cir2003-48. zero tolerance response to violence in the nsw

Policy Directive

Department of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

spacespace

Zero Tolerance Response to Violence in the NSW Health Workplacespace

Document Number PD2005_315

Publication date 27-Jan-2005

Functional Sub group Personnel/Workforce - Occupational Health & SafetyClinical/ Patient Services - Mental Health

Summary Purpose of policy is to ensure that in all violent incidents, appropriateaction is consistently taken to protect health service staff, patients andvisitors and health service property from the effects of violent behaviour.

Author Branch Workplace Relations and Management Branch

Branch contact 9391 9305

Applies to Area Health Services/Chief Executive Governed Statutory HealthCorporation, Board Governed Statutory Health Corporations, AffiliatedHealth Organisations - Non Declared, Affiliated Health Organisations -Declared, NSW Dept of Health

Distributed to Public Health System, NSW Department of Health

Review date 31-Jan-2011

Policy Manual Not applicable

File No. 01/5661-7

Previous reference 2003/48

Issue date 28-Jul-2003

Status Active

Director-GeneralspaceThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatoryfor NSW Health and is a condition of subsidy for public health organisations.

Distributed in accordance with circular list(s):

A 48 B C D E 73 Miller Street North Sydney NSW 2060 F G H I J Locked Mail Bag 961 North Sydney NSW 2059 K L M N P Telephone (02) 9391 9000 Facsimile (02) 9391 9101 In accordance with the provisions incorporated in the Accounts and Audit Determination, the Board of Directors, Chief Executive Officers and their equivalents, within a public health organisation, shall be held responsible for ensuring the observance of Departmental policy (including circulars and procedure manuals) as issued by the Minister and the Director-General of the Department of Health.

CIRCULAR

File No 01/5661-7 Circular No 2003/48 Issued 28 July 2003 Contact Centre for Mental Health

(02) 9391 9305

Zero Tolerance Response to Violence in the NSW Health Workplace NSW Health staff have the right to work in a violence free workplace. Patients and others have the right to visit, or receive health care, in a therapeutic environment free from risks to their personal safety. As a result of a key recommendation from the NSW Health Taskforce on Prevention and Management of Violence in the Health Workplace, NSW Health has adopted a zero tolerance response to all forms of violence on health service premises or any other place where health related activities are carried out. Zero Tolerance Policy and Framework Guidelines: The resulting ‘Zero Tolerance Policy and Framework Guidelines’ document was developed in consultation with Area Health Services, key violence prevention and security experts, police, criminologists and health unions. The policy applies to the NSW Department of Health, all Area Health Services, all statutory health corporations, all affiliated health organisations and the NSW Ambulance Service. The policy is a companion document to the Security Manual (currently under review), circular 2001/22 Workplace Health and Safety: A Better Practice Guide and circular 2002/19 Effective Incident Response: A Framework for Prevention and Management. These documents should be consulted when implementing the policy, and the emphasis of Health Service activity should always be on preventing violence in the first instance by using the risk management approach. A supporting zero tolerance brochure and posters have been produced in sufficient numbers for wide distribution, and bulk orders using the attached Publications Order Form, can be placed with the Better Health Centre. The brochure should be made available to staff and patients and included in staff orientation and patient information kits. The posters and a supply of brochures should also be displayed in relevant areas eg emergency departments, admissions areas, outpatient areas etc. The brochure will be posted on the intranet for longer term download, printing and use as required. Policy Implementation: A planned approach to this important initiative is required. Health Services will need to establish a steering group of key stakeholders to plan and implement the zero tolerance approach. Membership should include, but not be limited to, representation from the Area executive, facility senior management, media/public relations, OHS risk management, asset management, security, learning and development, emergency departments, mental health, admissions and outpatient areas and relevant unions.

Depending on the specific issues, communications with other groups will be needed eg medical records, purchasing etc. Local police should be consulted and involved when planning and implementing relevant sections of the policy. Legal advice should also be sought during the development of local violence prevention and management policies and procedures to ensure that they comply with all relevant legislation eg the Crimes Act 1900, Mental Health Act 1990, Anti-Discrimination Act 1977, Privacy and Personal Information Protection Act 1998. A Quick Zero Tolerance Checklist (page 50 of the policy guidelines) should be used as a guide to policy implementation. NSW Health training program: ‘A Safer Place to Work: Preventing and Managing Violent Behaviour in the Health Workplace’: To further support the zero tolerance policy, the Department is releasing a modular, accredited aggression minimisation training program for use by Health Services. Key aspects of the training include relevant information on the zero tolerance response, what zero tolerance means from a practical perspective for managers and staff and response options when confronted with violence. The training program is currently being introduced to NSW Health trainers. Monitoring Implementation of Zero Tolerance: Because of the importance of Taskforce initiatives, a subgroup of the NSW Health OHS Advisory Group will be convened to develop an evaluation plan, and to monitor implementation of key Taskforce strategies, including the zero tolerance policy and violence prevention training. NSW Health is committed to the zero tolerance response to violence, and its implementation should be given priority. Robyn Kruk Director-General

Zero ToleranceResponse to violence

in the NSW Health workplace

Policy and Framework Guidelines

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) 030002

ISBN 0 7347 35111

For further copies of this document please contact:

Better Health Centre – Publications Warehouse

Locked Mail Bag 5003 Gladesville 2111

Further copies of this document can be downloaded

from the NSW Health website:

www.health.nsw.gov.au

July 2003

NSW Health Zero tolerance : response to violence in the NSW Health workplace – Policy and Framework Guidelines i

1. About this document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 Zero tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.3 Version . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.4 Updates and feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.5 Related policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.6 Additional references . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.1 Purpose and scope of document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.2 Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.3 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3. Policy framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.1 Violence in the health workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.1.1 The social context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.1.2 Counting the cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.2 Policy statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.3 Creating a zero tolerance culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.3.1 Management commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.3.2 Workplace bullying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3.3.3 Accountability and responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3.3.4 Zero tolerance key messages to staff and managers . . . . . . . . . . . . . . . . . . 9

3.3.5 Zero tolerance communication strategies . . . . . . . . . . . . . . . . . . . . . . . . . . 10

4. Legislative environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

4.1 Occupational health and safety legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

4.2 Workers compensation legislation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

4.3 Mental Health Act 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

4.4 Anti-Discrimination Act 1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

4.5 Privacy and Personal Information Protection Act 1998 . . . . . . . . . . . . . . . . . . . . 13

4.6 The Crimes Act 1900 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

4.7 Other relevant legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Contents

Zero tolerance : response to violence in the NSW Health workplace – Policy and Framework Guidelines NSW Healthii

5. A risk management approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

5.1 Violence and the risk management approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

5.2 Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

5.3 Organisational planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

5.4 Relationships with local police . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

6. Violence risk identification and assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

6.1 Local incident reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

6.2 Information analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

6.3 Physical environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

6.4 Prioritising risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

7. Violence risk control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

7.1 Hierarchy of risk controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

7.2 Physical environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

7.2.1 Crime prevention through environmental design . . . . . . . . . . . . . . . . . . . . 21

7.2.2 Access controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

7.2.3 Surveillance and lighting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

7.2.4 Fittings and furniture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

7.2.5 Design series health facility guideline security and safety . . . . . . . . . . . . 24

7.3 Patient alert systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

7.3.1 File flagging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

7.3.2 Legal issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

7.3.3 Management plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

7.3.4 Developing local policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

7.4 Clinical initiatives nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

7.5 Education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

7.5.1 Benefits of education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

7.5.2 NSW health violence prevention and minimisation training program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

7.6 Other administrative controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

8. Responding to violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

8.1 Immediate response options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

8.1.1 Clinical guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

8.1.2 Summary of immediate response options . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Contents

NSW Health Zero tolerance : response to violence in the NSW Health workplace – Policy and Framework Guidelines iii

8.1.3 Verbal de-escalation and distraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

8.1.4 Verbal warning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

8.1.5 Back-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

8.1.6 Evasive self-defence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

8.1.7 Evasive self-defence training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

8.2 Long-term response options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

8.2.1 Summary of long-term response options. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

8.2.2 Written warnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

8.2.3 Conditional treatment agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

8.2.4 Inability to treat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

8.3 Duress alarm systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

8.4 Duress response planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

8.5 Post incident response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

8.5.1 Post incident support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

8.5.2 Incident reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

8.5.3 Incident investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

8.5.4 Operational review and debriefing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

9. Community health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

9.1 Risk management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

9.2 Response management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

10. Remote health services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

10.1 Risk management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

10.2 Response management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

11. The NSW Criminal Justice System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

11.1 Legal options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

11.2 Criminal prosecution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

11.3 Apprehended violence orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

11.4 Charter of victims rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

11.5 Role of witnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

12. Monitoring, review and continuous improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

12.1 Ongoing monitoring of the working environment . . . . . . . . . . . . . . . . . . . . . . . . 49

12.2 Formal review and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Contents

Zero tolerance : response to violence in the NSW Health workplace – Policy and Framework Guidelines NSW Healthiv

12.3 Performance indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

12.4 Continuous improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

12.5 A quick zero tolerance checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

13. References and additional resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

13.1 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

13.2 Related websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

13.3 Relevant Australian standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Contents

1

NSW Health Zero tolerance : response to violence in the NSW Health workplace – Policy and Framework Guidelines 1

About this document

Response to Violence in the NSW health workplace: Policy and Framework Guidelines.Copies may be obtained at www.health.nsw.gov.au/pubs/violence/index.html

Employee Relations Division and Centre for Mental Health

Version 1

Feedback is welcome and should be addressed to the Director,Employee Relations Division, NSW Department of Health

● C2001/22 – Workplace Health and Safety: A Better Practice Guide

● NSW Health Security Manual

● Management of Adults with Severe Behavioural Disturbances,2002 (green book)

● Mental Health for Emergency Departments, 2002 (red book)

● C2002/19 – Effective Incident Response: A Framework for Prevention andManagement in the Health Workplace

● Memorandum of Understanding between NSW Police and NSW Health,1998 and operational flowcharts, 2002

● C2001/109 – Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination

● Guidelines on the Management of Challenging Behaviour in Residential AgedCare Facilities in NSW, 2000

● Guidelines for the Promotion of Sexual Safety in NSW Mental Health Services(currently under review)

● C93/77 – Patient Restraints (currently under review)

● C94/127 – Policies on Seclusion Practices, the Use of Restraint and the use ofIV sedation in Psychiatric In-Patient Facilities (currently under review)

● C98/31 – Policy and Guidelines for the management of patients with possiblesuicidal behaviour for NSW Health staff and staff in private hospital facilities

● Strategy for Mental Health Care: Caring for Mental Health, 1998

● C2002/108 – Emergency Department Patients Awaiting Care

● NSW Needle and Syringe Exchange Policy and Procedures Manual, 1994

● Corporate Governance:A Better Practice Guide, 2003

● C1999/76 – The NSW Department of Health Smoke free Workplace Policy(under review)

● NSW Health Frontline Procedures for the Protection of Children and Young People, 2000

● C2003/16 – Protecting Children and Young People

1.1 Zero tolerance

1.2 Responsibility

1.3 Version

1.4 Updates and feedback

1.5 Related policies

Zero tolerance : response to violence in the NSW Health workplace – Policy and Framework Guidelines NSW Health2

● NSW Interagency Guidelines for Child Protection Intervention 2000

● NSW Health Occupational Health, Safety and Rehabilitation Guide,January 1998 (grey guide – currently under review)

● C1998/79 – Principles and Minimum Standards for the Development ofHealth Service Codes of Conduct

Other NSW Health Occupational Health and Safety related policies

● C2000/68 – Managing for Performance:A Better Practice Approach forNSW Health

● C2000/42 – Policy Framework and Better Practice Guidelines for the Development of Employee Assistance Programs (EAPS – currently under review)

● C2001/111 – Policy and Best Practice Guidelines for the Prevention ofManual Handling Incidents in NSW Public Health Services

● C2001/5 – The Occupational Health, Safety and Rehabilitation Numerical Profile

● C2001/119 – Better Practice Guidelines for including Health and Safety inthe Engagement, Management and Evaluation of Contractors in Health Services

● C1999/45 – Policy Framework and Best Practice Guidelines for theDevelopment of Health Service Grievance Management Systems

● C2000/92 – Policy Framework for Recruitment and Selection

● C2000/91 – NSW Health Policy on Orientation

● C2003/13 – Design Series Health Facility Guideline Security and Safety 2003

Related NSW Health policies in development

● NSW Health Policy and Procedures for Identifying and Responding toDomestic Violence

Additional references

NSW Department of Healthwww.health.nsw.gov.au/pubs/violence/index.html

NSW WorkCover Authoritywww.workcover.nsw.gov.au

National Occupational Health and Safety Commissionwww.noschc.gov.au

Office of the Director of Public Prosecutionswww.odpp.nsw.gov.au

About this document

1.6 Additional references

2


Introduction

The purpose of this policy and guidelines is to ensure that in all violent incidents,appropriate action is consistently taken to protect health service staff, patients andvisitors, and health service property from the effects of such behaviour.

The zero tolerance response does not take the place of effective risk management,and at all times the focus of activity must be on prevention. However, when aviolent incident does occur, action must be taken to minimise its impact andprevent its recurrence as far as possible, regardless of its source.

This document is a companion to the NSW Health Security Manual (the redmanual), and the Department’s publications Workplace Health and Safety:A BetterPractice Guide (circular 2001/22) and Effective Incident Response:A Framework forPrevention and Management (2002/19). These documents should be closelyconsulted when implementing this policy.

The policy applies to all health workplaces including those in the community, andto all forms of violence (see page 7). The guidelines are provided as a referencetool and should be used to develop local policies and procedures that reflect theintent of this document, and that are specifically targeted at and adapted to localworkplace cultures, situations and needs.

It is not the intent of this policy that inappropriate action be taken against patients whose violent behaviour is a direct result of a medical condition.In these circumstances, the emphasis is on prompt, effective clinical managementand compassionate care of the patient, while at the same time protecting the safetyof that patient, as well as the safety of staff and others who may be affected by the behaviour.

Management options provided in the guidelines and other supporting documentsare multifaceted.They are designed to address violence of clinical origin withappropriate clinical procedures, and violence from other sources by alternatemeans most appropriate to the situation.

The document also provides useful information on the associated legislativeenvironment and criminal justice system, and includes a range of government,departmental and other resources to assist managers and staff to work towardsachieving a violence free workplace.

