A safer place to work –

Preventing and managing violent

behaviour in the Health workplace

Module 2
AMT002
Aggression minimisation in high-risk
environments

Participant manual

NSW Health is a zero tolerance zone

NSW DEPARTMENT OF HEALTH
73 Miller Street
NORTH SYDNEY NSW 2060
Tel. (02) 9391 9000
Fax. (02) 9391 9101
TTY. (02) 9391 9900
www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in part for study training purposes subject to
the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or
sale. Reproduction for purposes other than those indicated above, requires written permission from the
NSW Department of Health.

© NSW Department of Health 2003

SHPN (CMH) 030207

ISBN 0 7347 3591 X

July 2003
updated August 2004
 MODULE 2
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Contents
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Modular structure of the aggression minimisation program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Learning outcomes for Module 2 – Aggression minimisation in high-risk environments . . . . . . . . . . . . . . . . 4

Part 1 Working in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

What are high-risk environments? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Why are they high-risk?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Zero tolerance approach to aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Some legal and ethical issues and scenarios in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Part 2 Prevention in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Keeping your area secure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Some principles for recognising and dealing with unauthorised visitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Working in the community and outreach environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Working in isolated areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
How to maintain safety when approaching a patient who is aggressive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Ensuring the safety of self and others when interviewing patients or others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Part 3 Understanding aggression in high-risk environments ............................... . . . . . . 19

Triggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................... . . . . . . 19
Cycle of aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................... . . . . . . 20
Some possible responses at each stage of the aggression cycle . . ............................... . . . . . . 21
Self-control plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................... . . . . . . 22

Part 4 Managing aggression in high-risk environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Core values and skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Options when a person has been identified as being high-risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Short-term options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Long-term options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Strategies during hostage or armed hold up situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Related NSW Health policies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

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Acknowledgments

This NSW Health violence prevention training program was developed by Brin FS Grenyer,
Olga Ilkiw-Lavalle and Philip Biro from the Illawarra Institute for Mental Health. Mark Coleman
provided assistance with the facilitator manuals and pilot workshops. The project was coordinated
from the Violence Taskforce, Centre for Mental Health by Frances Waters. The members of the project
contract steering committee who provided extensive guidance during the development of this project
were Frances Waters (Violence Taskforce, Centre for Mental Health), Kathy Baker (Community & Extended
Care Services and Nursing Services, Northern Sydney), Trish Butrej (Occupational Health and Safety,
NSW Nurses’ Association), Maggie Christensen (Learning and Development, Central Coast), Nicole Ducat
(Occupational Health and Safety, South Eastern Sydney), Louise Newman (Royal Australian and New
Zealand College of Psychiatrists), Gemma Summers (Learning and Development, Northern Sydney)
and Choong-Siew Yong (Australian Medical Association, NSW Branch).

A project content reference group also provided input during the development of the project, and the
members were Greg Hugh, Peter Bazzana, Greg Cole, Stephen Allnut, Distan Bach, Liz Cloughessy,
Jim Delaney, Regina McDonald, David Gray, Rajni Chandran, Jennifer Bryant, Terry Tracey and
Linda Sheahan. Consumer input was gratefully provided by Laraine Toms and Robyn Toohey. The
NSW Health Learning and Development Managers forum and others affiliated with the reference group
also provided helpful comment and guidance during the developmental phases of this project, including
Jenny Wright, Earle Durheim, Judy Saba, Brenda Bradbury, John Lain, Bill Wood, Aileen Ferguson,
Simon Richards, Vaughan Bowie, Louise Fullerton, Mira Savich, lain Morriset, Lorraine Hyde,
Glenda Hadley, Julie Reid, Natasha Mooney and Bill Tibben.

The developers would like to thank those staff of the South Western Sydney Area Health Service
who provided useful feedback during the four days of piloting of each of the modules in October 2002.
We also thank the fifteen educators from across the state who provided feedback during the two-day
trainer orientation at Western Sydney Area Health Service in November 2002.

