs
or redesigns is known as ‘target hardening’. Examples of strategies are in
the list below.
Explain and discuss

Keep your high-risk areas safe by using the following strategies:
● Deadlock drug storage areas.
● Designate safe escape routes.
● Have key or card access to staff working areas.
● Use metal detection systems.
● Install duress alarms.
● Minimise public entry points.
● Install barriers at reception desks.

NSW Health has developed the 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.
See also the NSW Health Security Manual.
Show overhead slide
Putting it all together

Explain and discuss
Use the Individual risk highlighter to help you identify the warning signs of
potential patient aggression. It may help you identify immediate triggers for
aggression in individual patients.
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.
Caveats and background

It is also important to recognise that staff or visitors may also be aggressive.

Although the following risk highlighter, risk awareness and risk reduction
checklists focus mainly on patient-initiated aggression, many of the same
principles apply to other sources of aggression.
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.
MODULE 1
The ‘Individual risk highlighter’ should be applied when:

1. staff feel afraid (trust the instinct)
2. person looks angry
3. person appears intoxicated
4. hunger and fatigue are present
5. person appears to be irrational or to have lost touch with reality
6. person seems to feel trapped and terrified
7. person is enraged or bizarre
8. there is a history of violence
9. person is accompanied by a crowd of others
10. person appears agitated and twitchy
11. person is demanding
12. person is very distressed.
Explain and discuss
Overview the following highlighter and checklists with participants. It is

recommended that the facilitator go through each one, discussing each
point and illustrating how the different factors identified can be associated
with increased risk of aggression. You may choose to invite participants to
volunteer relevant examples from their workplace to illustrate the points.
Individual risk highlighter

To be used for considering factors that increase the risk of violence in individuals.
Historical Behaviours that may indicate

1. History of previous violence. impending aggression
2. History of impulsiveness/risk taking behaviour. 1. Loud clipped or angry speech.
3. History of substance abuse. 2. Pacing.
4. History of childhood abuse. 3. Angry facial expression.
5. History of significant head injury. 4. Intense staring.
6. History of criminal behaviour, arrest 5. Refusal to communicate.

or imprisonment. 6. Threats or gestures.
7. Poor compliance to medication. 7. Physical agitation, eg clenching of fists.
8. Anti-social personality disorder. 8. Restlessness or fidgeting.
9. Few friends or family. 9. Delusions or hallucinations with violent content.
10. Young men. 10. Patient themselves reporting violent feelings.
11. Intoxication.
Current
12. The absence of a calming support person can
1. ‘Gut feeling’ of staff that person may exacerbate the situation.
be violent.
13. Aggressive to the environment, eg kicking
2. Recent stress (documented in notes or history). walls, banging doors.
3. Recent trouble with the law or arrest 14. Isolative behaviour.
(documented in notes or history).
15. Frequent demands.
4. Poor problem solving ability.
5. Substance abuse especially alcohol or
stimulants such as speed or cocaine.
6. Specific plan involving violence.
7. Potential victim is available.
8. Access to means – guns, knives, explosives
etc (documented in notes or history).
9. Agitated behaviour.
10. Current disturbed mental state, eg
head injury, intoxication, dementia:
– intoxication
– anger
– impulsivity
– depression
– mania
– hallucinations – particularly ones involving
violence or commands
– delusions – especially of infidelity, being
threatened, hypochondriacal, of violent acts,
or of a litigious or hyper-religious nature
– confusion/delirium/dementia.
MODULE 1
Violence risk awareness checklist
Individual factors Context

(client/visitors)
• Long waiting times.
• Intoxification or confusion. • Competing demands on staff.
• Hunger and fatigue. • High workload/busy.
• Head injury/psychosis. • Staff shortages.
• Humiliation. • Unpreparedness.
• Being ignored, rejected. • Unclear management plans.
• Concerns or requests dismissed. • Lack of timely information to
• Frustration/helplessness. patients, visitors or staff.
• Pain/grief. • Telephone ringing often.
• Anxiety/fear. • Cultural variation.
• Poor impulse control. • Presence of rival gang members.
• Anti-social personality. • Late at night.
• Narcissistic entitlement.
• History of aggression.
Risk
Physical environment Individual factors

• Crowded or noisy area. • Anxiety/fear.
• Inadequate space. • Personal issues – tiredness,
• Small examination rooms. stress, illness.
• Small, unclean waiting areas. • Inexperience.
• Dirty, poorly maintained areas. • Irritability.
• Isolated or dimly lit areas. • Discourteousness.
• Dangerous objects, eg scalpels, • Attitudes to different groups and
small oxygen cylinders, boxes, types of people.
breakable objects. • Ignoring patients, visitors,
other staff.
• Whispering about or openly
discussing confidential
information related to workplace.
What to do
• Take precautions.
• Alert others.
• Follow hospital procedure.
• Have clear patient
management plans.
• Apply ‘Individual risk highlighter’.
Violence minimisation checklist
Individual factors Context

(client/visitors)
• Update person about
• Be calm, don't confront. waiting times.
• Be aware of impact of • Regularly provide person with
environmental context and staff relevant information.
behaviours on patients, visitors • Rotate visiting support/family/
and other staff. other groups to reduce
• Anticipate effect of patient state congestion.
of mind. • Limit numbers of visitors.
• Speak to people courteously • Call for security or request Police
using their name. presence if rival gang members
• Try to understand main concerns, are present.
provide information. • Manage staff distribution/
• Emphasise a desire to help. placement to minimise the
• Allow ample personal space. impact of staff shortages.
• Set alert reminders to reduce
unpreparedness.
Risk • Clear management plans
reduction are available.
Physical environment Individual factors (staff)

• Well designed and maintained • Be attentive to patient/relatives
areas. concerns/needs.
• Reduce noise where possible. • Present a professional manner
• Good visibility. at all times to each other.
• Provide well lit, warm and tidy • Remain calm and courteous.
areas. • Buddy inexperienced staff.
• Provide distractions, eg reading • Provide timely information to
materials, toys, TV, good seating. patients, visitors and staff.
• Allow separation of patients, • Initiate staff wellbeing program.
What to do • Identify and provide suitable
visitors and staff.
• Limit the presence of dangerous • Take precautions/ interventions in high workload
objects, eg scalpels, small be vigilant. situations.
oxygen cylinders, boxes, • Alert others. • Participate in aggression
breakable objects. • Follow hospital procedure. management training.
• Familiarise yourself with • Be aware of patient's perceptions
specific management plans. of staff, ie don't stand and gossip
• Alert others to your in view of the public.
presence in isolated areas.
• Move patients or others
away from the disturbance.
• Allocate staff to provide
reassurance to patients
and their families in the
vicinity of the disturbance.
MODULE 1
Show overhead slide
What workplace strategies do you have?
Ask the group

What policies and procedures are in your workplace to manage an aggressive incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator: Familiarise yourself with local policies relating to the prevention

and management of aggressive incidents. Present them here. You may choose
to write these on the whiteboard.
What are your responsibilities in relation to workplace policies and procedures?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Participants should emphasise that it is everyone’s responsibility

to be involved in policy formation and carrying out procedures consistent with
these policies. It is also everyone’s responsibility to ensure their awareness of
the content of these policies.
How does your employer ensure that you have read and are up-to-date with current policies
and procedures on managing aggression?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Ascertain from participants what processes are in place to ensure

these policies have been read.
Show overhead slide
Key points to remember
● You have a key role to play in keeping your workplace safe.

● The risk management process involves identifying, assessing,
eliminating or controlling risks, and monitoring, reviewing and improving
the system.
● The design of your workplace plays an important role in
preventing aggression.
● Regularly monitor your workplace and the people around you.
MODULE 1
Part 3
Preventing aggression escalating
Session time
90 mins
Session overview
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.
Facilitator: Part 3 outlines the response options available for staff when a
person’s aggressive behaviour has begun to escalate. These response options
are then discussed outlining the appropriate timing for each, and the verbal and
non-verbal skills required for these options. The impact of cultural diversity is
also highlighted. Before leading this part, gain an awareness of the main ethnic
groups residing in the facility’s locality and catchment area and their differing
communication styles. You should also be aware of the relevant legal issues.
Show overhead slide
51
Show overhead slide
Levels of aggression
Explain and discuss
If an aggressive person confronts you, it can help to identify what level of aggression they
are displaying:
Level Examples of behaviour

Low Agitated, frowning, irritable.
Moderate Clenched fists, making direct verbal threats.
High Pushing, throwing, doing physical harm.
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.
Show overhead slide
Know your options for action

There are always options available when confronted with an aggressive person and
it is important that staff know the appropriate response options. These responses will
depend on a number of factors including the nature and severity of the event, whether
it is a patient, visitor or intruder, and the skills, experience and confidence of the staff
member/s involved. This may include going straight to calling for back-up, security
or local police.
MODULE 1
Explain and discuss

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.
Refer to Participant manual
Draw the participants’ attention to the following table on page 24.
Explain the following response options, emphasising that they are in no

particular order and that the circumstances referred to on the previous page
will affect which options are utilised. Also emphasise that at any time the staff
member feels it necessary, back-up should be called. The response options
below are a key component of the training.
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.
Show overhead slide
Explain and discuss
Deciding to stay or leave

An important decision to be made in a situation of potential aggression:
‘Do I stay or do I go’. When do you leave?
You should leave the situation when:

a. you feel you cannot control the situation or the situation is getting out of control
b. you endanger yourself or others by staying
c. when you are alone with an aggressive person.
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.
Ask the group

Consider some instances where you were confronted with an aggressive person.
What factors influenced your decision to stay or leave?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: You should expect participants to outline some of the reasons why
they came to this decision. These may be quite varied. Acknowledge all of them
and explain that the preceding list given is not exhaustive.
MODULE 1
Show overhead slide
When and who to call for back-up or help

Ask the group

If you feel unsafe at any time you need to call for back-up or help. Who can you call for back
up or help?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Answers may include security staff, peers, wards people and police.
Ask the group

Consider all of the above response options. Which would be suitable for the differing levels
of aggression?
Low ________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Participant answers should include:
● negotiating treatment
● issuing verbal warning
● using verbal de-escalation and distraction techniques
● seeking support from other staff.
Moderate ____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
● requesting that the person behaving aggressively leave
● negotiating treatment
● issuing verbal warning
● seeking support from other staff.
High ________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
● initiating unit emergency response
● initiating external emergency response
● leaving and seeking help.
Show overhead slide
MODULE 1
Danger and safety zones when faced with an

aggressive or violent person
Background reading
With a physically aggressive or violent person, the ‘danger zone’ is being in physical
proximity to the person so that you could be reached by a punch or kick. By keeping a
safe distance from the person, you will be in a ‘safer zone’. It is easier for an aggressive
person to lunge or move straight ahead than for them to move to the side or backwards.
Therefore, the ideal position to stand is out of the danger zone and slightly to one side
of the aggressive person.
Explain and discuss