NSW Health wishes to acknowledge its use of the excellent ‘Zero ToleranceZone’ materials developed by the National Health Service in the United Kingdomas a key source of information during the development of this document.

Client initiated violenceViolence that is inflicted on workers by their customers eg patients, visitors.

External violenceViolence that is perpetrated by persons outside the organisation or business such as during an armed hold-up.

2.1 Purpose and scope of document

2.2 Acknowledgment

2.3 Definitions


Hazard A source or a situation with a potential for harm in terms of human injury or ill-health, damage to property, damage to the environment, or a combinationof these.

Hazard identificationThe process of recognising that a hazard exists and defining its characteristics.

Internal violenceViolence that occurs between employees within an organisation, such as betweensupervisor and employee, and includes bullying.

IncidentAny unplanned event resulting in, or having a potential for injury, ill-health,damage or other loss.

NSW HealthDescribes collectively the NSW Department of Health, Health Services and any other body under the control and direction of the Minister for Health.For the purpose of this document ‘Health Service’ refers individually to publichealth organisations as defined under section 7 of the Health Services Act 1997(including Area Health Services, affiliated health organisations, CorrectionsHealth and the Children’s Hospital at Westmead), and the Ambulance Service of NSW.

Occupational violence For the purpose of the document, occupational violence is defined as anyincident in which employees are abused, threatened or assaulted in circumstancesarising out of, or in the course of their employment. Incidents include 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.

Occupational health and safety (OHS) management systemThat part of the overall management system which includes organisationalstructure, planning activities, responsibilities, practices, procedures, processes and resources for developing, implementing, achieving, reviewing andmaintaining the OHS policy, and so managing the risks associated with thebusiness of the organisation.

PatientFor the purposes of this document, refers to any person receiving health care onhealth service property, in the home or in the community.

Physical environmentThe physical location where work is actually carried out, including theimmediate surroundings.

Place of workPremises, or any other place, where persons perform work, including communitybased work.

RiskThe likelihood and consequence of a potential injury or harm occurring.

Introduction

2.3 Definitions (cont’d)


Risk assessmentThe overall process of estimating the magnitude of risk and deciding what actions will be taken.

Risk controlThe part of risk management that involves implementing policies, standards,procedures and physical changes to eliminate or minimise risks.

Risk management processThe systematic application of management policies, procedures and practices to the tasks of establishing the context, identifying, assessing, controlling,monitoring and communicating risk.

SafetyA state in which the risk of harm to persons or damage to property is limited as far as possible.

ViolenceFor the purpose of this document, violence is defined as any incident in which an individual is abused, threatened or assaulted and includes verbal, physical orpsychological abuse, threats or other intimidating behaviours, intentional physicalattacks, aggravated assault, threats with an offensive weapon, sexual harassment and sexual assault.

Introduction

2.3 Definitions (cont’d)

3Policy framework


3.1 Violence in the health workplace

Violence is an issue for the whole of society. However, violence does not happenin isolation, and violent crime as a whole has significant costs to society.

There is some evidence of a rise in non-fatal violent incidents at work over thepast decade.A number of studies cited in a discussion paper prepared for theViolence Taskforce by the University of NSW, Occupational Violence:Types, ReportingPatterns, and Variations between Health Sectors, have shown increases in workerscompensation claims, organisational records, insurance claims and police recordsassociated with occupational violence. However, the discussion paper did note thatat least some of this increase may have been due to increased reporting.

The discussion paper also cited research suggesting that high risk occupationalgroups include those whose work requires substantial face to face contact betweenworkers and clients and/or workers who provide care and services to people whoare distressed, fearful, ill or incarcerated. Other factors that heighten the level ofrisk include long client waiting periods, night and shift work, and working alonein off-site or in isolated work environments.

While there has been little substantive occupational violence research in theAustralian health care sector, some data is available. In 1999/2000 there were 113 claims from hospitals and nursing homes in NSW that involved being hit by aperson and that resulted in five or more days away from work.The estimated costof these claims was $1.3 million paid by WorkCover NSW.

This figure does not include the cost of violent incidents that did not result in a workers compensation claim or resulted in less than five days away from work. It also does not include other costs such as time associated with claimsadministration, investigations, fines, legal costs, absenteeism, staff turnover andrecruitment, or the impact of violence against patients.

The Australian Institute of Criminology estimates that each workplace homicidein Australia costs $1 million in terms of legal costs, insurance claims, investigationcosts and support to survivors.

None of the collected data however can fully encompass the direct human cost tostaff, patients and others who become involved in or witness violent incidents.

3.2 Policy statement

NSW Health staff have the right to work in a violence free workplace.Patients and others have the right to visit, or receive health care, in a therapeuticenvironment free from risks to their personal safety.

All Health Services must have in place a violence prevention program that focuses on the elimination of violent behaviour.Where the risks cannot beeliminated, they must be reduced to the lowest possible level using controlstrategies developed in consultation with employees.

3.1.1 The social context

Workplace violence appears

to be increasing.

Health care workers may

be at increased risk of

workplace violence.

3.1.2 Counting the cost

Workplace violence has

significant direct and indirect

costs on business and the

community.

Health Services must identify,

assess and control workplace

violence risks.


Policy framework

In addition, NSW Health, as a result of a key recommendation from the NSWHealth Taskforce on the Prevention and Management of Violence in the Health Workplace,has adopted a zero tolerance response to all forms of violence by any persontowards any other person on health service premises, or towards any NSWHealth staff working in the community.

The zero tolerance response means that in all violent incidents, appropriate action will be taken to protect staff, patients and visitors from the effects of such behaviour.

Health Services must ensure that managers and staff are appropriately trained andequipped to enable them to respond promptly, consistently and appropriately toeffectively manage violent incidents if they do occur, and as far as possible, toprevent their recurrence.

Managers must know and exercise their responsibilities in relation to preventingand managing violence, and encourage and support appropriate staff responsesconsistent with this document when they are confronted with violence.

Staff must comply with local violence prevention policies and strategies, report allviolent incidents, know their options when confronted with violence, exercise themconsistently and know that they will be appropriately supported in doing so.

Health Services will work towards establishing and maintaining a culture of zerotolerance to violence, as well as work systems and environments that enable,facilitate and support the zero tolerance response.

This document provides advice on violence risk management and the zerotolerance response, and its implementation should be given priority.

3.3 Creating a zero tolerance culture

In order for the zero tolerance response to be successful, every Chief ExecutiveOfficer, manager and staff member needs to recognise and acknowledge thatviolence is unacceptable and that NSW Health is committed to addressing this issue.

However, the message cannot be delivered in isolation, and the operationalsuccess of the zero tolerance response is based on the principles that staff:

● know how to report a violent incident and are encouraged and supported in doing so

● have access to training, work environments, equipment and procedures to enable them to respond confidently in violent situations

● know that their response will be supported by management

● know that management will respond appropriately after an incident.

These matters are discussed in more detail in later chapters.

Management commitment, particularly that of the Chief Executive Officer (CEO)and senior management, is vital to the success of creating a zero tolerance culture.Without the visible support of the CEO, it is likely that such an approach willmeet with only limited success.The CEO and senior managers should thereforetake a visible and active interest and role in establishing a zero tolerance cultureand, most importantly, leading by example.

Health Services must adopt

a zero tolerance response

to violence.

Health Services must train and

equip managers to effectively

prevent and manage violence.

Managers must know and

exercise their responsibilities.

Staff must report all

violent incidents.

Health Services must establish

and maintain a zero tolerance to

violence culture.

3.3.1 Management commitment

Violence is not an acceptable

part of the job.

Staff need to have protocols for

reporting violent incidents, and a

working environment that

supports zero tolerance.

All levels of management need

to be committed to the zero

tolerance response.


Related to this is a strong policy statement from the CEO that identifies clearcommitment to a zero tolerance response to violence.Appropriate actions andresponses to all forms of violence need to be developed in consultation with staff,clearly articulated, systematically communicated to staff, actively supported andconsistently enforced.

This requires the CEO to allocate clear responsibility for its various aspects, as wellas adequate authority and resources to the responsible parties.A key component ofCEO commitment is the local requirement that all violent incidents are reportedto the CEO.

Crucial to the success of creating a zero tolerance culture is the active eliminationof internal violence and bullying. It is very difficult for staff to take the zerotolerance response to violence seriously if internal violence and bullying isignored.All CEOs and senior managers are required to actively implement theNSW Health circular 2001/109 Joint Management and Employee Association PolicyStatement on Bullying, Harassment and Discrimination.

Violence towards staff is a significant occupational health and safety (OHS) issue,and just like other aspects of OHS, all staff have a role in, and responsibility formaintaining a safe workplace. Managers in particular are accountable for the health and safety of their staff to the level of their control and influence over theworkplace and work procedures.

Health Services should address appropriate accountability for the maintenance,review and improvement of OHS management systems and in particular thoserelated to the minimisation and management of violence against staff, clients and visitors.

In order to create and nurture a culture of zero tolerance, certain messages need tobe communicated to managers and staff, and regularly reinforced. Health Serviceswill need to develop and actively implement targeted local communicationstrategies to ensure that managers, staff, patients and visitors ‘get the message’.

Key messages to all managers should include:

● putting up with violence in the health workplace IS NOT an acceptable part of your job

● lead by example (if you don’t take violent incidents seriously, neither will your staff, patients or visitors)

● make sure your staff know their options when confronted with violence (there are options and it is important that all staff know what they are)

● encourage and support your staff in utilising these options (staff need to feelconfident in the decisions they make when confronted with violence and thattheir decisions will be supported, particularly when police are involved andduring any resulting legal process)

● know and exercise your responsibilities as a manager in dealing with violence(both short-term and long-term)

● ensure that all violent incidents are reported (keep it simple to encourage aculture of reporting)

● investigate all violent incidents (this is the only way to ensure that riskmanagement strategies continue to be effective)

Policy framework

Health Services need a policy

statement supporting zero

tolerance.

3.3.2 Workplace bullying

Health Services must actively

implement the NSW Health

anti-bullying statement.

3.3.3 Accountability andresponsibility

3.3.4 Zero tolerance keymessages to staff and managers

Managers need to accept that

violence does not belong in

the health workplace and lead

by example.

Managers need to make sure

their staff know how to respond

to violence and support them in

doing so.

Managers need to know about

all violent incidents so they can

try and fix the problems.


● respond promptly to all reports of bullying (if you don’t, staff will not take‘zero tolerance’ seriously)

● keep ‘zero tolerance’ on the agenda (include violence risk management on staffmeeting agendas, operational reviews and debriefings after violent incidents,communicate incident investigation results and remedial actions to your staff,encourage staff to feed back on how local protocols and procedures are working).

Key messages to all staff should include:

● putting up with violence in the health workplace IS NOT an acceptable partof your job (if you don’t get the message, neither will patients and visitors)

● know your options when confronted with violence and exercise themconsistently (the most effective way of protecting yourself AND getting themessage to patients and visitors)

● management will support you in utilising these options (that 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 morerecognised 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).

If staff behaviour consistently reflects these messages, patients and visitors willstart to get the message that violence is not acceptable.

The above messages can be conveyed in a range of ways including:

● information for staff summarising local procedures for getting assistance in an emergency and response options eg small pamphlets or laminated cards in patient reception areas, nurses’ stations and other relevant areas remindingstaff of their options including key phone numbers, response codes etc

● provision of similar information for community health staff

● ensuring that violence risk management is a regular item for discussion at staff meetings

● pamphlets that are provided to patients (including patients receiving care inthe community) and visitors clearly outlining their rights AND behaviouralresponsibilities when in, or visiting, hospital or receiving health care in the community

● placing copies of related materials in all bedside lockers and patientinformation kits (including patients receiving care in the community) andkeeping supplies in waiting areas, emergency departments, public health unitsand other areas based on local needs

● encouraging local media to promote health service initiatives aimed atproviding violence free health care environments

● managers positively reinforcing appropriate zero tolerance behaviour by staff(in line with local policies and procedures)

● posters placed on display in emergency departments and other relevant areasclearly stating that violence will not be tolerated.

Policy framework

Staff need to know that putting

up with violence is not part of

the job.

Staff need to know what to do

when confronted with violence

and know that their response

will be supported.

Staff should report all violent

incidents to their manager.

Problems that don’t get

reported don’t get fixed.

3.3.5 Zero Tolerancecommunicationstrategies

The zero tolerance

message needs to be

constantly reinforced.

Health Services can seek

assistance from their

communications staff

when developing local

communications strategies.


4Legislative environment

4.1 Occupational health and safety legislation

The NSW Occupational Health and Safety Act 2000 (OHS Act) is the main piece oflegislation setting out a worker’s right to a safe and healthy working environment.

The OHS Act requires employers to:

● ensure that the workplace, and any plant or substance provided for use in the workplace, is safe and without risks to health

● ensure that systems of work and the working environment are safe and without risks to health

● provide information, instruction, training and supervision necessary to ensureemployees’ health and safety at work

● provide adequate facilities for the welfare of employees at work

● consult with employees to enable them to contribute to decision makingaffecting their health, safety and welfare at work

● ensure that non employees using the workplace are not exposed to health and safety risks arising from the work of the employer.

The OHS Act also requires employees to:

● take reasonable care for the health and safety of people who are at theemployee’s place of work and who may be affected by the employee’s acts or omissions

● cooperate with their employer to enable the employer to comply with OHS legislation.

The Occupational Health and Safety Regulation 2001 (the Regulation) supportsthe OHS Act, and it requires employers to identify workplace hazards, assess therisks arising from those hazards, implement risk control measures, provide trainingand consult with employees. Occupational violence is a significant OHS risk and isspecifically referred to in the OHS legislation.

There are various offences and penalties, both financial and non-monetary, fornon-compliance with the Act and Regulation even if no-one has been injured.Penalties extend to employers, managers and employees.

4.2 Workers compensation legislation

Workers compensation is a statutory, no-fault system of compensation for work related injuries in NSW. A work related injury can be either physical orpsychological, provided that their employment is the significant contributing factor.

The NSW Workers Compensation Act 1987 together with the Workplace InjuryManagement and Workers Compensation Act 1998 outline the rights and obligationsof insurers, employers and workers in relation to workers compensation and injurymanagement.Together this legislation creates a single scheme for managingworkers compensation in NSW.

The OHS Act 2000 entitles

workers to a safe and healthy

working environment.

The OHS Regulation 2001

requires employers to identify,

assess and control all

workplace risks.

There are penalties for failure

to comply with the OHS Act

or Regulation.

The workers compensation

legislation provides benefits for

workers injured during the

course of their work.


