Preventing occupational violence A policy framework including principles for managing weapons in Victorian health services

4 Clinical review of area mental health services 1997-2004

Preventing occupational violence A policy framework including

principles for managing weapons

in Victorian health services

Updated December 2011

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AcknowledgementThe Department of Health would like to acknowledge the members of the Victorian Taskforce on Violence in Nursing who shared their extensive and diverse knowledge and experience in the Victorian health sector to inform this work. Professor Duncan Chappell has been involved in research and public policy development related to workplace violence for over a decade. He worked at the Australian Institute of Criminology (Canberra) and was the chair of the NSW Health Taskforce on prevention and management of violence in the health workforce. His contribution to this work requires special thanks.

Accessibility If you would like to receive this publication in an accessible format phone 9096 8398 using the National Relay Service 13 36 77 if required, or email: nursepolicy@health.vic.gov.au

This document is available as a PDF on the internet at: www.health.vic.gov.au/nursing/promoting/noviolence

© Copyright, State of Victoria, Department of Health 2011

This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

Authorised and published by the Victorian Government, 50 Lonsdale Street, Melbourne.

Except where otherwise indicated, the images in this publication show models and illustrative settings only, and do not necessarily depict actual services, facilities or recipients of services.

December 2011 (1109051)

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Acknowledgement 2

Accessibility 2

Introduction 5

The policy framework 7

Occupational violence prevention – strategic directions 7

Defining occupational violence 8

Policy context 8

Relevant legislation and regulation 9

Social context 12

Principles for managing firearms and non-firearm weapons within health care settings 13

General principles relating to all firearms and non-firearm weapons 13

Specific principles relating to Group A: Firearms 15

Specific principles relating to Group B: Non-firearm weapons 15

Specific principles relating to Group C: Dangerous articles (non-firearm) 16

Preventing occupational violence – applying an occupational health and safety framework 16

The hierarchy of control 22

Eliminate the hazards — Crime Prevention Through Environmental Design principles 23

Administrative controls (1) - occupational violence measures and indicators 24

Administrative controls (2) – checklist for occupational violence education and training 25

Administrative controls (3) – occupational violence staffing considerations 26

Administrative controls (4) - Resources for the prevention and management of bullying in Victorian health services 26

Administrative controls (5) – occupational violence post incident response hierarchy 28

Key related policies or documents 29

Appendix 1. Restraint, force and self-defence 30

Restraint, force and self-defence 30

Appendix 2. Summary of firearms and non-firearm weapons 32

Appendix 3. Suggested key elements of a health service firearms and non-firearms policy 34

Appendix 4. Establishing compliance with amendments to the Firearms Act 1996 and the Control of Weapons Act 1990. 35

References 37

Contents

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Violence within the workplace is increasingly being recognised as an issue for health service providers. Concern about this issue within nursing led to the 2002 Department of Human Services funded project to analyse the incidence of violence within four Victorian public hospitals (Department of Human Services (Victoria) 2005). In 2004, the Victorian Government established the Victorian Taskforce on Violence in Nursing (‘the taskforce’) to examine key issues and recommend strategies to address occupational violence against nurses. The ministerial taskforce brought together government, industrial, regulatory, health service and clinical nursing representation to provide strategic advice to the government regarding violence and bullying in the workplace directed towards nurses, and the strategies to reduce its occurrence.

The taskforce made 29 recommendations (Department of Human Services (Victoria) 2005) aimed at addressing the problem of violence against nurses in a more consistent and coordinated manner. In particular, the work highlighted the need for a framework to effectively address occupational violence in health services and for clear and consistent messages that:

• violence against nurses (or any healthcare worker) is unacceptable and must be proactively addressed,

• there is not a culture of tolerance of violence in healthcare workplaces and

• encourage a culture of reporting of occupational violence in heathcare.

New South Wales and United Kingdom policy development has focused on a zero tolerance approach to violence and bullying. The Victorian taskforce, while it concluded that it would ‘be informed by the NSW framework’, has not formally adopted the nomenclature of zero tolerance. Clearly, what may be ‘branded’ as zero tolerance may have an underlying sound framework that is embedded in occupational health and safety principles of risk identification assessment and control. A systematic occupational health and safety hazard management approach, which includes proactive input from the occupational health and safety representative committee, has demonstrated benefits for preventing occupational violence and has formed the foundation stone of this policy framework. This proactive approach includes health services having the ability to deter, detect and manage weapons.

The World Health Organisation (2006) defines injury and violence prevention policy as:

‘a document that sets out the main principles and defines goals, objectives, prioritised actions and coordination mechanisms for preventing intentional and unintentional injuries and reducing the health consequences.’

The value of developing injury and violence prevention policies is that it provides the basis for effective joint action.

This document explains the overarching policy framework for the prevention and management of occupational violence and bullying within Victorian public health services. It contains the guiding framework and rationale for health services to ensure that safe, healthy and productive workplaces are maintained. In this context, the workplace is more than just the health services’ ‘bricks and mortar’; it includes all settings where health services provide care or services, such as in community and residential settings.

This policy framework is a visible commitment to the prevention of occupational violence in Victorian health services and makes explicit the expectation that health services will be committed to the implementation and support of occupational violence prevention in their workplaces. It also recognises the department’s duty of care to staff and clients and that of health services to their staff and clients.

Policy principle:

Health services must have an integrated health workforce policy that acknowledges the imperative to provide safe and healthy workplaces and that specifically recognises the prevalence of occupational violence in health care.

Introduction

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The Department of Health is committed to providing all employees with a healthy and safe workplace free from violence. While this policy framework provides the strategic direction and guiding principles, it is anticipated that local health service policies and procedures will give effect to this framework.

The framework provides the policy principles to assist health services to:

• implement occupational violence prevention and management programs at the local level

• apply an integrated and systematic approach

• enhance the capacity of health services to effectively meet their obligations as employers

• continuously build on the evidence base and be informed by best practice

• promote awareness and a ‘no blame’ approach to occupational violence and bullying

• deter, detect and manage weapons.

This framework has been informed by existing knowledge and literature. It is not intended to replace existing policies and documents, such as those referenced in the key related policies. Rather, it recognises issues of implementing occupational violence and bullying prevention measures within an occupational health and safety framework, with specific reference to a health care context.

Policy principle:

An overarching framework is important; however, each health service setting will need to consider customisation and local solutions/implementation strategies.

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This framework applies to all public funded health workplaces in Victoria, including those in the community, as listed in Schedules 1-5 of the Health Service Act 1988. It is, however, expected that the same issues and responses will be appropriate for other sectors, including private health, aged care, community and welfare services.

Although the development of this framework originated from the recommendations of the Taskforce on Violence in Nursing, the framework applies to all staff employed by public health services. Further, the obligations of health services to provide a safe work environment for all those who enter the workplace are clearly defined in the relevant legislation. This means that elements of this framework apply to visitors, clients1, volunteers and contractors as well as all employees (including nurses).

Occupational violence prevention – strategic directions Effective management and prevention of occupational violence in health care requires an integrated systems approach. The key strategies underpinning this framework and the activities to progress the implementation of the taskforce recommendations were clustered around five areas of effort. These areas are:

Strategy 1 Setting the policy framework – this document forms the major plank of strategy 1

Strategy 2 Raising awareness of the importance of violence and bullying prevention – this includes the development of a communication strategy and public awareness campaign through engaging a variety of partners

Strategy 3 Enhancing the interface between health services, the police and the justice system

Strategy 4 Ensuring that education and training for the prevention and management of aggression reflects the organisational context and the needs of the employee

Strategy 5 Developing effective reporting and monitoring systems, including a standardised minimum data set that will enable health services to report, monitor and compare incidence of bullying and violence

Policy principle:

Although nurses are particularly exposed, it is recognised that occupational violence has the potential to affect all health workers. Therefore, it is important that health services develop whole-of-workforce health policies.

The policy framework

1 In this document, the term ‘client’ is used inclusively to refer to all those who are the recipients of services provided by health, community and aged care providers.

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Defining occupational violence Without consistent definitions, the true nature, extent and impact of workplace violence cannot be fully understood within the health care sector. The taskforce’s work summarised the issues and inconsistencies arising from the different language and definitions applied to workplace violence and bullying. In this framework, the term ‘occupational violence’ is used and has been broadly defined to include threats and actual violence. As recommended by the Victorian taskforce, the department has adopted the following definition for use in all Victorian health services:

Occupational violence is defined as:

Any incident where an employee is abused, threatened or assaulted in circumstances arising out of, or in the course of their employment (Adapted from WorkSafe guidance note, 2003).

Within this definition of occupational violence:

• ‘threat’ means a statement or behaviour that causes a person to believe that they are in danger of being physically attacked, and may involve an actual or implied threat to safety, health or wellbeing

• ‘physical attack’ means a direct or indirect application of force by a person to the body of, or clothing or equipment worn by, another person, where that application creates a risk to health and safety.

Neither intent nor ability to carry out the threat is relevant. The key issue is that the behaviour creates a risk to health and safety.