Here is a suggested ideal stance:
● Stand in the safer zone not the danger zone.
● Stand slightly to the side of the person so they cannot lunge straight at you.
● Shift your weight to your toes so you can move quickly if needed.
● Place your hands in front of you in an open position.
● Ensure you face them so you observe them clearly.
Facilitator: You may choose to demonstrate these zones in front of the group in
a role-play with a volunteer.
Show overhead slide
Self help strategies to remain calm

Background reading
In order to manage or control a situation of impending aggression, it is important to
keep calm and in control. This involves acknowledging and managing our own feelings
and responses.
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.
Verbal and non-verbal de-escalation skills to prevent

aggression and violence
Verbal and non-verbal de-escalation skills are an important strategy for reducing and
preventing aggression and violence. These skills will de-escalate aggressive behaviour in
most, but not all aggressive people. It is important to recognise that de-escalation skills
include both verbal and non-verbal skills.
Explain and discuss
Show overhead slide
Background reading
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.
Explain and discuss
MODULE 1
Show overhead slide
Background reading
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.
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.
Briefly acknowledge feelings

It can be helpful to briefly acknowledge the person’s emotional state first, before
addressing their need. Often just communicating to the person your awareness of their
emotional state can immediately calm them. An example might be to say, ‘I understand
that you are angry and frustrated by this situation’. Once you have acknowledged their
emotions, you can then seek more information or provide possible solutions to their need.
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.
Help the individual to have their needs met

It is important to realise that most aggressive people simply want their needs met.
Let them know you will support them in this as much as you can, without making
promises that cannot be kept.
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;
or 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.
Refer to Participant manual page 28
Point out that the workbook has a summary of the skills.
Explain and discuss
Summary of verbal and non-verbal de-escalation skills
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.
MODULE 1
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.
Consider one of the stressful situations listed previously.
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 practice 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.
Walk around the groups and offer assistance where required.
Show overhead slide
Explain and discuss
Attitudes are important

People have different ways of communicating. Misinterpreting a person’s behaviour
can lead to aggression being unnecessarily escalated. This misinterpretation can have
two sources:
● Your attitudes and expectations about certain people.
● Misunderstanding communication styles of people from different cultures.
Background reading
Your attitudes towards people

Attitudes influence behaviour.18 Therefore the beliefs, values, ideas and knowledge held
by an organisation’s employees and management is reflected in the workplace culture.
Certain attitudes in staff19,20,21,22 have been found to be associated with aggressive
behaviour in patients, staff and others including family members or visitors.
Attitudes that increase the risk of aggressive behaviour include:

● not liking the person and projecting this onto them
● not treating the person with respect
● making assumptions about a person without finding out their needs or concerns
● interacting with the person as if you are a parent
● being authoritarian
● being inflexible
● being controlling
● using a threatening tone or behaviour
● being coercive
● being argumentative
● stigmatisation of others.
Show overhead slide
Misinterpreting diverse communication styles
Facilitator: As examples, discuss the main ethnic groups residing in the

facility’s locality and catchment area and their differing communication styles.
Inform participants that it is important that they obtain as much information
as possible on the diverse cultures within the area.
MODULE 1
Explain and discuss

People from a different background may have different characteristic behaviours to
your own. Some examples can include different rules and conventions about:
a. eye contact
b. stance
c. tone of voice
d. listening style
e. gestures
f. language
g. personal space
h. gender of person providing advice/care.
Background reading
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.
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 from 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 ‘I have the impression that you might be angry because
you are speaking loudly’. 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.
Explain and discuss
Strategies for improving communication with people from

a different culture
To improve communication with people from different cultural backgrounds the following
strategies are recommended.23
● Always accept and respect differences between and among people.
● If required use interpreters.
● If working in areas where the population or person is of a specific cultural background,
learn as much as possible about the culture and the way they communicate.
● Be aware that mistakes can happen and you can misinterpret the person.
● Promote a feeling of acceptance.
● Show respect and dignity for the person.
● Do not stereotype by age, sex, ethnicity, socioeconomic status, style of dress and other
social categories.
● Do not assume you know where a person has come from, let them tell you.
● Clarify as accurately as possible how the person is thinking and feeling.
● Reflect the person’s feelings verbally but do not be critical.
● Avoid any unnecessary or unfamiliar words.
● Restate the problem in more specific ways.
● Use the same time perspective as the person, eg if they are using past or future tense,
use the same.
● Avoid giving mixed messages.
● Do not speak too quickly.
● Do not raise your voice to speak more clearly unless the person is hard of hearing.
● Check that you have been understood.
Remember communication is also affected by context. The context in which an interaction

occurs will impact on the outcomes of the interaction.
● Is the person familiar with the ‘rules’, eg do they know that the waiting time is three
hours, as the sign is in English and they may not be able to read it?
● Has the client had previous experience in this context, eg the health setting?
● What are the client’s expectations?
● What are the culturally bound behaviours?
● How do I check these things out with the client in context?
MODULE 1
Explain and discuss
Show overhead slide
Background reading
What governs your actions in responding to aggression?

Both the perpetrator of aggression and the victims of aggression have rights that are
protected by legislative frameworks such as the Crimes Act and the Mental Health Act.
In addition, people have a common law right not to be harmed by the acts or omissions
of another person or organisation. It is important that when you consider and implement
your options, the rights of the perpetrator as well as your rights are considered. Legal
issues to be considered here include:
Mental Health Act 1990

This NSW Act governs the care, treatment and control of people with mental illness
and disorder. Its underlying premise is that people should be treated using the least
restrictive care. The Mental Health Act defines a mentally ill person as someone suffering
from a mental illness and owing to that illness there are reasonable grounds for believing
that care, treatment or control of that person is necessary for the person’s own protection
or for the protection of others from serious harm. This Act sets out the circumstances in
which this can happen, provides a framework of checks and balances and ensures that
interference with a person’s rights, dignity and self-respect is kept to the minimum
necessary to keep the patient and others safe.
Facilitator: Inform participants of the following points:

● The patient may not be able to leave the unit due to involuntary admission.
● The patient may not be able to refuse treatment due to involuntary admission.
● The patient has the right to receive treatment.
● The patient has the right to be in the least restrictive environment.
● The patient has the right to be treated with dignity and respect.
Crimes Act 1900

Under the Crimes Act 1900, people who commit assaults and other acts of violence in
NSW Health can be charged with criminal offences under the Act. The Act also allows for
apprehended personal violence orders to be taken out where a person has reasonable
grounds to fear personal violence, harassment or molestation.
Explain and discuss

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.
Explain and discuss

The principle of reasonable force
Section 418 of the Crimes Act 1900 states that a person may use self-defence if and
only if the person believes the conduct is necessary:
● to defend himself or herself or another person, or
● to prevent or terminate the unlawful deprivation of his or her liberty or the liberty of
another person, or
● to protect property from unlawful taking, destruction, damage or interference, and the
conduct is a reasonable response in the circumstances as he or she perceives them.
These provisions were introduced in February 2002.
This means that a person who assaults another person in self-defence is not criminally
responsible if acting in lawful self-defence. As stated above self-defence is not limited to
the defence of one’s own person, and can be used as a defence for assaults that occur
when protecting property or other people.
In the past the test was whether the perception of a threat was reasonable in the
circumstances, and whether a ‘reasonable’ person in the same circumstances would also
have been able to come to the same conclusion. The defence is now broader and states
that as long as the accused believed that they were under threat, it does not matter that
a ‘reasonable’ person may not have perceived such a threat in the same circumstances.
However, a reasonable response is still required for the law of self-defence to operate.
The law states that there must be some reasonable proportion between the threat
perceived by the accused and his or her response to it. So the key issue is that the
person threatened must be able to persuade a court that they felt threatened, that
the threat was real to them and that their response was appropriate.
MODULE 1
Facilitator: Reinforce that when using self-defence techniques, the force used
must be consistent with the threat perceived by the individual.
Explain and discuss

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.
Explain and discuss

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.
Some more strategies when faced with a violent person

Show overhead slide
Background reading
In some situations, despite all your efforts to prevent aggression escalating, you may
find yourself having to manage an aggressive or violent situation. You should be prepared
to respond in an appropriate way. In responding to the person who is aggressive, your
behaviour should be calm and show that you are in control, with no more forcefulness
than the situation requires. Always remember that safety of yourself and others is given
priority. Here are some more strategies and tips for dealing with these situations.e
● Never attempt to deal with a physically violent situation alone.
● Only one staff member should speak to the person, do not allow other staff to
interrupt as this may cause the physically aggressive person to become confused.
● Evasive self-defence may be required if you are attacked, followed by leaving
the situation if required. The principle of reasonable force should be taken
into consideration.
● Initiate your duress alarm or local emergency response. If necessary, dial (0) 000 and
ask for the police. The following information needs to be reported to the police during
the call:
– that an assault is in progress or has just taken place
– the name of the facility, address, your name and telephone number
– the exact location of the assault and number of people involved
– what the person(s) looked like (if a vehicle was used to get away – the type of
vehicle it was)
– whether any weapons were used.
● Have all witnesses wait for the police, or obtain their name, address and telephone
number if they insist on leaving.
● Have a staff member at the entrance of the facility to direct police to the scene of
the assault.
● Utilise post-aggressive incident management strategies.
MODULE 1
Show overhead slides in sequence with discussion
Explain and discuss

Response options for repeatedly aggressive people.
These long-term response options are an important component of the training.

Go through each and discuss.
Response options for repeatedly aggressive people

The following options could be considered for dealing with repeated aggressive behaviour:
● Formal patient management plans.
● Written warnings.
● Conditional treatment agreements.
● Exclusion from visits.
● Conditional visiting rights.
● Patient alerts in conjunction with support management plans.
● Formal recognition of inability to treat in certain circumstances.
● Taking out an AVO to protect staff.
● Having charges laid.