Workers compensation legislation in NSW ensures that when someone is injuredat work or has a work related illness, there is:

● prompt and effective treatment of their injury or illness

● medical and vocational rehabilitation

● income support to injured workers and their dependents during incapacity,through weekly benefits

● payment for reasonable medical treatment and other related expenses

● benefits if injury or illness results in a permanent impairment or death.

In particular, the emphasis is on early notification of the illness or injury, promptmanagement of the worker’s injuries and early contact between the employer andthe worker to facilitate an early return to work.A key objective of this approachis to assist the injured worker to full recovery and return to meaningful work assafely and promptly as possible.

4.3 Mental Health Act 1990

The Mental Health Act 1990 establishes the legislative framework within which care,control and treatment can be provided for people with a mental illness in NSW.

Significant objectives of the Mental Health Act are to ensure that people with amental illness receive the best possible care and treatment in the least restrictiveenvironment enabling that treatment to be effectively given, and that anyrestriction of liberty and interference with the rights, dignity and self-respect of the person is kept to a minimum.

The Mental Health Act defines a mentally ill person as someone suffering from amental illness and owing to that illness there are reasonable grounds for believingthat care, treatment or control of that person is necessary for the person’s ownprotection or for the protection of others from serious harm.

People with a mental illness enjoy the same rights as everyone else in thecommunity. At times however, a mental illness may result in behaviour that leadsto those rights being curtailed. This Act sets out the circumstances in which thiscan happen, provides a framework of checks and balances and ensures thatinterference with a person’s rights, dignity and self-respect is kept to theminimum necessary in the circumstances.

4.4 Anti-Discrimination Act 1977

The Anti-Discrimination Act provides for the making, conciliation and/ordetermining of complaints about ‘unlawful discrimination’. Under the Act, it isunlawful to discriminate on the grounds of race, sexual preference, transgenderstatus, marital status or disability. Disability includes mental illness and infectiousdiseases status.

The Act addresses unlawful discrimination in specific areas, including employment,education, accommodation and the provision of goods and services.The Act statesthat it is unlawful for a person to refuse to provide goods and services to anotherperson on the grounds of a disability, or to place terms on provision of thosegoods and services on the grounds of disability.

Legislative environment

Workers compensation

legislation also aims to get

injured workers back to work as

quickly and safely as possible.

The Mental Health Act aims to

ensure that people with mental

illness get proper treatment with

minimum interference to their

rights, dignity and self respect.

The Anti-Discrimination Act

protects people from being

discriminated against because

of their race, sexual preference,

transgender status, marital

status or disability.


4.5 Privacy and Personal Information Protection Act 1998 (PPIPA)

Since July 2000 the NSW public health system has been subject to privacyobligations under the above Privacy and Personal Information Protection Act. It provides a comprehensive code designed to regulate the collection, use, storage and disclosure of information that can identify a person, including the obligationto ensure that any information that is used is relevant, accurate, up to date,complete and not misleading.

4.6 The Crimes Act 1900

Persons who commit assaults and other acts of violence in the NSW Health system can be charged with criminal offences under the Crimes Act. The Act also establishes provisions allowing apprehended personal violence orders to be taken out where a person has reasonable grounds to fear personal violence,harassment or molestation.

4.7 Other relevant legislation

Other pieces of legislation may be relevant to health services in relation toviolence prevention, minimisation and management strategies. For example, theInclosed Lands Protection Act 1901 contains a number of provisions that give theowners of ‘inclosed lands’ (which includes hospital premises) the right to controlaccess to the land and provides certain powers and offences to support this right.Section 6 of this Act includes a limited right to request persons’ names and addresses.

Because of the broad range of legislation that may be relevant to, or impact on,local violence preventions strategies, it is very important that there is legal inputduring the development of local violence prevention and management policies and strategies.

Legislative environment

Privacy and Personal

Information Protection Act

protects the privacy

of individuals.

Persons who assault health

staff can be charged by police.

The Inclosed Lands Protection

Act 1901 allows Health Services

to control access to Health

Service property.

Other legislation may also be

relevant to local violence

prevention strategies.

Legal input should be sought

during development of local

violence prevention and

management strategies.


5A risk management approach

5.1 Violence and the risk management approach

Workplace violence should be recognised as a significant workplace hazard.Numerous personal and business risks are associated with exposure to violenceincluding physical and emotional trauma, low morale, high staff turnover, financialcosts, lost productivity, public opinion and litigation. OHS legislation requiresemployers to take all practical steps to eliminate as far as possible workplaceviolence risks. If a violent incident does occur, there should also be responseprocedures in place to minimise the impact of the event.

5.2 Consultation

Consultation is a pivotal activity at all stages of the risk identification, assessmentand control process and an integral part of good management. Employees are inthe best position to know the risks associated with their work and suggest effectivesolutions.The NSW OHS legislation requires employers to consult with theiremployees to enable the employees to contribute to decision making that affectstheir health, safety and welfare at work. Employers must also consult withemployees when determining how consultation on OHS issues will take place ie when determining local consultative arrangements.

Employee involvement in the process will help ensure that employees take ownershipof, and are committed to any changes to work procedures, practices or environmentdirected towards minimising or better managing violent incidents.

Consultation should also take place when determining violence prevention andmanagement training needs; when designing, purchasing or customising equipmentaimed at improving safety and security; and when developing new facilities andrefurbishing existing facilities.

Effective consultation includes involving both staff and unions, keeping staffinformed of all relevant activities, and including representatives of affected groupson all relevant working parties. Consultation can occur through formal andinformal processes and may involve direct or representational participation.OHS committees are an important part of the consultative process.

5.3 Organisational planning

Planning takes place at all levels of the organisation and may result in changes tothe way things are done or to the work environment. During the risk managementprocess decisions can be made that result in similar changes.

Effective planning is needed when making and implementing changes to ensurethat they do not have unforeseen effects.This includes looking at the impact ofchanges both within and across the health facility.

Health Services should ensure that all significant decisions are made after ananalysis of the impact of such decisions on staff security.This requires consideringstaff security in all formal and informal Health Service planning processesincluding the development of strategic plans, business plans, service developmentplans, building/refurbishment plans and OHS improvement and management plans.

For detailed information on

security risk management

see the NSW Health

Security Manual.

Employees know the risks

they face at work.

Involving employees helps gain

their commitment to improved

security measures.

The OHS Committee is

an important OHS

consultative forum.

A useful resource when

establishing workplace OHS

consultation arrangements is

the WorkCover NSW ‘OHS

Consultation Code of

Practice 2001’.

All workplace changes need

to be well planned.


Similarly, facilities need to ensure that decisions flowing from the risk assessmentprocess, while aimed at solving one set of risks do not introduce new risks intothe workplace.

Avoiding introduction of new risks can be facilitated in a number of ways, including:

● researching the impact of similar risk control initiatives in other facilitiesbefore introduction

● consulting as widely as possible on proposed changes

● testing or piloting new arrangements

● implementing improvements in a planned and systematic way

● introducing changes in a graduated way or in a limited area

● closely monitoring changes, particularly in the early stages for any possible negative effects

● having proposed new risk control measures assessed by relevant experts before implementation.

5.4 Relationships with local police

Area Health Services need to establish relationships with the Local Area Command.Police can provide valuable assistance with, and advice on such issues as:

● security risk assessments

● security/violence vulnerability audits

● placement of ATMs and retail outlets

● crime prevention through environmental design (CPTED) principles

● CCTV placement, maintenance and monitoring.

Police can also provide information to community health workers on strategiesto protect them in the broader community.

Similarly, Health Services should:

● inform police on the location of (external) existing and new CCTVs

● report all crimes occurring on hospital premises eg assaults, cars broken into, wallets/bags/equipment stolen, damage to property etc

● report suspicious activity.

The NSW Health Memorandum of Understanding (MOU) between NSW Policeand NSW Health was developed and released in 1998.The MOU grew out ofthe need for a formalised system for cooperation between these important areasof service delivery.A primary objective of the MOU is to improve the responseto and outcomes in the management of mental health crises that involvedresponses from multiple services.

A review of the MOU commenced in 2000 resulting in the development of anumber of flowcharts that supported the MOU and provided more detailedguidance for the development of local protocols.The Centre for Mental Healthreleased the flowcharts in July 2002, and is coordinating their implementation.

A risk management approach

Health Services need to make

sure that solutions to one risk

do not create other risks.

All crimes on Health Service

property, particularly assaults,

should be report to police.

Copies of the MOU may

be obtained from the:

Better Health Centre

Locked Bag 5003

Gladesville NSW 2111

Tel. (02) 9816 0452.


6Violence risk identification and assessment

6.1 Local incident reporting

A core requirement of violence risk identification and assessment is access to goodinformation and data.All Health Services should have in place a local system forreporting and recording violent incidents regardless of whether or not the incidentresulted in an injury or lost time.

Reporting is required to ensure that:

● staff have access to information necessary to the risk management process

● information being used is an accurate reflection of the incidence of violence

● incidents can be investigated, their causes and contributing factors identified,and their recurrence prevented

● facilities are able to meet OHS legislative reporting requirements andDepartmental reporting requirements.

Current research suggests that violence in the health industry is significantly underreported, especially verbal abuse and bullying.This results in reduced opportunitiesfor information gathering, incident investigation and prevention activities. It alsopotentially reduces the management attention and focus occupational violencemight otherwise engender if the true extent of the problem was evident.

Staff need to be aware of reporting requirements, and be actively encouraged and supported in reporting all violent incidents.A readily accessible, simple toimplement reporting procedure will encourage reporting, as will prompt, sensitiveand appropriate follow-up.

6.2 Information analysis

As wide a range possible of other relevant information also needs to be considered.Any decisions made should be based on sound information or facilities run therisk of devoting time and resources to risk control measures that may not have the desired effect.

Information may be gained from a range of sources including:

● violence reports and associated aggregated data

● incident investigation reports and emergency response reviews

● consulting with staff and unions

● visual workplace inspections and violence vulnerability audits

● security surveys

● related OHS and workers compensation data

● staff records eg to identify areas of high staff turnover

● staff grievances and patient complaints

● exit interviews

● observation.

The Security Manual outlines

NSW Health policy and

guidelines on security risk

identification, assessment

and control.

Circular 97/58 ‘Incidents

Reportable to the Department’

outlines incidents that must be

reported to the Department

(under review).

Staff should report all

violent incidents as per local

reporting procedures.

Reporting systems should

be simple and accessible

to all staff.


Resulting information needs to be assessed to determine such things as severityof 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 andemployee groups which in turn provides a good starting point for identifying risk control measures.

6.3 Physical environment

The physical work environment may increase or decrease the risks associatedwith violence. However, the physical environment should not be viewed inisolation from operational aspects such as the activities to be undertaken in theenvironment and the policies and procedures that will govern its operation.

Physical security measures, on their own, may not adequately address security issueswithout appropriate supporting operational policy.A simple example includes therequirement that all doors and windows must be lockable.This is of limited valuewithout a supporting process for determining when they are locked, who isresponsible for ensuring that they are locked and unlocked, and who isresponsible for ensuring that all locks are regularly checked and maintained.

Keeping these points in mind, the following are some general things to considerduring the risk assessment process:

● Facility/unit location (proximity to a hotel or club, in or near a high crimearea 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 accessand egress, public telephones, lighting)

● General security eg alarm systems, access controls etc

● Activities undertaken in the workplace eg on-site storage of drugs,commercial outlets etc.

Additional environmental factors that may increase the risks of violence include:

● parking areas – away from the workplace, poorly lit, dark spots and hiding places

● entries and exits – multiple public access points, lack of staff escape routes,doors propped open for fresh air, exit doors that provide easy access to staffand clinical areas

● Emergency Departments – poor separation of public and treatment or staffareas, easy access to staff areas

● reception/waiting areas – poor staff view, easy access to staff areas, reducedpersonal space, inadequate seating, lack of public facilities eg phones, toilets,lack of privacy

● treatment/interview rooms – single access/egress point, inability to separatepatients from distraught, intoxicated or noisy family or friends.

From the above information it should be evident that many of these risks can beeffectively ‘designed out’ during the planning, design/redesign and constructionof new health facilities.

Violence risk identification and assessment

Risks need to be assessed so

priority risks can be quickly

identified and managed.

Incorporating ‘safer by design’

principles in health buildings can

reduce the risk of violence.

Facility and unit location,

design, layout, general security

measures and type of work

done can all influence the

likelihood of violence.

See the Security Manual for


guidelines on security in

higher risk areas.


6.4 Prioritising risks

In order to identify and implement effective risk control strategies it is necessaryto identify the level of threat posed by the various risks and hazards.This providesinformation on those risks that most urgently need action and helps prioritiseothers for future management.

Factors to consider when prioritising risks for remedial action include:

● What is the nature of the risk or hazard eg is it physical, psychological, chemical?

● What is the degree or severity of harm that the hazard/risk may cause?

● How often are staff and others exposed to violence?

● How likely is it that harm will occur as a result of the exposure?

● How often are staff exposed to the risk or hazard?

● How long are the periods of exposure?

● How many staff and others are exposed to the risk or hazard?

However, other risks that can be readily and inexpensively controlled should alsobe dealt with promptly. Ultimately, as far as is practicable, all factors identified ascontributing to workplace risks need to be eliminated or their impact minimisedthrough the risk control process.

Violence risk identification and assessment

Risks need to be prioritised so

the most significant risks can be

quickly managed.

See the Security Manual and

section 5.3.1 of C2001/22

Workplace Health and Safety:

A Better Practice Guide

for further information and

tools to assist with the risk

prioritisation process.


7Violence risk control

7.1 Hierarchy of risk controls

Risk control is the part of risk management that involves implementing preventiveand management activities, standards, policies and procedures to eliminate, avoid orminimise the risks facing an enterprise.The hierarchy of risk controls, which ranksrisk control measures from the most effective to the least effective, is a useful guideto implementing risk control measures.

Eliminating the hazard altogether is a permanent, and therefore most desirable,solution and should be the first consideration. If it is not possible, then the hazardshould be substituted with something less hazardous, or again if this is not possible,the hazard should be isolated from the person being put at risk. However thesecontrol measures may not be practical in all circumstances and often the finalcontrol options chosen are a combination of measures from different levels of the hierarchy.

Engineering controls are the most effective risk controls and include:

● 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.

Administrative controls include:

● rotating staff to reduce frequency and duration of exposure to the risk

● maintenance programs and housekeeping

● providing information and training in how to do the job safely

● developing procedures and protocols for hazardous activities

● providing personal protective equipment (PPE).

