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 Acknowledgement The 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: [email protected] 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)
2 Contents
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
3 4 Introduction
Violence within the workplace is increasingly being The World Health Organisation (2006) defines injury and recognised as an issue for health service providers. violence prevention policy as: Concern about this issue within nursing led to the 2002 ‘a document that sets out the main principles and defines Department of Human Services funded project to analyse goals, objectives, prioritised actions and coordination the incidence of violence within four Victorian public mechanisms for preventing intentional and unintentional hospitals (Department of Human Services (Victoria) injuries and reducing the health consequences.’ 2005). In 2004, the Victorian Government established the Victorian Taskforce on Violence in Nursing (‘the The value of developing injury and violence prevention taskforce’) to examine key issues and recommend policies is that it provides the basis for effective joint action. strategies to address occupational violence against This document explains the overarching policy framework nurses. The ministerial taskforce brought together for the prevention and management of occupational government, industrial, regulatory, health service and violence and bullying within Victorian public health services. clinical nursing representation to provide strategic advice It contains the guiding framework and rationale for health to the government regarding violence and bullying in the services to ensure that safe, healthy and productive workplace directed towards nurses, and the strategies to workplaces are maintained. In this context, the workplace reduce its occurrence. is more than just the health services’ ‘bricks and mortar’; it The taskforce made 29 recommendations (Department includes all settings where health services provide care or of Human Services (Victoria) 2005) aimed at addressing services, such as in community and residential settings. the problem of violence against nurses in a more This policy framework is a visible commitment to the consistent and coordinated manner. In particular, the work prevention of occupational violence in Victorian health highlighted the need for a framework to effectively address services and makes explicit the expectation that health occupational violence in health services and for clear and services will be committed to the implementation and consistent messages that: support of occupational violence prevention in their • violence against nurses (or any healthcare worker) is workplaces. It also recognises the department’s duty of unacceptable and must be proactively addressed, care to staff and clients and that of health services to their • there is not a culture of tolerance of violence in staff and clients. healthcare workplaces and • encourage a culture of reporting of occupational violence in heathcare. Policy principle: New South Wales and United Kingdom policy development Health services must have an integrated health workforce has focused on a zero tolerance approach to violence policy that acknowledges the imperative to provide safe and bullying. The Victorian taskforce, while it concluded and healthy workplaces and that specifically recognises that it would ‘be informed by the NSW framework’, has the prevalence of occupational violence in health care. 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.
5 The Department of Health is committed to providing all This framework has been informed by existing knowledge employees with a healthy and safe workplace free from and literature. It is not intended to replace existing policies violence. While this policy framework provides the strategic and documents, such as those referenced in the key related direction and guiding principles, it is anticipated that local policies. Rather, it recognises issues of implementing health service policies and procedures will give effect to occupational violence and bullying prevention measures this framework. within an occupational health and safety framework, with specific reference to a health care context. The framework provides the policy principles to assist health services to:
• implement occupational violence prevention and Policy principle: management programs at the local level • apply an integrated and systematic approach An overarching framework is important; however, each • enhance the capacity of health services to effectively health service setting will need to consider customisation meet their obligations as employers and local solutions/implementation strategies. • 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.
6 The policy framework
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.
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.
7 Defining occupational violence Policy context Without consistent definitions, the true nature, extent In relation to health and health service provision, there and impact of workplace violence cannot be fully are significant health and safety issues, including understood within the health care sector. The taskforce’s occupational violence and bullying, that need a systematic work summarised the issues and inconsistencies arising and coordinated approach. Providing a safe and healthy from the different language and definitions applied to work environment is a key policy objective of the Victorian workplace violence and bullying. In this framework, the term Government and the link between healthy and safe ‘occupational violence’ is used and has been broadly defined workplaces and workforce is critical. to include threats and actual violence. As recommended This framework aligns with the Health Priorities framework by the Victorian taskforce, the department has adopted the 2012-2022. The framework assists in planning and following definition for use in all Victorian health services: delivering an innovative, informed and effective health care Occupational violence is defined as: system that is responsive to people’s needs now and in Any incident where an employee is abused, threatened or the future. Specifically, its vision is for a health system that assaulted in circumstances arising out of, or in the course is highly productive and sustainable. Principles outlined in of their employment (Adapted from WorkSafe guidance the framework that support this policy document include note, 2003). evidence based decision making, maximum returns on system investments, sustainable use of resources through Within this definition of occupational violence: efficiency and effectiveness, continuous improvement and • ‘threat’ means a statement or