The developers would like to give special thanks to Professor Beverley Raphael and Professor Duncan
Chappel from the Violence Taskforce for support, Dr Claire Mayhew for timely insights, Linda Graham for
sharing her wisdom over the years through the development and implementation of the INTACT training
program, Professor Kevin Gournay and Steve Wright from the Institute of Psychiatry, London, for helpful
advice and resources, Dr Nadia Solowij and Jane Middleby-Clements for editorial assistance and to
Professor Frank Deane from the Illawarra Institute for Mental Health for practical support. We also
thank Shane Pifferi, Marie Johnson, Vicky Biro, Tim Coombs, Ralph Stevenson, Dr Alexandra Cockram,
Eugene McGarrell, Samantha Reis and Andrew Phipps for assistance with the project.

This program has incorporated and referred to relevant NSW Health policies and guidelines where
appropriate and a list of these is given at the end of the relevant modules. Modules 1 and 2 of this
program were adapted from a modular aggression minimisation program developed originally
by Austraining (NSW) Pty Ltd for the Central Coast Area Health Service, which was revised by
Jenelle Langham in 2000. Module 3 of this program is a revised version of that developed
by Jenelle Langham for the Central Coast Area Health Service.

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Modular structure of the

aggression minimisation program

Aggression in the health service industry is a significant problem.11,12,13 This program aims
to promote a working environment and practices which keep people safe from aggression.
The goals of this training are to improve health care workers’ knowledge in relation to the
major factors which contribute to safety and to gain knowledge and skills in responding
to different instances of aggression.

HLTCSD6A – Respond effectively to

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

The day is divided into five parts:

1. Understanding difficult or challenging behaviour.
2. Preventing aggression occurring.
3. Preventing aggression escalating.
4. Bullying, harassment and discrimination at work.
5. Reporting and reviewing aggressive incidents.

AMT002 – Aggression minimisation in

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

90405NSW – Course in aggression minimisation

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

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AMT004 – Aggression minimisation refresher training

Module 4
This two-hour module is designed for all staff identified as being at risk
of workplace violence, and should be repeated at a minimum of every two
years after completion of Module 1. Depending on the level of risk, some
staff may need to attend more frequently. It is designed to keep staff
up-to-date with policies and practices, provide refresher training of
skills, and workshop problems.

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Learning outcomes for Module 2 –

Aggression minimisation in high
risk environments

Module 2 is the second of four modules dealing with aggression prevention,

minimisation and management. It builds upon Module 1. The material in Module 1
is assumed knowledge for this module, and recent completion of Module 1, or its
equivalent, is a pre-requisite for completing Module 2. This module is focused on
the needs of staff working in high-risk areas where there is often a higher prevalence
of aggression. The module is designed to address more complex issues regarding
responses required to minimise aggression. Other modules focus on managerial
responsibilities and refresher training. Facilitators need to reinforce information
from Module 1, such as prevention and the risk management approach.

Learning outcomes
At the conclusion of this module, participants should be able to:
1. identify the legal and ethical issues governing aggression
2. identify safety strategies in responding to and managing aggression
3. identify the triggers for aggression and stages in the cycle of aggression
4. identify personal safety strategies when working in the community and
outreach environments
5. use communication skills to contain and reduce high tension situations
6. identify short and long-term options for managing an aggressive person.

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Part 1
Working in high-risk environments

This section looks at what high-risk environments are and why they are considered
to be high-risk. It also examines the legal and ethical issues that need to be taken
into account when responding to and managing aggression. These issues include
duty of care, professional negligence, reasonable force, assault, arrest, restraint,
false imprisonment, searching of patients and others, the Guardianship Tribunal,
children and the NSW Mental Health Act 1990.

What are high-risk environments?

Some examples of high-risk environments may include:
● Emergency Departments and admissions units
● mental health treatment facilities
● a patient’s home
● community facilities
● aged care facilities
● corrections health facilities and prisons
● dental clinics
● disability facilities
● midwifery and early childhood facilities
● drug and alcohol treatment facilities
● rehabilitation, neurology and brain injury units.

Why are they high-risk?

● The environment may be targeted by criminals because of money, drugs etc.
● Some environments may put the worker at higher-risk of aggression because of the type
of location and premises, the presence of others unknown to the worker and because
immediate support may not be available.
● Some environments may be associated with visitors being under greater sources of stress
which may be associated with a higher-risk of aggression.
● Some environments such as waiting rooms may contribute to a higher-risk of aggression
when there is overcrowding, long waiting times and people in distress.
● Environments where workers are alone may contribute to a higher-risk of aggression.