Examples of occupational violence include, but are not limited to, verbal, physical or psychological abuse, threats, throwing objects and sexual harassment (Department of Human Services (Victoria) 2005).

Sometimes a distinction is made between bullying and harassment; sometimes it is included in definitions of workplace violence. The taskforce’s recommended definition of occupational violence is broad enough to encompass aspects of behaviour such as bullying and harassment, while recognising that the relevant legal framework may include anti-discrimination legislation. The agreed definition of bullying is aligned with the WorkSafe definition and is: Workplace bullying is repeated, unreasonable behaviour directed toward an employee, or group of employees, that creates a risk to health and safety. Further detail is provided on page 26.

Policy context In relation to health and health service provision, there are significant health and safety issues, including occupational violence and bullying, that need a systematic and coordinated approach. Providing a safe and healthy work environment is a key policy objective of the Victorian Government and the link between healthy and safe workplaces and workforce is critical.

This framework aligns with the Health Priorities framework 2012-2022. The framework assists in planning and delivering an innovative, informed and effective health care system that is responsive to people’s needs now and in the future. Specifically, its vision is for a health system that is highly productive and sustainable. Principles outlined in the framework that support this policy document include evidence based decision making, maximum returns on system investments, sustainable use of resources through efficiency and effectiveness, continuous improvement and innovation, and local and responsive governance.

Role of the Department of Health

The Department of Health is responsible for funding public health services across Victoria. The department is committed to creating a safe and productive workplace through improving health, safety and wellbeing at work.

Considerable work on occupational health and safety (including management and prevention of occupational violence) has already been undertaken in specific health care settings or in relation to working with specific client groups (Department of Human Services (Victoria) 2004; Department of Human Services (Victoria) and Police 2004; Department of Human Services (Victoria) 2005). These policies provide direction and guidance to health services about the specific management and prevention of occupational violence in those care settings.

Further, an occupational health and safety management framework model has been developed for Victorian health services. The model provides the basis for health services to develop a comprehensive approach to managing health and safety obligations. This includes meeting legislated obligations to provide a workplace free of risk and continuously improving health and safety performance (Department of Human Services (Victoria) 2003).

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This framework is aligned to these documents and provides a complementary focus on preventing and managing occupational violence and bullying within health services. The department has a role in monitoring and evaluating policies that affect health services (Refer to page 21 monitoring and evaluation by the department).

Policy principle:

All staff are entitled to work in safe and healthy workplaces and the Department of Health is committed to ensuring that public health services are healthy and safe work environments, free from occupational violence and bullying.

Relevant legislation and regulationVictoria’s health services are required to reflect the requirements of State and Federal law, and the community’s expectations about health, safety and quality. A number of legislative acts, regulations and industry standards define and detail how health services manage the provision of health care/services while also ensuring the safety and health of all those involved (directly or indirectly) in the provision of care, as well as clients and their families.

Legislation

The following section contains information about some key legislation that is central to this policy. It is not an exhaustive list.

Occupational Health and Safety Act 2004

The purpose of the Occupational Health and Safety Act (the Act) is to secure the health, safety and welfare of employees and other persons at work, to ensure that the health and safety of members of the public are not placed at risk, and to provide for the involvement of all parties in the formulation and implementation of health, safety and welfare standards. Specifically, the Act:

• covers wherever staff are employed to provide health services (not just hospitals), for example, day centres, clinics, home care settings and residential aged care

• defines a workplace as ‘a place, whether or not in a building or structure, where employees or self employed persons work’ (s. 5)

• mandates that the department’s duty, so far as is reasonably practicable, is to provide and maintain a working environment that is safe and without risks to health (s. 21)

• requires employees, while at work, to: (a) take reasonable care for their own health and safety; (b) take reasonable care for the health and safety of persons who may be affected by the employee’s acts or omissions at the workplace; and (c) cooperate with their employer with respect to any action taken by the employer to comply with a requirement imposed by or under the Occupational Health and Safety Act 2004 or its associated regulations (s. 25)

• imposes duties on employers to consult with employees and health and safety representatives ‘so far as is reasonably practicable’ when undertaking certain tasks. These include, but are not limited to, identifying or assessing hazards or risks and making decisions regarding measures to be taken to control risks to health and safety (s. 35) (Refer also to pages 18–19 of the Taskforce Final report).

Mental Health Act 1986

The objectives of the Mental Health Act are to provide for the care, treatment and protection of mentally ill people who do not or cannot consent to that care, treatment or protection, and to facilitate the provision of treatment and care to people with a mental disorder. This Act has implications for wherever clients with mental illness are treated.

The five criteria for involuntary treatment that need to be met are that: the person appears to be mentally ill; the person requires immediate treatment and that treatment can be obtained by the person being subject to an involuntary treatment order only; it is necessary for the person’s health or safety or the protection of members of the public; the person has refused consent or is unable to consent to the necessary treatment; and the person cannot receive adequate treatment in a less restrictive manner. The care of clients with mental health issues can be very challenging and raises specific issues in relation to occupational violence.

Criminal law

The criminal law in Victoria is a combination of common law and legislation. The key piece of legislation is the Crimes Act 1958 (Victoria), which aims to punish all forms of criminal behaviour.

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In the context of occupational violence, consideration of criminal law is relevant as most forms of occupational violence will be criminal offences and, as such, subject to investigation by the police. Relevant offences include assault, threats to kill and threats to cause physical injury. The Summary Offences Act 1966, which relates to behaviour in public places, including, but not limited to, obscene, threatening and abusive behaviour, may have a bearing in cases of occupational violence in health services.

There are, however, some examples of occupational violence that will not be offences under criminal law, such as where an employee is physically attacked by a person, such as a psychiatric patient, who is incapable of forming the necessary intent. This may well require a careful appraisal of individual cases to decide if criminal liability may or may not be relevant (Worksafe, Victoria, 2003).

Weapons and firearms

A proactive approach is required in relation to the deterrence, detection and management of weapons. In addition, a legislative framework to govern control of weapons and detailed information regarding the various types of weapons in the community are required.

The legislation relevant to weapons and firearms includes:

• Control of Weapons Act 1990

• Control of Weapons Regulations 2000

• Firearms Act 1996

• Firearms Regulations 1997

• Victims Charter Act 2006

• Charter of Human Rights & Responsibilities Act 2006 (Vic)

• Crimes Act 1958

• Summary Offences Act 1966 (Vic)

Aged Care Act 1997

The Aged Care Act (the Act) governs all aspects of the provision of residential care, flexible care and Community Aged Care Packages (CACPs) to older Australians. The Act sets out matters relating to planning of services, approval of service providers and care recipients, payment of subsidies, and responsibilities of service providers including occupational health and safety requirements. There are also principles made under the Act that provide further detail regarding the matters set out in the Act. In relation to occupational violence, Part 4.2: User Rights Principles 1997 states that:

Each resident of a residential care service under section 10.13 of the user rights principles is required to: respect the rights of staff and the proprietor to work in an environment which is free from harassment.

Anti-discrimination legislation

State and Federal anti-discrimination legislation prohibits behaviour that amounts to discrimination or sexual harassment. Bullying and violence that occur within the workplace could also be covered by such legislation if it amounts to discrimination on the basis of a prescribed attribute and meets the legislation’s definition of unlawful harassment. The relevant legislation includes:

• Equal Opportunity Act 2010 (Victoria)

• Racial and Religious Tolerance Act 2001 (Victoria)

• Human Rights and Equal Opportunity Act 1986 (Commonwealth)

• Racial Discrimination Act 1975 (Commonwealth)

• Sex Discrimination Act 1984 (Commonwealth)

• Disability Discrimination Act 1992 (Commonwealth)

• Age Discrimination Act 2004 (Commonwealth)

Compensation legislation

The Accident Compensation Act (Occupational Health and Safety) 1996 and Accident Compensation (WorkCover Insurance) Act 1993, in relation to the regulation of Victoria’s WorkCover compensation and rehabilitation system, may be relevant to some cases of occupational violence.

Duty of care

The department is mindful of the complexities and issues that arise in health care in relation to providing care and services to clients. The paper, Duty of Care (Department of Human Services (Victoria) 2000), provides a broad understanding of the law governing the duty of care owed by the department and, in some cases, by agencies engaged by the department. Health services are directed to this resource as a useful summary of the key issues.

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Consideration of matters such as the use of restraint, force and self-defence are also important. Work done by the department in relation to staff working in youth justice can give some guidance in these matters (see Appendix 1).

In addition, the Victorian Quality Council (VQC), the Chief Psychiatrist and the Quality Assurance Committee (QAC) supported the development and implementation of the Creating Safety: Addressing Seclusion Practices project to enable clinicians to apply best available evidence to clinical practice. The project aimed to strengthen and support safety in adult acute mental health inpatient units and to minimise, wherever possible, the frequency and duration of the use of seclusion and restraint. These matters are of interest and relevance for all health services.