For further information, consult the following document: NSW Health Zero Tolerance
Policy and Framework Guidelines.
Show overhead slide
Key points
● Know your options when confronted with an aggressive situation.
● If you feel unsafe at any time call for back up.
● All times your priority is for the safety of yourself and others.
● Stay calm.
● Remember the danger and safer zones.
● Use appropriate verbal and non-verbal de-escalation techniques.
● Be aware of your own attitudes that may contribute to aggression.
● Always accept and respect differences between and among people.
● Keep in mind the legal issues surrounding your response options.
MODULE 1
Part 4
Bullying, harassment and
discrimination at work
Session time
60 minutes
Session overview
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.
This section aims to introduce participants to the issue of bullying, harassment
and discrimination in the workplace. Facilitators will need to know the local
policies and procedures relating to bullying, harassment and discrimination
in the workplace.
Show overhead slide
71
Scope of the problem

Ask the group

What is bullying, harassment and discrimination?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Inform participants that bullying may involve the bully having
a position of power over the person/people being bullied.
In the workplace this can be organisational power, however bullying in the

workplace is not restricted to this. Frequently in the workplace, the bully can
be in a junior position or a work colleague. In this case the power for the bully
is social or personal.
There are some analogies that can be made between bullying at school and
bullying in the workplace. An example at school is the bigger boys beating up
the smaller ones; likewise in the workplace an example is the supervisor bullying
their staff. An example of personal or social power in the school grounds is a more
popular younger pupil bullying one of the older less popular pupils. This person
has obvious social power and can mobilise other members of the class to exclude
the person from their games and call them names. Likewise in the workplace a
junior member of staff, that has been there for many years and has extensive
social networks, may bully a senior but more recent staff member. This can
result in social isolation.
MODULE 1
Ask the group

What behaviours are associated with bullying, harassment and discrimination?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: This is not an exclusive list and there are many behaviours
associated with bullying, harassment and discrimination.
● Consistent non-granting of reasonable requests.
● Sarcasm, put-downs.
● Consistently giving the worst jobs.
● Unreasonable criticism.
● Abuse (physical, verbal and/or psychological).
Facilitator: If criticism has not been raised by participants, raise this issue
and point out that when criticism is personal and not performance based, it
is bullying. Explain that not all criticism can be labelled as bullying. A distinction
needs to be made between reasonable and unreasonable criticism. Give the
example of a staff member displaying poor work performance. Explain this
needs to be addressed using the appropriate processes so that it cannot
be justified as bullying.
In addition, not all refusal of leave, transfer of applications or roster requests

can be labelled as bullying; only a certain number of staff can have annual
leave at certain times or days or on a certain day. The issue for bullying is
that there is a pattern of behaviour where there is a consistent non-granting
of reasonable requests. For example, if a staff member applies for annual leave
at Christmas, but enough people have already applied for Christmas leave,
then the non-granting of this request cannot be labelled as bullying.
Ask the group

What are the local policies for dealing with this?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator: Refer and talk about the local policies and procedures when
discussing the answers given.
Show overhead slide
Explain and discuss

The effects of bullying25,26, 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.
MODULE 1
Show overhead slide
The effects on an organisation25 include:

● increased absenteeism
● high staff turnover
● lower efficiency among staff experiencing bullying, harassment and discrimination
● more mistakes and accidents
● lower staff morale
● legal and tribunal costs
● compensation pay outs
● increased workers compensation premiums.
Show overhead slide
Explain and discuss
You have a role to play

You are able to promote a workplace that is free of bullying, harassment and
discrimination by 25:
● always treating others with respect
● when speaking to others, not condoning bullying, harassment and discrimination
● ensuring that personal behaviour does not support bullying, harassment
and discrimination
● reporting any incidents of bullying, harassment and discrimination immediately upon
witnessing them
● promoting anti-bullying, anti-harassment and anti-discriminatory behaviour.

For further information, consult the Joint Management and Employee Association Policy
Statement on Bullying Harassment and Discrimination.
Facilitator: Explain that in some circumstances there may be a case for initiating
legal action against a person who is bullying.
Explain and discuss

Some legal considerations
Defamation is the publishing (written or verbal) of material that will damage the reputation
of a person. It may lead to the ridicule, hatred or contempt of the person.
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.
Defenses against defamation

● Absolute privilege where the right for free speech is more important than the rights of
the individual.
● Qualified privilege where privilege exists, however malice would destroy this privilege.
● Public interest, ie where it is in the public interest to know.
Explain and discuss
Show overhead slide
Background reading
Overview the key points here.
MODULE 1
How to confront a person who is bullying, harassing

or discriminating against you
Not everyone lacks assertiveness to confront persons who are bullying, harassing or
discriminating, however, there are skills you can use so that you do not lose your temper
and embarrass or humiliate yourself.26
1. You need to understand why confrontation can work

Persons who bully, harass or discriminate usually lack appropriate social self-controlling
behaviours. By confronting the person this means that you are putting controls on
them. For example, an opening statement could be, “I’m sorry you feel you have
to demean and degrade me and I have no idea why you do this, but I will not put
up with this sort of behaviour. There is no place for this kind of behaviour in this
department/facility unit”.
2. When confronting the person, it might be helpful in some situations

to do this in private
This is so that the person is unprepared and has no witnesses. If there are witnesses
then these people should be your allies who support you and who may have been in
similar situations, and not people who support the bully.
3. Specify the specific behaviours and don’t use labels

Refrain from using statements such as, ‘I don’t like the way you bully me’ or
‘Stop putting me down in front of my colleagues’.
Try to use statements such as, ‘I find it unacceptable that you publicly criticise my
work. If there is a need for you to do that, could you please do it in private’.
4. Keep things simple

People who bully, discriminate or harass may have deep-seated motivations.
However it is best not to try and delve into or analyse what is motivating them to
behave in the way they do.
5. Describe to the individual the consequences of their behaviour on others

If you know that the person is doing the same to others it is reasonable to let them
know about this.
For example, ‘Several of us have noticed how Jane seems to be depressed and
upset recently. One of the reasons for that may be that you ridicule her work. Like me,
she would rather that if you had concerns with her work that you discuss them with
her privately’.
6. Reinforce the message

No matter what the person is trying to say in a confrontation keep the message clear
on what type of reputation they are making for themselves.
For example, ‘You know how you embarrass me when you ridicule me in public,
but you are not aware that you are also humiliating yourself. People see this behaviour
as a weakness and not a strength’.
7. Give positive alternatives

Try to think of some positive alternatives.
For example, ‘You were not always like this. I remember when you had a really good
effect on others, when you praised their work’. This type of statement makes it clear
that the person can behave in a positive and acceptable way and it is also a good
ending for the confrontation.
8. Keep a diary of events

Keep a diary of each incident.
For each incident include what circumstances led to the incident, who was present,
what type of behaviour was displayed and how you felt. These records may need to
be used in subsequent interviews with senior managers.
Show overhead slide
Explain and discuss
How to formally make a complaint

● Report the incident.
● Name any witnesses.
● Provide details in the complaint about:
– who was involved
– when it happened
– what happened
– consequences for you.
● Seek support in this process.
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.
MODULE 1
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.
Explain and discuss

Rights of the person making the complaint
The person who believes they are a victim of bullying, harassment or discrimination at
work has the right to:
● make a complaint
● be free from victimisation from having made this complaint
● have access, advice and support from either the Human Resources Unit or a professional
or industrial body
● have themselves and the complaint kept confidential.
Rights of the person that is being complained against

The person who is being complained against has the rights to:
● be informed of the complaint
● be able to respond to the complaint
● have the opportunity for representation in their response
● have themselves and the complaint kept confidential.

Discuss the obstacles to overcoming bullying, harassment and discrimination in your own
workplace and some possible solutions.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
This is a useful activity in small groups as it gives participants an opportunity to

discuss workplace bullying in a smaller and safer environment. Ask participants
at the end to share some reflections on the problems and solutions discussed.
Show overhead slide
Key points
● Bullying, harassment and discrimination affects the individual

and organisation.
● You have a role in promoting a workplace free of bullying, harassment
and discrimination.
● Report all incidents of bullying, harassment and discrimination.
MODULE 1
Part 5
Reporting and reviewing
aggressive incidents
Session time
60 minutes
Session overview
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.
The focus of Part 5 is to provide an understanding to all staff of the necessity

for and process of:
● reporting an incident
● the requirements of an investigation
● seeking support after an incident
● self care after an incident
● facilitators will require knowledge of local policies and documentation regarding
reporting an aggressive incident, the investigatory process and the care of staff
after aggressive incidents.
NB. Employers also have duties with regard to the above.
Show overhead slide
81
Background reading
Reporting aggressive incidents

All aggressive incidents need to be reported and documented on the appropriate
forms1,13,28 and, where relevant in the patient’s clinical notes. This includes verbal threats,
bullying, ‘near miss’ events, workers compensation claims, property damage insurance
claims, and security incidents. Depending on the nature of the aggressive incident, some
incidents will be reported by managers to the Health Executive, the NSW Department of
Health or other external agencies, eg WorkCover NSW, NSW Police, Department of
Community Services or the Treasury Managed Fund.a
Ask the group

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?)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Facilitator: It is useful to consider common objections to writing incident

reports. These can include:
● the incident was not seen as serious enough
● perception that nothing would be gained
● fear of being blamed for the incident
● feeling that management would not be supportive
● the incident may reflect badly on the victim
● in areas where many incidents involve low levels of aggression, staff feel other
duties are unable to be completed if they are continually completing incident
forms for less serious incidents
● fear of victimisation
● avoidance and denial of aggression
● bullying is less likely to be reported unless it is repeated and has escalated
in intensity.
MODULE 1
Reporting incidents is a key strategy of a zero tolerance response.
Show overhead slide
Refer to list of tips.
Key points
Emphasise the following key points below.
Tips for writing incident reports
● Make sure it can be easily read and understood.

● Incident reports and notes have the potential to be a legal document.
● Do not use ‘white-out’ (correction fluid).
● Focus on the facts of the event and what was witnessed
without interpretation.
● Keep your reports emotionally neutral.
Show overhead slide
Explain to participants that all significant reported incidents should

be investigated.
What to expect from an investigation of an

aggressive incident
Ask the group
Why do you think it is important that aggressive incidents are investigated?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: Answers should include:

● staff have access to information necessary to the risk management process
● incidents can be investigated, their causes and contributing factors identified,
and their recurrence prevented
● facilities are able to meet OHS legislative requirements and departmental
reporting requirements
● information can be assessed to determine such things as severity of the
event, task type and location, perpetrator characteristics, day/time eg Saturday
night and possible causes/contributing factors. This information will assist in
identifying high risk circumstances, times, locations, tasks and employee groups
which in turn provides a good starting point for identifying risk control measures.