Administrative controls are generally the least likely to eliminate the risks andengineering controls should be given priority in managing risks.

7.2 Physical environment

As the hierarchy of controls indicates, designing out workplace hazards duringconstruction or refurbishment should be the highest priority when controllingworkplace risks.There is a significant body of evidence that design of premises can play an important part in preventing violence in health care environments.Crime prevention through environmental design (CPTED) concepts are aimed at enhancing those aspects of building design that discourage criminal activities,including violence.

Risks are minimised through design or redesign of a facility and its immediatesurroundings in ways that reduce the opportunity to commit a violent act or other crime. CPTED is primarily accomplished through the work of architects,engineers, builders, landscape gardeners and those who develop purchasing



guidelines on security risk

identification, assessment

and control.

Engineering controls that

design out the risk are the

best control strategies.

7.2.1 Crime preventionthrough environmentaldesign (CPTED)

Buildings can be designed to

reduce security risks.


Violence risk control

procedures.They usually involve long term features that generally do not needcontinuing financial support and are therefore over time likely to be cheaper thanother violence reduction programs.

While the widespread application of generic CPTED strategies can reduce crimeopportunities, the environmental context of places can work against design basedstrategies, rendering them ineffective or even dangerous eg the use of boomgatesin some carparks can result in high levels of carbon monoxide.Therefore it isimportant that contextual considerations and site risk are properly identified,measured and assessed by appropriately trained personnel before design based risk management strategies are recommended.

CPTED principles fall into four broad categories; territorial reinforcement,surveillance, access control and space management.

Territorial reinforcement draws on the territoriality principle, and assumes that peoplecan be encouraged to express feelings of ownership over places with which theyfeel some connection or affinity eg work areas. For example, if ‘staff only’ areasare provided, workers are more likely to pay more attention to the area and notean intruder. In addition if these areas are separated from other areas it reduces thelikelihood of others entering the area.

Physical and symbolic barriers can be used as a form of access control to attract,channel or restrict pedestrian and vehicle movement.They reduce opportunitiesfor crimes and increase the effort required to commit crime. By making it clearwhere people can and cannot go, it increases the difficulty for criminals to reachpotential victims and targets.

Surveillance draws on the natural surveillance principle where people feel safe inpublic areas where they can see and interact with others. Natural surveillance can be achieved by creating effective sightlines between public and private space,strategically positioning buildings, accessways and meeting places and matchinglighting with crime risk (see ANZS 1158.3.1). Buildings can be designed so that high risk sections are overseen and watched by other staff going about theirnormal business eg pathways to car parks can be designed in full view of passers-by and overlooked by office windows.

Space management is linked to territorial reinforcement and also draws on theimage principle, which is based on the belief that a run down structure with poorperimeter definition and graffiti may attract criminal activity and offenders.Space management ensures that space is well used and maintained.

‘Target hardening’, another aspect of CPTED, involves architectural orengineering designs or redesigns that control access to specific areas and hencemake violence more difficult.

Strategies may include:

● deadlocks on drug storage areas

● reduced face to face contact during supply of pharmacy products

● designated safe escape routes

● key or card access to staff working areas

● fencing to prevent facility grounds being used as a public thoroughfare.

Contextual considerations

and site risk must be properly

identified, measured and

assessed by appropriately

trained personnel before design

based risk management

strategies are recommended.

People can be encouraged to

feel ownership of work areas.

By clearly identifying staff

only areas with physical or

symbolic barriers, it makes

it harder to reach potential

victims or targets.

Natural surveillance can

be achieved by creating

sightlines between public

and private space.

Facilities should be kept

clean and well maintained,

and vandalism and graffiti

rapidly repaired.

7.2.2 Access controls



guidelines on access controls.



Areas within heath care facilities at particular risk of hold-up violence includeshops and payment areas where money changes hands and pharmaceutical storageand dispensing areas, and target hardening of these areas should be prioritised.

Emergency Departments can be areas of increased risk for violence.Control strategies may include:

● minimised public entry points

● access control to treatment areas

● clear signage

● areas for separation of distressed or disturbed people

● wide, screened reception counters

● strategic close circuit television (CCTV) monitoring

● metal detection systems

● duress alarms (desk based and personal)

● bollards to restrict vehicle access near doorways

● designing out narrow underpasses or lanes leading to car parks,public transport etc

● separate staff car parks from visitor/client parking.

However, as referred to elsewhere in this document, it is important that introducedrisk controls do not create new risks eg increased access controls do not have thepotential to trap workers with violent clients.Access controls should preventunauthorised entry but not prevent exit.

Increased visibility is another important CPTED aspect in violence preventionaimed at discouraging offenders through improving the chance of their identification.

Such measures may include:

● adequate lighting of high risk areas including car parks, corridors,access paths and storage areas

● safety glass windows in interview rooms so patient/staff interactions can beseen by outsiders

● CCTV

● strategically placed convex mirrors

● large signage indicating that the site is being continuously monitored.

Furniture and fittings can be designed and arranged to reduce the risk of violenceusing CPTED principles.

For example, waiting areas should be comfortable, decorated in muted colours,spacious, have a clear path to commonly used fittings eg phones, water dispensersand have adequate seating, ventilation and temperature control. Pastel colourschemes and soft furnishings can co-exist with CCTV, discreet alarm systems and the fixing of movable objects that could be used as weapons.

Where waiting times are identified as a contributor to the degree of risk,television and reading materials could be provided. Also, provision of information,clear signs and explanations for delays in procedures and timing may reduce therisks (see section 7.4).



guidelines on pharmacy security.



guidelines on security in

the clinical environment.

7.2.3 Surveillance and lighting



guidelines on lighting.

7.2.4 Fittings and furniture

Comfortable, spacious

waiting areas may reduce

violence risks.

Providing information, signs

and explanations for delays

may reduce violence risks.



The design of desks or counters should be determined by their purpose and the degree of risk associated with the tasks and work area.The design should also be ergonomically sound so desks or counters do not introduce new risks.For example, while inquiry desks can be designed to be wide enough to make itdifficult for a client to strike a staff member or high enough to make it difficultto climb over, this will not protect a staff member from a thrown object, and mayintroduce manual handling risks from constantly having to lean forward.

Protection can be provided by well designed, clear screens with appropriatelyplaced slits for communications and passage of documents. If necessary, speakerscan be attached to the screen to assist hearing impaired people eg similar to thosefound at railway station ticket counters. Discreetly placed duress alarms can alsobe included.

Interview rooms can be designed to:

● include two doors (staff members should sit close to one of the doors, withfurniture between them and the client, and no obstruction blocking their exit)

● have controlled access

● include duress alarms

● include safety glass windows so staff can be seen while retaining patient privacy.

Furniture should be comfortable but kept to a minimum, and robust enough notto be used as a weapon.

A balance needs to be maintained between creating a relaxed environment andprocess of delivering the service to the client, while ensuring the safety of staffand other clients.

This balance needs to be worked out by individual sites according to the natureand degree of risk, the purpose of the site and supporting local operatingpolicies. Looking at the workplace and its fittings as part of the risk assessmentprocess can often suggest relatively simple changes that will increase security andthe overall ‘calmness’ of the working environment.

NSW Health staff involved in the facility planning and design process should bestrongly encouraged to attend training in CPTED principles.The NSW PoliceService provides training in this area as part of their ‘Safer By Design’ program.Further information on this training can be found at www.police.nsw.gov.au(safer by design homepage).

NSW Health has developed the document Health Building Guideline Security and Safety as part of its health building design and technical guidelines series. Itspurpose is to assist health facility planners and designers minimise security andsafety risks by providing appropriately designed and built facilities, work spaces,building services and systems based on CPTED principles.The information itcontains may also assist members of user groups during the constructionconsultation process.

Design of desks and inquiry

counters should consider

the type and level of risks

faced by staff.

High visibility and controlled

access to interview rooms

may reduce violence risks.

Health staff involved in facility

planning, design and

construction should attend

training in CPTED principles.

7.2.5 Design series healthfacility guidelinesecurity and safety



7.3 Patient alert systems

Patient alert systems or ‘file flagging’ is not a new concept, and has been used for a variety of reasons including:

● identification of patients with life threatening allergies, or unusual or difficult to manage medical conditions

● in association with the implementation of NSW Health Child Protection Procedures

● identification of patients presenting a risk to the health and safety of staff and other patients.

Anti-discrimination law does not specifically prohibit the flagging of files. In thepresent context employer obligations under OHS legislation may well be arguedto support, as part of the risk management process, policies to identify individualpatients and clients with a propensity to violence, where such identification isundertaken in order to protect staff and other patients.

Development and implementation of local file flagging policies and procedureswill need to be done with due consideration of relevant legal requirementsincluding anti-discrimination and privacy law.

The flagging of a file may result in the individual in question being provided withservice in a different manner than other patients.This may even, in extraordinarycases include refusal to supply the service in certain circumstances.

Care needs to be taken when developing criteria for flagging. Most importantly,the criteria must be directly linked to safety issues that arise from a person’sbehaviour, rather than personal characteristics of the patient, such as the fact theyhave a mental illness or disability. Using these kinds of blanket criteria or labelsmay raise problems under the Anti-Discrimination Act 1977.While such a disabilitymay in some cases be a cause of the violent behaviour, the focus must be on thebehaviour itself, the risk this poses to staff and patients and on its management.

Under the Privacy and Personal Information Protection Act 1998 (PPIPA), disclosure of personal information is permissible provided it is necessary ‘to prevent or lessena serious and imminent threat to the life or health of the individual to whom theinformation relates, or another person’. Any patient alert system therefore needs toincorporate these criteria.

Under both PPIPA and the Freedom of Information Act, patients have the right to know what is on their file and can request to view their file.There areexceptions to this, generally limited to circumstances where giving access to theinformation may have an adverse effect on the physical or mental health of theperson concerned.

Patients also have the right to request that their file be amended and this wouldapply to a flag inserted into a file. If the request is refused, the patient can seek thata notation be placed on their file outlining their concern, without erasing the flaginformation completely.

7.3.1 File flagging

7.3.2 Legal issues

File flagging may be a useful

violence risk control strategy.

File flagging policies and

protocols need to comply

with relevant legislation.

File flagging systems must

not be discriminatory.

File flagging systems must

meet privacy requirements.

File flagging is subject to

freedom of information

requirements.



Under section 15 of PPIPA, agencies have an obligation to ensure informationused is ‘relevant, accurate, up to date, complete and not misleading’.This has twoimplications for local file flagging procedures. Firstly, it emphasises the need toensure an accurate assessment of the patient that will support the flagging of thefile. Secondly, it reflects the importance of ongoing review to ensure that any flagplaced on a file is currently relevant.

Retention of a flag that is no longer accurate will have implications under PPIPAand possibly the Anti-Discrimination Act.Thus an active flag should not remain ona file once the risk is no longer current.A process to review and remove flags asappropriate is critical to any flagging system.

From a practical perspective, any file flagging system needs to be supported byrelated management plans. If a patient file has a flag for any reason, this needs tobe supported by an up to date management plan that enables those managing thepresenting patient to do so in a timely and appropriate manner. File flags can beof little use in the absence of an up to date, effective management plan.

In summary, the following issues need to be covered in local file flagging policies:

● clearly defined purpose for the flag eg to protect the health and safety of treating staff and/or other patients

● who is to be covered by the flag eg patient only, family, regular visitors as it is not only patients who may provide a significant threat

● readily accessible patient management advice that supports the flag eg how to manage the patient so that violence is prevented

● clearly defined scope of who has access to the information eg facility wide,AHS wide, other agencies, and justification for the scope

● clear criteria for the particular flag eg need to focus on staff and patient safety issues, be clearly related to violent behaviours, and avoid use of criteria based on impairment or condition

● avoidance of stigmatisation of particular individuals or classes of individuals eg it needs to focus on behaviours and possible outcomes of those behaviours

● review of flags for ongoing relevance eg needs to be regular enough to ensurethat the flag is still current

● regular review of management plans for continued appropriateness eg should be part of the flag review indicated above, though may need to be reviewed more regularly if they are not meeting the flag’s purpose or the patient’s circumstances change

● delegated responsibility for initiating, reviewing and removing flags

● delegated responsibility for reviewing and updating associated management plans.

File flagging information must

be kept relevant, accurate and

up to date.

7.3.3 Management plans

Support management plans

need to be in place and kept

up to date.

7.3.4 Developing local policies

When local policies and

procedures are being

developed a range of

issues need consideration.



It is recommended that all stakeholders are consulted in the development of localpatient alert policies and procedures including management, clinicians, triage andtreating nurses, medical records, security, OHS, administrative and clerical supportstaff.As appropriate this may also include drug and alcohol, mental health andsocial work staff. Legal advice should also be sought to ensure compliance withrelevant legislation.A similar panel should also be responsible for regular review of related policies and procedures. Similarly, those involved in the treatment andmanagement of the patient should be involved in the development and review ofpatient management plans.

7.4 Clinical initiatives nurse

The position of Clinical Initiatives Nurse (CIN) has recently been created to assistwith the management of emergency department patients.Their priority will beemergency department patients waiting for care, and their families/carers.Thisincludes providing assessment, information and reassurance to those for whomwaiting for care cannot be avoided and for expediting or initiating care where thisis possible and appropriate.The CIN function will be integral to the emergencydepartment team, with a wide liaison role, a patient-focused approach and wherenecessary and appropriate, conflict resolution.

7.5 Education and training

OHS legislation requires employers to provide training to enable staff to do their work safely.Violence prevention, minimisation and management training for staff has been widely recommended both nationally and internationally as aneffective measure in controlling the risks associated with occupational violence.However, while training is essential in terms of risk management, it is primarily an administrative control and should not be the major focus for control of risks.

A number of studies have identified various benefits for staff including increases in staff confidence in managing violence, increases in staff skills to competentlymanage violent incidents, and have resulted in reduced fear and anxiety, negativeattitudes and burnout. Relevant training has also been seen as an importantvariable in staff feelings of overall safety.

Studies on the impact of training also indicate that there are benefits for consumers,including a decrease in the:

● number of incidents of aggression

● number of injuries to staff and patients

● level of aggression and type of injury

● number of days missed from work

● overall costs associated with service delivery.

The training needs to be targeted to the needs of the particular group, with theemphasis being on prevention of violence, on how to minimise the impact ofviolence if it occurs and on self protection.

All key stakeholders should be

identified and involved in

developing file flagging policies

and protocols and supporting

patient management plans.