Accreditation and industry standards

Health services are required to comply with or consider accreditation and industry standards, and a number of these standards have specific requirements that relate to the management and prevention of occupational violence. These include:

Aged Care Act 1997

This act requires approved providers of residential aged care homes to comply with the accreditation standards. The accreditation standards are set out in the quality of care principles (The Aged Care Standards and Accreditation Agency Ltd. 2006). There is an obligation that management actively work to provide a safe work environment that meets OHS regulatory requirements.

National Safety and Quality Health Service Standards (NSQHS)

The Australian Commission of Quality and Safety developed the NSQHS in health care. The ten standards have been designed for use by all health services and may be used as part of their internal quality assurance mechanisms or as part of an external accreditation process. The first standard is Governance for safety and quality in health service organisations which describes the quality framework required for health services to implement safe systems.

Emergency management

The Department of Health has a responsibility to work with the health sector in planning for, responding to and recovering from emergencies.

In doing so, the department has dedicated policy, planning and response resources and specialist expertise that work in partnership with the health sector to ensure, where possible, a whole-of-health approach to emergency management. The department supports the Victorian hospitals emergency managers (VHEM) group which discusses and share resources across a wide range of emergency management topics including occupational violence prevention. In particular, health services use a standard code system for internal and external emergencies. One mandated code (code black) and one optional code (code grey) are relevant to occupational violence prevention.

Code black

The code black is an alert to elicit a response to an armed threat. It is part of the Australian Standard AS 4083-Planning for emergencies-Health care facilities.

Code grey

The code grey is an alert to elicit a rapid clinical response to a situation of anticipated danger or risk by a person towards themself, other patients, staff members or visitors. This type of response is optional at present in Victoria and may involve verbal de-escalation or restraint of a potentially aggressive person by an emergency response team trained in the management of aggression. It has had demonstrated positive results when used in Victorian health services. It is highly recommended that health services consider the use of a separate code grey response that is a clinical response.

Policy principle:

The Department of Health and employers must comply with relevant legislation and regulation relating to workplaces.

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Social contextViolence is unacceptable and must be proactively addressed. Recent views argue the necessity for ‘comprehensive proactive organisational strategies to reduce workplace violence and assert the need for these to be complemented by wider social initiatives to address the roots of violence in our communities’ (Paterson 2005). These comprehensive strategies include adequate attention to physical and procedural security without compromising relational care. This requires the utilisation of clinical decision making processes that are professionally rational, while integrating risk assessments into care processes (Middleby-Clements and Grenyer 2007, Secker et al 2004, Rew and Ferns 2005).

Clearly, managing violence and aggression in health care is a complex and sensitive issue where illness and highly charged emotional states impact on the environment. Recognising the socio-political facets of occupational violence allows for the adoption of prevention measures that move beyond introspective initiatives and permit committed interagency partnerships using evidence-based interventions.

The interface of health care, police and the justice system

The interface between the justice system, police and health services in relation to occupational violence is an area in which the Department of Health is undertaking further work.

The taskforce highlighted a requirement for health services to support health workers in pursuing charges by having formal protocols and procedures to provide information and assistance to staff with this process. The taskforce also noted a requirement for this issue to be promoted to Victoria Police.

As part of the implementation of the taskforce recommendations, a justice, police and health service interface working group was formed to develop strategies to implement the taskforce’s recommendations. This group had representatives from WorkSafe, criminal law policy, justice policy, Victoria Police, directors of nursing, directors of human resources, occupational health and safety managers and the Department of Health. The work undertaken by this group included policy analysis relating to complex legislative and operational issues that require further consideration by the department and health services.

The need to deter, detect and manage weapons in health services

Following the implementation of the policy framework in 2007, considerable work has been undertaken to manage the risk of weapons in health services. Health services are impacted by the communities in which they exist. Unfortunately, the use of weapons and dangerous articles is prevalent in society, permeating health services and leading to a potential for exposure to occupational violence. There is an ongoing need to be aware of the rights and responsibilities in relation to weapons management within health services and to ensure local policies are developed and implemented.

A proactive approach is required in relation to the deterrence, detection and management of weapons. In addition, a legislative framework to govern control of weapons and detailed information regarding the various types of weapons in the community are required.

The Victorian Taskforce on Violence in Nursing Final Report (2005) identified the need for a coordinated approach to the management of weapons and dangerous articles within health care settings, including consideration of the issues of search, seizure, storage and disposal or return of such items. These issues were explored during the implementation process at which time it was acknowledged that these matters required further review.

On 1 November 2010, amendments to the Firearms Act 1996 and the Control of Weapons Act 1990 came into effect allowing for specified health professionals, health service security staff and ambulance workers (operational staff members) to be exempt from breaches of these acts in regard to seizure and temporary storage (‘possession’) of weapons in the course of their duties. Appendix 4 provides detailed information about the implications of these amendments for Victorian health services.

Health services are encouraged to continue developing and reviewing specific policies and procedures, in consultation with their own local police and legal counsel, that combine a prevention and deterrence approach with clear direction about how weapons (if detected) are managed.

This approach needs to comply with legislation, while ensuring the safety of all staff, clients and visitors.

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Health services–Victoria Police partnerships

The aim of weapons legislation is to reduce the general availability of weapons to the public, thereby decreasing the risks of crime and injury due to misuse. Formal collaboration between public health services and Victoria Police to deter, detect and manage firearms and non-firearm weapons is the key to success in these endeavours .

It is considered imperative that health service–police partnerships are established at the local level to support implementation of the principles relating to all firearms and non-firearms weapons. Existing police liaison committees may form the basis of the health service–police partnership, although the role of the partnership should go beyond liaison to form joint local agreements and procedures to deter, detect and manage firearms and non-firearm weapons in individual health services.

In 2010 – 2011, 11 health services were funded to participate in the Building better partnerships (BBP) initiative, an opportunity to identify ways to improve the interface of health services and other key agencies (in particular, police) across a range of different situations and contexts.

Five high impact interventions were identified by the 11 demonstration sites as part of the BBP initiative. The five interventions are:

• commit to continuously building shared understanding of each other’s (agency’s) roles, strengths and limitations

• formalise joint agreements, policies and procedures

• actively manage occupational violence incidents from occurrence through to review

• focus on enhancing processes for managing absconding/missing patients/clients, and

• optimise the patient/client handover process.

These interventions will positively contribute to best practice interagency management of issues that occur at the interface of healthcare and police, including the issue of weapons within health services.

Principles for managing firearms and non-firearm weapons within health care settingsThe following principles provide guidance on how firearms and non-firearm weapons should be managed by health services and provide a framework for health services to develop their own specific operational policies and procedures. The principles are applied equally to all persons in the health service (staff, contractors, volunteers, visitors and clients) and recognise that as employers, public health services are responsible for ensuring a safe environment for all those in ‘the workplace’, which includes outreach teams, home care or mobile services.

General principles relating to all firearms and non-firearm weapons

The following principles pertain to all firearms and non-firearm weapons including dangerous articles:

Safety first

1.1 Under the Victorian Occupational Health and Safety Act 2004 and relevant Australian standards, the safety of clients, visitors and staff within health care settings is the overriding priority. Health service employees have an obligation to act based on a risk assessment, in a way that enables clients to receive medical or clinical care without endangering themselves or others. This may include delaying treatment until a risk assessment is undertaken, taking action to minimise the risk and contacting the local police for assistance or advice, and is in accordance with the Victorian Public Hospital Patient Charter (2002).

1.2 The presence of firearms or non-firearm weapons in a health care setting poses an increased risk to the health and safety of the community (staff, clients, and visitors). Under occupational health and safety legislation and regulation, health services are required to manage such risks and provide a safe environment.

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1.3 Health services provide care to vulnerable groups (for example, confused, elderly and juvenile clients) in public spaces where illness and highly-charged emotional states coexist. In this context, the presence of weapons, including dangerous articles, poses an even greater risk to clients, visitors and staff alike. Health services need to manage such risks irrespective of a person’s need for medical care, their authority to carry a weapon, or their competence to manage their own weapon.

Deterring and preventing

1.4 Health service providers, including ambulance services, have an obligation to keep each other informed (whether transferring clients into, out of, or within health care facilities) about any actual or potential risks a client may pose, because of identified or known dangerous behaviour, including use or possession of weapons.

1.5 The best way to protect staff, clients and visitors is to deter individuals from bringing firearms and non-firearm weapons into health services. Health service weapons policies should apply equally to all those entering the workplace. The message that firearms and non-firearm weapons are not permitted on health services premises and that refusal of entry may result if a person is found in possession of a weapon, should be clearly communicated to all staff, clients and visitors, and reflected in local policies and procedures.

1.6 Local health service weapons policies need to integrate emergency/incident management responses (such as Code Black) and ongoing strategies to proactively deter, detect and manage firearms and non-firearm weapons.

1.7 Crime Prevention through Environmental Design (CPTED) principles should be consistently applied to the workplace to reduce the risks to staff, clients and visitors from firearms and non-firearm incidents and to help deter, detect and manage firearms and non-firearm weapons in health services.