behaviour that causes innovation, and local and responsive governance. a person to believe that they are in danger of being physically attacked, and may involve an actual or Role of the Department of Health implied threat to safety, health or wellbeing The Department of Health is responsible for funding • ‘physical attack’ means a direct or indirect application public health services across Victoria. The department is of force by a person to the body of, or clothing or committed to creating a safe and productive workplace equipment worn by, another person, where that through improving health, safety and wellbeing at work. application creates a risk to health and safety. Considerable work on occupational health and safety Neither intent nor ability to carry out the threat is relevant. (including management and prevention of occupational The key issue is that the behaviour creates a risk to health violence) has already been undertaken in specific health and safety. care settings or in relation to working with specific client Examples of occupational violence include, but are not groups (Department of Human Services (Victoria) 2004; limited to, verbal, physical or psychological abuse, threats, Department of Human Services (Victoria) and Police throwing objects and sexual harassment (Department of 2004; Department of Human Services (Victoria) 2005). Human Services (Victoria) 2005). These policies provide direction and guidance to health services about the specific management and prevention of Sometimes a distinction is made between bullying and occupational violence in those care settings. harassment; sometimes it is included in definitions of workplace violence. The taskforce’s recommended Further, an occupational health and safety management definition of occupational violence is broad enough to framework model has been developed for Victorian health encompass aspects of behaviour such as bullying and services. The model provides the basis for health services harassment, while recognising that the relevant legal to develop a comprehensive approach to managing framework may include anti-discrimination legislation. health and safety obligations. This includes meeting The agreed definition of bullying is aligned with the legislated obligations to provide a workplace free of risk WorkSafe definition and is: Workplace bullying is repeated, and continuously improving health and safety performance unreasonable behaviour directed toward an employee, (Department of Human Services (Victoria) 2003). or group of employees, that creates a risk to health and safety. Further detail is provided on page 26.
8 This framework is aligned to these documents and • mandates that the department’s duty, so far as is provides a complementary focus on preventing and reasonably practicable, is to provide and maintain a managing occupational violence and bullying within health working environment that is safe and without risks to services. The department has a role in monitoring and health (s. 21) evaluating policies that affect health services (Refer to page • requires employees, while at work, to: (a) take 21 monitoring and evaluation by the department). 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 Policy principle: or omissions at the workplace; and (c) cooperate with their employer with respect to any action taken by the All staff are entitled to work in safe and healthy workplaces employer to comply with a requirement imposed by or and the Department of Health is committed to ensuring under the Occupational Health and Safety Act 2004 or that public health services are healthy and safe work its associated regulations (s. 25) environments, free from occupational violence and bullying. • imposes duties on employers to consult with employees and health and safety representatives ‘so far as is reasonably practicable’ when undertaking certain Relevant legislation and regulation tasks. These include, but are not limited to, identifying or assessing hazards or risks and making decisions Victoria’s health services are required to reflect the regarding measures to be taken to control risks to requirements of State and Federal law, and the health and safety (s. 35) (Refer also to pages 18–19 of community’s expectations about health, safety and quality. the Taskforce Final report). A number of legislative acts, regulations and industry standards define and detail how health services manage Mental Health Act 1986 the provision of health care/services while also ensuring The objectives of the Mental Health Act are to provide for the the safety and health of all those involved (directly or care, treatment and protection of mentally ill people who do indirectly) in the provision of care, as well as clients and not or cannot consent to that care, treatment or protection, their families. and to facilitate the provision of treatment and care to people Legislation with a mental disorder. This Act has implications for wherever clients with mental illness are treated. The following section contains information about some key legislation that is central to this policy. It is not The five criteria for involuntary treatment that need to be met an exhaustive list. are that: the person appears to be mentally ill; the person requires immediate treatment and that treatment can be Occupational Health and Safety Act 2004 obtained by the person being subject to an involuntary The purpose of the Occupational Health and Safety Act treatment order only; it is necessary for the person’s health or (the Act) is to secure the health, safety and welfare of safety or the protection of members of the public; the person employees and other persons at work, to ensure that the has refused consent or is unable to consent to the necessary health and safety of members of the public are not placed treatment; and the person cannot receive adequate at risk, and to provide for the involvement of all parties in treatment in a less restrictive manner. The care of clients the formulation and implementation of health, safety and with mental health issues can be very challenging and raises welfare standards. Specifically, the Act: specific issues in relation to occupational violence. • covers wherever staff are employed to provide health Criminal law services (not just hospitals), for example, day centres, The criminal law in Victoria is a combination of common clinics, home care settings and residential aged care law and legislation. The key piece of legislation is the • defines a workplace as ‘a place, whether or not in a Crimes Act 1958 (Victoria), which aims to punish all forms building or structure, where employees or self employed of criminal behaviour. persons work’ (s. 5)
