1. A 10-pronged approach to the prevention of occupational violence against health workers South Pacific Nurses Forum November 1, Mark Staaf, M.Bus. HR/IR., B Hlth Sci. RN. Grad. Cert Crit Care Nsg. MACN Professional Officer Australian Nursing and Midwifery Federation (Victorian Branch)
Hello I am Mark Staaf, I am one of the RN/Professional Officer’s at the ANMF Victorian Branch in Melbourne Australia.
I would like to acknowledge our host country and thank them and the Organising Committee for the opportunity to present to you today.
This is the 4th SPNF I have attended and I am delighted to be back amongst you all again.

2. I commencing my presentation today I would like to acknowledge my colleague Ms Kathy Chrisfield and her leading work as the Unit Coordinator of our Occupational Health and Safety team at the Australian Nursing and Midwifery Federation (Victorian Branch).
Some of you maybe aware that we are the industrial/professional union for nurses and midwives in Victoria. We currently are the largest state branch of the Federation, representing the Industrial, professional and OHS interests for over 76,000 members in our state. The ANMF represents over 258,000 nurses/midwives and care workers nationally.
I am here today to speak to you about a Systems Approach to the Prevention of Occupational Violence.
It still comes as a huge surprise to many in the general public; - that within the professions of Nurses and Midwives, that we are the one of the most commonly exposed professions to occupational violence in Australia.
Throughout the healthcare industry this fact has been widely recognised… but this does not mean it has been, or always is, appropriately addressed - by either legislation, governments, health services or our policymakers.

3. Setting the scene…Victoria
ANMF (Vic Branch) introduces a “Zero Tolerance and Occupational Violence and Aggression” Policy.
Vic PS EBA Calls for improved measures. Results in a State Taskforce. ANMF becomes a stakeholder for the safety interim standards.
Victorian Taskforce on Violence in Nursing Report. 29 Recommendations, including implementation of Code Grey.
2009
Victorian Coalition pre-election promise to:
Evaluate existing anti-violence tools;
Legislate for harsher penalties for those who attack nurses/midwives;
Proper health and safety measures.
La Trobe University investigates violence against nurses nurses included in the study.
Over the past decade we have been working to improve the safety of nurses, midwives and other health care staff employed in our Victorian health care facilities.
We have all too often seen nurses and midwives being exposed to violent incidents in their workplaces. Our members are regular victims of occupational violence and aggression, which has resulted in serious injuries, both physical and psychological, that occur too frequently.
So what has the ANMF been doing about it?
To set the scene for you, let me explain the developments around occupational violence, specific to Victoria, and to put the context and background in place.
Whilst there has been constant activity (certainly on our part) around the issue, I’ll just highlight some key points.
Firstly, in terms of the legislative framework around Occupational Health and Safety, we have had legislation (an Act) in place since That Act has required a risk management framework to be applied to hazards and risks throughout workplaces.
The Act was reviewed in 2004, however no significant changes were made to this area, and yet, more than 30 years down the track, we are effectively working from square one to implement such a framework in relation to occupational violence in health care.
More specifically, in 2001, we introduced our first branch Zero Tolerance policy, but we all knew the issue existed before that time.
Our initial policy in 2001, was based on the September 1998 policy from the National Health Service (NHS), when the “Zero Tolerance” policy for the health industry was first articulated.
Following that, in 2002 our Victorian Department of Human Services funded a project entitled Occupational Violence in Nursing: An analysis of the phenomenon of code grey / black events in four Victorian hospitals, with the report published three years later in February 2005.
Just to digress slightly – a Code Grey is an alert to elicit a rapid clinical response to a situation of anticipated danger or risk by a person towards themselves, other patients, staff members or visitors, whilst a Code Black is a hospital wide internal security response to actual or potential aggression involving a weapon or serious threat to personal safety.
So in 2004, following lobbying from ourselves, a Ministerial Taskforce was established specifically to examine the violence in nursing, and in particular how it could be prevented, and this taskforce reported in November of 2005, providing 29 recommendations to reduce the risks.
In 2005, WorkSafe Victoria, developed guidance, not specifically for health, but incorporating the health sector, titled Prevention of Violence and Bullying in the Workplace.
The ANMF continued to lobby for change, (which went on for more than 6 years) and meet with taskforce implementation committees throughout the duration at this time, but the next event of particular note occurred in 2011, when the Victorian Labor Party in opposition, as an election commitment, - proposed to spend $21m to place armed Protective Services Officers in all Victorian Public hospital Emergency Departments, which raised widespread anger, given that the last thing we want to introduce into these already volatile situations were additional weapons in the hands of people who are not trained to deal with the circumstances.
A further proposal they included was around increased legislative powers relating to the sentencing when offences of assault were committed against emergency health workers.
The initial proposal created such outrage that a Parliamentary Inquiry was announced, and undertaken to further investigate the issue of violence and security in Victorian hospitals, and a report was released in December of 2011, which contained 39 recommendations (one of which was to implement and evaluate the previous 29 recommendations).
The Liberal Government of the day, ‘accepted’ or ‘accepted in principle’ all of these 39 recommendations, but nothing happened and there was no change to improve workplace violence against nurses and midwives.
I expect that much of this does not differ significantly from the UK experience… but recent studies have shown that the main types of occupational violence nurses are exposed to in Australia are-
Verbal abuse (90%)
Physical (44%)
Threat of harm (27%)
with a 2010 study reporting that 36% of nurses reported experiencing some kind of occupational violence, and 85% indicating 1-5 instances of violence over the last four working weeks.
We also know that occupational violence is significantly underreported in Australia. Whilst some studies have estimated that approximately 50% are reported, other recent investigations show that the rate is much lower than this, with even the parliamentary inquiry noting that approximately 1 in 5 incidents are reported using formal incident reporting mechanisms.
Whilst much of the discussion around occupational violence can be quite distressing, I find it particularly disturbing that 55% of nurses who had been involved in incidents rated their organisation’s management of the situation as only ‘fair’ or ‘poor’.