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Certain medical problems that patients experience may be associated with a higher-risk
of aggression, such as:
● confusion, eg delirium and acute organic brain syndromes, dementia such as
Alzheimer’s disease, multiple infarcts or brain dysfunction and trauma
● anxiety associated with their illness and treatment or psychosocial concerns
● mental illness and disorder
● pain
● substance abuse
● dual diagnosis (both mental illness and substance abuse)
● impulsive behaviours (such as those due to personality disorder)
● deafness, blindness and sensory impairment
● developmental disability
● brain impairment resulting from head injury, epilepsy, neurochemical disturbances,
metabolic disturbance (such as hypoglycaemia and limbic system disorder), tumours,
infection and other factors
● neurological disorder such as Huntington’s disease, Parkinson’s disease, Pick’s disease,
Multiple Sclerosis or AIDS dementia.

Zero tolerance approach to aggression

NSW Health is committed to the minimisation of violence in the public health system, and
the focus should always be on the prevention of violence. However, in the event that a violent
incident does occur, NSW Health, as a result of a key recommendation from the Taskforce
on the Prevention and Management of Violence in the Health Workplace, has adopted a zero
tolerance response to threatening, abusive or violent behaviour by any person towards any
other person on health service premises, or towards NSW Health staff working in the community.
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.

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).

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Some legal and ethical issues and scenarios in

high-risk environments

Case study
A person who is drunk has been brought into the hospital with a head wound and
other cuts received in a fight. The person does not like the treatment being provided,
and starts to become abusive. The individual feels no treatment is needed and wants
to go home.

What should the worker do?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

How might the principles governing ‘duty of care’ versus ‘professional negligence’ be relevant to a
worker’s response to the incident?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

How might the principles governing ‘reasonable force’ versus ‘assault’ be relevant to a worker’s
response to the incident?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Case study
A fifteen-year-old boy was in hospital after he fell off his pushbike. The boy went over to
the drug trolley with his backpack, put something in his backpack, and ran out the door.

What should the worker do?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

A suggestion is made that the security officer should run after the boy and restrain him.

What should the worker do?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

How might the principles governing ‘citizen’s arrest’ versus ‘restraint’, ‘false imprisonment’ and
‘assault’ be relevant to the worker’s response to the incident?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Consider the case where the boy does not run out of the hospital but after putting
something in his backpack from the drug trolley he sits down on a nearby chair.

What should the worker do?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

How might the principles governing ‘searching patients’ be relevant to the worker’s response to
the incident?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Case study
An involuntary patient decides she wants to leave the hospital and becomes excited
and angry when told that she cannot leave the hospital. A staff member considers her
‘at risk’ and tells her she will give her something to calm her down. The drug injected
has the effect of making the patient unconscious.

Could the patient claim false imprisonment? How might the principles governing the
Mental Health Act be relevant to the worker’s response to the incident?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Consider the above scenario of the patient being administered a sedative. Instead of
being an involuntary patient, the individual is elderly, repeatedly aggressive and under
the Guardianship Tribunal.

How might the principles governing the Guardianship Tribunal be relevant to the worker’s response
to the incident?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Case study
In the evening two youths were noticed suspiciously hanging around a health facility
building. There is no-one in the premises after hours. Staff working in another building
noticed that the youths had driven their car and parked it outside the front door. One of
the youths threw a rock at a window and no alarm was set off. They then proceeded to
try to break into the building.

What is the role of staff when a crime is being committed?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Key points

• Some environments are at a higher-risk because they may be targets for crime.
This may be due to money handling, design, type and location of premises, visitors
being under a greater source of stress, staff working in isolation and the types of
problems patients experience.
• No staff member should knowingly place themselves at unnecessary risk of violence.
• The zero tolerance response means that in all instances of aggression, appropriate
action must be taken to protect staff, patients and visitors from the effects of that
aggression. In order for this to be successful, staff must recognise that aggression
is not an acceptable part of the job.
• Always keep in mind the legal and ethical issues when responding to and
managing aggression.

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Part 2
Prevention in high-risk environments

This part looks at safety strategies in high-risk environments. It considers circumstances

where unauthorised persons have entered restricted and unauthorised areas, safety when
working in the community, how to approach an aggressive person and safety strategies
when interviewing patients and others.

