Previous Section | Table of Contents | Next Section

6. Risk assessment and Management - assessing and managing the risks arising from violence

Risk assessment requires identifying the hazards and assessing and controlling those risks.

Although individuals are sometimes unpredictable, violent episodes or incidents in this industry happen with sufficient frequency in certain settings to make them a predictable event.

In certain healthcare situations, management of violence may be best achieved through the application of a 'process'. In other situations, redesign of the physical work environment will be more productive.

Community homes where care occurs are workplaces and should be subject to the same hazard identification and management.

Recognising and Responding to the Risk

Once actual or potential violence is recognised, the most appropriate response is by means of "work practice" interventions, for example calming and de-escalation, and this is an integral part of mental health training. In this instance personal safety and good practice are synonymous.

Conscious Violence

Column 1 of Table 1 describes a variety of potential warning signs or cues that may indicate that a patient may be about to respond violently. Column 2 describes suggested responses to each warning sign that the caregiver can use to try and diffuse the potentially violent situation.

Table 1: Warning signs of conscious violence

Warning signs/cues of violence	Responses that may help diffuse aggression
Repeated succession of questions	Appear calm, self-controlled and confident, confirming that you are addressing their concerns.
Using another language in an aggressive manner	Identify language origin and locate interpreter to assist. A list of interpreters could be held in an Accident and/or Emergency Department.
Using obscenities or sarcasm	Do not match their language.
Shouting	Ask for information with a calm voice.
Replying abruptly or refusing to reply	Calmly confirm the received information back to the assailant.
Rapid breathing	Breathe slowly and evenly
Pacing	Attempt to sit them comfortably
Clenched fist or pointing fingers	Do not fold your arms or clench your fists in reaction.
Invading your personal space	Maintain a comfortable distance.
Staring	Maintain normal, but broken eye contact.
Tight jaw with clenched teeth	Open hands to the assailant
Shoulders squared up and dominating	Stand to the side.

Unconscious Violence

This guidance is not intended to assist in the diagnosis of the patient, but to identify that there may be a different trigger and management process necessary when responding.

For example, it would be unwise to call for police assistance to a patient who has hit an employee following a general anaesthetic, as they will have had no intention of harming the staff member and probably have no recollection of events once the effects of the anaesthesia have worn off.

Unconscious violence may occur as a result of the assailant experiencing:

• acute head injury
• post-operative effects of anaesthesia
• blood level of toxins, glucose, septicaemia, electrolytes and oxygen.

The purpose of so identifying these situations is all about risk identification so that appropriate thought and planning can go into care plans. In this way, staff safety is preserved while appropriate standards of patient care are supported.

Identify the Hazard, Assess the Risk and Control the Hazard

After identification and risk assessment (the likelihood of injury or harm occurring, assessing the consequences and rating the risk) hazard control or management involves a preferred hierarchy of risk control measures, the most effective being elimination followed by isolation and finally the least effective, minimisation. Work practice interventions, for example, are a form of minimisation, engineering solutions usually fit into the isolation category and are more effective and cheaper in the long run.

There are a number of self-assessment templates at the end of this best practice document which can be used, and adapted to particular workplace settings, as aids to practical implementation.

• Appendix 1 includes an organisational self-assessment tool
• supported by Appendix 2 which includes the framework for assessing an individual's propensity for violence or conducting an area assessment
• Appendix 4 includes some completed examples for reference purposes.

As part of workplace risk identification and management, employers/managers may:

• investigate and identify those patients or clients who have been involved in assaults/ incidents in the past (or who fall into a recognised risk situations such as acute 'P' intoxication);
• review the triggers or circumstances relating to the incident; and assess whether the person's behaviour is still a risk to staff
• identify situations where clients are likely to respond adversely and investigate the likelihood of serious harm
• consult with staff to develop management plans, including adequate training, which may be included in the 'daily care plan', support plan or client's personal plan.
• Communicate these to all staff potentially at risk
• put into place strategies to support each individual client to manage their his or her own behaviour
• ensure clients are adequately matched to services/activities/programmes.
• Involve referring agencies/agents where appropriate
• have adequate emergency response routines in place
• monitor the results of these management solutions.
• Make long term plans to ensure adequate facilities, properly engineered to isolate or minimise the risk.