4. What has been done in the Victorian Health System
What has been done in Vic.
Victoria Australia
Some individual health services are taking action
Some consult with their staff
Some are considering many factors
Some have implementing individual components of a system (but not the entire system…)
What has been Done in Victoria?
It’s not all bad news… some of our public and private health services have and do take some measures to prevent occupational violence. Unfortunately, though they have often been unstructured and occurred in an ad-hoc way, with no centralised, standardised requirements put in place to guide employers in Victoria.
Some are consulting with staff.
And some are considering many factors associated with occupational violence, and some are even implementing parts of what we would consider to be a ‘system’..
But not many actually looked at the ‘bigger’ or total picture.

5. Where has the system gone wrong?
Incident reporting
Lack of true consultation
Lack of collaboration
Short sighted
Superficial
No systemic view
Too much concentration on ‘mopping up after’ (and even then poorly…)
Lack of consistency in approach across health services
Money $$$
So why is this happening? Why has it gone wrong?
One of the most critical factors in this relates to Incident reporting, which comparatively was consistent with some of the recommendations and outcomes from the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry that came out of England and the UK back in 2010.
The UK experience highlighted that there was a lack of encouragement of incident reporting, and a lack of feedback where incidents were reported.
The information which has been able to be gained from those incident reports is not collated nor shared, nor the lessons which could have been learned applied generally across the board.
The approaches we see, usually continue to show a lack of respect for the input that nurses and midwives can have into these processes. There is often a lack of consultation with staff around the issue, and certainly a lack of collaboration with representatives of those on the front line.
The activities are short sighted and superficial, and whilst they may prevent an incident with exactly the same set of circumstances as the previous one, the systemic issues that have allowed it to occur haven’t been identified, let alone addressed.
There is also a significant component of any investigation that occurs (if one occurs) which only considers how the individual clinician could have ‘behaved’ more appropriately, and doesn’t investigate whether there were clinical issues associated with the incident, or at which points the system failed.
There is sometimes quite a lot of effort put into ensuring the staff member feels supported afterwards, however we also see approaches where there are directives not to speak about the incident, because you will ‘re-traumatise’ the staff involved…
And there is certainly no consistency of approach in terms of compliance with a set of guiding principles to prevent occupational violence.
There was no leadership shown by anyone in authority in our Department of Health and Human Services to indicate that hospitals and facilities need to implement a preventative approach to occupational violence, nor any resources provided to allow them to take their own lead in the process… and as always, it boils down to money…
Back in December 2013, in Victoria, an investigation from the Independent Auditor General’s Office, found Public Hospital staff were being put at unnecessary risk of violence and aggression… WorkSafe, as the OHS regulator, and the Department of Health, as the health system manager; could have assisted public hospitals to reduce their sector-wide OHS risk. Yet we found that neither authority had a very good understanding of sector-wide OHS risk at that time.