Keeping your area secure

Case study
You notice a stranger is in the staff room with the door to a locker open and hanging on
one hinge. The person is going through the locker of a staff member you know and you
suspect this person is stealing.

What strategies could you use?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Case study
An elderly gentleman came to the receptionist’s desk. He was of non-English speaking
background. He was speaking loudly, and abruptly said, “I want to see my wife, where
is Ward 14”. Ward 14 is a high dependency unit with restricted admission. The staff
member is worried that the gentleman is going to become aggressive and asks him in
a quiet, polite manner what his wife’s name is. He answers loudly, “Where is Ward 14?”
and puts his hand in his pocket as if he is about to take something out. At the same time
he notices a sign with an arrow pointing toward Ward 14. He walks briskly toward the
ward and pushes open the doors, entering the ward. The staff member panics, picks
up the phone and calls security. Several security staff arrive and escort the gentleman,
shouting and struggling, off the premises.

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Discuss the incident and the worker’s response. What strategies should be used when dealing
with unauthorised access?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

What might be the socio-cultural issues that might have contributed to this incident escalating?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Some principles of recognising and dealing with

unauthorised visitors
● Where possible control access at the door.
● Call security, staff or police assistance if required (in-line with local procedures).
● If inside, ask them to leave (note details and call security if necessary).
● Complete an incident report.

Unauthorised access
● Know your escape route.
● Know your emergency numbers.
● Know your local emergency procedures.
● Know location of duress alarms.
● Remain calm.
● Know that your safety is the first priority.
● Know how to contact security or police.
● Know your rights.
● Use non-confrontational methods.
● Use open hand gestures.
● Note clothing or distinguishing features.
● Complete an incident report.
● Seek counselling if appropriate.

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Working in the community and outreach environments

Staff working in the community face particular risks that need to be managed by the
employer.3,7

Discuss what risk assessment activities can be done prior to making community visits,
in particular the first visit.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

SAFETY HINT: Recognise that the busier you are, the more at risk you may be.
Being busy may lead to the following:
● You may be less likely to notice early warning signs of aggression.
● You may take less time to clarify a person’s problem before acting.
● You may be more vulnerable to taking unnecessary risks.

Case study
Jane works in a small community health centre. She is leaving her office to visit a
well known client, John, in his home. When Jane arrived at the house, John’s parents
welcomed Jane in. When Jane walked in she realised she had left her mobile phone in
the car but did not go back outside to get it. John was in his bedroom with a friend Bill
who Jane recognised and knew had a history of aggression. John closed the door behind
Jane and when Jane started talking to John his friend Bill became abusive to Jane and
started yelling and shouting at her. Jane immediately left the room and Bill started to
follow her. Jane ran for the front door and tried to open it. John’s parents came to see
what was going on but Bill pushed them aside. Jane eventually opened the door and
ran to her car and was trying to find her keys in her bag. Meanwhile Bill grabbed Jane
but let her go when John stopped him. Jane eventually got in her car and drove off.

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Consider the scenario. Discuss what you can do to ensure your safety in the community.
Fill in the relevant issues to consider in the boxes provided.

Prior to leaving the office After the visit Visiting alone

Travelling to and fro SAFETY IN THE COMMUNITY

On arrival During the visit Visiting after hours

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Working in isolated areas

If possible staff should not work alone in isolated areas. However, if this is unavoidable,
appropriate risk controls must be in place.

Managers, and staff as appropriate, should:

● be vigilant when entering, using or leaving isolated clinics
● have all emergency numbers programmed into the phone
● have all essential phone numbers displayed
● ensure that an effective contact network is established
● ensure security doors are locked and all doors locked when working after hours in the clinic
● all door and window locks are in good working order
● ensure facility and approaches are well maintained
● ensure all fixtures and fittings are in good working order
● ensure there is adequate lighting during and after hours
● inform communication networks of all your movements to and from the site and record in travel
log times of arrival and departure, route taken and any foreseeable difficulties with travel
● be aware of how to activate a duress alarm or security system.

SAFETY TIPS in community work

● Always ensure you have as much information as possible about the location and person being visited.
● Ensure patients are aware of the visit and purpose.
● Under no circumstances should you knowingly place yourself or co-workers at risk. This also applies
to those in an inspectorial role. Where the threat of violence presents itself, you should leave and/or
seek further assistance, eg police. If you are unable to escape, evasive self-defence may be necessary.
● Always contact police if you are concerned about your own or another's security.