The position of Clinical

Initiatives Nurse (CIN) has

recently been created to assist

in the management of patients

waiting for care in the

emergency department.

7.5.1 Benefits of educationand training



guidelines on security

education and training.

Violence minimisation training

also benefits consumers.



One of the key outcomes of the Taskforce on the Prevention and Managementof Violence in the Health Workplace is the development of an accreditedviolence minimisation and management training program.This program will beavailable in mid 2003, and will provide an integrated set of training modules forspecific staff groups.

7.6 Other administrative controls

Examples of other administrative controls, referred to elsewhere in thisdocument, include:

● appropriate local policies and procedures for violence prevention andmanagement eg restraint procedures, duress response

● appropriate dress codes eg avoiding dangling jewellery (earrings, necklaces) or clothing (neckties) that could be grabbed during an attack and ensuringthat identification tag necklaces are of the break-away kind to avoid injury if grabbed by an assailant

● appropriately trained, available security staff

● communication systems

● development of relationships and agreements with other key agencies eg police, community services

● communication strategies for ensuring that patients and visitors are aware of their behavioural responsibilities.

7.5.2 NSW Health ViolencePrevention andMinimisation Training Program

Administrative controls

are generally the least likely

to eliminate the risks and

engineering controls should

be given priority in

managing risks.


8Responding to violence

8.1 Immediate response options

Every effort should be made, via the risk management process, to prevent violenceoccurring. However, in the event that a violent incident does eventuate, it isimportant that staff are aware that they do have a range of response options.These response/s will depend on a number of factors including the nature andseverity 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 backup, security or local police.

When a patient becomes violent, consideration should always be given to thepossible clinical aspects of the behaviour.A violent outburst by a patient waiting tobe seen by a doctor in the emergency department may be secondary to a numberof medical conditions, physical or mental, and initial clinical assessment andprompt treatment should be of primary concern.

NSW Health documents Mental Health for Emergency Departments (red book) andManagement of Adults with Severe Behavioural Disturbances (green book) provide thebest currently available information on clinical management of violent patients.They also send a clear message that functional cooperation and good workingrelationships between the emergency department, mental health and drug and alcohol services, with clearly delineated responsibilities and localprotocols, is crucial to the effective management of the clinical aspects of violence.Both publications have recently been updated and copies are available from theBetter Health Centre.

Health Services should have in place local procedures and protocols to support the range of available options. Procedures need to be communicated to staff,and staff should be provided with training to enable them to exercise the optionsappropriately and effectively, particularly those involving clinical restraint.

Immediate and short-term options available to staff (in no particular order) include the following:

● issuing a verbal warning (violent patient or visitor)

● using verbal de-escalation and distraction techniques (violent patient or visitor)

● seeking support from other staff (violent patient or visitor)

● requesting that the aggressor leave (violent visitor)

● requesting review by a clinician (violent patient)

● retreating (violent patient or visitor)

● utilising NSW Health clinical restraint policies as appropriate (violent patient)

● utilising NSW Health sedation policies as appropriate (violent patient)

● negotiating conditional treatment, or determining inability to treat under thecurrent circumstances (violent patient)

● initiating internal emergency response in line with local protocols eg security,duress response team etc (violent patient or visitor)

● initiating external emergency response in line with local protocols eg externalsecurity services, police (violent patient or visitor).

8.1.1 Clinical guidelines



guidelines for security risk

management in the clinical

environment.

The red and green books

provide useful, easy to read

guidelines and advice on the

clinical management of violent

patients, including immediate

response options.

8.1.2 Summary ofimmediate response options

Department circulars 93/77

‘Patient Restraints’ and 94/127

‘Policies on Seclusion Practices,

the Use of Restraint and the

Use of Sedation in Psychiatric

In-patient Facilities’ outline NSW

Health policy and guidelines for

use of restraint, sedation and

seclusion in the clinical setting.

NSW Health publication Best

Practice Model for the Use of

Psychotropic Medication in

Residential Aged Care Facilities

and Guidelines on the

Management of Challenging

Behaviour in Residential Aged

Care Facilities in NSW provides

information on the management

of violence in aged care.


When considering options, the following points should always be kept in mind:

● the possibility of an underlying clinical condition contributing to the violent behaviour

● when confronted with challenging behaviour it is important to remain calmand assess the level of threat, as this will allow decisions to be made as to themost appropriate action

● regardless of action taken, de-escalation and containment should always be considerations

● if a staff member feels unsafe at any time, they should call for back-up or retreat if appropriate

● at all times the key priority is to prevent injury (to yourself, those around you)

● be aware of the potential for violence, recognise contributing factors/warning signs, stay calm, initiate early, appropriate action

● more than one option may be utilised.

All incidents of assaults, theft and robbery on Health Service property or damageto Health Service property should be reported to police.

When confronted with challenging behaviour, de-escalation may be sufficient tomanage the situation. Staff should remain calm, listen to the individual’s concernsin an empathic, non-confronting manner, emphasise their desire to help, try andmake the individual more comfortable and utilise accompanying friends/relativesif appropriate. Staff should feel able to call for back-up or leave the scene at anytime they think it is necessary.

De-escalation techniques should form part of all violence minimisation andmanagement training, as well as how to recognise escalating conditions and signsof impending violence.

In the face of verbally violent or abusive behaviour, it may be appropriate to issue a warning. If the staff member feels unable to do this, that it is notappropriate to the situation or that it will further inflame the situation, back-upshould be sought. If the situation does warrant issuing a warning, this should bedone in a calm, respectful, ‘informative’ manner, possibly drawing the individual’sattention to the displayed zero tolerance poster and patient information brochuresoutlining patient and visitor behavioural responsibilities.

If the individual fails to respond to verbal warnings or the situation escalates,staff should seek back-up and/or retreat if necessary. As noted earlier, if staff feel unsafe at any time, they should call for back-up.

Depending on the level of perceived threat, imminence or actuality of violence,effects of the behaviour on others, availability of support and local protocols, thismay include any/all of the following:

● calling on a more senior staff member or clinician – in some circumstancesthis may be enough to calm a violent patient and also allow for a clinicalassessment if warranted

Responding to violence

Part C of the Security Manual

provides NSW Health policy and

guidelines for the management

of theft, bomb threat, violence

and armed hold up, as well as

policy and guidelines on duress

response planning and use of

weapons by security staff.

8.1.3 Verbal de-escalationand distraction

8.1.4 Verbal warning

8.1.5 Back-up

Staff need access to back-up

support if necessary.


● contacting security staff – the presence of security staff may act as a deterrentand/or assist in the protection of staff and visitors

● using the duress alarm or initiating the duress response

● calling police

● withdrawing to a safer location.

While all staff should have access to appropriate emergency response procedures, all high risk areas such as emergency departments, mental healthfacilities, methadone dispensing areas etc should have a well defined and clearlyarticulated duress response (see section 8.4). Staff should be able to initiate theduress response at any time they feel it is necessary. Larger facilities and facilitieswith more than one high risk area should consider having a secondary duressresponse protocol in the event that two incidents occur at the same time.

The law recognises that individuals may protect themselves or another from athreat of attack or injury.The protection afforded by the law is however limited to situations where the person believes the conduct is necessary to defend himself,herself or another person or to prevent or terminate the unlawful deprivation ofhis or her liberty or the liberty of another person.

In order to be lawful, however, the conduct must be a reasonable response in the circumstances as he or she perceives them, and there must be some reasonableproportion between the threat perceived and his or her response to it.

As outlined throughout this document and in the NSW Health Security Manual,no staff member should knowingly place themselves or others at unnecessary risk. However, effectively exercised evasive self-defence may provide staff with acontrolled physical response when retreat is blocked, when all other non-physicalstrategies have failed and the staff member is under threat of or actual attack.Thepurpose of evasive self-defence in these circumstances is to assist staff to escapefrom a violent situation.When properly used, it may minimise the risk of injuryand minimise the potential trauma.

Health Services may determine, via the risk assessment process, that evasive self-defence training is necessary for particular group/s of staff at high risk ofviolence. However, evasive self-defence brings its own set of risks such as thepotential for being charged with assault, or sustaining further injury.

The decision to provide evasive self-defence should only be made after thefollowing considerations:

● Have all other possible risk control strategies aimed at preventing violenceoccurring, and protecting the target group been implemented?

● Does the level of risk faced by the target group warrant provision of evasiveself-defence training eg do the risks outweigh those associated with providingevasive self-defence training?

Where evasive self-defence training is to be provided, the training should:

● emphasise retreat, escape and self-protection

● cover legal issues associated with evasive self-defence including the concept ofreasonable force


Staff need access to emergency

response procedures.

8.1.6 Evasive self-defence

Staff are entitled to protect

themselves against attack,

within the framework of the law.

Staff behaviour should

be defensive, and evasive

self-defence only utilised where

no other options are available

and escape is not possible.

8.1.7 Evasive self-defencetraining

Evasive self-defence

training should complement

other risk control strategies

and should only be considered

after all other practical violence

prevention strategies have

been implemented.

Evasive self-defence training

should be developed and

delivered by experts, and be

targeted to the needs of the

group being trained.


● be developed and delivered by appropriately experienced and accredited experts

● provide techniques that are relevant to the tasks of the target group, the risksfaced by the group and the environment in which it operates

● include the need for, and provision of regular practice

● consider the physical characteristics of the target group, and those of theperpetrators of violence where possible

● include the dangers and precautions when using evasive self-defence.

8.2 Long-term response options

Long-term options to deal with repeated violent behaviour include:

● formal patient management plans (violent patient)

● written warnings (violent patient or visitor)

● conditional patient treatment agreements (violent patient)

● exclusion from visits (violent visitor)

● conditional visiting rights (violent visitor)

● patient alerts in conjunction with support management plan (violent patient or visitor) – see section 7.3

● alternate treatment arrangements eg a different facility (violent patient)

● formal recognition of inability to treat in certain circumstances (violent patient)

● AVOs to protect staff (violent patient or visitor) – see section 11

● having charges laid (violent patient or visitor).

The zero tolerance response is only meaningful in an environment whereappropriate, consistent action is taken in the face of violence.This includes calling the police when there is an attempted or actual assault against staff, andwhere appropriate, requesting that charges be laid.

As referred to elsewhere in this document (see section 2.1), it is not the intentthat inappropriate action is taken against those whose violence arises directly froma medical condition. However, some people, despite having a mental illness, canform the requisite intent to commit a criminal act, are aware of the consequencesof their action and can therefore be held accountable for their conduct.

Even in situations where a person’s mental illness may have prevented them from forming ‘intent’, mental health legislation and criminal law establish specificprocedures to address the situation.Thus, health staff should not presume that if aperson is receiving treatment for a mental illness or is detained in a mental health facility that no action can be pursued regarding alleged criminal acts(NSW Health/NSW Police MOU).

Depending on the circumstances it may be appropriate to issue a letter ofwarning to a patient or visitor who has exhibited repeated violent behaviour,and verbal discussion with the patient or visitor has failed to resolve the situation.A number of factors will need to be considered in determining whether a letter is appropriate, or whether it is necessary to utilise other risk control strategies eg a conditional treatment agreement.


8.2.1 Summary of long-term response options

8.2.2 Written warnings


These factors may include:

● frequency, nature and severity of the behaviour

● circumstances surrounding the behaviour

● extent of exposure of staff, visitors and others to the behaviour

● level of threat or risk the behaviour presents to others

● individual’s ability to comprehend the issues associated with their behaviourand capacity to modify their behaviour

● previous attempts made by staff to discuss concerns with the individual

● individual’s ability to read and understand English.

Where it is determined that a letter is the appropriate first step, thecorrespondence should:

● be drafted in consultation with key stakeholders eg relevant level ofmanagement, clinical staff involved in determining and delivering care

● be polite, respectful and have an informative tone

● not be accusative, blaming or judgemental

● clearly articulate the matters of concern

● focus on the behaviour

● identify the possible effects their behaviour may have on staff and other patientsand that it may impact on the ability of staff to provide effective health care ina safe and therapeutic environment

● identify the implications the behaviour has for the facility eg OHS, duty of careto other patients

● clearly identify the preferred or expected behaviour

● seek the support of the individual in helping the facility meet its OHS andduty of care requirements

● clearly indicate in a practical manner the consequences of failing to behave inan appropriate manner eg conditional treatment agreement; provision of serviceelsewhere and under different circumstances; calling the police

● be written clearly and simply eg plain English

● invite a response

● be signed by a senior clinician, unit manager, facility manager or Area HealthService Chief Executive Officer as most appropriate (the signatory should havethe appropriate level of authority).

Health Services should always keep in mind that as with any correspondenceissued, such letters are essentially a public statement of the Health Service position,and should be drafted accordingly, with due regard to the above requirements.


Managers need to determine if a

written warning is appropriate.

Written warnings should be

clear, concise and polite.

Written warnings should

be signed by the most

senior person appropriate

to the situation.

Written warnings may be

read by others.


In some circumstances it may be necessary to establish a conditional treatmentagreement with the patient.

Such circumstances may include where the patient has a history of repeatedly:

● presenting for treatment under the influence of alcohol or other drugs,leading to violent or disruptive behaviour

● being accompanied by groups of friends/relatives significantly disrupting thetreating environment

● being accompanied by persons with a history of violent behaviour towardsstaff or others

● presenting in a violent manner late at night or at change of shift timesdisrupting the treating environment

● regularly threatening, attempting or perpetrating violence against staff or other patients.

Depending on the circumstances, the following conditions may be consideredwhen developing conditional treatment agreements:

● clearly articulated behavioural requirements (the patient and thoseaccompanying him/her need to understand what behaviour is required)

● stated results of the patient’s failure to comply eg treatment may need to beprovided in a different way or at different times, visitors may not be permitted etc

● where the treatment will be provided eg at what facility and at what locationwithin that facility

● specified time/s

● who will accompany the patient eg a friend/relative with a calming influence

● who will not accompany the patient eg friend/relative who is regularlythreatening or violent towards staff, other patients

● the condition of the patient and those accompanying the patient eg not underthe influence of alcohol.

Not all conditional treatment agreements will include all of the above conditions,and some may be relatively simple.

In any event, the conditional treatment agreement should:

● be developed in consultation with the patient and other relevant stakeholderseg guardian, relatives, treating staff, security etc

● not be discriminatory eg focuses on behaviour, not personal characteristics ofthe individual

● be regularly reviewed according to an agreed timetable (from both a clinicaland practical perspective)

● be reviewed when there are changes in the patient’s circumstances eg movesto a different residential location, condition/behaviour improves

● focus on the ability to provide meaningful treatment in an appropriate facilityand a safe environment

● include an appeals mechanisms.