1.8 Health service employees do not have special privileges or status to search for firearms and non-firearm weapons. A health service may, however, impose consent to be searched for weapons as a condition of entry to health premises. Clear local search policies and procedures using a risk assessment approach should be established by each health service, and should include clear direction to guide actions if staff, clients or visitors decline a search, or where an individual’s ability to consent to a search is impaired.2

1.9 If a search is to be conducted, it should be undertaken with sensitivity and respect for a person’s dignity. The level of intervention should be proportionate to the reason for the search and should ensure staff safety.3

Meeting compliance and governance requirements

1.10 Legislation controls the possession and use of firearms and non-firearm weapons so the actions of health service employees (as for any member of the public) must be lawful, comply with the relevant legislation and be in accordance with their health service’s policies and procedures.

1.11 The effective and lawful management of firearms and non-firearm weapons in public health services requires collaboration between health services and Victoria Police (and other relevant agencies such as ambulance services). Health service–police partnership committees are the governance mechanism by which health services develop and ratify joint agreements with Victoria Police, for the deterrence, detection and management of weapons.

1.12 Robust documentation, reporting and monitoring procedures for the management of firearms and non-firearm weapons in health services ensures that accurate data and evidence informs the evaluation and continuous improvement safety activities of health services.

2 Imposing ‘consent to be searched for weapons’ as a condition of entry to health premises may help deter people from bringing weapons into health services.

3 Each health service should develop its own search policy which clearly states the need for consent, who can conduct a search, the precise process to follow when conducting a search and who is authorised to refuse entry if a person refuses to consent to a search. Health services need to determine their own screening activities but in most contexts no-contact screening activities should be sufficient. Examples of no-contact screening include requesting a person to empty their pockets or open their bags for a visual check, or temperature, x-ray and metal detection scanning (including the use of electronic wands).

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Specific principles relating to Group A: Firearms

Group A: Firearms

`Firearm’ is any device:

• whether assembled or in parts

• whether or not temporarily or permanently inoperable or incomplete

• which is designed or adapted to discharge a bullet or other missile; or

• which has the appearance of an operable firearm.

The Firearms Act 1996 is the framework for the control of firearms and any person wishing to carry or use a firearm must hold a licence under this Act.

2.1 Under the Firearms Act 1996, only police have the right to search for (without consent) or confiscate firearms in the community. Health service employees do not have this right.

2.2 Given that some officers, such as police and prison officers, are legally authorised to carry and use firearms (as well as prohibited weapons such as capsicum spray and batons) in the course of their duties, health services need to negotiate agreements with the relevant agencies regarding the appropriate authorised carriage and use of weapons within the different areas of the health service based on a risk management approach. The agreed procedures should form part of the local firearms and non-firearm weapons policy and be agreed by the local health service–police partnership.

2.3 Police should be contacted immediately when the presence, or likely presence, of a firearm is detected in a public health service. Agreements should be negotiated to ensure that firearms are collected by Victoria Police, in accordance with agreed local procedures and timeframes. If necessary, the firearm should be safely stored, only for the purposes of making the health care facility safe, while awaiting collection by the police. After collection, Victoria Police should determine an appropriate course of action for the item.

Specific principles relating to Group B: Non-firearm weapons

Group B: Non-firearm weapons

For the purpose of this guide, non-firearm weapons are those items defined as ‘prohibited’ and ‘controlled’ weapons under the Control of Weapons Act 1990. Prohibited weapons are particularly dangerous and should only be available to persons able to display a specific need for such weapons. Controlled weapons are potentially very dangerous and more common than prohibited weapons. They can only be possessed, carried or used with a lawful excuse.

Note: It is not an expectation that all health care workers would be able to distinguish between a prohibited and a controlled weapon.

3.1 All individuals known to be, or suspected of being, in possession of a non-firearm weapon, irrespective of whether they have a lawful reason for having the weapon, should be advised they may not enter the health premises whilst in possession of the weapon, thereby preventing its possible misuse by the individual or others (refer to principles 1.5 and 1.8).

3.2 Health service procedures for responding to the detection of a non-firearm weapon (when no imminent threat to safety exists) should include steps to ensure the safety of others and interventions targeted to the category of individual involved. Employees identified as carrying a weapon may need counselling or performance management, visitors will be asked to leave the premises, and clients will be advised about the conditions under which clinical care will be provided.

3.3 Agreements should be negotiated to ensure that non-firearm weapons are collected by Victoria Police, in accordance with agreed local procedures and timeframes. After collection, Victoria Police should determine an appropriate course of action for the item. Until police arrive, non-firearm weapons should be safely stored, only for the purposes of making the health care facility safe, while awaiting collection by, or discussion with the police, regarding the appropriate course of action for the item.

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3.4 Joint agreements that are developed and ratified by individual health services with their local police should support and guide decision making about the return of non-firearm weapons to owners who have a legitimate reason for having such an item.

Specific principles relating to Group C: Dangerous articles (non-firearm)

Group C: Dangerous articles (non-firearm)

Dangerous articles are dealt with separately in this framework as they are objects that may potentially be used as weapons, and may, due to their design or the intention of the individual carrying them, be classified as weapons when taken out of the everyday situation in which they are intended to be used.

4.1 Health services need to recognise and manage the potential for everyday items such as furniture and crockery, as well as items used specifically in health care such as syringes and scissors, to be used as weapons. Assessing risk associated with dangerous articles and applying a risk management methodology requires a systematic, proactive approach. This needs to include an awareness of and recognition that different contexts, settings and clients (or groups of clients) and their clinical needs will require different approaches to ensure a safe workplace.

Preventing occupational violence – applying an occupational health and safety frameworkIt is vital that there are prioritised actions and coordinated mechanisms for preventing injuries and their health consequences arising from exposure to violence and bullying hazards in a health care setting. This policy provides the overarching context and direction for all of the work undertaken to ensure the recommendations of the taskforce are implemented.

Occupational health and safety involves recognising and managing any risk to the psychological and physical safety and wellbeing of employees, contractors, volunteers and visitors in the workplace. Hazards are present in every health care workplace and are a threat to everyone’s health and safety. While not always recognised as such, occupational violence and bullying are a risk to an individual’s mental and physical safety and wellbeing.

The risk management process represents the basic preventative philosophy of occupational health and safety legislation and regulation. It also reflects the key responsibilities placed on employers to provide a healthy and safe workplace. As conditions in the workplace frequently change, hazard identification and risk control needs to be a continuous process (Department of Human Services (Victoria) 2003).

Under the legislation and supporting guidelines, there are three steps that should be followed.

• Hazard identification – the process of identifying occupational violence hazards in the workplace that could cause harm to staff or others.

• Risk assessment – the process of assessing the risks associated with the hazard, including the likelihood of injury or illness being caused by that hazard, and identifying the factors that contribute to the risk.

• Risk control – the process of determining and imple-menting measures to eliminate or minimise workplace violence (Department of Human Services 2004, p. 13).

Occupational health and safety principles require that either the hazards should be eliminated or the risks they pose must be controlled so that people remain safe and healthy. One framework for conceptualising risk control is the preferred order of control model (also referred to as the ‘hierarchy of control’).

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Figure 1. Risk control

Once hazards have been identified and their level of risk assessed steps must be taken to control the risk. Risk controls are usually identified in the form of a hierarchy.

Hierarchy of control

Eliminate the hazard and so eliminate any risks

Substitute a less hazardous alternative (for example, use water based chemicals rather than solvent based ones)

Isolate the hazard (for example, enclose a noisy machine)

Use engineering controls (for example, install exhaust ventilation to extract dangerous fumes or dusts)

Use administrative controls (for example, job rotation to make sure people don’t work close to a hazard for a long time)

Use personal protective equipment and clothing

The hierarchy of risk control reflects the philosophy of prevention, in that the best approach is to eliminate risks, if this is possible. People, therefore, have a safe workplace so they do not have to be concerned about risks and their own safety. The least desirable risk controls are those which require people to always do the right thing by following set procedures or using personal protective equipment.

Source: Occupational health and safety management framework model (Department of Human Services 2003).

SAFE PLACE

SAFE

PERSON

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Figure 2. Schematic representation of risk control measures

Below is a schematic representation of risk control measures targeting occupational violence that were identified as part of the body of work Industry occupational health and safety interim standards for preventing and managing occupational violence and aggression in Victoria’s mental health services (Department of Human Services (Victoria) 2004).

YesIncidentNo

Maintain focuson prevention

Post-incident management• immediate staff support• staff respite• formal debriefing• return to work support• clinical review

Critical incident management• activate emergency procedure/ response and defuse situation• activate clinical response• secure environment

Policies and procedures• integrate into OH&S and

management systems• training strategies/plans• emergency response teams• incident reporting and review• staff support

Incident review• events leading

to incident• adequacy of

response• evaluate prevention

strategies

Training• predicting, preventing and

managing aggression• aggression control• emergency processes• post trauma awareness• induction

Staffing issues• rostering – experience,

gender mix• reliance on casual/

part time• buddy system –

high risk areas• isolation

Environment• building design• alarm systems• crowding• noise• electronic

communications• lighting• security• décor – colours, • furnishings, etc• work systems –

task allocation/design/training

Pre-incident prevention

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Figure 3. Risk management model (Department of Human Services 2003)

The Department of Human Services - Public Hospital Sector OHS Management Framework Model (Department of Human Services (Victoria) 2003) provides an excellent basis for conceptualising the implementation of the recommendations from the taskforce. The framework uses a simple, comprehensive three level systems approach – occupational health and safety system structure, activity and review. The following framework identifies some of the issues related to occupational violence prevention programs that health services should consider.