6. Campaigning the Issue What did we do?
In 2013 we run a high profile member based campaign that was aimed at raising the awareness, not only to the Victorian public, but also all nurses, midwives and health care workers exposed to violence and aggression at work. We wanted them to report incidents, so that the data to support the issue is more realistic.
We initiated an on-line reporting form to allow our members to alert us to incidents. We started an online petition calling for action from the state government in an attempt to take action. We used our social media profile through Twitter and Facebook to continue to keep the issue active.

7. A SYSTEMS APPROACH TO PREVENTION
Integrates OVA into OHS, Risk Management, Clinical Management, Clinical Assessments and any other dealings with persons.
Does not only look at how OVA is dealt with AFTER the fact.
Recognises that OVA can be prevented in most instances, and minimised in others.
LEARNS from instances where the system has failed… and doesn’t accept that ‘it is going to happen’… rather the question is asked as to
HOW CAN WE PREVENT THIS HAPPENING AGAIN?
CLICK MOUSE x5
A Systems Approach to Prevention
When we discuss a systems approach to the prevention of occupational violence and aggression. With this appraoch, we are talking about one that integrates all our current data collection systems, and also the findings of these into one place.
The primary purpose of the systems approach is the prevention, and learning from instances, learning from where it has occurred, and taking those lessons learnt, and implementing the findings so that they can be applied in a broader circumstance, and therefore preventing future incidents.
So, primarily, it asks how can we prevent this from happening again?

8. A 10-pronged APPROACH The 10 Pronged Approach
This systems approach is like a jigsaw – if any piece of the puzzle is missing, the picture is incomplete, and therefore the system is doomed to fail.
This is a broad topic, and covers the expected and relevant policies and procedures, but also many that perhaps would not always be considered to be relevant, including the Statement of commitment to prevention, and no acceptance that ‘it will happen’.
There are Behavioural contracts – where there are patients or clients (or often even visitors) who have placed staff at risk due to violence and aggression, are put in place, where an agreement about a standard level of behaviour is reached and the consequences of the failure to comply with the agreement are spelt out.
There are also Client alert systems – to highlight particular client behavioural risk. Nurses and midwives needed to know:-
What are their triggers?
How do they need to be managed?
We developed Emergency response, and in particular, Code Grey and Code Black – as mentioned previously, this is an approach that distinguishes between levels of threat, and therefore is a tailored, more structured approach around management of potentially violent situations.
But also policies such as: Incident reporting, incident investigation, training, induction, post-incident response, escalation processes for additional staff requests.
We must acknowledge that there is often a clinical component, or a reason for the behaviour, and this must be taken into account, and preventative strategies put in place to deal with known risk factors –
We have to know if there are particular triggers that escalates patient behvaiour, then we can pre-empt this and either prevent the risk factor, or if this is not possible, put in place management strategies to deal with this BEFORE the escalation occurs…
We are regularly re-admitting people who have a history of violenceto the system we are working in. Therefore, it is critical that, wherever possible, we are looking at the person’s history PRIOR to admission to ascertain the details of this, and allowing us to then make a decision as to whether this is the appropriate facility for them to be admitted to, or the appropriate clinical area.
We also need to do a risk assessment when patients come into ED, before we admit them to secure areas, not just assessing the patient, but also the family or accompanying persons, to determine if there are appropriate actions that can be taken to reduce the risk, for example limiting number of visitors.
We cannot underestimate the need for security as a component of a systems approach. But security is not just guards at doors.
Security also involves CCTV, personal duress alarms for staff, and the response to all of these things.
In every component of the systems approach there is a need for training and education … in the policies and procedures of the organisation, for everyone in the organisation (as is appropriate to their role), in a collaborative environment – for example - train all of the disciplines who respond to the codes together, so that everyone is very clear on their role in the process, de-escalation techniques are critical. It is especially important to train staff in what is and isn’t considered to be appropriate behaviour and what (and how) reporting should happen, as well as what they should be able to expect should an incident occur…
We must also consider how the physical environment is set up.
Are the ‘measures’ being implemented actually increasing levels of aggression. For example if you put glass screens at the triage desk to protect the triage nurses, is the nature of these such that it requires a patient who presents to yell their personal details to get them through, thereby allowing everyone in the waiting room to hear, and thereby increasing the agitation and frustration of those presenting? Look at the screens then – involve staff in the design process – they know what cause problems, and they also generally know how to fix them… but there are experts who can assist…
We need to make sure that everyone who is involved or comes into contact with a patient, client or visitor (depending upon the setting) has a common understanding of how things are done in the facility. It is not enough to empower nursing staff to report aggression if this is overruled by a treating psychiatrist who does not consider that the patient is ‘aggressive’ in the very small window where they have contact. EVERYONE has to be on board with a common approach, and this needs to be clearly and consistently documented on treatment plans and notes.
Staff need to be very clear that all reports of violence and / or aggression that they make will be taken seriously, and that it is not an ‘underlying’ ‘subconscious’ expectation that this is a part of their job. Staff also need to be very clear when making decisions around violent or aggressive behaviour ,that the facility will support, and back them up, and not immediately begin investigating with the intention of laying blame at the feet of those involved.
Yet, even in the best, most robust systems, occasionally there may be failures.
These need to be anticipated and structured, with clear processes in place to support someone who has been exposed to OVA , and what can be expect in this circumstance.
Our prevention activities are only as good as the data which is gathered.
Incident reporting must be encouraged, and this means using systems which are fit for purpose, as well as be user-friendly.