8.2.3 Conditional treatmentagreements

Conditional treatment

agreements may assist in

managing a violent patient.

Conditional treatment

agreements can stipulate

such things as time and

location of treatment,

conditions under which

the treatment will be

administered and who will

accompany the patient.

Agreements should be

developed in consultation with

the patient and relevant others,

and focus on behaviour.


It is not the objective of patient treatment agreements to ultimately result inwithdrawal of treatment.This should only occur in exceptional circumstances afterall other efforts have failed (see below). Conditional treatment agreements shouldbe negotiated with patients as far as possible.Agreements should form part ofbroader risk control strategies aimed at protecting staff, patients and visitors fromviolence, while at the same time, as far as possible, allowing for appropriatetreatment to be administered in a therapeutic environment.

Despite the options available for managing violent patients, there may be, on rare occasions, and usually as a temporary measure, a situation where it is almost impossible to treat a patient without significant, unacceptable risks to those involved.

Depending on the circumstances surrounding this situation, options may include:

● deferring treatment where possible (if not life threatening) to a time when therisks are better able to be managed eg when more suitably skilled andexperienced staff are available, or when the patient is more settled

● arranging for treatment to be carried out in a different, more secure location.

The option not to treat (at a particular time, or under particular conditions or at a particular location) would only arise after all other mechanisms have beeninvestigated to their full capacity, and should always be a last resort unlessimmediate escape from a violent event is necessary.

8.3 Duress alarm systems

Where the risk identification and assessment process identifies the risk of violence, duress alarms should be considered as part of the risk control response.However they should not be considered, on their own, as the primary riskcontrol mechanism, but rather should form part of an overall risk managementprocess and complement other risk control strategies.

Whenever an alarm is installed or provided, there needs to be an appropriateresponse mechanism in place that staff are aware of and able to comply with, aswell as regular testing of the alarms and appropriate maintenance.

8.4 Duress response planning

All staff, including those working in the community, should feel assured that,in the event of their triggering a duress alarm or seeking urgent assistance in athreatening situation, an appropriate response is available.

The nature of that response will vary from facility to facility depending on local issues such as the size and nature of the facility or unit within the facility,availability of support staff including security and clinicians and access to externalservices such as police or private security firms.

Regardless of local issues, however, the following characteristics should always befeatures of the duress response:

● requires one call or alarm trigger

● call or trigger is earlier rather than later in the event

● staff are aware of procedures for getting assistance


8.2.4 Inability to treat

An ‘inability to treat’

response may be necessary

in certain circumstances.



guidelines for alarm systems.

All alarms need an appropriate

response mechanism.



guidelines on duress

response planning.

All staff must have access to

help in an emergency.

All duress responses need to

address a range of issues.


● response is as fast as possible

● response is standardised as far as possible to reduce confusion

● response is sufficient to meet local needs

● response team members are well trained in the response procedure (including physical restraint) and their roles

● each team has a clear leader

● all shifts are covered and processes are in place to cover unexpected staffshortages eg due to sick leave etc

● links with local protocols for retreat, restraint, sedation and additional back-up

● incorporates necessary post incident processes

● includes operational review and debriefing

● is regularly evaluated and updated as necessary.

The most desirable response is one that is readily translated across Health Servicesto facilitate staff movements. However, there will almost always be variationsbased on local needs and resources, and new staff working in environments whereviolence has been identified as a workplace risk will need to be trained in localprotocols as soon as possible.

As described in Australian Standard 4083 – 1997 Health Services should refer tothe call to initiate a duress response as ‘code black’.

8.5 Post incident response

When the incident is concluded, staff should be provided with clear guidelinesregarding support services (if they have not already been provided) and theoption of time out from duties. Operational debriefing(s) should be set up and coordinated.

Other actions will include:

● obtaining names and numbers of those involved in the incident, includingstaff, visitors and members of the community, to enable follow-up

● provision of first aid and medical attention as required

● notifying the local injury management coordinator so prompt follow-up ofinjured staff can occur

● provision of prompt support services including comfort and support, responseto physical and personal needs

● provision of ongoing support and future follow-up as necessary

● provision of outreach/follow-up for staff with specific needs.

Violent incidents should be reported and recorded using the appropriate localformat eg hospital incident form, incident database etc. Depending on the natureof the incident, it may also need to be reported to the Health Service Executive,the NSW Department of Health or other external agencies eg WorkCover NSW,Health Care Complaints Commission, NSW Police, Department of CommunityServices or the Treasury Managed Fund.


8.5.1 Post incident support

Department circular 2002/19

‘Effective Incident Response’

outlines NSW Health policy

and guidelines on

managing incidents.

8.5.2 Incident Reporting


There are special considerations for handling incidents that may attract, or haveattracted, media attention.A carefully coordinated media response will minimisethe risk of distorted facts, breaches of staff and patient privacy and sensationalismin the media, and may help in some instances by quickly providing essentialinformation to a large number of people.The designated Media Liaison Officershould be contacted as early as possible when an incident that may attract mediaattention occurs.

The most effective way to prevent a recurrence of an incident is to determine why it happened and if it was preventable. Incident investigations should:

● be promptly instigated

● be conducted in a supportive and non judgemental way

● focus on identifying the underlying root cause/s and contributing factors

● not apportion blame

● focus on system breakdowns and identifying control measures to prevent a recurrence

● be undertaken by managers and supervisors in consultation with relevantclinical and non-clinical staff

● canvas all sources of relevant information eg witnesses, incident reports, relevantwork policies and procedures, the working environment, equipment used, levelof supervision at the time, relevant training provided and expert advice egOHS or risk management staff

● include an operational review if relevant (see below)

● result in clear recommendations to address the causes and where possible toprevent a recurrence.

It is crucial to the success of the investigation process that it results in clearlyarticulated recommendations to prevent a recurrence, resource implications (if any), who is responsible for their implementation and appropriate time frames.Recommendations may include changes to policies, procedures, equipment, theworking environment, training etc. However, implemented recommendationsshould not create unforeseen or undesirable outcomes such as introducing newrisks into the environment.

Operational review and debriefing is the process of analysing the effectiveness of the response to, and management of, the specific incident. It allows for anynecessary improvements to be made to the duress response procedure and incidentmanagement plans.

Operational review procedures should include:

● involving staff who were involved in the response or experienced the incident

● consulting with others who may have been involved eg police

● identifying the positive and negative aspects of the response

● identifying ways of improving future response

● a brief, documented summary of findings, recommendations and outcomes

● allocating responsibility for implementing improvements.


Circular 97/58 ‘Incidents

Reportable to the Department’

outlines NSW Health policy and

guidelines on incidents that

must be reported to the

Department (under review).

8.5.3 Incident investigation

Investigations should be prompt,

with clear outcomes.

8.5.4 Operational review and debriefing


9Community Health Services



guidelines for risk management

in community health.

Community health staff should

not knowingly place themselves

or others at risk.

Any violence against community

health staff is not acceptable.

All assaults should be

reported to police.

9.1 Risk management

NSW Health employees working in the community, including those in aninspectorial role, face a particular set of risks associated with working inenvironments not under the control of the employer and away from theimmediate support of their colleagues. However the OHS legislation equallyapplies to staff working in the community and all reasonable action must be takento prevent community health staff being exposed to violence. Chapter 16 of theSecurity Manual provides detailed information on risk management whenworking in the community, and as with other workplace hazards, preventionshould be the key focus of Health Service activity.

9.2 Response management

Under no circumstances should any NSW Health staff member working in thecommunity knowingly place themselves or co-workers at risk.This also includesthose in an inspectorial role.Where the threat of violence presents itself, staffmembers should retreat and/or seek further assistance eg police.Where retreat isnot an option ie the staff member is trapped with an assailant, all non-physicalstrategies have failed and the individual is under imminent or actual attack, evasiveself-defence may be the only option (see section 8.1.6).

Where, despite all preventive actions, an assault is threatened, attempted or actuallytakes place against a staff member working in the community, the incident shouldbe afforded the same degree of consideration as an on site incident. It is just asunacceptable for a staff member to be subjected to violence while working in thecommunity, and community health workers need to have access to the relevantrange of response options in both the immediate and long-term (see section 8).

In particular the incident needs to be reported as per local reporting procedures,investigated as far as possible and solutions proposed and implemented as far aspracticable to prevent a recurrence.

If a staff member is assaulted, the matter should be reported to the police.


10Remote Health Services

10.1 Risk management

Health care workers in rural and remote areas face unique challenges such asisolation and limited support that can make implementing risk controls andmanaging violent incidents particularly difficult.

In particular, the risk management process may be influenced by such factors as:

● position held by the staff member

● type of community worked in

● degree of isolation of the community

● access to emergency services (eg police), referral and other agencies

● working arrangements eg on call.

10.2 Response management

In rural and remote services, it is most important that there is an appropriate and consistent response to violence (see section 8). Because of the reduced optionsfor receiving health care in these communities there are often limited options forproviding alternatives for service delivery to violent patients requiring ongoing or regular care, or for related strategies to manage regular visitors with a history of violence.

It is particularly important that staff working in rural and remote areas get the message that violence is not acceptable and that action will be taken to ensure that staff, other patients and visitors are protected from such behaviour (see sections 3.3.4 and 3.3.5).

Ensuring that incidents are effectively managed requires being well prepared in the event of a violent incident. Preparedness requires gathering information that isrelevant to the local service and region, developing local policies and proceduresthat will work in a particular situation, and setting up support systems to assist the recovery of victims of violence, the health service and the community.Consultation and close liaison with local police should be a key part of local planning.

If a staff member is assaulted, the matter should be reported to the police.



guidelines for risk management

in rural and remote

health services.

Rural staff need access to

planned options for responding

to violence.

Staff, patients and visitors need

to get the message that violence

is unacceptable.

All assaults should be reported

to police.


11The NSW Criminal Justice System

11.1 Legal options

It is important that staff members who are victims of work related violenceunderstand and have confidence in the criminal justice system.The two main legaloptions following serious threats, attempted or actual violence are charging andapprehended violence orders (AVO).

Facility management should provide all possible support for staff members leadingup to and during the legal process, including:

● requesting that police take out AVOs on behalf of staff if appropriate

● providing correspondence supporting the AVO

● requesting that police press charges

● providing legal support where appropriate

● providing a support person during court hearings, when attending the policestation to make a statement etc.

11.2 Criminal prosecution

All significant violent incidents should be reported to the police. Recent changesto the Crimes Act now mean that the occupation of the victim of an assault will beconsidered in determining an appropriate sentence.These changes are designed toallow tougher penalties to be imposed on those who assault health staff in thecourse of their work.

Police are responsible for charging the alleged perpetrator.The majority of assaultcases are dealt with in the Local Court, as only the most serious matters will becommitted for trial to higher courts and prosecution by the Department of PublicProsecutions (DPP).

In the Local Court the Police Prosecutor will be assigned to handle the case andthe police officer in charge of the case is responsible for the preparation of thebrief of evidence.The officer in charge is also responsible for organising andsupporting the victims and witnesses leading up to and during the court case,and there is access via the officer in charge to a range of support services.

Generally in the Local Court, if the defendant pleads ‘not guilty’, the witnesses andvictim are required to give their evidence before the Magistrate.The Magistratewill then determine the case based on the evidence presented. If, in determiningthe case, there is a view that the Magistrate makes an error at law or hands down asentence that is manifestly inadequate, the Public Prosecutor may prepare a file topresent to the DPP seeking an appeal.

The Police Prosecutor operates under the same set of rules as the DPP, which isgoverned by the Department of Public Prosecution Guidelines.

The DPP is responsible for prosecuting all very serious crime in NSW.

Health Services should support

staff during the legal process.

All assaults or attempted

assaults should be reported

to police.

Most assaults are dealt with in

the Local Court by Police

Prosecutors. Only the most

serious matters are committed

for trial to higher courts.

The DPP is responsible for

prosecuting very serious crimes.


The following outlines the key steps in the prosecution of such crimes in NSW:

● police charge the defendant, who may apply for bail and, if it is refused, canre-apply any time until the case is finished

● the defendant appears in the Local Court, where the case is adjourned so thata hearing date can be set

● police prepare and send a ‘brief ’, which includes charges, statements ofwitnesses etc, to the DPP

● a DPP lawyer is assigned to prosecute the case at the Local Court

● witnesses may be needed to attend the Local Court hearing to give evidencebefore the magistrate; police or the DPP lawyer notifies the victim if they areneeded, and if not the victim statement is given to the magistrate to read

● the Local Court hearing, known as the committal hearing, occurs and themagistrate decides whether there is enough evidence for the defendant to betried in the District Court (or Supreme Court in the most serious matters)

● if the magistrate decides that there is enough evidence, the defendant can becommitted for trial, which means that the case is adjourned until a trial canbe held

● if the defendant is committed for trial he/she is known as the accused untilthe trial is finished

● the case is given to a DPP lawyer to prepare for the trial

● the accused appears in front of a judge (the arraignment) and either pleadsguilty, or the case is adjourned so that a trial date can be set

● witnesses (including the victim) are given court notices (subpoenas) that tellthem when the trial is going to be held

● before the trial the trial prosecutor may wish to discuss the case with thevictim or witnesses

● the trial is held in front of a judge and usually a jury, where all witnessesincluding the victim where possible, give their evidence

● the jury (or judge where there is no jury) decides if the accused is guilty ornot guilty

● if the accused is found guilty, the judge will decide the sentence, usually onanother day

● the accused may lodge an appeal to the Court of Criminal Appeal againstbeing found guilty or against the sentence

● the DPP can appeal against the sentence if it thinks the sentence is too lenient.

Not all cases proceed through all of these stages, for a variety of reasons.For example:

● the defendant can plead guilty at any time during the process

● depending on how serious the charges are, the case may be finished in theLocal Court with the magistrate deciding if the defendant is guilty anddeciding the sentence (see page 43)

The NSW Criminal Justice System

The local court determines if the

accused is committed for trial.

At the trial the judge (or jury if

there is one) decides if the

accused is guilty or not.

If found guilty, the judge

determines the sentence.

The accussed can appeal against

the finding or sentence.

The DPP can appeal against a

lenient sentence.

Not all cases go to trial.

Useful information is available on

the Office of the Director of Public

Prosecutions (ODPP) website at

www.odpp.nsw.gov.au.


● the magistrate may decide that there is not enough evidence and ‘discharge’the defendant

● the DPP may stop the prosecution from continuing if, for example there is notenough evidence or if the victim does not wish to proceed.