For further information on aggressive incident investigations, consult Effective Incident
Response: A Framework for Prevention and Management in the Health Workplace.
MODULE 1

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?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Answers
Facilitator: After participants have informed the larger group of their

answers, inform participants that staff can expect that the incident be
promptly investigated and that the investigation is:
● conducted in a supportive and non-judgmental way
● focused on identifying the underlying root cause/s and contributing factors
● conducted without apportioning blame
● focused on system breakdowns and identifying control measures to prevent
a recurrence.
Explain and discuss
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.
Type of stress reactions that can be experienced

● Positive reactions – feeling strong, concerned for others in an unselfish way, increased sense of
personal worth and achievement.
● Physical – fatigue, sleep disturbance, hyperarousal, eg hypervigilance, somatic complaints
(psychological disorders with physical symptoms).
● Emotional – shock, anger, irritability, helplessness, loss of control, numbness, being fearful
and helpless.
● Cognitive – poor concentration and memory, worry, intrusive thoughts, flashbacks.
● Interpersonal – social withdrawal, relationship difficulties.
● Substance abuse.
● Acute or Post-traumatic Stress Disorder.
Facilitator: If staff members do not know the difference between Acute Stress
Disorder and Post-traumatic Stress Disorder explain the difference.
Post-traumatic Stress Disorder – may result from exposure to a very severe

or life threatening incident. Symptoms range across three clusters comprising of:
1. re-experiencing, eg flashbacks, intrusive recollections, nightmares
2. avoidance and numbing, eg avoidance of reminders of the trauma,
emotional detachment, withdrawal and dissociation
3. hyperarousal symptoms, eg hypervigilance, concentration and
memory problems.
Symptoms must be present at least one month post-incident and symptoms must
be severe enough to impair normal functioning.
Acute Stress Disorder – is an acute (short-term) form of Post-traumatic

Stress Disorder. The person experiences dissociation, re-experiencing,
avoidance and hyperarousal.
MODULE 1
Show overhead slide
Participants may wish to write down the following in their workbooks.
Depending on your reactions the following types of support should be available

to youb:
Psychological first aid – Immediate social and practical help
Facilitator: Inform participants that psychological first aid is an initial

intervention following an incident. It focuses on the establishment of safety,
providing basic human needs and physical care, ie comfort, support, safety
and communication. The focus is on providing practical help.
Employee assistance programs
Facilitator: Inform participants about the local Employee Assistance program.
Peer support programs
Facilitator: Inform participants that peer support programs use volunteers
that are trained in appropriate methods for assisting colleagues in their
workplace. This is not counselling or therapy. Identified peer support persons
should not have been directly involved in the incident and such assistance
is only implemented if the affected person has agreed.
Supportive or specialised counselling
Facilitator: Explain to participants the difference between supportive and

specialised counselling.
Supportive counselling is carried out by a trained counsellor for an acutely

distressed person. It involves comforting and reassurance, practical advice,
allowing the person to discuss their experience (only if they feel they need to
do so) linking them to support networks, and identifying those at risk who may
need follow-up and specialised services.
Specialised counselling is for people experiencing severe or prolonged distress

or disturbance following an incident, or for those determined to be at significant
risk of adverse outcomes and is provided after appropriate clinical assessment.
A specialist clinical professional (usually with mental health training) provides this
counselling and it may be linked to a range of other interventions. The specialised
counselling should be provided by a clinician with whom the distressed staff
member has no working relationship.
Supportive group discussion
Facilitator: Inform participants that supportive group discussion involves

groups of people who have been affected by an incident coming together
naturally in the aftermath to talk through or discuss their experience. This is
often seen as helpful and people may consider it an opportunity to ‘debrief’
about their experience.
Formal critical incident debriefing is no longer recommended by NSW Health

as a structured intervention post-incident.
MODULE 1
Operational debriefing
Facilitator Instruction
Facilitator: Inform participants that operational review and debriefing is the

process of analysing the effectiveness of the response to, and management of,
the specific incident. It allows for any necessary improvements to be made to
the duress response procedure and incident management plans. Operational
procedures should include:
● involving staff who experienced the incident
● with others who may have been involved, eg police
● identifying the positive and negative aspects of the response
● identifying ways of improving future response
● producing a brief, documented summary of findings, recommendations
and outcomes
● allocating responsibility for implementing improvements.
Mental health care
Facilitator: Inform participants that specialised mental health care may involve
psychiatric treatment, which may include counselling and possibly medication
for those who have developed psychiatric problems.
Other practical help
Facilitator: Inform participants that other practical help may be offered, such
as transport home after an incident, and help if children need to be picked up.
Show overhead slide
Explain and discuss
Self care following an aggressive incident

How you react to an aggressive incident may interfere with the way you function at work
and in your personal life for a period of time.
The following strategies can help you to deal with these reactions.h
You might like to write down some suggestions from participants for each of
the following.
Use your own distress tolerance skills.
______________________________________________________________________________
______________________________________________________________________________
Facilitator: Inform participants that dealing with the distress includes:

● accepting that you are distressed and expressing your feelings
● using controlled breathing techniques, meditation or relaxation techniques
that work for you
● going slow, doing one thing at a time (set small realistic goals and use small
tasks to achieve these goals)
● looking after yourself (make time for physical exercise, keep a healthy balanced
diet, avoid excessive caffeine, alcohol, sedatives and nicotine).
Take time out.
______________________________________________________________________________
______________________________________________________________________________
Facilitator: Inform participants that taking time out includes:

● having lunch, morning and afternoon tea breaks and chats with colleagues
and peers
● taking time out to do hobbies or other meaningful activities for yourself
● making time for stress management activities.
MODULE 1
Use time management strategies.
______________________________________________________________________________
______________________________________________________________________________
Facilitator: Inform participants that some time management strategies includes:
● scheduling, planning and prioritising tasks
● setting goals for what you want to achieve
● giving yourself a reward for completing tasks.
Don’t always be alone.
______________________________________________________________________________
______________________________________________________________________________
Facilitator: Inform participants that engaging family, social and work support
is important.
Develop self-awareness and mindfulness.
______________________________________________________________________________
______________________________________________________________________________
Facilitator: Inform participants that self-awareness and mindfulness includes:

● engaging in activities and tasks for the intrinsic value of doing so
● focusing on the process rather than the outcome. Look at what you’re doing
and how you’re doing things – take note and be aware of this. Look at what
works and doesn’t work
● focusing on what you’re doing at the time rather than dwelling on the past
or present.
Use techniques for starting and finishing each day.
______________________________________________________________________________
______________________________________________________________________________
Facilitator: Inform participants that transition techniques for starting and

finishing each day includes:
● reviewing each day and looking at what you have done well today
● keeping to your normal routine
● winding down at night time
● preparing for each new day.
Individual reflection exercise

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.
Facilitator: Give participants time to complete this by themselves in class,
or you may suggest they do it after the workshop.
What I do now What I would like to try

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
MODULE 1
Explain and discuss
What support can you expect from your manager

You can expect your manager to support you with the following:
● Assistance with appropriate support mechanisms.
● Not forcing you to provide care for a patient who has injured you.
● Support when you return to work.
● Providing access to injury management programs, eg return to work programs,
rehabilitation, retraining.
● Help with compensation issues.
● When a request has been made for police to take out an AVO on behalf of you.
● When a request has been made for police to press charges.
● During any court hearings.
● If you need to attend the police station to make a statement.
● Support at any other times during the legal process.
Show overhead slide
Key points
1. Report and document all aggressive incidents.

2. Intense emotions and stress reactions can be experienced following
aggressive incidents.
3. Support mechanisms in the workplace are available.
4. Self-care is important.
5. You can expect your manager to support you.
Assessment
You are now to conduct the assessment for this module. The assessment
exercise is described at the beginning of this module. Case scenarios,
assessment question sheets and the marking guide can be found at the
back of the Facilitator manual. The CD-ROM contains a separate document
including the case scenarios and assessment question sheets, for the
purpose of printing copies to hand to participants.
At the conclusion of the assessment the module has been completed.

Reinforce the message that participants should read and review their
participant manuals from time to time.
Show overhead slide
MODULE 1
Related NSW Health

policies and guidelines
a. NSW Health Zero Tolerance Policy and Framework Guidelines.

b. C2002/19 Effective Incident Response: A Framework for Prevention and Management
in the Health Workplace.
c. C2001/22 Workplace Health and Safety: A Better Practice Guide (currently under review).
d. Design Series (DS) Health Facility Guideline – Security and Safety 2003.
e. NSW Health Security Manual.
f. C2002/50 Joint Management and Employee Association Policy Statement on Bullying,
Harassment and Discrimination.
g. Mental Health for Emergency Departments, May 2002 (red book).
h. Management of Adults with Severe Behavioural Disturbance, May 2002 (green book).
i. C2003/88 Reportable Incident Briefs to the NSW Department of Health.
j. C94/127 Policies on Seclusion Practices, the Use of Restraint and the Use of IV Sedation in
Psychiatric In-Patient Facilities (currently under review).
95
MODULE 1
References
1. Mayhew C, Chappell D (2001a). Occupational violence: types, reporting patterns,

and variations between health sectors. Working Paper Series no. 139, School of Industrial
Relations and Organisational Behaviour and the Industrial Relations Research Centre, paper
written for the Taskforce on the Prevention and Management of Violence in the Health
Workplace, University of NSW, Sydney.
2. Mayhew C, Chappell D (2001b). Prevention of occupational violence in the health workplace.
Working Paper Series no. 140, School of Industrial Relations and Organisational Behaviour
and the Industrial Relations Research Centre, paper written for the Taskforce on the
Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney.
3. Mayhew C, Chappell D (2001c). Internal violence (or bullying) and the health workforce.
Working Paper Series no. 141, School of Industrial Relations and Organisational Behaviour
and the Industrial Relations Research Centre, paper written for the Taskforce on the
Prevention and Management of Violence in the Health Workplace, University of NSW, Sydney.
4. O’Connell B, Young J, Brooks J, Hutchings J, Lofthouse J (2000). Nurses’ perceptions of the
nature and frequency of aggression in general ward settings and high dependency areas.
Journal of Clinical Nursing, 9 (4), 602-610.
5. Barlow K, Grenyer B, Ilkiw-Lavalle O (2000). Prevalence and precipitants of aggression in
psychiatric inpatient units. Australian and New Zealand Journal of Psychiatry, 34, 967-974.
6. Farrell GA (1999). Aggression in clinical settings: nurses’ views – a follow-up study.
Journal of Advanced Nursing, 29 (3), 532-541.
7. Everley GS, Lasting JM (1995). Psychotraumatology: key papers and care concepts in post
traumatic stress. New York: Plenum Press.
8. Ilkiw-Lavalle O, Grenyer B (2003). Differences between patient and staff perceptions of
aggression in mental health units. Psychiatric Services, 54, 389-393.
9. Perrone S (1999). Violence in the workplace. Research and Public Policy Series no. 22,
Australian Institute of Criminology, Canberra.
10. Baron SA (1996). Organizational factors in workplace violence: developing effective
programs to reduce workplace violence. Occupational Medicine: State of the Art Reviews,
11 (2), 335-348.
11. Fletcher TA, Brakel SM, Cavanaugh JL (2000). Violence in the workplace: new perspectives in
forensic mental health services in the USA. British Journal of Psychiatry, 176, 339-344.
12. Smith-Pittman MH, McKoy D (1999). Workplace violence in healthcare environments.
Nursing Forum, 34 (3), 5-13.
13. Jones J, Lyneham J (2000). Violence: part of the job for Australian nurses? Australian Journal
of Advanced Nursing, 18 (2), 27-32.
97
14. Erickson L, Williams-Evans SA (2000). Attitudes of emergency nurses regarding patient