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How to maintain safety when approaching a person with the

potential for aggression
When approaching or interviewing a person who has the potential for aggression keep in
mind some key points to ensure the safety of yourself, the person and others. By approaching
the person in an appropriate way and being aware of simple safe practices, the likelihood of
the person becoming aggressive is reduced.

SAFETY TIP

Do
● Always remove any personal items that could
be used by the patient to grab a hold of you,
eg tie, necklace, earrings, stethoscope, etc,
prior to approaching the person and not in
view of the person.
Don’t
● Use any sudden or violent gestures.
● Have prolonged eye contact.
● Address the patient in a confrontational manner.
● Corner or tower over the patient.

● Be calm and confident. ● Turn your back on the patient until you are well
clear of the situation.
● Give the patient ample space.
● Be empathic and emphasise your desire to help.

Ensuring the safety of self and others when interviewing

patients or others
● Always be alert for the potential for aggressive behaviour.
● Always consider the safety of yourself, the patient, staff or others present.
● Let other staff know where you are in case assistance is required.
● Have other staff present (this can include security).
● Interview in environments where there are easy exits for you and the patient. This prevents
any feelings of being trapped.
● Place yourself near the door and avoid putting yourself in a position where your exit may
be blocked by the patient, or where you are blocking the patient’s exit.
● The furniture in the room should be heavy enough to make it difficult for the person to
use it as a projectile.
● Wear a personal duress alarm and know how to use it.
● Remove any excessive items that could be used as weapons, eg heavy staplers, scissors, etc.
● Be alert to any potential hidden weapons.
● Do not assume that patients who have been in recent contact with the police have been
searched and disarmed of weapons.
● Do not give ultimatums.

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Key points

• Always know your local emergency response procedures; call security, staff or
police if assistance is required with unauthorised visitors.
• Know your emergency numbers and escape routes.
• Always remain calm and non-confrontational.
• Under no circumstances should you place yourself or co-workers at
unnecessary risk.
• Always use the police if you are concerned about your safety when doing visits in
the community.
• Always use the safety strategies prior to approaching persons who are,
or have the potential to be, aggressive.
• Always use the safety strategies when interviewing patients or others.

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Part 3
Understanding aggression
in high-risk environments

This section aims to extend your knowledge of aggression through discussing

common triggers for aggression in the health care industry and the cycle of
aggression. The aggressive person’s and the recipient’s responses are both
outlined and discussed. It is the recipient’s response that can give control
back to the recipient in an aggressive situation.

Triggers
A trigger is a specific occurrence that precipitates the escalation of a person’s aggressive
behaviour. Triggers may be grouped under the following headings:

• Environmental
• Personal
• Cultural
• Workplace practices

Name triggers you have witnessed or experienced under the following headings:

Environmental
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Personal
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Cultural
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Workplace practices
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Cycle of aggression

3 5

2
1
Baseline 6

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Some possible responses at each stage of the aggression cycle

Cycle of Aggressive Recipient Strategies

aggression person
1 Baseline ● Calm and relaxed. ● Calm and relaxed. ● Observe for verbal
. and non-verbal cues.

2 Trigger ● Increased muscle ● Anxious. ● Reflect feelings.

tension. ● Increased heart rate. ● Offer help.
● Dry mouth. ● Worried. ● Problem solve.
● Tremor. ● Be aware of your
● Palpitations. body language.
● Flushed. ● Be aware of
personal space.
● Be aware of your
voice tone.
● Use open questions.

3 Escalation ● Pacing. ● Dry mouth. ● Stay calm.

● Irregular, rapid,
shallow breathing.
● Tremor.
● Reduced
concentration.
● Fear and anxiety.
● Pale or ashen skin.
● Tense. ● Explain things are
● Increased breathing. getting out of control.
● Maintain safety.
● Fight or flight
impulses. ● Offer medication
if appropriate.
● Keep dialogue
simple and direct.
● Have back-up and
an escape plan.

4 Crisis ● Loss of control. ● In control. ● Maintain safety.

● Assault. ● Self defence. ● Yours and others.
● Run or escape. ● Panic and attack. ● Call for back-up.
● Self harm. ● Increased heart rate.
● Run or escape.
● Freeze.