9 In the context of occupational violence, consideration of Each resident of a residential care service under section criminal law is relevant as most forms of occupational 10.13 of the user rights principles is required to: respect violence will be criminal offences and, as such, subject the rights of staff and the proprietor to work in an to investigation by the police. Relevant offences include environment which is free from harassment. assault, threats to kill and threats to cause physical Anti-discrimination legislation injury. The Summary Offences Act 1966, which relates to behaviour in public places, including, but not limited to, State and Federal anti-discrimination legislation prohibits obscene, threatening and abusive behaviour, may have a behaviour that amounts to discrimination or sexual bearing in cases of occupational violence in health services. harassment. Bullying and violence that occur within the workplace could also be covered by such legislation if it There are, however, some examples of occupational amounts to discrimination on the basis of a prescribed violence that will not be offences under criminal law, such attribute and meets the legislation’s definition of unlawful as where an employee is physically attacked by a person, harassment. The relevant legislation includes: such as a psychiatric patient, who is incapable of forming the necessary intent. This may well require a careful • Equal Opportunity Act 2010 (Victoria) appraisal of individual cases to decide if criminal liability • Racial and Religious Tolerance Act 2001 (Victoria) may or may not be relevant (Worksafe, Victoria, 2003). • Human Rights and Equal Opportunity Act 1986 (Commonwealth) Weapons and firearms • Racial Discrimination Act 1975 (Commonwealth) A proactive approach is required in relation to the • Sex Discrimination Act 1984 (Commonwealth) deterrence, detection and management of weapons. • Disability Discrimination Act 1992 (Commonwealth) In addition, a legislative framework to govern control of • Age Discrimination Act 2004 (Commonwealth) weapons and detailed information regarding the various types of weapons in the community are required. Compensation legislation The legislation relevant to weapons and firearms includes: The Accident Compensation Act (Occupational Health and Safety) 1996 and Accident Compensation (WorkCover • Control of Weapons Act 1990 Insurance) Act 1993, in relation to the regulation of Victoria’s • Control of Weapons Regulations 2000 WorkCover compensation and rehabilitation system, may be • Firearms Act 1996 relevant to some cases of occupational violence. • Firearms Regulations 1997 Duty of care • Victims Charter Act 2006 • Charter of Human Rights & Responsibilities Act 2006 (Vic) The department is mindful of the complexities and issues • Crimes Act 1958 that arise in health care in relation to providing care and • Summary Offences Act 1966 (Vic) services to clients. The paper, Duty of Care (Department of Human Services (Victoria) 2000), provides a broad Aged Care Act 1997 understanding of the law governing the duty of care owed The Aged Care Act (the Act) governs all aspects of the by the department and, in some cases, by agencies provision of residential care, flexible care and Community engaged by the department. Health services are directed Aged Care Packages (CACPs) to older Australians. The to this resource as a useful summary of the key issues. 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:
10 Consideration of matters such as the use of restraint, force In doing so, the department has dedicated policy, planning and self-defence are also important. Work done by the and response resources and specialist expertise that work department in relation to staff working in youth justice can in partnership with the health sector to ensure, where give some guidance in these matters (see Appendix 1). possible, a whole-of-health approach to emergency management. The department supports the Victorian In addition, the Victorian Quality Council (VQC), the Chief hospitals emergency managers (VHEM) group which Psychiatrist and the Quality Assurance Committee (QAC) discusses and share resources across a wide range of supported the development and implementation of the emergency management topics including occupational Creating Safety: Addressing Seclusion Practices project to violence prevention. In particular, health services use enable clinicians to apply best available evidence to clinical a standard code system for internal and external practice. The project aimed to strengthen and support emergencies. One mandated code (code black) and one safety in adult acute mental health inpatient units and to optional code (code grey) are relevant to occupational minimise, wherever possible, the frequency and duration violence prevention. of the use of seclusion and restraint. These matters are of interest and relevance for all health services. Code black Accreditation and industry standards The code black is an alert to elicit a response to an armed threat. It is part of the Australian Standard AS Health services are required to comply with or consider 4083-Planning for emergencies-Health care facilities. accreditation and industry standards, and a number of these standards have specific requirements that relate to Code grey the management and prevention of occupational violence. These include: The code grey is an alert to elicit a rapid clinical response to a situation of anticipated danger or risk by a person Aged Care Act 1997 towards themself, other patients, staff members or This act requires approved providers of residential aged visitors. This type of response is optional at present in care homes to comply with the accreditation standards. Victoria and may involve verbal de-escalation or restraint The accreditation standards are set out in the quality of care of a potentially aggressive person by an emergency principles (The Aged Care Standards and Accreditation response team trained in the management of aggression. Agency Ltd. 2006). There is an obligation that management It has had demonstrated positive results when used in actively work to provide a safe work environment that meets Victorian health services. It is highly recommended that OHS regulatory requirements. health services consider the use of a separate code grey response that is a clinical response. National Safety and Quality Health Service Standards (NSQHS)
The Australian Commission of Quality and Safety developed Policy principle: the NSQHS in health care. The ten standards have been designed for use by all health services and may be used as The Department of Health and employers must comply part of their internal quality assurance mechanisms or as with relevant legislation and regulation relating to part of an external accreditation process. The first standard workplaces. 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.