9. ANMF 10 Point Plan to Prevent & Manage OVA 1. IMPROVE SECURITY
The Department of Health must develop adequate baseline standards for security and fund healthcare organisations to comply.
Standards must take into account:
1. Specifically trained security personnel
2. Access to secure areas and safe zones
3. Security cameras
4. Personal duress alarms
5. Searching of personal belongings
6. Regular security audits of healthcare facilities, including maintaining security equipment
7. Monitoring systems for community clinics.
The 10 point Plan to Prevent and Manage Occupational Violence and Aggression.
1. Improve Security and develop standards.

10. ANMF 10 Point Plan to Prevent & Manage OVA 2
ANMF 10 Point Plan to Prevent & Manage OVA 2. IDENTIFY RISK TO STAFF AND OTHERS
Identifying the risk of a patient or client being aggressive or violent towards staff must be part of clinical pre-admission, admission procedures and throughout the patients’ stay.
When a patient or client is admitted without notice to a healthcare facility – for example to an emergency department – a violence risk assessment must be initiated immediately.
It is critical that staff are alerted as soon as possible to the possibility of a patient (or their relatives/visitors) to be violent or aggressive. Healthcare facilities must ensure violent or aggressive patient/client alert systems are part of their admissions and patient stay procedure. This allows for preventative measures – for example, placing the patient in a highly visible area, or nursing in pairs with security staff.
2. Identify Risk/s to staff and others. CLICK MOUSE x 3
As part of the clinical pre-admission, admission procedures and throughout the patients’ stay.
a violence risk assessment must be initiated immediately on admission.
It is critical that staff are alerted as soon as possible to the possibility of a patient (or their relatives/visitors) being violent or aggressive.

11. ANMF 10 Point Plan to Prevent & Manage OVA 3
ANMF 10 Point Plan to Prevent & Manage OVA 3. INCLUDE THE FAMILY IN THE DEVELOPMENT OF PATIENT CARE PLANS
Patient care plans must not only take into account the clinical component of caring for a patient but also how caring for the patient may impact on staff or others.
The patient’s history, presentation and risk factors must be taken into account.
Where possible, care plans should involve family members to ensure clear standards of behavior are set and healthcare professionals can provide a consistent care approach.
3. Include families in the development of the Patient Care Plans CLICK MOUSE x 3

12. ANMF 10 Point Plan to Prevent & Manage OVA 4
ANMF 10 Point Plan to Prevent & Manage OVA 4. REPORT, INVESTIGATE AND ACT
Introducing a reporting system that allows accurate, timely and appropriate recording of information, including a quarterly report to be made public by the department;
Investigating incidents in a consultative and collaborative manner;
Taking clear and relevant action over incidents;
Communicating actions taken as a result of incident reports;
Ensuring the Health Minister and Boards are provided with details of violent incidents, not just statistics, so they understand the effects of violence on healthcare workers;
Working with police to enable prosecution of offenders.
Within health services, there is a culture of not reporting violent incidents.
To change this culture, the Department of Health and health services must build trust by:
4. Report, Investigate and Act
CLICK MOUSE x 3

13. ANMF 10 Point Plan to Prevent & Manage OVA 5
ANMF 10 Point Plan to Prevent & Manage OVA 5. PREVENTION VIOLENCE THROUGH WORKPLACE DESIGN
The principles of crime prevention through environmental design should be mandatory in designing, refurbishing, renovating and retrofitting workplaces to prevent and minimise violence.
5. Prevent violence through workplace design – ensure barriers and other deterrents are considered in building design.