Building your occupational health and safety system structure

Developing policies, procedures and plans to establish the occupational health and safety management system

System elements Occupational violence issues (as identified by taskforce and other department policies)

• OHS policy and commitments

• OHS responsibilities

• OHS consultation

• OHS training

• OHS procedures

• Contractor management

• OHS performance indicators

Responsibilities

Health organisations will establish an aggression management reference group, which will be responsible for developing policies and procedures around the management of aggressive incidents, primarily through a clinically led aggression management team.

Physical workplace design

The physical environment of public spaces and buildings can have a strong influence on behaviour. The principles of affecting behaviour through environmental design and management will be applied to all future building and refurbishment.

Systems of work

Program specific policies and procedures designed to control occupational assault hazards will be developed and implemented, with priority to high-risk groups. When designing work, occupational violence hazards will be eliminated where practicable. Elements to be considered will include staffing levels, workload, work patterns, work plans and competence (Department of Human Services (Victoria) 2004).

Information, instruction and training

Staff will be trained in identifying, assessing and planning for control of occupational assault hazards. Priority will be given to workplaces where increased risk of occupational assault injury is present. Relevant information and training will be provided to contractors where appropriate.

Clinical behaviour assessment and management

Clients will be assessed using existing systems and behaviour management strategies will be developed and documented. Behaviour management strategies will be reviewed as required to maintain a working environment which is safe and without risk to health.

Supervision

Management will provide appropriate supervision in relation to the control of the hazard arising from exposure to occupational violence. Supervisors will monitor employee skills and competence in implementing aggression management strategies.

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Running your occupational health and safety system activity

Implementing the policies, procedures and plans to maintain the operations of the OHS management system

System elements Occupational violence issues (as identified by taskforce and other department policies)

• Risk management processes

• Inspection, testing and corrective action

• Emergency response

• Injury management and return to work programs

• OHS document control

Responding to incidents (post incident management)

Responses will vary depending on the scale and severity of the incident, but a number of responses that may be appropriate are outlined below.

• Provide first aid and medical treatment if required.

• Give any employees involved the option of being relieved of their duties.

• Give the target of occupational violence the opportunity to talk through immediate issues with a counsellor and/or other employees.

• Offer further debriefing or ongoing counselling to targets of violence and witnesses.

• Ensure the incident is reported.

• Review control measures and if necessary conduct further risk assessments and implement further risk controls to prevent a recurrence.

• Notify health and safety representative and health and safety committee.

• Notify the Victorian WorkCover Authority if required.

• Notify the police in circumstances where criminal acts of violence have taken place.*

Reviewing your occupational health and safety system performance

Assessing the performance of the policies, procedures and plans to achieve improvements in OHS performance

System elements Occupational violence issues (as identified by taskforce and other department policies)

• OHS performance review

• OHS auditing and corrective action

• OHS continuous improvement

Data collection

Incident report forms should:

• record factual information (for example, who was involved, when and where the incident occurred, whether a weapon was used, what injuries were sustained)

• describe how the incident occurred and what the outcome was

• allow staff to make suggestions or comments to management

• be concise and easily understandable

• provide for mandatory feedback to staff involved (Department of Human Services 2004, p. 35)

• notify the police in circumstances where criminal acts of violence have taken place.

*Refer to page 9 for information on criminal law.

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Monitoring and evaluation by health services

Encouraging incident reporting is critical to prevention and management of occupational violence and is integral to achieving culture change.

Individual health services should develop specific outcomes related to local implementation and occupational health and safety frameworks, and these should aim to monitor different parts of the overall program. Some examples of different indicators or measures that could be used to monitor and evaluate the impact of local occupational violence prevention programs are provided on page 24 of this document.

Accreditation standards, such as National Safety and Quality Health Service Standards and aged care standards, also place a requirement on health services in relation to data collection and monitoring of occupational health and safety including occupational violence.

WorkSafe

Health services may find it useful to receive information from the regulator. WorkSafe monitors compliance with the Occupational Health and Safety Act 2004 and its regulations, gives advice in relation to occupational health, safety and welfare, and engages in, promotes and coordinates the sharing of information to achieve the objects of this Act.

Monitoring and evaluation by the department

The level of detail needed by health services to effectively manage and continuously monitor events is different from that required by the department to monitor the health system. The Department of Health has a key role in system-wide monitoring of occupational violence in health care and is developing data collection and reporting processes to support this role.

The Victorian Health Incident Management System (VHIMS) is a standard methodology for incident and feedback reporting available to all publicly funded health services within Victoria.

VHIMS includes specific data that is used to capture information relating to all incident notifications reported at each health service.

From 2012 the department will use the VHIMS as the basis of system-wide monitoring. A data set was proposed by

the taskforce and has been revised with input from health services and data standards. This will be incorporated into the incident information system. When this data can be collated and analysed, the department will facilitate benchmarking across health services. The data related to occupational violence in health care will allow the department to:

• collate and analyse the data provided by health services

• produce and disseminate reports on system-wide aggregated data to assist health services to compare their reported levels of occupational violence with peers

• monitor system-wide trends over time to assess the impact of health services implementing the recommendations of the taskforce.

System-wide data will be used to validate the classification system proposed by the taskforce to ensure it meets the needs of the health services and the department in relation to supporting the development of prevention strategies. As recommended by the taskforce, there will be preliminary analysis of the data set and strategies in 2013, and a comprehensive evaluation of the same after three years.

Policy principle:

Reporting and measuring is important to be able to predict trends, assist with prevention and control measures and build an evidence base for future policy development.

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The hierarchy of controlThe hierarchy of control prescribes an order of actions for hazard control. In the first instance, where practicable, hazards should be eliminated at the source. If that is not practicable, substitution should then be adopted. If this is not practicable, design modifications are to be adopted. In turn, administrative controls may be adopted if it is determined that it is not practicable to adopt higher order controls.

Figure 4 – Hierarchy of control

Eliminate the hazard and so eliminate any risks

Substitute a less hazardous alternative (for example, use water based chemicals rather than solvent based ones)

Isolate the hazard (for example, enclose a noisy machine)

Use engineering controls (for example, install exhaust ventilation to extract dangerous fumes or dusts)

Use administrative controls (for example, job rotation to make sure people don’t work close to a hazard for a long time)

Use personal protective equipment and clothing

1. Crime Prevention Through Environmental Design (CPTED) principles

2. Occupational violence measures and indicators

3. Checklist for occupational violence education and training

4. Occupational violence staffing considerations

5. Bullying prevention guidance (Worksafe)

6. Deter, detect and manage. A guide to better management of weapons in health services.

7. Occupational violence post incident response hierachy

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Eliminate the hazards — Crime Prevention Through Environmental Design principlesCrime Prevention Through Environmental Design (CPTED) has been defined as systematic processes of creating features within our built environments that influence social behaviour in a positive way. These concepts have evolved from use in shopping centres, residential zones and parkland, but the principles are applicable in health care settings to design for the prevention of violence (Department of Human Services (Victoria) 2005).

Key principles of CPTED that are applicable to the health care setting are:

• Territorial reinforcement: people assume and express feelings of ownership and possibly pay more attention to an area or note potential intruders or acts of violence.

• Access control: physical and symbolic barriers control access. Clearly identifying staff-only areas with physical or symbolic barriers makes it more difficult to reach potential victims or targets.

• Natural surveillance: as people often feel safe where they can be seen and interact with others, natural surveillance can be achieved by creating sightlines between public and private space.

• Space management: there is a belief that a well-maintained facility may reduce criminal activity, whereas a run down, empty, graffiti covered building may attract criminal activity and offenders.

Control strategies that are components of the key principles include:

• clear communication strategies to provide information and signs

• service delays are minimised

• activity or noise levels are minimised

• adequate lighting in waiting areas, entrances and car parks

• consistent, clear and concise signage that caters to the needs of clients who may be culturally and linguistically diverse

• fixtures are secured wherever possible, with sharp corners and edges eliminated

• staff identification is worn at all times

• access to buildings is restricted, staff-only access points are clearly signposted and access is reduced in times of reduced staffing, such as after hours in smaller health services

• legal implications with regards to weapons are specified

• computerised access control systems for locks and for recording of audit trails

• security/reception areas are protected through design

• closed circuit television (CCTV) monitoring clearly states whether monitors are staffed by security or not

• CCTV monitor is reversed, where the public watches themselves

• waiting rooms are comfortable, spacious, provide reading material, access to phones, water dispensers and so on.

To be effective, CPTED requires:

• cooperation from all staff

• chief executive officer and senior management endorsement and support

• an understanding of the impact of environmental design and its benefits, which should be included in education and training programs.

