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8. Taking All Practicable Steps to Manage Risk Situations

All Practicable Steps

Employers are required to take 'all practicable steps' to keep their employees safe. The steps described here are examples only, they are not applicable in every circumstance in every organisation and need adapting to each situation to follow the order of priority of elimination, isolation and minimisation.

Given the nature of many patients or clients, elimination of the hazard in the healthcare sector is often difficult or impossible. However, there are a few options which include:

• changing the system of work to completely eliminate the trigger for workplace violence or aggression
• Identifying and addressing underlying clinical influences that are having an effect on the individual's violent behaviour.

Isolation is often not the most practicable solution for those front-line staff caring for individuals. However, those who are in the vicinity of the place of work could be protected by isolation. In practical terms this could mean the use of a side room on a ward or a triage room in an emergency department.

If the opportunities to eliminate and/or isolate violence have been exhausted, minimisation may be the most practicable management mechanism. The principles of minimisation may include:

• issuing a clear policy statement
• designing and building for safety
• implementing work organisation controls
• implementing work practice controls
• ensuring the correct use of personal protective equipment; e.g. appropriate uniforms, appropriate footwear, shin guards etc.
• implementing an adequate emergency response plan
• the monitoring of management mechanisms
• having mechanisms in place to ensure an adequate response by suitably trained staff is in place for violent episodes.

In all situations, a combination of management methods systematically managing for all eventualities is likely to be the most successful.

Clear Policy Statements

Employers should have clear policies and procedures in place to inform staff, patients and clients that violence towards staff, and indeed anyone in the workplace, is unacceptable, and detail the procedures required when violence occurs.

• The principles of such policies are detailed by the World Health Organisation (WHO) at http://www.who.int/ [external link - pdf file]
• A range of examples of such policies exist as part of the United Kingdom's NHS "zero tolerance" programme such as: http://www.dvh.nhs.uk/ [external link - pdf file]

Designing For Safety

Most of the following best practice documents concerning the safe design of premises are taken from Occupational Safety and Health Administration (OSHA) advice supplemented by the WHO/ILO document.

This is supplemented by the Australasian experience with respect to the necessary requirements of psychiatric facilities (residential and inpatient).

This section applies to in-patient care services and is not necessarily applicable to community-based service providers.

The principles of such advice include:

Access

• provide safe access and quick egress from the workplace
• minimise multiple areas of public access to healthcare facilities
• locate security services at the main entrance, near the visitors' transit route in emergency departments
• locate staff parking areas with close proximity to the workplace if possible
• ensure the reception area is easily identifiable by patients and visitors, and easily accessible to other staff
• restrict access to staff areas (changing rooms, rest areas and toilet facilities) to personnel of the facility.

Space

• provide enough space per person to reduce interference with personal space
• design waiting areas to accommodate all visitors and patients comfortably - provide adequate seating, especially if long waiting periods are a possibility
• provide employees with separate rest areas and/or meal rooms away from patients/clients, particularly when doing night work or dangerous work
• install protective barriers for workers at special risk and to separate dangerous patients/clients from other patients and the public consistent with assessment of therapeutic needs.

Fixtures and Fittings

• Provide good lighting
• Provide an environment with an appropriate temperature, humidity and ventilation
• Where high-risk patients are cared for, ensure that the wall coverings are sufficiently robust to withstand assault
• Ensure fixtures and fittings cannot be used as weapons.

Premises

When the opportunity presents itself for new premises or redesign:

• Design facilities with the potential for emergencies in mind
• Address the issue of "black spots". These are the areas that either promote violence by tunnelling people into confined spaces, or by restricting egress from a hostile situation
• Ensure interview rooms have two exits (to avoid a staff member becoming trapped) and viewing window(s) so that other staff can intervene if necessary
• Ensure treatment rooms in emergency service areas are apart from public areas
• Keep levels of noise to a minimum to reduce stress, irritation and tension
• Provide facilities for waste management i.e. soiled linen, clothing etc
• Provide extra services of facilities and equipment where needed, e.g. where a patient/client is know to be hepatitis B positive
• In problematic areas, and where proven need exists, introduce facilities to ensure that weapons or mood-altering substances are not smuggled to patients/clients
• Ensure weapons removed are stored off site by police or security
• Ensure that windows and doors are secure so that patients/clients can be cared for in an environment safe for them, the staff and the public at large
• Isolate potentially dangerous equipment, chemicals or medication supplies (i.e. locked cupboards where appropriate)
• Consider the use of closed-circuit TV where oversight may be required in geographically difficult or distant parts of the building
• Where appropriate, install security devices such as metal detectors to prevent armed persons from entering the facility
• Test these security devices and personal/other alarm procedures regularly
• Where appropriate, provide adequate security lighting and security escorts for evening or night staff.