5 Recovery ● Cry. ● Worn out. ● Quiet time.

● Tired. ● Frustrated. ● Talk with colleagues.
● Drained. ● Emotional. ● Reflect.

6 Post-crisis ● Sad. ● Guilt. ● Seek formal support

depression ● Remorse. ● Blame. mechanisms.

● Apologetic. ● Questioning.

NB. Staff may call for back-up at any time. Back-up can include a more senior experienced member of staff.

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Sometimes these responses can prevent you from responding in a way that you would
desire. You may under or over react to a situation possibly:

placing the aggressive person, others or yourself at greater risk of harm.

Self-control plan
You need to have a self-control plan in place so that when you are confronted with an
aggressive incident your response acts to calm the aggressive person and not to further
escalate the individual.

Your self-control plan should take only a couple of seconds.

What self-control plan can you use when confronted with an aggressive incident?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

When might these self-control plans be difficult to implement?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Key points

• Look for any triggers.

• Identify what stage of the cycle of aggression the person is in and use appropriate
strategies to manage the person.
• Be aware of your own bodily response and always use your own self-control plan.

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Part 4
Managing aggression in
high-risk environments

This part discusses the core values and skills required to manage aggressive people.
Short and long-term strategies are discussed to both prevent and manage aggression in
high-risk environments. Finally, the protective factors involved in an armed hold-up or
hostage situation are identified.

Core values and skills

Paterson and Leadbetter16 suggest the following five core values and skills that staff need
to possess when managing aggressive behaviour:
● Consistency in showing respect for the values and dignity of the individual.
● Empathic, non-judgmental approach.
● Honesty.
● Self-awareness.
● Effective communication skills.

To enhance relationships:
● Treat the person as an individual.
● Listen to others and make them feel comfortable about their problems.
● Enable others to have input into decisions.
● Spend time to help establish needs (patients and others).
● Provide choices.
● Provide reasons for decisions.
● Assist with needs other than medical treatment.

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Options when a person has been identified as being high-risk

The outcome of your response options should be either to:

● eliminate risk
or
● reduce the risk to the lowest possible level.

It is important that all staff be aware that a range of options exist when faced with aggressive
or violent individuals. 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; the experience, skills and
confidence of the staff member/s involved. This may include calling for back-up, security or
local police.

Short-term options
Some short-term options for dealing with aggression may include the following. The order in
which they are used or the appropriateness of the strategy depends on the specific situation.

1. Issue a verbal warning

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

2. Use communication skills

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

3. Decide to stay or leave

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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4. Medication management
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

5. Duress response options and calling for back-up

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

6. Defending self
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Case study
A seventy-eight year old patient is in intensive care after suffering a cardiac arrest.
He has been in for two-days and has improved only slightly. He begins to become
agitated, and as the morning progresses he becomes louder calling for the doctor and
his wife saying he wants to go home because he will be better off there. Attempts by the
staff to calm him are not successful and he begins to lash out at staff as they approach
him. He tries to climb out of bed saying that his taxi is out the front waiting for him. He is
pulling at his IV line and repeats that he will miss his taxi if staff don’t get out of the way.

Which short-term options would be useful in managing this patient?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Long-term options
1. Written warnings
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

2. Conditional treatment agreements

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

3. Conditional visiting rights

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

4. Exclusion from visits

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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5. Flagging and patient alerts

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

6. Individual patient care plans

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

7. Inability to treat
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

8. Apprehended violence orders (AVO)

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

9. Laying charges
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Case study
Jan, a community nurse, was on a routine visit to check up on a six-month-old baby.
The baby’s father sells drugs and when Jan arrives on one of her visits a group of young,
intoxicated males comes out of the kitchen, traps her and begins to threaten her. At this
point the baby’s mother comes out and intervenes and Jan runs out shaking and drives
back to the community health centre.

What are the long-term response options for this incident?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Case study
A person brought in her hurt five-year-old child with a head injury. She was very
agitated and one of the staff noticed that an alert was flagged on her file with regard
to a risk for aggression. The staff called security and the child was removed from the
care of the person because they suspected the person caused the injury. The person
then became very aggressive and assaulted security.

What are the short-term response options for this incident?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Strategies during hostage or armed hold-up situations

When faced with a hostage or armed hold-up situation your priorities are:
1. safety of self
2. safety of others.