11 Social context The need to deter, detect and manage weapons in health services Violence is unacceptable and must be proactively addressed. Recent views argue the necessity for Following the implementation of the policy framework ‘comprehensive proactive organisational strategies to in 2007, considerable work has been undertaken to reduce workplace violence and assert the need for these manage the risk of weapons in health services. Health to be complemented by wider social initiatives to address services are impacted by the communities in which they the roots of violence in our communities’ (Paterson exist. Unfortunately, the use of weapons and dangerous 2005). These comprehensive strategies include adequate articles is prevalent in society, permeating health services attention to physical and procedural security without and leading to a potential for exposure to occupational compromising relational care. This requires the utilisation of violence. There is an ongoing need to be aware of clinical decision making processes that are professionally the rights and responsibilities in relation to weapons rational, while integrating risk assessments into care management within health services and to ensure local processes (Middleby-Clements and Grenyer 2007, Secker policies are developed and implemented. et al 2004, Rew and Ferns 2005). A proactive approach is required in relation to the Clearly, managing violence and aggression in health care is a deterrence, detection and management of weapons. complex and sensitive issue where illness and highly charged In addition, a legislative framework to govern control of emotional states impact on the environment. Recognising weapons and detailed information regarding the various the socio-political facets of occupational violence allows types of weapons in the community are required. for the adoption of prevention measures that move beyond The Victorian Taskforce on Violence in Nursing Final Report introspective initiatives and permit committed interagency (2005) identified the need for a coordinated approach partnerships using evidence-based interventions. to the management of weapons and dangerous articles The interface of health care, police and the within health care settings, including consideration of justice system the issues of search, seizure, storage and disposal or return of such items. These issues were explored The interface between the justice system, police and during the implementation process at which time it was health services in relation to occupational violence is an acknowledged that these matters required further review. area in which the Department of Health is undertaking On 1 November 2010, amendments to the Firearms Act further work. 1996 and the Control of Weapons Act 1990 came into The taskforce highlighted a requirement for health services effect allowing for specified health professionals, health to support health workers in pursuing charges by having service security staff and ambulance workers (operational formal protocols and procedures to provide information staff members) to be exempt from breaches of these acts and assistance to staff with this process. The taskforce in regard to seizure and temporary storage (‘possession’) also noted a requirement for this issue to be promoted to of weapons in the course of their duties. Appendix 4 Victoria Police. provides detailed information about the implications of As part of the implementation of the taskforce these amendments for Victorian health services. recommendations, a justice, police and health service Health services are encouraged to continue developing and interface working group was formed to develop strategies reviewing specific policies and procedures, in consultation to implement the taskforce’s recommendations. This with their own local police and legal counsel, that combine group had representatives from WorkSafe, criminal law a prevention and deterrence approach with clear direction policy, justice policy, Victoria Police, directors of nursing, about how weapons (if detected) are managed. directors of human resources, occupational health and This approach needs to comply with legislation, while safety managers and the Department of Health. The work ensuring the safety of all staff, clients and visitors. undertaken by this group included policy analysis relating to complex legislative and operational issues that require further consideration by the department and health services.