For community-based social service organisations in the disability and mental health sectors:

• identify situations where clients may be likely to react adversely
• put strategies in place that will mitigate these circumstances and assist the clients to manage his or her own behaviour
• ensure clients are appropriately matched to services and to activities or programmes within services.
• Involve referring agencies where appropriate.

Employee Participation and Responsibilities

Effective workplace health and safety management is strongly dependent on the involvement of staff in identifying hazards, and on the sharing of information.

This can be achieved by a number of methods, including: employee surveys, hazard identification by teams, regular weekly meetings where work is reviewed and systems discussed, or a health and safety committee including both elected employee and management representatives.

Under the HSE Act, employees have a duty to take all practicable steps to avoid

harming themselves or any other person. This general duty implies the following:

• behaving appropriately
• taking care to avoid behaviours that generate inappropriate responses from others (including bullying or being dismissive of the needs of others)
• co-operating with the employer and providing constructive feedback in matters of health and safety
• a duty to follow care plans and to bring to the attention of the supervisor/ employer any difficulties with those care plans
• attending training and implementing the health and safety objectives of the training as far is possible
• fully participating in communication programmes
• reporting hazards and incidents (including stress and fatigue)
• taking part in incident investigations and debriefing exercises.

Transfer of Information

A number of incidents of violence in recent years have resulted from the non-transfer of information between agencies and to individual employees. For example, a health provider or social agency has not transferred information to a home-based or residential care organisation. Two such cases were:

1. a patient killed a home-based healthcare worker during a violent assault. The caregiver had not received the information that her client was potentially dangerous
2. a home-based caregiver took a client into her home. The organisation knew but did not tell the caregiver there was a history of violence. The person became violent towards the caregiver.
3. number of reasons were cited for the failure to warn of the risk. These included:
   1. inadequate or not regularly updated clinical assessment or patient history
   2. inadequate documentation at inception of care, e.g. an acute psychiatric admission may lead to a dangerous patient going to an inappropriate environment
   3. referral agencies reported they were too busy or 'could not be bothered'
   4. staff in some health care organisations did not believe that it would be responsible to pass on certain information on the grounds that the 'downstream' caregivers were either
      1. 'not equipped' (presumably it is thought that they are not adequately trained or experienced) to handle it or
      2. there is no need for them to know
   5. staff feared repercussions from the misapplication of the Privacy Act and the Health Information Privacy Code (HIPC)
   6. the organisation may have wished to place a patient/client with another organisation and therefore did not pass on information seen as likely to compromise the placement
   7. the 'upstream' care-giving organisation may not have taken steps to obtain patient/client consent (when the information was initially being gathered) for subsequent passing on to 'downstream' caregivers
   8. emergency admissions without the right skill mix, appropriate care provider or understanding of client needs.

The normal care and precautions concerning the supply of patient or client information apply but information relevant to the safe and proper care of patients or clients, including information concerning risks posed to employee wellbeing, is a necessary part of quality patient care and adequate employer health and safety management.

This information should be made available to caregivers consistent with provisions of the Health Information Privacy Code (HIPC):

• Referring agencies need to provide adequate information to permit comprehensive risk identification and ongoing support plan development.
• Where a group of providers are involved in the provision of support to a client, ensure mechanisms are in place to enable exchange of relevant information.
• Advise incidents of violence leading to physical or psychological harm (deliberate or not) by a patient or client to downstream caregivers so that staff safety and high-quality patient care can be provided for.

---

Previous Section | Table of Contents | Next Section