assaults. Journal of Emergency Nursing, 26 (3), 210-215.
15. WorkCover NSW (2001). Risk management at work guide [On-line].
Available www.workcover.nsw.gov.au/
16. Illawarra Health. (2001). Risk management in occupational health and safety. Development
Version for OHS Task Force Review. Risk management Unit, Human Resources Department.
17. Bowie V (2000). Preventing and managing violence by intruders in the workplace: situational,
organisational and societal response. Journal of Occupational Health and Safety:
Australia and New Zealand, 16, 5, 443-448.
18. Poster EC, Ryan JA (1989). Nurses’ attitudes toward physical assaults by patients.
Archives of Psychiatric Nursing, 3 (6), 315-332.
19. Beech P, Norman IJ (1995). Patients’ perceptions of the quality of psychiatric nursing care:
finding from a small-scale descriptive study. Journal of Clinical Nursing, 4, 117-123.
20. Lowe T (1992). Characteristics of effective nursing interventions in the management of
challenging behaviour. Journal of Advanced Nursing, 17, 1226-1232.
21. Quintal SA (2002). Violence against psychiatric nurses: an untreated epidemic?
Journal of Psychosocial Nursing, 40 (1), 46-53.
22. Mental Health Council of Australia. (2000). Enhancing relationships between health
professionals and consumers and carers – Final Report.
23. Kavanagh KH, Kennedy PH (1992). Promoting cultural diversity: strategies for health care
professionals. California: Sage Publications.
24. Field T (1996). Bully in sight. Oxfordshire: Success Unlimited.
25. McCarthy P. Henderson M, Sheehan M, Barker M (2001). Bullying. Module 7 – The CCH
Equal Opportunity Training Manual. Commercial Clearing House (CCH), North Ryde,
50,001-50,453.
26. McMillan I (1995). Loosing control. Nursing Times, 91 (15), 40.
27. Randall P (1997). Adult bullying: perpetrators and victims. London: Routledge.
28. Macdonald G, Sirotich F (2001). Reporting client violence. Social Work, 46 (2), 107-114.
29. Rees C, Lehane P (1996). Witnessing violence to staff: a study of nurses’ experiences.
Nursing Standard, 11 (13-15), 45-47.
MODULE 1
Module 1 assessment
Aggression minimisation scenarios

1. Support staff.
2. Mental health.
3. Enrolled nurse.
4. Registered nurse.
5. Food services.
6. Administration.
7. Community – generalist.
8. Community mental health.
9. Youth worker.
10. Bus driver.
11. Drug and alcohol.
12. Security.
13. Medical officers.
99
Scenario 1: Support staff

Aggressor
Pat Wild – 50 years old
Pat is a homeless person walking along a poorly lit highway, when he was struck by a car.
He doesn’t remember this very clearly.
The car did not stop, but a passing motorist called an ambulance, and in a semi-conscious state
Pat was taken into the Accident and Emergency Department.
He awoke to find you trying to take off his trousers.
He is extremely alarmed and frightened.
He begins to raise his voice and yell:

“What the bloody hell do you think you are doing?”
Defuser
Sid Barrat – (Personal services assistant) PSA
You are a PSA working on evening shift in the Accident and Emergency Department.
A fifty year old homeless person who was struck by a car is brought in.
He is in a dirty, dishevelled state. He appears to be in a semi-conscious state.
You begin to undress him, in readiness for examination by a doctor.
MODULE 1
Scenario 2: Mental health

Aggressor
Bob Jones – 59 years old
Bob has been put in the mental hospital again for a break, and to make sure he takes his
medication. He thinks it is not too bad, except they take his cigarettes, and hassle him to
have showers all the time when he believes there’s nothing wrong with him.
He has just gone back to bed after breakfast for a rest when you come in and tell him to
have a shower and get dressed. You want to take his dressing gown away and place a shirt
and pants out for him to wear. He doesn’t mind the shirt, but feels very uncomfortable about
the pants. He has told hospital staff over and over again that he is half man, half woman.
They must be either liars or idiots.
When you come back a second time, and approach him, he tells you to:
“Bugger off, you silly bitch.”
Defuser
Jenny White – Registered nurse
You are working in psychiatric unit and have an older chronic schizophrenic man on your
client load today. This man lives with his elderly brother who has done his best to take care
of his sibling through his many acute psychotic episodes, and his wandering ways.
Bob often disappears for days on end and always has a personal hygiene problem. He is rarely
functional enough to think of showering, shaving, or even changing his clothes. This is usually
supervised by his community nurse when he is out of hospital. He has the delusion that he is
‘half man’, ‘half woman’ among others, and appears to have continual auditory hallucinations.
Though physically he is a big man, he is usually a gentle soul, so it shocks you when you go
to his room for the second time that morning to prompt him to have a shower and get out
of his old, smelly, cigarette and food-stained dressing gown and he sits suddenly upright
in bed, glares at you and yells:
“Bugger off, you silly bitch.”
Scenario 3: Enrolled nurse

Aggressor
Mr Sainsbury – Lawyer
Mr Sainsbury is visiting his child in the paediatric unit of Sandtown Hospital. He was at a friend’s
wedding when he received a call to say his six year-old child was knocked over by a car.
He has a younger child, and since his wife died twelve months ago, he has been struggling
to maintain his legal practice and to be a father and mother to both of his children.
He is extremely worried about his son as he has multiple injuries and is barely conscious.
He is dying for a cigarette, but he does not wish to go too far from his child’s bedside.
He decides to step into the hall and have a quick smoke while they are taking his observations.
Suddenly you come up beside him, and start telling him to put out his cigarette. He at first
tries to explain he is only going to have a few puffs, when you call him inconsiderate.
He sees red, and is determined not to let this bitch push him around!
Defuser
Nurse Moore – Enrolled nurse
You are working in a paediatric unit on a Saturday afternoon. You can smell cigarette smoke.
You follow the smell out into the corridor to investigate.
You see a tall, thin man, who is slightly dishevelled, but well dressed. He is smoking and
swaying slightly.
You tell him that he is not able to smoke here, and that he will have to go outside, explaining
that he is being inconsiderate by smoking in a hospital.
MODULE 1
Scenario 4: Registered nurse

Aggressor
Mrs Steele
Mrs Steele has just come to visit her beloved elderly mother in the nursing home to which she
was admitted three weeks ago. Mrs Steele had cared for her as long as she possibly could at
home, but with a family of teenagers, husband, dog and a part-time job, she found that looking
after her mother adequately was beyond her.
It was upsetting enough to have to put her in a home, but to make it worse, each time Mrs Steele
visits she has found her with:
● dried bits of food on her face
● a wet bed and nightdress
● the wrong clothes – even though she have supplied a dozen outfits and sets of nightclothes.
Mrs Steele is so angry she asks to see the nurse in charge, and demands to know why her
mother is not being cared for.
She has had enough, and feels like reporting the nursing home to the authorities.
Defuser
Nurse Andrews – 35 year old registered nurse
You work in a nursing home on Friday, Saturday and Sundays as you are also studying part-time.
In the past couple of weeks you have heard comments in passing about the relative of an elderly
woman who was admitted recently. Apparently this person is very critical and always complains
about something at every visit. The staff have been known to say:
“Stay out of the way when the relative visits.”
You are in the clinic room preparing for the evening medication round when this relative appears
at the door, red-faced and yells at you:
“I can’t believe what goes on in this place... I thought you were supposed to care for people
here... It is an absolute disgrace! I intend to report you to the authorities.”
Scenario 5: Food Services

Aggressor
Jack Gleeson – 52 year old farmer
Jack Gleeson is in a surgical ward recovering from an abdominal operation he had four days ago.
He is a farmer with a normally healthy appetite. Because of his surgery and tests in the previous
week, he has not had a decent meal for some time.
Since surgery, he has gradually been introduced to solid food. However, in the past two days:
● his menu was lost, and he only received a meal after he had to make several inquiries
● he has had his meal preferences changed without anyone consulting him
● his meals are usually luke-warm and bland
● his evening meal, which he has been looking forward to all day, has just arrived – it is cold
and it is a very small helping
● he has HAD ENOUGH! He rings for the nurse, and yells:
– “How the hell do you people expect us to get well when you feed us such tripe!?”
– “I want to see the Matron of the hospital, so that I can give her a piece of my mind!”
Defuser
Mavis Davis – Food services
You are doing an evening shift on a Saturday after returning from three weeks leave.
It is a busy surgical ward, and you are just starting to get to know the patients.
Suddenly, just after the evening meals are delivered, there is a buzzer and a large middle-aged
male patient starts bellowing at you about the food, and demanding to see the ‘Matron’.
MODULE 1
Scenario 6: Administration
Aggressor
Harold Johnston – 22 years old
Harold Johnson is a twenty-two year old from a non-English speaking background. He lives
in the local area, with his aunt, uncle, father and four brothers. There is a group of teenagers
in the area who regularly gang up on him and assault him physically and verbally. Tonight he
has been attacked again just outside the hotel where he was having a quiet drink with his friends.
His friends have taken him to the Emergency Department at the hospital as he has a laceration
over his right eye which may need stitching. As he enters he notices that the Accident and
Emergency Department is not very busy, there is only one other person in the waiting room.
He comes to the desk and asks you how long he will have to wait. You are busy shuffling
papers and tell him, “We will get to you when we can.” He feels upset, he is injured and in
pain and he wants to be treated immediately. He swears at you in a loud voice and tells you,
“If I am not seen immediately I will put a cut over your eye and see how you feel!”
Defuser
Kim Jackson – Receptionist
You are working in the Accident and Emergency Department at 11 o’clock at night. You attend
to a person at the desk who has been brought in to have a laceration over their right eye stitched.
You vaguely recognise them as young person who lives near your family. As you come closer
you smell alcohol on their breath. The casualty waiting room is quiet, but all the beds are full and
nursing staff are busy with car accident victims brought in the last half hour. You tell the patient,
“we will get to you when we can”. He swears loudly at you and threatens to physically hurt you.
Scenario 7: Community – generalist