11.3 Apprehended violence orders

Where a staff member fears that there may be future violence, harassment orintimidation from someone they have been exposed to in the workplace or in the course of their work, regardless of whether charges of assault are being laidagainst the person, the staff member may seek to take out an apprehendedviolence order (AVO).

An AVO is an order made by the court to protect people from abuse, violence or threats of violence.They can also be applied for if someone is being stalked,intimidated or harassed, or reasonably fears that they may be in the future.TheAVO is an agreement between the defendant and the court that the defendant will not engage in certain behaviours. It usually states that the defendant cannot assault, harass, threaten, stalk or intimidate the person seeking the order (the complainant), or go within a certain distance of their home or workplace.Other orders can be included if necessary.

There are two types of AVO. An apprehended domestic violence order (ADVO) ismade where those involved are related, have lived or a still living together or are inan intimate relationship.An apprehended personal violence order (APVO) is anAVO made where the people involved are not related and is the one most likely to apply in workplace violence situations.

To seek an APVO the complainant can make the complaint directly to a ChamberMagistrate at their Local Court, or in matters of a more serious nature, the policemay consider taking out the order on behalf of the complainant.

The Chamber Magistrate will then issue a summons requiring the defendant to goto court.The summons can be served on the defendant by police.The defendant isalso provided with a copy of the complaint.The Chamber Magistrate may refuse toissue a summons for an APVO if he/she believes the case is frivolous, vexatious orhas no reasonable chance of success. In refusing to issue a summons, the ChamberMagistrate may take into account whether the matter is suitable for mediation.

The court date is identified at the bottom of the AVO application, and thecomplainant is required to attend court so that a magistrate can decide whether to grant the AVO. If police have applied on behalf of the complainant a lawyer isnot needed as the police prosecutor will represent the complainant. If not, thecomplainant should arrange legal representation, although complainants canrepresent themselves in court if they so wish.

If the defendant fails to appear at court without good reason, then it is likely thatthe AVO will be granted. If the defendant does come to court, he/she can consentto the AVO being made without admitting any wrong doing. In this case the AVOwill be made that day.


The ODPP Prosecutions Policy

and Guidelines is also available

on the site.

There are two types of AVO,

an apprehended domestic

violence order (ADVO) and an

apprehended personal violence

order (APVO).

An APVO is the one most

likely to be taken out by a

health worker.

Police may take out the AVO if

the matter is serious enough.

The complainant and

defendant are both required

to attend court.


If the defendant does not consent to the AVO, the case will be adjourned toanother day so that the court can hear evidence from both parties. In this casethe complainant can request an interim (temporary) AVO for protection until he hearing.

At the hearing, the complainant and his/her witnesses (if any) will give evidenceand can be questioned by the defendant or the defendant’s solicitor if one isbeing used.Then the defendant and his/her witnesses (if any) give evidence andthe complainant or lawyer (or police prosecutor if police are taking out the AVO)can question them.

The magistrate then decides whether or not to grant the AVO. To get an AVO, the complainant needs to convince the magistrate that he/she fears physicalviolence or harassment or intimidation or stalking, and also that it is reasonable tobe fearful under those circumstances.

If the court grants an AVO, the magistrate may tell the defendant to pay thecomplainant’s costs in bringing the case to court.

However if the AVO is not made, the magistrate may tell the complainant to paythe defendant’s costs, but only if the defendant can convince the magistrate thatthe complaint was frivolous or vexatious.

Once an AVO is granted, it can only be changed, deleted or extended beyond itsexpiry date by the court.The protected person or police can apply to the courtfor such changes to be made.

If the defendant does not abide by the conditions outlined in the AVO iebreaches the AVO, the police should be called.The police are required toinvestigate the breach before they can charge the defendant with a breach of theAVO. It is important for protected persons to keep a copy of the AVO with themat all times.While the granting of an AVO does not give the defendant a criminalrecord, a defendant who breaches an AVO may be arrested and charged with anoffence.The defendant will have a criminal record if found guilty of the offence.

11.4 Charter of Victims Rights

The rights of all victims of crime are outlined in the Charter of Victims Rights.The Charter is part of the Victims Rights Act 1996. It aims to protect the rights of victims and make sure they are properly informed and supported. Specifically,the Charter outlines how victims of crime should be treated by governmentdepartments such as police, health, courts, support services and the Departmentof Public Prosecutions (DPP).

The Victims of Crime Bureau monitors implementation of the Charter of Victims Rights in NSW, and may be contacted on (02) 9374 3000 or 1800 633 063 (toll free outside the Sydney metropolitan area).These numbersalso provide access to the Bureau’s 24 hour Victim Support Line, and victims of crime may also be eligible for counselling paid for by Victims Services.The Bureau’s postal address is Locked Bag A5010, Sydney South, NSW 1235 and website www.lawlink.nsw.gov.au/vcb.


If the defendant does not

consent to the AVO, then a

hearing is required.

Both sides give evidence

at the hearing, then the

magistrate decides if the

AVO will be granted.

If an AVO is granted and the

defendant breaches the AVO,

the police should be called.

Victims of crime have rights

as outlined in the Charter of

Victims Rights.


The following outlines the key components of the NSW Charter of Victims Rights.Full copies are available from the Victims of Crime Bureau.

● To be treated with courtesy, compassion and respect.

● To be provided with information about relevant services and remedies availableat the earliest opportunity, and access where necessary to available welfare,health, counselling and legal assistance responsive to their needs.

● To have access to information and assistance in preparing any victim impactstatement authorised by law to ensure that the full effect of the crime on thevictim is placed before the court.

● To be provided, upon request, with information on progress of the investigationof the crime, unless the disclosure might jeopardise the investigation.

● To be informed, upon request, of charges laid against the accused or reasons for not laying charges, any changes to charges or decision not to proceed withcharges, date and place of any hearings and outcome of criminal proceedingsagainst the accused and the sentence, if any is imposed.

● To be informed about trial process and role of the victim as a witness in theprosecution of the accused if the victim is to be a witness.

● To be informed about any special bail conditions imposed on the accused thatare designed to protect the victim or the victim’s family.

● To be informed of the outcome of a bail application if the accused has beencharged with sexual assault or other serious personal violence.

● To be informed, upon request, of the offender’s impending release or escapefrom custody or any change in security classification that results in the offenderbeing eligible for unescorted absence from custody.

● To be protected from unnecessary contact with the accused and defencewitnesses during court proceedings.

● To have the need or perceived needs of the victim for protection to be putbefore a bail authority by the prosecutor in any bail application by the accused.

● To have their residential address and phone number kept confidential unless thecourt otherwise directs.

● To be relieved from appearing at preliminary hearings or committal hearingsunless the court otherwise directs.

● To have any inconvenience to the victim minimised should any property of the victim be held by the State for the purpose of investigation or evidence,and to have that property returned promptly.

● To be provided, upon request, with the opportunity to make submissionsconcerning the granting of parole to a serious offender or any change insecurity classification that would result in a serious offender being eligible forunescorted absence from custody.

● To be entitled, if the victim of a crime involving sexual or other seriouspersonal violence, to make a claim under a statutory scheme for victims compensation.


Victims of crime have the

right to be provided with

certain services.

Victims of crime have rights to

certain information.

Victims of crime have the right

to be protected.

Victims of crime may be entitled

to compensation.


Victims who feel their rights have not been observed can discuss the matter withthe relevant government agency and if necessary, can contact their complaintsunit. If there are still concerns, the Victims of Crime Bureau can be contacted tofind out what, if any, other assistance can be given under the Charter.

11.5 Role of witnesses

The DPP Witness Assistance Service is available to provide support throughoutthe prosecution being undertaken by the DPP, where a staff member, as a victimof a very serious crime, may have to become involved in a criminal prosecution.Trained social workers, psychologists and counsellors staff the Service.

When preparing for court, the witnesses should make sure they have a copy ofany statements they made to police, and think about the related events, includingdates, times, descriptions etc. Statements, notes or documents relevant to the caseshould be taken to court for the hearing. Evidence should not be discussed withother witnesses.

On court day the DPP lawyer will usually arrange to see the witness prior totheir being called to give evidence.There may also be considerable waiting time.If witnesses require special care or feel threatened in any way, they should tell thepolice officer or the DPP lawyer. Court usually sits from 10am until 4pm with a15 minutes morning tea break and a lunch break from 1pm until 2pm.

When called to give evidence, the witness is shown to the witness box at thefront of the courtroom.After being sworn, the witness will then be asked to statetheir name and occupation, and possibly their address. If a witness does not wishto make their address public, the DPP lawyer should be told beforehand.

The Crown Prosecutor or DPP lawyer will question the witness about what happened, and the witness is then ‘cross-examined’ by the lawyer for theaccused.The judge or magistrate may also ask the witness questions about theevidence. Judges sit in the District and Supreme Courts and are addressed as‘Your Honour’. Magistrates sit in the Local Court and are addressed as‘Your Worship’.

When giving evidence in court, witnesses should take their time, consider each question before answering and speak clearly. If witnesses have difficultyunderstanding or speaking English, police or the DPP lawyer can arrange for aninterpreter beforehand.After the witness is excused, he/she is free to leave,though may stay unless required to give evidence again later in the proceedings.

There are special protections and arrangements available for victims of sexualassault offences. For further details, advice should be sought from the DPP lawyer handling the case or the Witness Assistance Service. If witnesses have anyquestions about their court appearance, evidence or anything else to do with thecase, they should speak to the DPP lawyer handling the case. If they still havequestions or feel confused or anxious about anything to do with the courtappearance, they should contact the DPP Witness Assistance Service on Sydney (02) 9285 2502 or toll free 1800 814 534.


Staff can contact the

Victims of Crime Bureau on

(02) 9374 3000 or

1800 633 063

(toll free outside the

Sydney metropolitan area).

When giving evidence,

witnesses should take their

time, consider the questions

and speak clearly.

If further assistance is required,

witnesses can contact the

Witness Assistance Service on

(02) 9285 2502 or toll free on

1800 814 534.


12Monitoring, review and continuous improvement

Department circular 2001/22,

Workplace Health and Safety:

A Better Practice Guide includes

Departmental guidelines on

evaluation and monitoring of

workplace safety systems.

Responsibility needs to be

allocated for monitoring, review

and evaluation of violence

prevention strategies.

12.1 Ongoing monitoring of the working environment

Staff should be encouraged to monitor the working environment for related riskfactors and take appropriate action, including reporting of hazards, within theirscope of authority where they are identified.

Such risk factors may include (see section 6.3 and 7.2):

● damaged furniture or damaged or loose fittings

● inadequate lighting due to blown bulbs or tubes

● poor housekeeping

● over or under heated premises

● overcrowding or long delays in treatment

● damaged or faulty patient facilities eg drink or food dispensers, phones,toilets, televisions etc

● unplanned staff shortages

● indicators of potential outbreaks of violence by patients or visitors.

While such factors may be readily identified after a violent event, continuousmonitoring by staff is far more effective as a preventive measure.

12.2 Formal review and evaluation

In addition to ongoing monitoring of the working environment, there should be formal allocation of responsibility for monitoring, review and evaluation ofviolence prevention strategies. Employees who are allocated responsibilities need to have the appropriate skills, training, authority and resources to carry them out.

In particular, responsibility should be allocated for the following:

● conducting regular security and violence vulnerability audits

● implementing and monitoring recommendations from the audits

● reviewing local policies, procedures and protocols for continuing relevance and effectiveness

● testing and maintaining safety equipment such as duress alarms andcommunication devices

● ensuring safety equipment continues to effectively meet the needs/purposes for which it was initially provided

● monitoring the incident reporting system/procedures for ‘user friendliness’and compliance

● investigating incidents and ensuring any recommendations from theinvestigation are implemented in a timely manner

● ensuring that appropriate post incident support is provided to those involved in violent incidents

● reviewing responses to violent incidents, including the duress response


● implementing and monitoring recommended modifications to the response protocols

● ensuring staff are appropriately trained, including induction/orientation of new staff

● ensuring that training continues to be relevant to the needs of the target audience

● ensuring that all related legal requirements are met

● identifying and regularly reviewing performance indicators

● keeping abreast of new violence prevention and management strategies

● requesting periodic law enforcement or external reviews of the worksite forrecommendations on improving staff safety.

All of the above should include consultation with staff involved in the process oraffected by any potential changes.

12.3 Performance indicators

The most obvious way of determining whether violence prevention andmanagement strategies are working effectively is looking for a reduction in thefrequency and severity of violent incidents. However, the difficulty associatedwith this, as referred to earlier, is that current research suggests that violentincidents are significantly under reported.While this results in a range of issues,it also reduces the ability of facilities to directly measure the effects of their riskcontrol strategies on frequency and severity.

It should be noted that getting the reporting message across to staff may result inan increase in reported incidents, though there may not necessarily be an increasein the number of actual incidents.

Other sources of quantitative data can be utilised as part of the evaluationprocess, although it will depend upon the availability and reliability of suchinformation and whether baseline data exists for comparison.

Examples could include:

● hazard reports

● number of times the duress response is instigated

● frequency of OHS committee meetings

● number/percentage of workplace changes that involved staff consultation

● results of safety and security audits and vulnerability audits

● workers compensation data

● first aid records

● workplace grievance records and staff turnover in high risk areas.

Qualitative data could include staff interviews and/or surveys on theirperceptions regarding their personal safety.

Monitoring, review and continuous improvement

Performance indicators

need to be identified as part

of the evaluation process.


Another important aspect of the evaluation process is identifying those initiatives with the greatest potential for impact on frequency and severity andevaluating/monitoring their implementation.The literature suggests that solutionsmost likely to reduce violence include utilising CPTED principles, adopting anappropriately supported zero tolerance approach and providing training in how toprevent and manage potential or actual violent situations.

Indicators could include:

● number of violence vulnerability audits conducted and where

● number of improvements instigated as a result of the audits

● percentage of incidents investigated

● percentage of incidents that resulted in changes or additions to theenvironment, incident response protocols or other existing risk control measures

● increases in security related personnel

● proportion of staff who have attended violence minimisation and management training

● outcomes of training evaluation

● degree of implementation of key aspects of the Department’s zero tolerancepolicy eg percentage of patients receiving information on their behaviouralresponsibilities; percentage of staff attending violence prevention training;implementation of zero tolerance communications strategies; introduction of, or improvements to, patient alert systems; changes to frequency of violentincident reports; percentage of assaults reported to police; percentage of assaultsresulting in charges being laid; results of management and staff surveys on their attitudes to workplace violence; and level of awareness of the zerotolerance response.