The following principles apply:

● If someone is pointing a gun in your direction, behave as if the gun is loaded and real,
even if you have some doubts.
● Remain calm.
● Control your emotions, avoid eye contact, do not stare and avoid sudden movements.
● Do not attack the intruder or touch anything they have touched.
● Take note of intruder’s clothing and any other distinguishing features, but do not stare.
● If safe to do so, activate an alarm.
● Attempt to stay facing the person.
● Do not threaten the person in any way. This may mean that if you are a tall, large person,
you may need to stay seated as long as possible so that you don’t present yourself as a threat.
● Comply with all demands that are not likely to cause harm, eg If the demand is for the key
to the car – give them the key. If the demand is for the contents of the drug cupboard –
give them the contents. Not meeting these demands will threaten your safety.
● Do not comply with unreasonable demands. Examples of unreasonable demands
might include being ordered to jump out of a high window where the risk of death is high.
● Do not give them information about other people taken hostage.
● If taken hostage, do not draw attention to yourself, eg do not try to assert yourself.
If someone is to be harmed, the people most often chosen are those of privilege or those
who have been non-compliant or irritating.
● If involved in an armed hold-up, do not chase the person when they attempt to escape as
this puts you at greater risk of harm.

Key points

• Always show respect and dignity for others.

• Use effective communication skills.
• Treat people as individuals not as problems.
• Know your short-term and long-term options.

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Related NSW Health policies

and guidelines

a. Mental Health for Emergency Departments, May 2002 (red book).

b. Management of Adults with Severe Behavioural Disturbance, May 2002 (green book).
c. C2003/88 Reportable Incident Briefs to the NSW Department of Health.
d. C2001/22 Workplace Health and safety: A Better Practice Guide (currently under review).
e. C2002/19 Effective Incident Response: A Framework for Prevention and Management
in the Health Workplace.
f. C2002/50 Joint Management and Employee Association Policy Statement on Bullying,
Harassment and Discrimination.
g. NSW Health Security Manual.
h. NSW Health Zero Tolerance Policy and Framework Guidelines.
i. IB94/4 Restraint of Children and Adolescents in Psychiatric Facilities.

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References

1. 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.
2. Bell DM, Espie CA (2002). A preliminary investigation into staff satisfaction, and staff emotions
and attitudes in a unit for men with learning disabilities and serious challenging behaviours.
British Journal of Learning Disabilities 30 (1), 19-27.
3. Chaplin E, Allison G (1998). The prevention and management of violence in the community.
British Journal of Community Nursing 3 (6), 277-282.
4. Claravall L (1996). Health care violence: a nursing administration perspective.
Journal of Nursing Administration (26) 2, 41-46.
5. Delaney J, Cleary M, Jordan R, Horsfall J (2000) An exploratory investigation into the
nursing management of aggression in acute psychiatric settings. Journal of Psychiatric
and Mental Health Nursing 8 (1), 77-84.
6. Fry AJ, O’Riordan, Turner M, Mills KL (2002). Survey of aggressive incidents experienced
by community mental health staff. International Journal of Mental Health Nursing 11, 112-120.
7. Hunter E (1997). Violence prevention in the home health setting. Home Healthcare Nurse
15 (6), 403-409.
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. Jones J, Lyneham J (2000). Violence: part of the job for Australian nurses? Australian
Journal of Advanced Nursing 18 (2), 27-32.
10. Martin E (1995) Nursing the psychiatric emergency. London, Butterworth, Heinmann.
11. 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.
12. 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.
13. 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.

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14. Mental Health Council of Australia (2000) Enhancing relationships between health
professionals and consumers and carers. Final Report.
15. NSW Interagency guidelines for child protection intervention, 2000. (online).
Available www.kids.nsw.gov.au.
16. Paterson B, Leadbetter D (1999). De-escalation in the management of aggression and
violence: towards evidence-based practice. In Turnbull J, Paterson B (eds) Aggression and
violence: approaches to effective management (pp 95-123). Basingstoke: Macmillan.
17. Shah A (1999). Aggressive behaviour in the elderly. International Journal of Psychiatry
in Clinical Practice 3, 85-103.
18. Zook R (2001). Developing a crisis response team. Journal for Nurses in Staff
Development 17 (3), 125.

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