12 Health services–Victoria Police partnerships Principles for managing firearms and The aim of weapons legislation is to reduce the general non-firearm weapons within health availability of weapons to the public, thereby decreasing the care settings risks of crime and injury due to misuse. Formal collaboration between public health services and Victoria Police to deter, The following principles provide guidance on how firearms detect and manage firearms and non-firearm weapons is and non-firearm weapons should be managed by health the key to success in these endeavours . services and provide a framework for health services to develop their own specific operational policies and It is considered imperative that health service–police procedures. The principles are applied equally to all partnerships are established at the local level to support persons in the health service (staff, contractors, volunteers, implementation of the principles relating to all firearms visitors and clients) and recognise that as employers, and non-firearms weapons. Existing police liaison public health services are responsible for ensuring a safe committees may form the basis of the health service– environment for all those in ‘the workplace’, which includes police partnership, although the role of the partnership outreach teams, home care or mobile services. should go beyond liaison to form joint local agreements and procedures to deter, detect and manage firearms and General principles relating to all firearms and non-firearm weapons in individual health services. non-firearm weapons In 2010 – 2011, 11 health services were funded to The following principles pertain to all firearms and non- participate in the Building better partnerships (BBP) initiative, firearm weapons including dangerous articles: an opportunity to identify ways to improve the interface of health services and other key agencies (in particular, police) Safety first across a range of different situations and contexts. 1.1 Under the Victorian Occupational Health and Safety Five high impact interventions were identified by the 11 Act 2004 and relevant Australian standards, the demonstration sites as part of the BBP initiative. The five safety of clients, visitors and staff within health care interventions are: settings is the overriding priority. Health service employees have an obligation to act based on a • commit to continuously building shared understanding risk assessment, in a way that enables clients to of each other’s (agency’s) roles, strengths and limitations receive medical or clinical care without endangering • formalise joint agreements, policies and procedures themselves or others. This may include delaying • actively manage occupational violence incidents from treatment until a risk assessment is undertaken, occurrence through to review taking action to minimise the risk and contacting • focus on enhancing processes for managing the local police for assistance or advice, and is in absconding/missing patients/clients, and accordance with the Victorian Public Hospital Patient • optimise the patient/client handover process. Charter (2002). These interventions will positively contribute to best 1.2 The presence of firearms or non-firearm weapons practice interagency management of issues that occur at in a health care setting poses an increased risk the interface of healthcare and police, including the issue to the health and safety of the community (staff, of weapons within health services. clients, and visitors). Under occupational health and safety legislation and regulation, health services are required to manage such risks and provide a safe environment.
13 1.3 Health services provide care to vulnerable groups 1.8 Health service employees do not have special (for example, confused, elderly and juvenile clients) privileges or status to search for firearms and non- in public spaces where illness and highly-charged firearm weapons. A health service may, however, emotional states coexist. In this context, the impose consent to be searched for weapons presence of weapons, including dangerous articles, as a condition of entry to health premises. Clear poses an even greater risk to clients, visitors and local search policies and procedures using a risk staff alike. Health services need to manage such assessment approach should be established by risks irrespective of a person’s need for medical each health service, and should include clear care, their authority to carry a weapon, or their direction to guide actions if staff, clients or visitors competence to manage their own weapon. decline a search, or where an individual’s ability to consent to a search is impaired.2 Deterring and preventing 1.9 If a search is to be conducted, it should be 1.4 Health service providers, including ambulance undertaken with sensitivity and respect for a services, have an obligation to keep each other person’s dignity. The level of intervention should informed (whether transferring clients into, out of, be proportionate to the reason for the search and or within health care facilities) about any actual should ensure staff safety.3 or potential risks a client may pose, because of identified or known dangerous behaviour, including Meeting compliance and governance requirements use or possession of weapons. 1.10 Legislation controls the possession and use of 1.5 The best way to protect staff, clients and visitors is firearms and non-firearm weapons so the actions to deter individuals from bringing firearms and non- of health service employees (as for any member of firearm weapons into health services. Health service the public) must be lawful, comply with the relevant weapons policies should apply equally to all those legislation and be in accordance with their health entering the workplace. The message that firearms service’s policies and procedures. and non-firearm weapons are not permitted on health 1.11 The effective and lawful management of firearms services premises and that refusal of entry may result and non-firearm weapons in public health services if a person is found in possession of a weapon, should requires collaboration between health services be clearly communicated to all staff, clients and and Victoria Police (and other relevant agencies visitors, and reflected in local policies and procedures. such as ambulance services). Health service– 1.6 Local health service weapons policies need police partnership committees are the governance to integrate emergency/incident management mechanism by which health services develop and responses (such as Code Black) and ongoing ratify joint agreements with Victoria Police, for the strategies to proactively deter, detect and manage deterrence, detection and management of weapons. firearms and non-firearm weapons. 1.12 Robust documentation, reporting and monitoring 1.7 Crime Prevention through Environmental Design procedures for the management of firearms and (CPTED) principles should be consistently applied to non-firearm weapons in health services ensures that the workplace to reduce the risks to staff, clients and accurate data and evidence informs the evaluation visitors from firearms and non-firearm incidents and and continuous improvement safety activities of to help deter, detect and manage firearms and non- health services. firearm weapons in 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).