14. ANMF 10 Point Plan to Prevent & Manage OVA 6
ANMF 10 Point Plan to Prevent & Manage OVA 6. PROVIDE EDUCATION AND TRAINING TO HEALTHCARE STAFF
Education and training about how to prevent and manage aggression and violence should begin at the undergraduate level and continue throughout a health worker’s career, with: employer-specific training and education; accredited and standardised training of both health workers and security staff; and regular refresher training.
Provide education and training to healthcare staff on how to prevent and manage aggression and violence. Start in early career development and evolve over career.

15. 1. Post incident support policies 2. Training and education policies
ANMF 10 Point Plan to Prevent & Manage OVA 7. INTERGRATE LEGISLATION, POLICIES & PROCEDURES
Healthcare facilities’ responses to aggression and violence such as Code Grey and Code Black must be defined consistently state-wide and apply to all situations of occupational violence and aggression.
Workplaces should also integrate their violence prevention policies with related plans such as:
1. Post incident support policies
2. Training and education policies
3. Security policies
Systematic policy changes and decisions about a patient’s care should take into consideration any potential for the change to increase the incidence of aggression and violence.
Integrate legislation, policies and procedures
CLICK MOUSE x 3

16. ANMF 10 Point Plan to Prevent & Manage OVA 8
ANMF 10 Point Plan to Prevent & Manage OVA 8. PROVIDE POST INCIDENT SUPPORT
Ideally, there will be no violent incidents. But in the event of violence, staff members deserve extensive and appropriate follow-up, support and care, including information about, and access to, the workers’ compensation system and the police reporting process. Incident investigation and actions taken as a result must also be reported.
8. Provide post incident support
CLICK mouse X1

17. ANMF 10 Point Plan to Prevent & Manage OVA 9
ANMF 10 Point Plan to Prevent & Manage OVA 9. APPLY ANTI-VIOLENCE APPROACH ACROSS ALL DISIPLINES
All healthcare and other workers who come into contact with patients (and their families and visitors) should have uniform knowledge around the prevention and management of violence.
All workers in healthcare settings should have the expectation that they will not encounter violence or aggression at their workplace.
All workers’ reports about aggression or violent behavior from a patient or their visitors should be taken into consideration when making decisions about the patient’s care and management.
In making decisions, it is important to communicate, consult and collaborate with all staff involved in the patient’s management and care.
9. APPLY ANTI-VIOLENCE APPROACH ACROSS ALL DISIPLINES
CLIAK MOUSE x 3
All healthcare and other workers who come into contact with patients (and their families and visitors) should have uniform knowledge around the prevention and management of violence.
All workers in healthcare settings should have the expectation that they will not encounter violence or aggression at their workplace.
All workers’ reports about aggression or violent behaviour from a patient or their visitors should be taken into consideration when making decisions about the patient’s care and management.
In making decisions, it is important to communicate, consult and collaborate with all staff involved in the patient’s management and care.

18. ANMF 10 Point Plan to Prevent & Manage OVA 10
ANMF 10 Point Plan to Prevent & Manage OVA 10. EMPOWER STAFF TO EXPECT A SAFE WORKPLACE
Management must demonstrate commitment to changing the culture of healthcare workplaces to ‘no aggression or violence’ workplaces.
In workplaces where there is no expectation of aggression or violence, staff will become empowered to report incidents and believe in their right to a safe workplace.
All policies and procedures around prevention and managing violent incidents should be developed in consultation with staff.
And finally
10. EMPOWER STAFF TO EXPECT A SAFE WORKPLACE
CLICK MOUSE x 3
Management must demonstrate commitment to changing the culture of healthcare workplaces to ‘no aggression or violence’ workplaces.
In workplaces where there is no expectation of aggression or violence, staff will become empowered to report incidents and believe in their right to a safe workplace.
All policies and procedures around prevention and managing violent incidents should be developed in consultation with staff.

19. THANK YOU. REFERENCE MATERIAL:
Contact:
Mark Staaf
Australian Nursing and Midwifery Federation.