Aggressor
Trevor White – 70 years old
Trevor White returned home four days ago from hospital following an operation for abdominal
cancer. In hospital he developed a number of complications due to:
i. infection of his wound site
ii. an allergic reaction to drugs which were given, and
iii. an ulcer on his left shin which developed following a fall in the hospital bathroom.
He has been told that a nurse will visit twice each day to change his dressings. Until then,
he cannot be showered. He wants to maintain his personal standards despite this damn
disease, and it angers him that the nurse comes at a different time each day, sometimes
even after 12 noon.
His lifelong companion, Rex, died six months earlier and now he has been hit with this trouble.
When you finally arrive, Trevor tells you that he intends to complain to your manager, and to
write a letter to the newspapers telling how incompetent our public health service is.
He is in pain and furious.
Defuser
Justin Brown – Registered nurse
You are visiting your sixth patient for the morning, and have two more to go before you return
to the office. You have only seen this elderly man three times before, and he was generally a bit
irritable, possibly due to his terminal illness.
As you go inside to attend to his care, he begins shouting at you:

“Can’t you do better than this? I might as well be living in a third world country, or dead,
for all people care in this world!”
MODULE 1
Scenario 8: Community mental health

Aggressor
Edna Goffman – 60 year old with a mental illness
Edna Goffman is on a clinical ‘holiday’ camp that she has paid for out of her pension, with a
group of nursing students and some mental health teachers.
One morning a student nurse comes in to tell her it is time to get up. Edna tells her to bugger
off and let her sleep in; she is on holidays. But the student nurse is persistent, and says if Edna
doesn’t get out of bed, have her shower and breakfast in the next half an hour, everyone will be
waiting for her if they want to go out.
Edna has had enough of her whining voice, and tells her if she doesn’t shut up and mind her
own business she’ll smash her face in.
Defuser
Mr/s Trainer – Mental health nurse
You are a clinical teacher with a group of student nurses and clients on a clinical teaching camp.
The clients have all been diagnosed at some time with a mental illness. Some are living in the
community, while some are long stay patients at a large psychiatric facility in the area.
A student nurse has just come into the dining area and asked you to speak to the client, because
her client will not get out of bed, and had threatened her with violence. What will you do?
Scenario 9: Youth worker

Aggressor
Jack White – 70 years old
Jack White is the grandfather of a fifteen year old boy called Jason. Jason has had a bit of
trouble at school and with the police for wagging and shoplifting. Jack has just learnt that the
government social workers have got involved in the family’s business because of this. Jack is
irate, as this is totally unnecessary, in his opinion. In his day, families sorted these things out
themselves. Jack also doesn’t want his mates at the RSL Club to find out that this is happening.
Jack phones you at your office and tells you they should: ‘Drop the case’. When you say that
isn’t possible, he is outraged at this ‘Big brother watching you’ tactics. He begins to tell you,
in no uncertain terms, what he thinks.
Defuser
Jacky Lee
You are a youth worker who has recently taken a fifteen year-old male referred to the service by
a school counsellor.
The boy has a number of personal issues to resolve. He has been truanting school, allegedly
selling drugs with a number of others from his school and is in trouble with the police. His parents
have a relationship pattern: separate then come together for a short while, argue, then separate
again. Both parents drink heavily.
You have reason to suspect there may be issues of sexual abuse involving a male uncle
or parental grandfather. You are called to the phone to answer inquiries by a male relative
of the youth.
The male tells you to ‘Drop the case’. When you try to find out to whom you are speaking,
and to explain your professional obligations, the caller begins calling you ‘A bloody fascist’,
and making angry threats.
MODULE 1
Scenario 10: Bus driver

Aggressor
Jack White – 70 years old
Jack White has worked hard all his life, only to be struck with a number of illnesses from heart
disease to kidney problems since the year after he retired. He also has shortness of breath from
sixty years of smoking.
He doesn’t know how much longer he is going to be on God’s earth, but he wants it to last as
long as he can.
Jack has to regularly visit the local hospital, and takes the train as he no longer drives a car.
However, the courtesy bus provided by the hospital to save him the walk up a long hill, always
seems to be longer than the maximum wait of 15 minutes they state on the timetable. This usually
means that he is late for your appointment in the clinic, and often he is pushed to the end of the
queue, and has to wait even` longer because of it.
It is a hot day, and sure enough, he has been waiting twenty-one minutes for the bus to come
since getting off his train. HE HAS HAD ENOUGH!
When the bus finally arrives, Jack struggles in, then YELLS at you:
“How the hell do you expect us to get well when you don’t meet us when you should?!”
“I want to see the person in charge so that I can make a complaint!”
Defuser
John/Jean – Courtesy bus driver
Your name is John/Jean and you are one of the staff of Health Service who drives the courtesy
bus around the hospital campus and the train station.
You are making your first trip to the train station after morning tea, when a skinny looking old man
begins abusing you as soon as you stop.
Scenario 11: Drug and alcohol

Aggressor
Robert White – Methadone clinic client
Robert White is a client at a methadone clinic in the drug and alcohol unit. He has had a
‘take-away’ dose for the next day stolen by someone who came into his flat.
Robert explains this to you and asks for another dose, but is told that he can’t have another
one until tomorrow.
This pisses him off and he becomes very angry, as it seems that the staff never exhibit trust
in him, and he is scared that he will have to ‘hang-out’ until he gets another dose.
He bloody thought this would happen, as soon as he realised the dose had been pinched.
He begins to raise his voice and yells at you.
Defuser
Bob Brown – Nurse
You are a nurse working at a methadone clinic in the drug and alcohol unit.
A client comes in who has already been given a ‘take-away’ dose for the day and he is asking
for a second dose.
You tell him that he cannot have another dose, and he becomes angry and begins to raise his
voice and yell at you.
MODULE 1
Scenario 12: Security

Aggressor
Byron Bay – 45 years old
Byron Bay was at work this morning when he received a phone call from a neighbour informing
him that there had been an accident at home and his wife and child had been taken to hospital.
When he contacts the hospital to obtain information he is transferred to a number of people who
do not seem to know what is going on and nobody will answer his questions about the condition
of his wife and child. This makes him very angry and he goes to the hospital to sort this mess out.
Defuser
Alice/Alan Springs – Hospital security
You are working a day shift when you receive a duress call to the patient inquiry area.
The information you receive is a large male person has become hostile and threatening
towards the staff in this area. The staff are having a great deal of difficulty with this person
as he will not cooperate with their attempts to deal with his inquiries; he is now threatening
to pull the place apart unless something is done.
Scenario 13: Medical officer

Aggressor
Mark Peterson – 22 years old
Mark Peterson is at a friend’s party, the night is going well until a group of people arrive
who are not invited. When they asked him to leave, a physical struggle occurs and he receives
a cut to his head. He feels that the injury is only minor but his friends want to take him to hospital
as they want to ensure that he is not seriously injured. This irritates him as he feels this is
unnecessary but he agrees to go to the Hospital.
When he arrives he notices that the Emergency Department is crowded and there is a long wait.
This irritates him further.
Defuser
Kim Black – Medical officer
You are on duty in a busy Emergency Department on a Saturday night. You have been
informed by the nursing staff that a young man has come to the department with a head
wound after being in a fight at a party. The information you receive is that he has become
more agitated since he has arrived and is now stating that if he does not get attention
immediately he is going to leave. Previously, when the triage nurse had suggested that
the wound may need stitches, the client stated if anybody hurt him they will pay for it.
MODULE 1
Assessment
NSW Health Aggression Minimisation Training Program

Module 1 – HLTCSD6A Respond effectively to difficult or challenging behaviour
Name: ____________________________________________________________________________
Position: __________________________________________________________________________
Location: __________________________________________________________________________
Department/unit: __________________________________________________________________
Support staff
Mental health registered nurse
Enrolled nurse
Registered nurse
Food services
Administration
Community – generalist
Community mental health
Youth worker
Bus driver
Drug and alcohol
Hospital security staff
Medical officer
You are to answer each question, based on the scenario you have selected. Please read
the scenario carefully and write your response to the following questions. Please indicate which
scenario you are responding to.
113
MODULE 1
Responding effectively to difficult or challenging behaviour
S U P P O RT S TA F F SCENARIO 1
1. What are your options in responding to this aggressive incident keeping in mind your
duty of care. Number the most appropriate option/s for this scenario in priority order.
(1 = do first)
Use of reasonable force
Obtain clinical assessment/review of current physical and mental health
Obtain assistance
Deal with situation alone
2. How would you ensure the safety of yourself and others in this situation?
Number each appropriate option/s for this scenario in priority order. (1 = do first)
Obtain assistance to do task according to policy and procedure manual
Universal precautions/infection/age
Use of appropriate body language
Speak in a calm friendly manner
Defusing techniques
Physical self defence
3. Where would you get assistance?

Duress response team if available
Visitors
Police
Fellow staff/considering gender issues
4. What communication skills might you use?

Tick each appropriate option/s for this scenario. (Not in priority order)
Listening to/giving information
Using assertiveness verbal/non-verbal
Speaking to client at their level, being sensitive to cultural background and

education level using simple, easy-to-understand language
Speaking in a slowed controlled fashion
Limiting setting where appropriate
SCENARIO 1 S U P P O RT S TA F F
5. You are now required to complete the attached incident form in relation to this incident.
Please submit the incident form and these pages to the assessor.
6. Why is it important this incident is investigated?

To identify the contributing factors to prevent or reduce the likelihood of a recurrence
To identify patterns of severity within location, type of work tasks being performed
To find somebody to blame
7. What assistance is available to you after an aggressive incident?