Work Organisational Practices

Every workplace is unique, therefore a combination of different factors and management tools will apply. Principles taken from the World Health Organisation, International Labour Organisation and the National Health Service (UK) documents include:

Risk Assessment Routines

• "Isolate" the risk of violence by ensuring that clients are appropriately placed in organisations with the ability to cope with them and with people within those organisations who have adequate training and experience
• Obtain a current medical report from the referral agency, a general practitioner, psychologist or psychiatrist
• Ensure that clients with a history and likelihood of violence are identified beforehand
• Obtain information from those with recent responsibility for the patient/client (e.g. caregivers, family)
• Rule 11 of the Health Information Privacy Code makes it clear that personal health information must be transferred to downstream caregivers - recognising the possibility that a patient or client will be violent towards a caregiver.
• Develop a procedure for assessing changes in patient/client behaviour, communicating them to staff (via patient/client profiles) and implementing the changes in the way care is given
• Assess the risk of harm to employees that may result from contact with the patient or client .e.g. if the person has an infectious disease or where the infection causes the client to have an increased risk of behaving violently.

Communication

• Prepare care plans that address issues of actual or potential violence
• Ensure that the staff member has knowledge of the way the patient/client may respond to medication that they are receiving (i.e. the caregiver's knowledge is matched to the person's needs and circumstances)
• Consider the client's behaviour as it changes with time, record those changes on the client profile and report them to staff
• Assess accidents and incidents and make changes to the patient/client profiles as indicated.

Appropriate Staff Skills for the Demands of the Job

• Use best practice selection methods and pre-employment procedures to identify people who are suitable or unsuitable for this work
• Identify people who require training and their specific training needs before they begin the work
• Assess employee skills in relation to dealing with patients/clients and assign employees accordingly.

Other Factors that Impact on Staff Safety and Client Care

• Rotate jobs to reduce the period of exposure (with respect to long-term mental fatigue)
• Remove potentially dangerous weapons (e.g. scissors, knives) within the boundaries established by the law and management policies
• Assess the physical safety of the facilities in which patients and clients live and learn

Work Practice Procedures

Suggestions include:

• provide feedback on performance and opportunities for the development of skills
• patient/client notes should include a section which assesses the risk to caregivers. In particular, the nature of the risk should be specified by asking the following types of questions:
  • is there information in the patient/client record that suggests violence has occurred to staff in the past?
  • if you are aware of such incidents, from the information available, how frequent are they?
  • do family members or support people report a history of violence or abuse in the recent past?
• A procedure similar to this (risk assessment of patients/clients and situations) is required by most jurisdictions and professional associations.

Work Practice Procedures

• Define tasks and vary them if possible
• Assign tasks to people who have the skill and ability to do them - consider general abilities and things that may impact in the short term such as pregnancy, fatigue and/or fitness
• Rotate staff who do dangerous and/or unpleasant tasks or who are new to the job
• Introduce team care or buddying in situations where risk is unknown or high
• Consider the cultural factors (e.g. culturally inappropriate behaviour of employee) that may escalate or de-escalate client aggression
• Provide clear messages to patients/clients and their visitors that violence is unacceptable and has consequences
• Consider the use of appropriate models and techniques for managing different situations and client groups (for instance the 'yellow/red card system' as applied to those consenting to violence in the United Kingdom, has been used with marked success)
• Use behavioural techniques to promote non-violence

Personal Protective Equipment

Where appropriate:

• Ensure that clothing is appropriate to the level of risk encountered
• Ensure that emergency response devices cannot be used as a weapon (e.g. a personal alarm used as a garrotte)
• Instruct staff not to wear jewellery or carry tools or pens in at-risk situations
• Provide staff in hazardous environments with personal communication devices

Adequate Emergency Response

Where appropriate:

• Signpost areas for staff, patients and visitors
• Use signage to identify areas of special risk or restricted areas
• Ensure that areas where people may be assaulted are visible through windows
• Provide easy egress from areas where violence may occur
• Install other security devices such as cameras and good lighting in hallways
• Provide emergency exits

Allowing Staff to Summon Help Easily

Where appropriate:

• Develop emergency signalling, alarm and monitoring systems as appropriate, and test periodically (make sure that other staff are available to respond to alarms)
• Have a mixture of personal and wall-mounted alarms so that staff have a variety of options to summon assistance
• Test these systems regularly and measure the response time to ensure that intervention occurs before serious harm can be inflicted
• Have a system in place to treat and monitor employees who report suffering harm, serious harm or have been in an incident that could have lead to such harm (i.e. 'first aid' response and monitoring as required by the HSE Act)
• Have a 'check-in system' whereby staff are all accounted for at the end of each shift (refer to section 7, subsection Community Service Providers)

Further Guidance on Managing Violence

Communication

Use a variety of communication methods as covered in the training programme to ensure that clear information is given to the person in a manner that does not inflame (if the person has insight appropriate cognitive function) the situation.

Positioning the Individual

Having a clear communication link does not guarantee that a person who displays violent behaviour will not strike you. Maintaining a safe distance at all times is still very important. In some cases the use of a padded cot side as a physical barrier is enough to prevent repeated kicks and strikes while the individual remains in bed.

Never place yourself in a vulnerable position.

Always ensure you have a clear line of retreat.

Remember the right to refuse dangerous work.

Community Service Providers

Community service providers are a particularly vulnerable group. They often work in isolation and within premises that cannot be designed with the safety of the service provider in mind.

What can Employers Do?

• The best protection an employer can offer is to establish a zero-tolerance policy towards workplace violence
• Establish a workplace violence prevention policy. Ensure all employees know the policy and understand that all claims of workplace violence will be investigated and remedied promptly
• Provide safety education for employees so they know what conduct is not acceptable, what to do if they witness or are subjected to violence, and how to protect themselves
• Equip field staff with cell phones and hand-held alarms or noise devices
• Establish a daily work plan for field staff that requires employees to keep a designated contact person informed of their location throughout the day. Have the contact person follow up if an employee does not report in as necessary
• Keep employer-provided vehicles properly maintained
• Instruct employees not to enter any location where they feel unsafe
• Introduce a 'buddy system' or provide an escort service or police assistance in potentially dangerous situations or at night
• Develop policies and procedures covering visits by home healthcare providers. Address the conduct of home visits, the presence of others in the home during visits and the worker's right to refuse to provide services in a clearly hazardous situation
• Develop methods for rapid response back-up to community workers. Workers need to be able to access rapid support, which has implications for both the issue of communication devices and plans that enable the rapid deployment of assistance
• Advise staff to take extra care in lifts, stairwells and unfamiliar residences; leave the premises immediately if there is a hazardous situation or request police escort if needed
• It may be necessary on some occasions, where there is a history of violence, for the client to be brought to the office or clinic for treatment.

What can Employees Do?

• Attend personal safety training programmes to learn how to recognise, avoid and diffuse potentially violent situations
• Alert supervisors to any concerns about safety or security and report all incidents immediately in writing
• Raise any ongoing safety issues with health and safety representatives and/or union delegate
• Avoid travelling alone to unfamiliar locations or situations whenever possible
• Carry only minimal money, prescription medication and required identification into community settings.

Monitoring

When employees are exposed to a significant hazard, and when an employer can only minimise the hazard, the employer must monitor the employees' exposure to the significant hazard and, with the employee's informed consent, the health of the employee in relation to the hazard. This includes the physical and mental aspect of any actual or threatened violence.

Such apprehension, ("near misses") should be reported, investigated and managed rather than waiting for the "big event" to occur.

A system to report violence and/or its effects and a system to ask staff from time to time about their perceptions of the potential for violence (using a paper questionnaire, for example) would be a useful way of fulfilling these legal and best practice obligations.

Under-reporting of incidents is a particular problem with occupational aggression/violence. Reporting an incident does not reflect on the individual caregiver's treatment standards, but it is important to help identify and manage such situations. A positive culture to encourage reporting is therefore required.

Maintain an up-to-date and accurate incident/accident reporting system. Ensure that such reports are considered in the development of care plans, and are communicated to involve staff.

Investigate all incidents of violence and, where appropriate, make changes to practice. Such changes may include:

• Regular training programmes and retraining of the staff member
• Reassessment of the risk status of that client or patient
• Changes to the relevant care plans, including clinical reassessment
• Changes to the management measures for that unit
• Rotation of staff in certain areas
• Complaints being laid with the Police and the Police laying charges
• Procedural steps regarding the right to refuse to carry out work likely to cause serious harm
• A long-term plan to address facility needs, e.g. funding.

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