14 Specific principles relating to Group A: Specific principles relating to Group B: Firearms Non-firearm weapons
Group A: Firearms Group B: Non-firearm weapons
`Firearm’ is any device: For the purpose of this guide, non-firearm weapons • whether assembled or in parts are those items defined as ‘prohibited’ and ‘controlled’ • whether or not temporarily or permanently inoperable or weapons under the Control of Weapons Act 1990. incomplete Prohibited weapons are particularly dangerous and should only be available to persons able to display a specific need • which is designed or adapted to discharge a bullet or for such weapons. Controlled weapons are potentially very other missile; or dangerous and more common than prohibited weapons. • which has the appearance of an operable firearm. They can only be possessed, carried or used with a lawful The Firearms Act 1996 is the framework for the control of excuse. firearms and any person wishing to carry or use a firearm Note: It is not an expectation that all health care must hold a licence under this Act. workers would be able to distinguish between a prohibited and a controlled weapon.
2.1 Under the Firearms Act 1996, only police have the right to search for (without consent) or confiscate 3.1 All individuals known to be, or suspected of being, firearms in the community. Health service employees in possession of a non-firearm weapon, irrespective do not have this right. of whether they have a lawful reason for having the 2.2 Given that some officers, such as police and prison weapon, should be advised they may not enter the officers, are legally authorised to carry and use health premises whilst in possession of the weapon, firearms (as well as prohibited weapons such as thereby preventing its possible misuse by the capsicum spray and batons) in the course of their individual or others (refer to principles 1.5 and 1.8). duties, health services need to negotiate agreements 3.2 Health service procedures for responding to the with the relevant agencies regarding the appropriate detection of a non-firearm weapon (when no authorised carriage and use of weapons within the imminent threat to safety exists) should include steps different areas of the health service based on a risk to ensure the safety of others and interventions management approach. The agreed procedures targeted to the category of individual involved. should form part of the local firearms and non- Employees identified as carrying a weapon may need firearm weapons policy and be agreed by the local counselling or performance management, visitors health service–police partnership. will be asked to leave the premises, and clients will 2.3 Police should be contacted immediately when the be advised about the conditions under which clinical presence, or likely presence, of a firearm is detected care will be provided. in a public health service. Agreements should be 3.3 Agreements should be negotiated to ensure that negotiated to ensure that firearms are collected non-firearm weapons are collected by Victoria Police, by Victoria Police, in accordance with agreed local in accordance with agreed local procedures and procedures and timeframes. If necessary, the firearm timeframes. After collection, Victoria Police should should be safely stored, only for the purposes of determine an appropriate course of action for the making the health care facility safe, while awaiting item. Until police arrive, non-firearm weapons should collection by the police. After collection, Victoria be safely stored, only for the purposes of making Police should determine an appropriate course of the health care facility safe, while awaiting collection action for the item. by, or discussion with the police, regarding the appropriate course of action for the item.
15 3.4 Joint agreements that are developed and ratified Preventing occupational violence – by individual health services with their local police applying an occupational health and should support and guide decision making about the return of non-firearm weapons to owners who have a safety framework legitimate reason for having such an item. It is vital that there are prioritised actions and coordinated Specific principles relating to Group C: mechanisms for preventing injuries and their health consequences arising from exposure to violence and Dangerous articles (non-firearm) bullying hazards in a health care setting. This policy Group C: Dangerous articles (non-firearm) provides the overarching context and direction for all of the work undertaken to ensure the recommendations of the Dangerous articles are dealt with separately in this taskforce are implemented. framework as they are objects that may potentially be used as weapons, and may, due to their design or the intention Occupational health and safety involves recognising and of the individual carrying them, be classified as weapons managing any risk to the psychological and physical safety when taken out of the everyday situation in which they are and wellbeing of employees, contractors, volunteers and intended to be used. 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, 4.1 Health services need to recognise and manage occupational violence and bullying are a risk to an the potential for everyday items such as furniture individual’s mental and physical safety and wellbeing. and crockery, as well as items used specifically in The risk management process represents the basic health care such as syringes and scissors, to be preventative philosophy of occupational health and used as weapons. Assessing risk associated with safety legislation and regulation. It also reflects the key dangerous articles and applying a risk management responsibilities placed on employers to provide a healthy methodology requires a systematic, proactive and safe workplace. As conditions in the workplace approach. This needs to include an awareness of frequently change, hazard identification and risk control and recognition that different contexts, settings and needs to be a continuous process (Department of Human clients (or groups of clients) and their clinical needs Services (Victoria) 2003). will require different approaches to ensure a safe workplace. 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’).
16 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 SAFE Eliminate the hazard and so eliminate any risks PLACE 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 SAFE people don’t work close to a hazard for a long time) PERSON 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).
17 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).