Before recommending or implementing any such strategy, it is important that contextual considerations and site risk are properly identified, measured and assessed by appropriately trained personnel, such as occupational health and safety representatives and risk managers. This particularly applies to health services that vary in their size, purpose, location and resources.

It is important to establish a balance between creating a safe environment for all and delivering care to the clients. Risk assessment and risk management are imperative in reducing environmental risks.

Security resources have been identified as a component for promoting a safe environment in some health care settings. The need for security officers will depend on a range of factors, including the size and needs of the health care setting and other locally implemented safe environment strategies, and should be considered by health organisations as part of their risk assessment and management framework.

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Administrative controls (1) - occupational violence measures and indicators The following table uses the Public Hospital Sector OHS Management Framework Model (Department of Human Services (Victoria) 2003) to outline examples of the types of measurements and indicators that health services may use to monitor their systems of occupational violence prevention.

System structure

Proposed outcome Types of measurements

OHS policy and commitments

OHS responsibilities

Contractor management

OHS performance indicators and targets

Prevention of violence and bullying training

Improved consultation

The accessibility of policies and procedures

Number of contract staff receiving training and orientation related to prevention of violence and bullying

Number of staff completed training

Frequency of OHS committee meetings

Number/percentage of workplace changes that involved staff consultation

Workplace grievance records

System activity

Proposed outcome Types of measurements

Risk management processes

Inspection, testing and corrective action

Number of risk assessments conducted

Emergency response Staff satisfaction surveys, decrease in injuries

Injury management and return to work programs

Return to work rates

System review

Proposed outcome Types of measurements

Prompt reporting of incidents Hazard reports for example DINMA

Incident reports on occupational violence WorkCover data.

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Administrative controls (2) – checklist for occupational violence education and trainingEffective and worthwhile education and training for the prevention of violence in health care plays a significant role in the broader hazard management approach. The taskforce recommended that guidelines to ensure minimum standards of education be provided to health services.

The following is a checklist to assist health services in their endeavours to provide education as part of an approach to prevent violence and bullying. As there are many training providers, it is important that health services become acquainted with the various courses on offer.

Current research provides advice in relation to what has been established as ‘effective training in violence management’:

1. The content tends to be broader rather than focusing on individual competence.

2. The content tends to be closely allied to perceived need.

3. The content needs to clearly demonstrate (include evidence) of a proactive organisational response to workplace violence (Zarola & Leather 2006).

Key training considerations

The following has been identified as important when health services are considering training in relation to occupational violence and bullying (Department of Human Services (Victoria) 2004, p 25). The key components should be:

• the policies and procedures of the workplace

• legal issues and legislative framework

• predicting, preventing and managing aggression and potentially assaultive situations

• system of emergency processes

• post-incident processes including access to support systems

• induction systems for all staff, including permanent casuals, part-time staff and students on commencement of work and regularly thereafter

• competency-based skills for all staff for the roles undertaken by them

• local practice issues that have an impact on response, such as access to support from others, sufficient staff available to respond to an incident, availability of emergency services and acceptable response times

• management personnel at all levels should be trained in emergency response

• training should be compulsory for all staff and be provided in paid time to ensure attendance.

Principles of training

Training should:

• be practical and relevant to the workplace

• be flexible enough to allow modification to address particular issues within a workplace to include direct and non-direct care staff

• be available in a way that facilitates regular updates

• emphasise both proactive and reactive responses

• address physical and psychological protective measures, such as follow-up after a critical incident and care of self

• ensure all temporary, casual and agency staff are trained to a competent level before being engaged

• consider local factors that have an impact on the type of response available to a consumer and staff member to support them.

Considerations

• Clinicians need to feel that training can assist them in everyday practice.

• Training should be competency-based.

• Additional suitable modules should be provided according to whether staff participate in direct or indirect care.

• Training providers should be appropriately accredited.

More details on the key competencies of occupational violence response training are provided in the Industry occupational health and safety interim standards for preventing and managing occupational violence and aggression in Victoria’s mental health services (Department of Human Services (Victoria) 2004).

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Administrative controls (3) – occupational violence staffing considerations How staff are managed can be important in preventing and managing occupational violence (Department of Human Services (Victoria) 2004). The organisation’s approach to risk control in relation to staffing should cover:

• rostering and staffing ratios, for example, ratio of staff to clients should be adequate for the level of care needed and also take into account range of required activities

• skill level, training and experience appropriate for duties

• where possible, staff should be permanent or regular employees who are known to the clients and workplace

• capacity to rotate staff into alternate duties to reduce exposure

• procedures and back up for staff working alone or in isolation

• regular support and supervision.

Administrative controls (4) - resources for the prevention and management of bullying in Victorian health services.There are a number of valuable resources, such as toolkits and publications, currently available to Victorian public health services to help prevent and manage bullying in the workplace. Of particular relevance are:

• the various publications developed by the State Services Authority to help organisations respond to bullying and promote positive work environments

• WorkSafe Victoria guidance note on Preventing and responding to bullying at work.

On the following page you will find addresses for websites and links containing useful information and resources to assist with developing strategies for preventing bullying in the workplace and dealing with bullying when it occurs. A content synopsis for each website and resource has been included.

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State Services Authority (Victoria) www.ssa.vic.gov.au

The State Services Authority (SSA) works to improve the performance of the Victorian public sector to enable it to provide services more effectively and efficiently. The SSA website has an array of publications to support workforce development, governance and culture in the Victorian public sector, including resources relevant to bullying prevention and management.

The following resources are available from the SSA website. Go to www.ssa.vic.gov.au and click on ‘products’ in the top banner. Type the title of the required resource using the ‘find a product’ tab, or browse using the ‘a-z’ tab.

how positive is your work environment? the organisational, management and individual perspective on making improvements at work

This toolkit is of particular relevance to the prevention and management of bullying. It includes a ‘quick check tool’ that allows you to assess your work environment from three perspectives: organisational, management and individual. It also provides practical tips on how to improve your workplace.

Ethics resource kit

The Ethics resource kit contains a set of posters called the Value and employment principle posters. The set includes one poster entitled Respect and another entitled Fair and reasonable treatment, both of which promote a workplace free of bullying.

code of conduct for victorian public sector employees

This code emphasises the values contained in the Public Administration Act 2004. The values are relevant to the many and diverse operational settings in which Victorian public sector employees work, including healthcare settings.

Developing conflict resilient workplaces

An implementation guide for Victorian public sector managers and teams.

This guide describes the features of a conflict resilient workplace – one where conflict (including bullying behaviour) is managed well, and not left to escalate. It is mainly diagnostic, encouraging organisations to ask questions about their systems, values and behaviours to help identify the most important issues to work on.

Developing conflict resilient workplaces – a report for Victorian public sector leaders

This report is the companion document to the above guide. It provides the business case for changing the way that conflict is managed in the workplace.

People matter survey

The People matter survey measures a range of aspects of workforce culture and climate (including bullying) in the Victorian public sector. The information from the survey can be used by organisations to identify their strengths and weaknesses and to measure their progress in embedding the public sector values and employment principles in their organisation’s culture.

WorkSafe Victoria www.worksafe.vic.gov.au

WorkSafe Victoria has a leading role in the promotion and enforcement of health and safety in Victorian workplaces. Two WorkSafe Victoria’s broad responsibilities are helping to avoid the occurrence of workplace injuries and enforcing Victoria’s occupational health and safety laws.

As with the State Services Authority website, WorkSafe Victoria’s website also contains information to assist Victorian health services with the prevention and management of bullying within their workplaces.

Bullying and occupational violence information can be accessed at the website via the ‘Safety and Prevention’ link in the top banner.

The following resource can be accessed at the website via the ‘Forms & Publications’ link in the top banner by entering the resource name in the ‘Quick Search’ field.

Preventing and responding to bullying at work

This guide aims to ‘help employers to develop systems that will prevent bullying, respond to reports of bullying and effectively meet their legal duties under occupational health and safety (OHS) laws’ (July 2009).

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Administrative controls (5) – occupational violence post incident response hierarchyThe following hierarchy of response guidelines has been adapted from the Zero Tolerance: response to violence in the NSW Health workplace: policy and framework guidelines.

Response Possible interventions

Immediate Immediate response options

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 options appropriately 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

• using verbal de-escalation and distraction techniques

• seeking support from other staff

• requesting that the aggressor leave the immediate area

• requesting review by a clinician

• retreating

• initiating code grey/code black as appropriate.

Options specifically related to clients/patients include:

• utilising clinical restraint policies as appropriate (violent client)

• utilising sedation policies as appropriate (violent client)

• negotiating conditional treatment, or determining inability to treat under the current circumstances

Long term Long-term response options

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

• formal management plans

• written warnings

• exclusion from visits or conditional visiting rights

• apprehended violence orders

• requesting that charges be laid (via police).

Options specifically related to clients/patients include:

• conditional patient treatment agreements

• patient alerts in conjunction with support management plan

• alternate treatment arrangements, for example, a different facility

• formal recognition of inability to treat in certain circumstances.