Peer debriefing
Change jobs
Counselling/group/one-on-one
8. If you feel affected by the incident, how can you access assistance?
Support from fellow workers
Staff counsellors (if available)
Employee assistance (if available)
Approach manager
Private counselling
9. Complete a risk management plan for this incident.
MODULE 1
MENTAL HEALTH SCENARIO 2

(1 = do first)
Takes clothes when they are unattended
Attain assistance
Consider clinical assessment
Insist they obey your instructions
Determine if this is a critical procedure and needs to occur
Obtain assistance
Separate from others in case aggression escalates
Ensure self defence

Visitors
Fellow ward staff
Police

Communicate slowly and clearly
Limit setting where appropriate
Use negotiation skills
Use communication strategies that are appropriate to client’s present mental state
Use authoritative tone
5. You are now required to complete the attached incident form in relation to
this incident. Please submit the incident form and these pages to the assessor.
SCENARIO 2 MENTAL HEALTH

Ongoing clinical management of client
Identify contributing factor
Develop strategies to improve ward safety
Find someone to blame

Peer debriefing
Change jobs
Approach manager
Private counselling
MODULE 1
ENROLLED NURSE SCENARIO 3

(1 = do first)
Inform of hospital policy and explain if required
Ensure your own safety
Escort the person from the hospital grounds
Attempt to keep other people out of area
Inform security of situation
Remove cigarettes
Leave area safely and calmly
Attempt to gauge level of intoxication
Use communication skills to effectively defuse situation

Visitors
Police

Listening/giving information
Speaking to client at their level using simple, easy-to-understand language
Speaking in a slowed contracted fashion
Using communication appropriate to level of intoxication
SCENARIO 3 ENROLLED NURSE

For hospital environment safety
For hospital statistics
To review policy in relation to staff intervention rules

Peer debriefing
Change jobs
Approach manager
Private counselling
MODULE 1
REGISTERED NURSE SCENARIO 4

(1 = do first)
Ignore complaints as the family is over involved
Review personal care procedures
Awareness of family issues about long-term care for mother
Acknowledgment of relative’s concerns
Attend to client immediately
Use defusing communication techniques
Move to a more appropriate environment
Make staff aware of possible difficulties that may occur at visiting times
Inform the relative of the nurses’ busy workloads

Relatives
Police
Fellow staff
Other patients

Tick each appropriate option/s for this scenario (Not in priority order)
Setting limits
Providing information
Speaking slowly and calmly
Communicating to gain empathy
Validating the families concerns
5. You are now required to complete the attached incident form in relation to this
incident. Please submit the incident form and these pages to the assessor.
SCENARIO 4 REGISTERED NURSE

To keep OH&S unit busy
To ensure best practice guidelines are followed
To review policy and procedures

Group/personal counselling
Peer debriefing
Change jobs
Private counselling
Approach manager
MODULE 1
FOOD SERVICES SCENARIO 5

(1 = do first)
Speak in an abrupt manner
Inform clinical staff of behaviour
Assessment of environmental safety issues/food trays and other hazards
Determine what level of threat is displayed
Pull curtain around to isolate
Inform clinical staff
Remove of environment hazards
Blame the hospital chefs

Police
Other patients to alert other staff
Ward staff
Visitors

Argue back
Attempt to negotiate a solution
Remain calm and in control
Set limits where appropriate
Keep sentences short and words simple
SCENARIO 5 FOOD SERVICES

To develop strategies to improve services
To identify contributing factors

Peer debriefing
Change jobs
Private counselling
Approach manager
MODULE 1
ADMINISTRATION SCENARIO 6
(1 = do first)
Obtain clinical assistance to assess urgency of medical condition
Consider safety of others in the reception area
Assess level of threat
Obtain assistance
Use physical self defence
Use of defusing communication techniques

Visitors
Police

Speaking to client at their level being sensitive to cultural background and education level
using simple, easy-to-understand language
SCENARIO 6 ADMINISTRATION

Peer debriefing
Change jobs
Approach manager
Private counselling
MODULE 1
COMMUNITY – GENERALIST SCENARIO 7

(1 = do first)
Explain limitation and constraints in home care
Compliance with the organisation policy on home visits
Refuse home visit due to danger
Empathy towards patients emotional state/bereavement/deteriorating health
Refer to mental health because of aggression
Use of home visit safety policy
Transfer of information to appropriate staff
Ensure client is aware of changes of routine

Police
Others at the house

Tick each appropriate option/s for this scenario (Not in priority order).
Using communication techniques to defuse the situation
SCENARIO 7 COMMUNITY – GENERALIST

To identify the contributing factors and so prevent or reduce the likelihood of a recurrence

Private counselling
Peer debriefing
From friends and family
Group counselling
Private counselling
Approach manager
A safer place to work – preventing and managing violent behaviour in the Health workplace Module 1 HLTCSD6A NSW Health
128 Respond effectively to difficult or challenging behaviour (Version 1) © July 2003 – updated August 2004
MODULE 1
Responding effectively to difficult or challenging behaviour
COMMUNITY MENTAL HEALTH SCENARIO 8

(1 = do first)
Determine if clinical review required for patient
Tell student not to bother you
Ensure student is aware of safety issues
Gauge level of threat
Inform other staff of situation
Intervene with appropriate techniques to educate student
Call police
3. Where would you get assistance? Number each appropriate option/s for this
scenario in priority order. (1 = do first)
Fellow staff
Local farmer
Police

SCENARIO 8 COMMUNITY MENTAL HEALTH

To identify safety issues related to aggression displayed outside of usual clinical settings
To determine if the aggression is a behaviour as a result of deteriorating mental state
To blame somebody
For best practice guidelines

Change jobs
Peer debriefing
Counselling/group/individual
Approach manager
Private counselling
MODULE 1
YOUTH WORKER SCENARIO 9

(1 = do first)
Offer an appointment to discuss the callers concerns further
Use strong language to show the caller they cannot push you around
Use of telephone aggression minimisation policy (if available)
Explain your professional/legal responsibilities
Ignore the episode to stop any further difficulties
Note caller’s hostile attitude and record this in the appropriate place
Place a ban on any further contact with the family
Appropriate safety/security issues used if appointment accepted

Just hang up the phone
Use of hospital/Area Health Service phone policy
Police
Use of verbal defusing techniques

Speaking in a slowed contracted fashion
SCENARIO 9 YOUTH WORKER

Possible legal implications
Possible escalation to higher level of aggression eg physical
To follow mandatory procedures

Peer debriefing
Change jobs
Private counselling
Approach manager
MODULE 1
BUS DRIVER SCENARIO 10

(1 = do first)
Ignoring the client’s protests
Assessing the level of threat posed to other users of the service
Refusing the client access to the bus
Attempting to defuse the situation ie giving information
Refuse access to the bus
Monitor client’s behaviour during the trip
Use mechanical restraints on the client
The other passengers need to lookout for themselves
Assess the level of threat to other passengers
Ignore the behaviour and it will go away

Ward staff
Duress team
Police
Passers by

Set limits where appropriate
Give relevant information
Keep sentences short and words simple
Use communication skills to effectively defuse the situation
Ignore client’s concerns
SCENARIO 10 BUS DRIVER

To keep people in employment
To identify the causes and contributing factors so as to prevent or reduce the likelihood
of a recurrence
To identify patterns of severity, location and type of work performed

Peer debriefing
Change jobs
Approach manager
Private counselling
MODULE 1
DRUG AND ALCOHOL SCENARIO 11

(1 = do first)
Attempt to gauge level of aggression
Discuss other options to assist the client
Explain policy in relation to methadone administration
Obtain assistance
Physical self-defence

Police
Visitors

Speak to client at their level being sensitive to cultural background and education level
using, simple-easy-to-understand language
SCENARIO 11 DRUG AND ALCOHOL

To identify the contributing factors so as to prevent or reduce the likelihood of a

recurrence

Change jobs
Peer debriefing
Approach manager
Private counselling
MODULE 1
HOSPITAL SECURITY STAFF SCENARIO 12

(1 = do first)
Obtain assistance
Use defusing techniques to calm the situation
Remove other people from the area
Universal precautions/infection/age
Obtain assistance to do task according to policy and procedure manual
Physical self defence
Defusing techniques

Visitors
Police

using, simple easy-to-understand language

To identify the contributing factors so as to prevent or reduce the likelihood
of a recurrence

Peer debriefing
Change jobs
Approach manager
Private counselling
MODULE 1
MEDICAL OFFICER SCENARIO 13

(1 = do first)
Attempt to gauge level of aggression
Engage client to enable an adequate investigation of their physical condition
Examine need to be detained against their wishes for medical reasons
Allow client to leave because of their aggressive behaviour
Obtain assistance
Physical self-defence
Defusing techniques
Explain and inform client of reasons for your concern

Police
Visitors
SCENARIO 13 MEDICAL OFFICER

Demanding that they stop what they are doing immediately
To identify the contributing factors so as to prevent or reduce the likelihood
of a recurrence

Change jobs
Peer debriefing
Counselling/group/individual
Private counselling
Approach manager
MODULE 1
MARKING GUIDE
S U P P O RT S TA F F SCENARIO 1
(1 = do first)
3 Use of reasonable force
1 Obtain clinical assessment/review of current physical and mental health
2 Obtain assistance
4 Deal with situation alone
1 Obtain assistance to do task according to policy and procedure manual
6 Universal precautions/infection/age
4 Use of appropriate body language
3 Speak in a calm friendly manner
2 Defusing techniques
5 Physical self defence

3 Duress response team if available
5 Visitors
2 Hospital security staff
4 Police
1 Fellow staff/considering gender issues

Listening to/giving information
Speaking to client at their level, being sensitive to cultural background and

education level, using simple-easy-to understand language
MARKING GUIDE
SCENARIO 1 S U P P O RT S TA F F

✓ To identify the contributing factors to prevent or reduce the likelihood of a recurrence
✓ To identify patterns of severity within location, type of work tasks being performed

✓ Peer debriefing
Change jobs
✓ Counselling/group/one-on-one
✓ Support from fellow workers
✓ Staff counsellors (if available)
✓ Employee assistance (if available)
✓ Approach manager
✓ Private counselling
MODULE 1
MARKING GUIDE
MENTAL HEALTH SCENARIO 2

(1 = do first)
3 Takes clothes when they are unattended
2 Attain assistance
1 Consider clinical assessment
4 Insist they obey your instructions
3 Determine if this is a critical procedure and needs to occur
1 Obtain assistance
2 Separate from others in case aggression escalates
4 Ensure self-defence

5 Visitors
1 Fellow ward staff
4 Police

✓ Communicate slowly and clearly
✓ Limit setting where appropriate
✓ Use negotiation skills
✓ Use communication strategies that are appropriate to client’s present mental state
Use authoritative tone
5. You are now required to complete the attached incident form in relation to
this incident. Please submit the incident form and these pages to the assessor.
MARKING GUIDE
SCENARIO 2 MENTAL HEALTH

✓ Ongoing clinical management of client
✓ Identify contributing factor
✓ Develop strategies to improve ward safety
Find someone to blame

✓ Peer debriefing
Change jobs
MODULE 1
MARKING GUIDE
ENROLLED NURSE SCENARIO 3

(1 = do first)
2 Inform of hospital policy and explain if required
1 Ensure your own safety
4 Escort the person from the hospital grounds
3 Attempt to keep other people out of area
3 Inform security of situation
5 Remove cigarettes
2 Leave area safely and calmly
4 Attempt to gauge level of intoxication
1 Use communication skills to effectively defuse situation