When identifying performance indictors to be used as part of the evaluationprocess, a balance of qualitative, quantitative, positive and negative performanceindicators is necessary to give the clearest picture on the effectiveness of localviolence prevention and management strategies.

12.4 Continuous Improvement

Review and evaluation of violence prevention and management activities are onlyof benefit if their findings and resulting recommendations are continuously fedback into the relevant components of the system.

This allows risk control strategies to be dynamic and responsive to changingsystems, technologies and environments, and ensures that they remain up to dateand continue to be effective.




12.5 A quick zero tolerance checklist

● Is there a written policy on zero tolerance signed by the CEO?

● Is it appropriately supported by other violence control strategies?

● Has there been legal input during the development of all key violenceprevention strategies, including localised zero tolerance policies?

● Are targeted communication strategies in place to inform managers and staffof the zero tolerance response and key messages?

● Is the zero tolerance message clearly displayed in relevant areas eg admissionsareas, emergency departments etc?

● Is there documentation that clearly outlines patient behavioural requirements?

● Is this documentation provided to all patients, including those receiving carein the community?

● Is there documentation that clearly outlines visitor behavioural requirements?

● Is this documentation available for visitors?

● Does all staff, including community health staff, have ready access to a simpleviolence incident report form?

● Are all staff trained in the reporting procedure?

● Are all staff encouraged to report all violent incidents?

● Are all violent incidents reported to the CEO?

● Are all assaults reported to police?

● Are all staff identified as being at risk of violence provided with violenceminimisation and management training?

● Are all staff aware of their options when confronted with violence?

● Do all staff, including community health staff, have access to urgent assistancein the event of a violence related emergency?

● Do all staff know how to access this assistance?

● Are there guidelines in place for the prevention and management ofworkplace bullying?

● Are all staff aware of these guidelines?

● Are staff involved in facility planning provided with CPTED training?

● Are CPTED principles incorporated into new and refurbished facilities?

● Are both formal and informal mechanisms in place for facilitating ongoingliaison with local police?

● Is there a patient alert system in place?

● Are there procedures in place to ensure that file flags are regularly reviewedfor relevance?

● Do all flagged files include an up to date management plan?

● Are there procedures in place, with appropriately allocated responsibility,to ensure that all management plans are regularly reviewed for relevance and effectiveness?

● Are key aspects of the zero tolerance response regularly reviewed forcontinuing relevance and effectiveness?


13References and additional resources

13.1 Bibliography

California Division of Occupational Safety and Health (CAL/OSHA), (1998): Guidelines for security and safety of health care and community service workers, Division of Occupational Safety andHealth, Department of Industrial Relations, San Francisco.

California Division of Occupational Safety and Health (CAL/OSHA), (1995): Guidelines forworkplace security, Division of Occupational Safety and Health, Department of IndustrialRelations, San Francisco.

California Division of Occupational Safety and Health (CAL/OSHA), (1995): Injury and illnessprevention model program for workplace security, Division of Occupational Safety and Health,Department of Industrial Relations, San Francisco.

Chappell D and Di Martino V (2000), Violence at work, International Labour Office, Geneva.

Department of Health and Human Services (1996), Violence in the workplace: risk factors and preventionstrategies, The United States Department of Health and Human Services, Centres for DiseaseControl and Prevention, National Institute for Occupational Safety and Health, Cincinnati,Ohio, USA.

Department of Industrial Relations (2002), Report of the Queensland Government Workplace Bullying Taskforce, Creating safe and fair workplaces: strategies to address workplace harassment in Queensland,Queensland Government.

Fisher J, Bradshaw J, Currie B, Klotz J, Robins P, Searl K and Smith J (1995), Context of silence:violence and the remote area nurse, Faculty of Health Science, Central Queensland University.

McCarthy P, Henderson M, Sheehan M and Barker M (2001), Module 7: bullying, The CCH equal opportunity training manual, Commercial Clearing House (CCH), North Ryde,pp50,001-50,453.

Mayhew C and Chappell D (2001), Occupational violence: types, reporting patterns, and variations betweenhealth sectors, Working Paper Series no. 139, UNSW, Sydney.

Mayhew C and Chappell D (2001), Prevention of Occupational Violence in the Health Workplace,Working Paper Series no. 140, UNSW, Sydney.

Mayhew C and Chappell D (2001), Internal violence (or bullying) and the Health Workforce, WorkingPaper Series no. 141, UNSW, Sydney.

National Health and Medical Research Council (2002), When it’s right in front of you: assisting healthcare workers to manage the effects of violence in rural and remote Australia, August 2002.

National Health Service (NHS) (1997), We don’t have to take this, resource pack, NHS Zero ToleranceZone, National Health Service, United Kingdom.

National Occupational Health and Safety Commission (NOHSC) (1999), Program one report:occupational violence, paper discussed at the 51st Meeting of the Australian NationalOccupational Health and Safety Commission, held 10 March 1999, Hobart, unpublishedNOHSC papers.

National Occupational Health and Safety Commission (NOHSC) (1999), Work-related homicide inAustralia, 1989-1992, NOHSC, Sydney.


Office of the Employee Ombudsman (2000), Bullies not wanted: recognising and eliminating bullyingin the workplace, Office of the Employee Ombudsman, South Australia.

Paterson B and Leadbetter D (2002), Standards for violence management training, in Gill M, Fisher Band Bowie V, (eds), Violence at work: causes, patterns and prevention,Willan Publishing, UnitedKingdom pp132-150.

Royal District Nursing Service Research Unit (2002), Preventing workplace violence: towards a best practice model for work in the community, School of Nursing, Flinders University of South Australia.

United States Department of Labor (1998), Guidelines for preventing workplace violence for health careand social service workers, Occupational Safety and Health Administration,Washington, DC.

Victorian WorkCover Authority (2001), Issues Paper: Code of practice for prevention of workplacebullying, Victorian WorkCover,Victoria.

Whitehorn D and Nowlan M (1997),Towards an aggression-free health care environment,The Canadian Nurse, 93(3): 24-6.

WorkCover Authority of NSW (2001), NSW health and safety code of practice, WorkCover NSW, Sydney.

WorkCover Authority of NSW (2001), Risk management at work, WorkCover NSW, Sydney.

13.2 Related websites

Australian Institute of CriminologyWebsite: www.aic.gov.au

California Division of Occupational Safety and Health (CAL/OSHA)Website: www.dir.ca.gov/dosh/dosh_publications

National Health and Medical Research CouncilWebsite: www.health.gov.au/nhmrc/advice/pdf/violence.pdf

National Health Service, United KingdomWebsite: www.nhs.uk/zerotolerance/

National Occupational Health and Safety Commission (NOHSC)Website: www.nohsc.gov.au/

NSW Attorney General’s DepartmentWebsite: www.lawlink.nsw.gov.au

NSW Police ServiceWebsite: www.police.nsw.gov.au

Office of the Director of Public ProsecutionsWebsite: www.odpp.nsw.gov.au

Office of the Employee Ombudsman, South AustraliaWebsite: www.employeeombudsman.sa.gov.au

Queensland Department of Industrial RelationsWebsite: www.whs.qld.gov.au

United States Department of Health and Human ServicesWebsite: www.cdc.gov/niosh/homepage.html

References and additional resources


Victorian WorkCover AuthorityWebsite: www.workcover.vic.gov.au

WorkCover Authority of NSW Website: www.workcover.nsw.gov.au

WorkCover South AustraliaWebsite: www.workcover.com.au

13.3 Relevant Australian Standards

Australian Standard (2001), Occupational health and safety management systems – Generalguidelines on principles, systems and supporting techniques,AS/NZS 4804:2001,Standards Australia.

Australian Standard (2001), Occupational health and safety management systems – Specificationwith guidance for use,AS/NZS 4801:2001, Standards Australia.

Australian Standard (1999), Risk management,AS/NZS 4360:1999, Standards Australia.

Australian Standard (1998),Amendment No. 1, Hard-wired patient alarm systems,AS 3811-1998,Standards Australia.

Australian Standard (1998), Hard-wired patient alarm systems,AS 3811-1998, Standards Australia.

Australian Standard (1997), Planning for emergencies – Health care facilities,AS 4083-1997,Standards Australia.

Australian Standard (1997), Security for health care facilities, Part 1: General requirements,AS 4485.1-1997, Standards Australia.

Australian Standard (1997), Security for health care facilities, Part 2: Procedures Guide,AS 4485.2-1997, Standards Australia.

Australian Standard (1996),Amendment No. 1, Guards and Patrols,AS 4421-1996,Standards Australia.

Australian Standard (1996), Guards and Patrols,AS 4421-1996, Standards Australia.

References and additional resources

Managers should also consult the following NSW Health publications when putting in place a zero tolerance approach:

• NSW Health Security Manual

• Workplace Health and Safety: A Better Practice Guide (C2001/22)

• Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination (C2001/109)

• Effective Incident Response: A Framework for Prevention and Management in the Health Workplace (C2001/19).

All these publications are available atwww.health.nsw.gov.au

Why we’re takingthese stepsIn response to a number of violent incidents in the NSW public health system, the NSW Minister for Health established the Taskforce on Prevention and Management of Violence in the Health Workplace,in July 2001. Zero tolerance was a key recommendationin the Taskforce’s report.

Other TaskforceinitiativesIn addition to the zero tolerance policy and frameworkguidelines, the Taskforce will be releasing:

• Zero tolerance posters for display in public areas such as Emergency Departments and admission areas.

• Design Series (DS) Health Facility Guideline – Security and Safety, incorporating crime prevention through environmental design (CPTED)into health building protocols.

• Research Report on Baseline Estimates of Violence.

• NSW Health training program A Safer Place to Work: Preventing and Managing Violent Behaviour in the Health Workplace.

zero tolerance zoneNSW Health is a

Staff and patients need to work and be cared for in a safe environment.

Violence and verbal abuse will not be tolerated.

NSW Department of Health73 Miller Street, North Sydney NSW 2060Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in part, subject to the inclusion of an acknowledgement of the source and non-commercial usage or sale.


For further copies, please contact:Better Health Centre, Publications WarehouseLocked Mail Bag 5003 Gladesville NSW 2111Tel. (02) 9816 0452 Fax. (02) 9816 0492

A copy of this report can be downloaded fromNSW Health website. www.health.nsw.gov.au

SHPN (CMH) 030004

July 2003

What is ZeroTolerance• Every person working in or utilising the

NSW public health system – staff, patients and visitors – has a right to personal safety.

• To boost safety, NSW Health has adopted a policy of zero tolerance towards violence by any person on health service premises,or when giving or receiving health care in the community.

• Threatening, abusive or physically violent behaviour will not be accepted from anyone under any circumstances.

• Action will be taken when a violent incident occurs. Such action may include a prompt medical response where appropriate, a formal warning, utilising security services and/or calling the police and laying charges.

• NSW Health will continue to strive to stop violence before it happens. However if it does happen, it will be met with an immediate and appropriate response aimed at minimising its effects and the risk of it happening again.

Zero Tolerance is about keeping health staff, patients and visitors safe.Help make it happen.

What does ZeroTolerance mean for you?Every person working in or using the public healthsystem has a role to play in minimising the risk of violence.

Health staff

Respect others – Patients, visitors and healthcolleagues have the right to be treated with dignity and respect and to be free from violence. Health staffplay a key role in preventing violence.

Look out for warning signs – Prevention is the bestoption for dealing with violence.

Know and exercise your options – There are ways to deal with and minimise violence. Get to know yourlocal procedures and follow them. Participate in violenceminimisation training. Be consistent in your approach.This will help protect you, your colleagues, patients and visitors.

Report all violent incidents – Problems that don’t get reported don’t get fixed. All reported violent incidentswill be investigated regardless of the perpetrator,and appropriate action taken.

Further information for staff on dealing with violence canbe found in the NSW Health publication Zero Tolerance –NSW Health Response to Violence in the Public HealthSystem, Policy and Framework Guidelines.

Patients and visitors

Respect others – You have the right to be treated with dignity and respect and to receive treatment in a violence-free environment. You also must respect the rights of the health professionals treating you,your family and friends, and the rights of other staff, patients and visitors.

Show restraint – Patients and visitors must not harass,abuse, threaten or put health staff, or any other person on health service premises, at risk of physical orpsychological harm.

It is never acceptable to assault others – Violencemakes it harder for health workers to provide good healthcare to you or your loved ones.

Further information on patient rights and responsibilitiescan be found in the NSW Health publication You and Your Health Service.

Managers

Get everyone up to speed – Make sure staff knowtheir options when confronted with violence. If you takeviolence seriously so will your staff, patients and visitors.

Encourage staff to report violence – Keep thereporting mechanism simple to encourage a culture of reporting.

Investigate all violent incidents – This will helpensure that violence prevention strategies are working,and allow for improvements if necessary.


For more information visit www.health.nsw.gov.au



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Managers should also consult the following NSW Health publications when putting in place a zero tolerance approach:

• NSW Health Security Manual

• Workplace Health and Safety: A Better Practice Guide (C2001/22)

• Joint Management and Employee Association Policy Statement on Bullying, Harassment and Discrimination (C2001/109)

• Effective Incident Response: A Framework for Prevention and Management in the Health Workplace (C2001/19).

All these publications are available atwww.health.nsw.gov.au

Why we’re takingthese stepsIn response to a number of violent incidents in the NSW public health system, the NSW Minister for Health established the Taskforce on Prevention and Management of Violence in the Health Workplace,in July 2001. Zero tolerance was a key recommendationin the Taskforce’s report.

Other TaskforceinitiativesIn addition to the zero tolerance policy and frameworkguidelines, the Taskforce will be releasing:

• Zero tolerance posters for display in public areas such as Emergency Departments and admission areas.

• Design Series (DS) Health Facility Guideline – Security and Safety, incorporating crime prevention through environmental design (CPTED)into health building protocols.

• Research Report on Baseline Estimates of Violence.

• NSW Health training program A Safer Place to Work: Preventing and Managing Violent Behaviour in the Health Workplace.




NSW Department of Health73 Miller Street, North Sydney NSW 2060Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in part, subject to the inclusion of an acknowledgement of the source and non-commercial usage or sale.


For further copies, please contact:Better Health Centre, Publications WarehouseLocked Mail Bag 5003 Gladesville NSW 2111Tel. (02) 9816 0452 Fax. (02) 9816 0492

A copy of this report can be downloaded fromNSW Health website. www.health.nsw.gov.au

SHPN (CMH) 030200

July 2003

cir2003-48. zero tolerance response to violence in the nsw

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