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Key related policies or documentsThe following documents are some of the key related policies or standards, in addition to this policy, that health services should be mindful of as they discharge their responsibilities to provide a safe and healthy workplace free from occupational violence.

Department of Health

• Staff safety in the workplace: guidelines for the prevention and management of occupational violence for Victorian child protection and community-based Juvenile Justice staff (Office for Children, 2005)

• Industry occupational health and safety interim standards for preventing and managing occupational violence and aggression in Victoria’s mental health services (2004)

• Public hospital sector occupational health and safety management framework model (2003)

• Creating safety; addressing seclusion practices, project report (Victorian Quality Council and Chief Psychiatrist’s Quality Assurance Committee 2009)

• Victorian Health Incident management policy guide. (2011)

Other documents

• NSW Health, Zero tolerance response to violence in the NSW health workplace – policy and framework guidelines (2003)

• WorkSafe Victoria, Preventing and responding to bullying at work (June 2009)

• WorkSafe Victoria, Information pack for WorkSafe Victoria’s intervention on occupational violence in hospitals (Health and Aged Care Team. Public Sector and Community Services Division November 2005)

• Australian Nurses Federation (Vic Branch), Zero tolerance policy and toolkit (November 2002)

• Victorian WorkCover Authority. Labour hire agencies: managing the safety of on-hired workers (June 2006)

• Health and Community Services Union, Occupational assault: a health hazard…or is it ‘just part of the job?’ Health and Community Services Union, Victoria Number 2 Branch of the Health Services Union. Undated

• State Services Authority, Tackling Bullying, Public Sector Standards Commissioner (2010)

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The following is an extract from Staff safety in the workplace: guidelines for the prevention and management of occupational violence for Victorian Child Protection and community based juvenile justice staff (pages 35–36).

Restraint, force and self-defenceThe department has a duty of care to ensure staff are provided with adequate training, resources and appropriate systems of work to enable them to respond appropriately to situations of assault. Mechanisms, such as restraint, time out and sedation, should not be the primary approach to minimising the risks of assault in departmental workplaces. Such mechanisms should only be used to provide the necessary protection for staff and clients where the process of risk assessment and control have identified and put in place the range of appropriate controls, but some risk of assault still exists.

Physical restraint should only be used where an immediate risk of injury exists and no other option for resolving the situation is available. The physical restraint used should be the minimum required.

Reasonable force is the force that is sufficient to stop the assaulting person causing injury or harm to themselves or others-and no more.

In addition to civil law where staff are provided with a duty of care to clients which justifies the use of physical restraint, staff owe a duty of care to protect clients from being assaulted or assaulting others. The use of reasonable force sufficient to prevent this is acceptable. This includes situations where there is an overriding necessity to protect someone.

The ‘emergency’ or ‘rescue’ powers given to departmental workers provide the right (and responsibility) to rescue a person from a dangerous situation. There are situations the law ‘excuses from being assault’, such as:

Implied consent

Everyday activities of caring for clients require some physical contact between individuals. The department’s clients have consented to the care provided and therefore to the physical contact involved in that caring. However, consent to such physical contact is not consent to restraint or seclusion.

Part 5, Division 3 of the Mental Health Act 1986, s. 44 of the Intellectually Disabled Persons’ Services Act 1986 [repealed], and ss. 256 (a), (b), and (c) of the Children and Young Persons Act 1989 [repealed] provide specific detail on the use of restraint and seclusion in those settings and should be consulted and complied with in relation to the use of restraint and seclusion for such clients.

Please note these acts might have recently been amended and care should be taken to ensure the most recent version is consulted.

Self-defence and defence of others

This is permitted where a direct care worker (or someone in care) is attacked or has a reasonable belief there is about to be an attack. Training in self defence techniques, including evasive self-defence, provides employees with controlled physical intervention when all other non-physical strategies have failed. Services and programs in which staff work with clients who might display aggressive behaviour should provide adequate training for staff in containment and self-defence techniques.

Reasonable force

The person responsible might be liable for prosecution for assault if an incident of aggressive behaviour occurs under provisions set down in the Victorian Crimes Act 1958. The main defence against assault actions available to staff is self-defence. Staff behaviour should therefore be defensive rather than aggressive, controlling rather than punitive, and use no more force than is necessary in the given situation. The justification of ‘self-defence’ relies on the argument that the level of force used is reasonable given the threat faced. The level of force considered appropriate for self-protection or to ensure the safety of others will remain a matter of judgement, depending on the context of the specific persons and the situation involved.

Appropriate responses

Appropriate responses to aggressive incidents are:

• crisis communication and negotiation where staff are being verbally abused or verbally threatened

• evasive self-defence to the threat of assault and battery, such as where physical contact or injury might occur

• physical intervention and controlling self-defence to aggravated assault only where serious injury might be inflicted.

Appendix 1. Restraint, force and self-defence

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Use of restraints

General law provides that no person can be physically restrained against their will; however, in some instances it might be appropriate to place reasonable restraints on a client in a manner that is consistent with legal requirements. This applies only to the necessary and reasonable restraints or seclusion required to ensure the safety of the client and others, such as staff, other clients and visitors.

Medication and sedation

If medication is used outside the parameters of normal clinical practice and procedure and has no other clinical purpose or benefit other than sedation, then it is illegal and an assault against the person.

Post-incident issues

There are usually a number of relevant legal issues following incidents of occupational violence. These can include internal requirements, professional ethics, industrial issues, workers’ compensation matters, and civil or criminal actions.

Management must ensure employees are aware of their rights (for example, their entitlement to claim compensation, and their right to report the assault to the police) and also the legal requirements and responsibilities placed on them under law by the organisation or with respect to professional ethics.

Management should also make provision for employees who are involved in giving evidence in court (if relevant). These provisions should advise on the format of criminal court procedure and also provide debriefing following the trial (preferably on an individual basis). Managers can seek advice and assistance from the legal unit in relation to these matters.

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Weapon type Definition/examples Legislation Authorisation

Firearms `Firearm’ is defined in section 3 of the Firearms Act 1996 as any device:

• whether assembled or in parts;

• whether or not temporarily or permanently inoperable or incomplete; and

• which is designed or adapted to discharge a bullet or other missile; or

• which has the appearance of an operable firearm.

Firearms Act 1996 Any person wishing to possess, carry or use a firearm must obtain a permit for each firearm they possess and must hold a licence under this Act.

Non-firearm weapons The Control of Weapons Act 1990 divides non-firearm weapons into three defined categories:

• prohibited weapons,

• controlled weapons, and

• dangerous articles.

Details of the specific weapons are set out in the Control of Weapons Regulations 2000.

Control of Weapons Act 1990 and Control of Weapons Regulations 2000

Dependent on category of non-firearm weapon.

Non-firearm weapons

1. Prohibited weapons

Prohibited weapons are particularly dangerous and should not be available in the community, except to persons able to display a specific need for such weapons. The list of prohibited weapons consists of 47 different items including certain prescribed knives such as:

• flick knives • daggers

• butterfly knives • double ended knives.

Other prescribed items such as:

• swords • extendable batons

• capsicum spray • blow guns

• crossbows • martial arts weapons

• knuckledusters.

Control of Weapons Act 1990 and Control of Weapons Regulations 2000

Persons wishing to possess and use these weapons must obtain a Governor in Council Exemption or a Chief Commissioners Approval.

Appendix 2. Summary of firearms and non-firearm weapons

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Weapon type Definition/examples Legislation Authorisation

Non-firearm weapons

2. Controlled weapons

Controlled weapons are potentially very dangerous but more common weapons, which can only be possessed, carried or used with a lawful excuse.

These weapons include:

• knives (other than those prescribed as prohibited weapons)

Other prescribed items including:

• spear guns • bayonets

• batons • cattle prods.

Control of Weapons Act 1990 and Control of Weapons Regulations 2000

A person can only legally possess, carry or use a controlled weapon if he or she has a lawful excuse to do so. A lawful excuse would include employment related activities; sport, entertainment or recreational pursuits; and legitimate collection, display or exhibition. Lawful excuse does not include carrying weapons for the purpose of self-defence in case of attack.

Non-firearm weapons

3. Dangerous articles

Dangerous articles are other items either adapted for use as a weapon or carried with the intention for being used as a weapon. These articles include, for example:

• a baseball bat deliberately fitted with nails so that it can be used as a weapon

• a pair of scissors or a syringe when carried for use as a weapon.

Control of Weapons Act 1990 and Control of Weapons Regulations 2000

Dangerous articles can only be possessed or carried in a public place with a lawful excuse, including the use of the article for the purpose for which it was intended.

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Robust and integrated local operational policy and procedures should articulate the following aspects of detecting, deterring and managing firearms and non-firearm weapons within the specific health service setting:

1. Policy context and aims that:

• apply to the whole health service community, that is, clients, visitors and staff

• include a clear rationale for deterring and controlling weapons

• ensure primacy of ‘safety first’

• promote establishment of a health service–police partnership

• include clear proactive deterrent messages (such as entry with a weapon prohibited or refusal of entry - see point 4 below).