Pre-incident prevention
Environment • building design • alarm systems • crowding Staffing issues • noise • rostering – experience, Policies and procedures Training Incident review • integrate into OH&S and • predicting, preventing and • events leading • electronic gender mix management systems managing aggression to incident communications • reliance on casual/ • training strategies/plans • aggression control • adequacy of • lighting part time • emergency response teams • emergency processes response • security • buddy system – • incident reporting and review • post trauma awareness • evaluate prevention • décor – colours, high risk areas • staff support • induction strategies • furnishings, etc • isolation • work systems – task allocation/ design/training
No Incident Yes
Post-incident management Critical incident management • immediate staff support • activate emergency procedure/ Maintain focus • staff respite response and defuse situation • formal debriefing on prevention • activate clinical response • return to work support • secure environment • clinical review
18 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 Responsibilities • OHS responsibilities Health organisations will establish an aggression management reference group, • OHS consultation which will be responsible for developing policies and procedures around the • OHS training management of aggressive incidents, primarily through a clinically led aggression • OHS procedures management team. • Contractor management Physical workplace design • OHS performance indicators 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.
19 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 Responding to incidents (post incident management) • Inspection, testing and Responses will vary depending on the scale and severity of the incident, but a number of corrective action responses that may be appropriate are outlined below. • Emergency response • Provide first aid and medical treatment if required. • Injury management and return • Give any employees involved the option of being relieved of their duties. to work programs • Give the target of occupational violence the opportunity to talk through immediate • OHS document control 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 Data collection • OHS auditing and corrective Incident report forms should: action • record factual information (for example, who was involved, when and where the • OHS continuous improvement 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.
20 Monitoring and evaluation by health services the taskforce and has been revised with input from health services and data standards. This will be incorporated Encouraging incident reporting is critical to prevention and into the incident information system. When this data can management of occupational violence and is integral to be collated and analysed, the department will facilitate achieving culture change. benchmarking across health services. The data related Individual health services should develop specific to occupational violence in health care will allow the outcomes related to local implementation and occupational department to: health and safety frameworks, and these should aim • collate and analyse the data provided by health services to monitor different parts of the overall program. Some • produce and disseminate reports on system-wide examples of different indicators or measures that could aggregated data to assist health services to compare be used to monitor and evaluate the impact of local their reported levels of occupational violence with peers occupational violence prevention programs are provided on page 24 of this document. • monitor system-wide trends over time to assess the impact of health services implementing the Accreditation standards, such as National Safety recommendations of the taskforce. and Quality Health Service Standards and aged care standards, also place a requirement on health services in System-wide data will be used to validate the classification relation to data collection and monitoring of occupational system proposed by the taskforce to ensure it meets the health and safety including occupational violence. needs of the health services and the department in relation to supporting the development of prevention strategies. As WorkSafe recommended by the taskforce, there will be preliminary analysis of the data set and strategies in 2013, and a Health services may find it useful to receive information comprehensive evaluation of the same after three years. 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 Policy principle: and coordinates the sharing of information to achieve the Reporting and measuring is important to be able to predict objects of this Act. trends, assist with prevention and control measures and Monitoring and evaluation by the department build an evidence base for future policy development. 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
21 The hierarchy of control The 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.
1. Crime Prevention Through Environmental Figure 4 – Hierarchy of control Design (CPTED) principles 2. Occupational violence measures and Eliminate the hazard and so eliminate any risks indicators Substitute a less hazardous alternative (for example, use 3. Checklist for occupational violence water based chemicals rather than solvent based ones) education and training Isolate the hazard (for example, enclose a noisy machine) 4. Occupational violence staffing considerations Use engineering controls (for example, install exhaust ventilation to extract dangerous fumes or dusts) 5. Bullying prevention guidance (Worksafe) Use administrative controls (for example, job rotation to 6. Deter, detect and manage. A guide to better make sure people don’t work close to a hazard for a long management of weapons in health services. time) 7. Occupational violence post incident response hierachy Use personal protective equipment and clothing