5 Visitors
4 Police

✓ Listening/giving information
✓ Using assertiveness verbal/non-verbal
✓ Speaking to client at their level using simple, easy-to-understand language
✓ Speaking in a slowed contracted fashion
✓ Limiting setting where appropriate
✓ Using communication appropriate to level of intoxication
MARKING GUIDE
SCENARIO 3 ENROLLED NURSE

✓ For hospital environment safety
✓ For hospital statistics
✓ To review policy in relation to staff intervention rules

✓ Peer debriefing
Change jobs
MODULE 1
MARKING GUIDE
REGISTERED NURSE SCENARIO 4

(1 = do first)
5 Ignore complaints as the family is over involved
2 Review personal care procedures
3 Awareness of family issues about long-term care for mother
1 Acknowledgment of relative’s concerns
4 Attend to client immediately
3 Use defusing communication techniques
1 Move to a more appropriate environment
2 Make staff aware of possible difficulties that may occur at visiting times
4 Inform the relative of the nurses’ busy workloads

4 Relatives
3 Police
1 Fellow staff
5 Other patients

✓ Setting limits
✓ Providing information
✓ Speaking slowly and calmly
✓ Communicating to gain empathy
✓ Validating the families concerns
MARKING GUIDE
SCENARIO 4 REGISTERED NURSE

To keep OH&S unit busy
✓ To ensure best practice guidelines are followed
✓ To review policy and procedures

✓ Group/personal counselling
✓ Peer debriefing
Change jobs
MODULE 1
MARKING GUIDE
FOOD SERVICES SCENARIO 5

(1 = do first)
4 Speak in an abrupt manner
3 Inform clinical staff of behaviour
1 Assessment of environmental safety issues/food trays and other hazards
2 Determine what level of threat is displayed
3 Pull curtain around to isolate
2 Inform clinical staff
1 Remove environment hazards
4 Blame the hospital chefs

4 Police
3 Other patients to alert other staff
1 Ward staff
5 Visitors

Argue back
✓ Attempt to negotiate a solution
✓ Remain calm and in control
✓ Set limits where appropriate
✓ Keep sentences short and words simple
MARKING GUIDE
SCENARIO 5 FOOD SERVICES

✓ To develop strategies to improve services

✓ To identify contributing factors

✓ Peer debriefing
Change jobs
MODULE 1
MARKING GUIDE
ADMINISTRATION SCENARIO 6
(1 = do first)
1 Obtain clinical assistance to assess urgency of medical condition
2 Consider safety of others in the reception area
2 Assess level of threat
1 Obtain assistance
6 Use physical self-defence
5 Use of defusing communication techniques

5 Visitors
4 Police

✓ Speaking to client at their level being sensitive to cultural background and education level
✓ Speaking in a slowed controlled fashion
MARKING GUIDE
SCENARIO 6 ADMINISTRATION

✓ Peer debriefing
Change jobs
MODULE 1
MARKING GUIDE
COMMUNITY – GENERALIST SCENARIO 7

(1 = do first)
3 Explain limitation and constraints in home care
1 Compliance with the organisation policy on home visits
5 Refuse home visit due to danger
2 Empathy towards patients emotional state/bereavement/deteriorating health
4 Refer to mental health because of aggression
1 Use of home visit safety policy
4 Transfer of information to appropriate staff
3 Ensure client is aware of changes of routine

2 Police
1 Others at the house

✓ Using communication techniques to defuse the situation
MARKING GUIDE
SCENARIO 7 COMMUNITY – GENERALIST

Tick each appropriate option/s for this scenario. (Not in priority order).
✓ To identify the contributing factors and so prevent or reduce the likelihood of a recurrence


✓ Peer debriefing
✓ From friends and family
✓ Group counselling
MODULE 1
MARKING GUIDE
COMMUNITY MENTAL HEALTH SCENARIO 8

(1 = do first)
1 Determine if clinical review required for patient
4 Tell student not to bother you
2 Ensure student is aware of safety issues
2 Gauge level of threat
3 Inform other staff of situation
1 Intervene with appropriate techniques to educate student
4 Call police
3. Where would you get assistance? Number each appropriate option/s for this
scenario in priority order. (1 = do first)
1 Fellow staff
3 Local farmer
2 Police

✓ Use of defusing communication techniques
MARKING GUIDE
SCENARIO 8 COMMUNITY MENTAL HEALTH

✓ To identify safety issues related to aggression displayed outside of usual clinical settings
✓ To determine if the aggression is a behaviour as a result of deteriorating mental state
To blame somebody
✓ For best practice guidelines

Change jobs
✓ Peer debriefing
✓ Counselling/group/individual
MODULE 1
MARKING GUIDE
YOUTH WORKER SCENARIO 9

(1 = do first)
3 Offer an appointment to discuss the callers concerns further
4 Use strong language to show the caller they cannot push you around
2 Use of telephone aggression minimisation policy (if available)
1 Explain your professional/legal responsibilities
4 Ignore the episode to stop any further difficulties
1 Note caller’s hostile attitude and record this in the appropriate place
3 Place a ban on any further contact with the family
2 Appropriate safety/security issues used if appointment accepted

3 Just hang up the phone
1 Use of hospital/Area Health Service phone policy
4 Police
2 Use of verbal defusing techniques

✓ Speaking in a slowed contracted fashion
MARKING GUIDE
SCENARIO 9 YOUTH WORKER

✓ Possible legal implications
✓ Possible escalation to higher level of aggression eg physical
✓ To follow mandatory procedures

✓ Peer debriefing
Change jobs
MODULE 1
MARKING GUIDE
BUS DRIVER SCENARIO 10

(1 = do first)
4 Ignoring the client’s protests
1 Assessing the level of threat posed to other users of the service
3 Refusing the client access to the bus
2 Attempting to defuse the situation ie giving information
3 Refuse access to the bus
2 Monitor client’s behaviour during the trip
5 Use mechanical restraints on the client
6 The other passengers need to lookout for themselves
1 Assess the level of threat to other passengers
4 Ignore the behaviour and it will go away

4 Ward staff
5 Duress team
1 Police
2 Passers by

✓ Set limits where appropriate
✓ Give relevant information
✓ Keep sentences short and words simple
✓ Use communication skills to effectively defuse the situation
Ignore client’s concerns
MARKING GUIDE
SCENARIO 10 BUS DRIVER

To keep people in employment
✓ To identify the causes and contributing factors so as to prevent or reduce the likelihood of
a recurrence

✓ To identify patterns of severity, location and type of work performed

✓ Peer debriefing
Change jobs
9. Complete a risk management plan for this incident
MODULE 1
MARKING GUIDE
DRUG AND ALCOHOL SCENARIO 11

(1 = do first)
2 Attempt to gauge level of aggression
4 Discuss other options to assist the client
3 Explain policy in relation to methadone administration
2 Obtain assistance
6 Physical self-defence

4 Police
3 Duress response team (if available)
5 Visitors

✓ Speak to client at their level being sensitive to cultural background and education level
MARKING GUIDE
SCENARIO 11 DRUG AND ALCOHOL

✓ To identify the contributing factors so as to prevent or reduce the likelihood
of a recurrence

Change jobs
✓ Peer debriefing
MODULE 1
MARKING GUIDE

(1 = do first)
2 Obtain assistance
1 Use defusing techniques to calm the situation
3 Remove other people from the area
6 Universal precautions/infection/age
1 Obtain assistance to do task according to policy and procedure manual
5 Physical self defence

5 Visitors
4 Police

MARKING GUIDE

of a recurrence

✓ Peer debriefing
Change jobs
MODULE 1
MARKING GUIDE
MEDICAL OFFICER SCENARIO 13

(1 = do first)
2 Attempt to gauge level of aggression
3 Engage client to enable an adequate investigation of their physical condition
1 Examine the need to be detained against their wishes for medical reasons
6 Allow client to leave because of their aggressive behaviour
4 Obtain assistance
7 Physical self-defence
3 Explain and inform client of reasons for your concern

4 Police
5 Visitors
2 Duress response team (if available)
MARKING GUIDE
SCENARIO 13 MEDICAL OFFICER

Demanding that they stop what they are doing immediately
6. Why is it important this incident is investigated? Tick each appropriate option/s for this
scenario. (Not in priority order)
of a recurrence

Change jobs
✓ Peer debriefing
✓ Counselling/group/individual

Mod1 Facilitator

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A safer place to work –

preventing and managing violent

NSW Health is a zero tolerance zone

© NSW Department of Health 2004

SHPN (CMH) 030136

Part 4 Bullying, harassment and discrimination at work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

NSW Health: Preventing and managing aggression in the

What materials are provided?

All of the above are included on the CD.

Who will attend?

Overview of the manual

Modular structure of the aggression minimisation program

The day is divided into five parts:

The day is divided into four parts:

How the manual is set out

All facilitator notes throughout each module look like this.

Explain and discuss

Ask the group

Small group exercise

Individual reflection exercise

Important training point

You are on Participant manual page X

Show overhead slide

Write responses on board

Suggested break time

Readings and resources

Facilitator preparation before training

Sequence and timing of the modules

Recognition of prior learning

Recognition of prior learning is based on the following:

The following types of evidence may be collected:

How Module 1 fits into the whole program

Training room requirements

Assessment for Module 1

Health Training Package Competency: (HLTCSD6A) – Respond Effectively to Difficult or

Elements of competency and performance criteria

National code Element name

HLTCSD6A/02 Apply response

HLTCSD6A/03 Report and review incidents

Learning outcome Elements of competency and Assessment

1. Identify and apply strategies Question 9

2. Identify and select Element: Apply response Question 1

3. Give priority to the safety of self Element: Plan responses Question 2

4. Identify when, how and who to Element: Plan responses Question 3

5. Use verbal and non-verbal Element: Apply response Question 4

6. Identify appropriate reporting Element: Report and review incidents Question 5

Yes No Unsure How

*Ensured the safety of self

*Identified when, how and

Identified what can be

Identified support expected

Identified and applied

* Denotes criteria for competence.

Session plan for Module 1

Training session: Module 1 Date:

90 mins ● Preventing aggression occurring. 1, 2, 3 and 4 Small and large group

90 mins ● Preventing aggression escalating. 2, 4 and 5 Small and large group

60 mins ● Bullying, harassment and 4, 5 and 6 Small and large group

60 mins ● Reporting and reviewing 6, 7, 8 and 9 Small and large group

60 mins ● Assessment of competency. All learning Staff members respond to

Beginning the training session

1. Welcome participants to the module

You may wish to facilitate an introductory activity (ice-breaker).