• identify opportunities to inform the public and reinforce the messages using positive language (admission advice sheets, signage)

• use clear and consistent language, terminology, and weapons definitions

• include values of respect and dignity central to operational aspects.

2. Include in, or link to, the emergency procedures within existing code black responses for situations involving weapons.

3. Include specific procedures for non-emergency management:

• procedures for contacting and arranging for collection of all firearms by police when a firearm is detected

• Include responses and interventions for when a non-firearm is detected or when staff, a visitor or client is identified as carrying a weapon.

4. Include refusal of entry or service to those people who possess a weapon or do not consent to being searched.

5. Include as a condition of entry that clients will consent to a search if required. A person who refuses to consent to a search can be asked to leave, and a subsequent refusal to leave upon request may amount to the summary offence of trespass [Section 9(1)(d), Summary Offences Act 1966 (Vic)].

6. Include specific procedures (separate policy) for no-contact screening activities that may be employed, noting that this may only occur with consent. 4

7. Identify the specific processes for negotiating entry to health services by police and other officers authorised to carry and use firearms, and firearm control.

8. Identify standards and requirements for documentation, reporting and monitoring of local policy and procedures including client records, incident management and security records.

9. Identify the specific processes for recognising and managing dangerous articles in health services.

Appendix 3. Suggested key elements of a health service firearms and non-firearms policy

4 No-contact screening activities should be sufficient. Examples of no-contact screening include requesting a person to empty their pockets or open their bags for visual check, or temperature, X-ray and metal detection scanning (including the use of electronic wands). Health service policies will clearly state who can search and how the search will be conducted. ‘Searching’ can only occur with consent. In determining the need for a search and the type of search to be conducted, the level of intervention should be proportionate to the reason for the search and should ensure staff safety.

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All Victorian public health services will ensure that:

their local weapons management policies and procedures are developed and/or reviewed in consultation with their local police and legal counsel to ensure joint agreement about how weapons will be managed within their specific environment, taking into consideration variables such as access to gun safes (or agreed alternatives) and proximity of police (particularly in rural environments)

there are clear policies and procedures that identify which workers are specified as exempt in the Firearms Act and the Control of Weapons Act, including through contractual arrangements (for example, external security contracts or ‘agency’ staff), as well as the specific circumstances under which the exemptions apply

relevant policies and procedures include information about what is meant by a ‘prohibited person’, as set out in section 3(1) of the Firearms Act

employment processes are in place to keep the health service informed of any current or potential employees who are ‘prohibited persons’ (and therefore not exempt from the specific breaches of the Acts), and that these employees and their managers are aware that the exemptions do not apply to prohibited persons

affected staff members are aware of their responsibilities under the Firearms Act and Control of Weapons Act and that policies and procedures reflect and support lawful actions

these legislative changes are included on the agenda of the organisation’s Police and other key agencies collaborative committee (however titled)

joint agreements with local police are in place regarding the processes for safe storage of weapons while awaiting collection by the police and the safe disposal of weapons

processes are in place for accurate reporting and reviewing of incidents where health care workers need to take possession of a firearm or other weapon in the course of carrying out their duties.

Health services are encouraged to consult their local police and legal counsel when developing or

reviewing policies and procedures that are affected by these legislative changes.

The changes and implications for health service employers and employees

What are the new sections in the Firearms Act 1996 and the Control of Weapons Act 1990?

A new section 54AA has been inserted into the Firearms Act and a new section 7A has been inserted into the Control of Weapons Act. These new sections should be read in conjunction with other relevant sections.

What are the exemptions?

Section 54AA of the Firearms Act exempts specified health service workers, in specific circumstances, from committing an offence when ‘possessing’ a firearm. Section 7A of the Control of Weapons Act exempts specified health service workers from committing an offence when ‘possessing’ a controlled weapon, prohibited weapon or dangerous item.

What are the specific circumstances?

The specific circumstances under which the exemptions apply are that the health service worker, in the course of carrying out his or her duties, takes possession of a firearm or other weapon that is either:

a) given to them by a patient; orb) removed from a patient; orc) found in the vicinity of the patient; or d) given to them by a health service worker who has taken

possession of the firearm or weapon in one of the above circumstances.

Which health service workers are exempt?

The exemptions only apply to the health service workers specified in the new sections of the Firearms Act and Control of Weapons Act. The specified health service workers are:

• health professionals (registered nurses and midwives, registered medical practitioners, registered psychologists)

• health service security guards (defined in the Firearms Act and Control of Weapons Act as ‘a security guard licensed under the Private Security Act 2004 when working in a health service facility as a contractor or an employee’)

• ambulance workers (defined in the Firearms Act and Control of Weapons Act as ‘an operational staff member of the ambulance services as defined in the Ambulance Services Act 1986’).

Note: The exemptions do not apply to a health service worker who is a ‘prohibited person’.

Appendix 4. Establishing compliance with amendments to the Firearms Act 1996 and the Control of Weapons Act 1990.

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What is a ‘prohibited person’?

The definition of ‘prohibited person’ as set out in the ‘definitions’ section 3(1) of the Firearms Act includes (but is not limited to) a person who is convicted of an indictable offence or assault, or who is subject to a final order under the Family Violence Protection Act 2008 or Stalking Intervention Orders Act 2008.

In what areas do the exemptions apply?

For specified health professionals and health service security guards, these exemptions only apply within a health service facility. For ambulance workers, exemptions extend to public places. A health service facility is:

• a day procedure centre; or

• a denominational hospital; or

• a multi purpose service; or

• a private hospital; or

• a public health service; or

• a public hospital;

as defined in the Health Services Act 1988.

What requirement is there to notify police?

Section 54AA (4) of the Firearms Act and section 7A (4) of the Control of Weapons Act require the police to be notified as soon as practicable after a health service worker has taken possession of a weapon. Joint agreements should be negotiated to ensure that weapons are then collected by Victoria Police, in accordance with agreed local procedures and timeframes. Principles 2.3 and 3.3 on page 15 of this document continue to apply in relation to these requirements.

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Australian Commission on Quality and Safety in Health Care (2011), National Safety and Quality Health Services Standards, NSW

Australian Council on Healthcare Standards (2011), The ACHS EQuIPS Guide, Sydney, Australia

Australian Health Ministers’ Conference (2004), National Health Workforce Strategic Framework, Australian Health Ministers Council, Sydney

Australian Standards 1997, Security for health care facilities - Procedure Guide, AS4485.2 -1997, SAI Global, Sydney

Department of Human Services (Victoria) (2000), Duty of care, DHS, Melbourne

Department of Human Services (Victoria) (2003), Public hospital sector occupational health and safety management framework model, DHS, Melbourne

Department of Human Services (Victoria) (2004), Design guidelines for hospitals and day procedure centres, DHS, Melbourne

Department of Human Services 2002, Public Hospital Patient Charter, DHS Melbourne – available at <http://www.health.vic.gov.au/patientcharter>.

Department of Human Services (Victoria) (2004), Industry occupational health and safety interim standards for preventing and managing occupational violence and aggression in Victoria’s mental health services, DHS, Melbourne

Department of Human Services (Victoria) (2005), Occupational violence in nursing: an analysis of the phenomenon of code grey/black events in four Victorian hospitals, DHS, Melbourne

Department of Human Services (Victoria) (2005), Staff safety in the workplace: 45, DHS, Melbourne

Department of Human Services (Victoria) (2005), Victorian taskforce on violence in nursing: final report, DHS, Melbourne

Department of Human Services (Victoria) & Victoria Police (2004), Protocol between Victoria Police and the Department of Human Services Mental Health Branch: 70, DHS, Melbourne

Middleby-Clements, JL & BFS, Grenyer (2007), ‘Zero tolerance approach to aggression and its impact upon mental health staff attitudes’, Australian and New Zealand Journal of Psychiatry 41: 187–191

Paterson, DBL & Miller, G. (2005), ‘Beyond Zero Tolerance: a varied approach to workplace violence’, British Journal of Nursing 14(15): 810–815.

Rew, Maggie and Ferns, Terry. (2005), ‘A balanced approach to dealing with violence and aggression at work’, British Journal of Nursing 14(4): 227-232.

Schopper D, Lormand JD, Waxweiler R (eds). Developing policies to prevent injuries and violence: guidelines for policy-makers and planners. Geneva, World Health Organization, 2006.

Secker et al (2004), ‘Understanding the social context of violent and aggressive incidents on an inpatient unit’, Journal of Psychiatric and Mental Health Nursing 11 (2): 172-178.

The Aged Care Standards and Accreditation Agency Ltd. (2011), Accreditation Grant Principles, Paramatta, NSW.

WorkSafe Victoria 2008, Prevention and management of aggression in health services: A handbook for workplaces, WorkSafe Victoria Melbourne – available at <http://www.worksafe.vic.gov.au/wps/wcm/connect/WorkSafe>.

Zarola, A & Leather, P (2006), Violence and aggression management training for trainers and managers. A national evaluation of the training provision in health care settings. Part 1: Research report, Health and Safety Executive, United Kingdom.

References

Preventing occupational violence A policy framework including principles for managing weapons in Victorian health services