22 Eliminate the hazards — Crime • access to buildings is restricted, staff-only access points Prevention Through Environmental are clearly signposted and access is reduced in times of reduced staffing, such as after hours in smaller health Design principles services Crime Prevention Through Environmental Design (CPTED) • legal implications with regards to weapons are specified has been defined as systematic processes of creating • computerised access control systems for locks and for features within our built environments that influence recording of audit trails social behaviour in a positive way. These concepts have • security/reception areas are protected through design evolved from use in shopping centres, residential zones • closed circuit television (CCTV) monitoring clearly states and parkland, but the principles are applicable in health whether monitors are staffed by security or not care settings to design for the prevention of violence • CCTV monitor is reversed, where the public watches (Department of Human Services (Victoria) 2005). themselves Key principles of CPTED that are applicable to the health • waiting rooms are comfortable, spacious, provide care setting are: reading material, access to phones, water dispensers and so on. • Territorial reinforcement: people assume and express feelings of ownership and possibly pay more attention To be effective, CPTED requires: to an area or note potential intruders or acts of violence. • cooperation from all staff • Access control: physical and symbolic barriers control • chief executive officer and senior management access. Clearly identifying staff-only areas with physical endorsement and support or symbolic barriers makes it more difficult to reach • an understanding of the impact of environmental design potential victims or targets. and its benefits, which should be included in education • Natural surveillance: as people often feel safe where and training programs. they can be seen and interact with others, natural surveillance can be achieved by creating sightlines Before recommending or implementing any such strategy, between public and private space. it is important that contextual considerations and site • Space management: there is a belief that a well- risk are properly identified, measured and assessed by maintained facility may reduce criminal activity, whereas appropriately trained personnel, such as occupational a run down, empty, graffiti covered building may attract health and safety representatives and risk managers. This criminal activity and offenders. particularly applies to health services that vary in their size, purpose, location and resources. Control strategies that are components of the key principles include: It is important to establish a balance between creating a safe environment for all and delivering care to the clients. • clear communication strategies to provide information Risk assessment and risk management are imperative in and signs reducing environmental risks. • service delays are minimised Security resources have been identified as a component • activity or noise levels are minimised for promoting a safe environment in some health care • adequate lighting in waiting areas, entrances and car settings. The need for security officers will depend on parks a range of factors, including the size and needs of the • consistent, clear and concise signage that caters to the health care setting and other locally implemented safe needs of clients who may be culturally and linguistically environment strategies, and should be considered by diverse health organisations as part of their risk assessment and • fixtures are secured wherever possible, with sharp management framework. corners and edges eliminated • staff identification is worn at all times
23 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 The accessibility of policies and procedures OHS responsibilities Number of contract staff receiving training and orientation related to prevention of Contractor management violence and bullying OHS performance indicators and targets Number of staff completed training Prevention of violence and bullying Frequency of OHS committee meetings training Number/percentage of workplace changes that involved staff consultation Improved consultation Workplace grievance records
System activity
Proposed outcome Types of measurements
Risk management processes Number of risk assessments conducted Inspection, testing and corrective action
Emergency response Staff satisfaction surveys, decrease in injuries
Injury management and return to work Return to work rates programs
System review
Proposed outcome Types of measurements
Prompt reporting of incidents Hazard reports for example DINMA Incident reports on occupational violence WorkCover data.
24 Administrative controls (2) – checklist • local practice issues that have an impact on response, for occupational violence education such as access to support from others, sufficient staff available to respond to an incident, availability of and training emergency services and acceptable response times Effective and worthwhile education and training for the • management personnel at all levels should be trained in prevention of violence in health care plays a significant emergency response role in the broader hazard management approach. The • training should be compulsory for all staff and be taskforce recommended that guidelines to ensure minimum provided in paid time to ensure attendance. standards of education be provided to health services. Principles of training The following is a checklist to assist health services in their Training should: endeavours to provide education as part of an approach to prevent violence and bullying. As there are many training • be practical and relevant to the workplace providers, it is important that health services become • be flexible enough to allow modification to address acquainted with the various courses on offer. particular issues within a workplace to include direct Current research provides advice in relation to what and non-direct care staff has been established as ‘effective training in violence • be available in a way that facilitates regular updates management’: • emphasise both proactive and reactive responses • address physical and psychological protective measures, 1. The content tends to be broader rather than focusing such as follow-up after a critical incident and care of self on individual competence. • ensure all temporary, casual and agency staff are trained 2. The content tends to be closely allied to perceived need. to a competent level before being engaged 3. The content needs to clearly demonstrate (include • consider local factors that have an impact on the type of evidence) of a proactive organisational response to response available to a consumer and staff member to workplace violence (Zarola & Leather 2006). support them. Key training considerations Considerations The following has been identified as important when health • Clinicians need to feel that training can assist them in services are considering training in relation to occupational everyday practice. violence and bullying (Department of Human Services (Victoria) 2004, p 25). The key components should be: • Training should be competency-based. • Additional suitable modules should be provided according • the policies and procedures of the workplace to whether staff participate in direct or indirect care. • legal issues and legislative framework • Training providers should be appropriately accredited. • predicting, preventing and managing aggression and potentially assaultive situations More details on the key competencies of occupational violence response training are provided in the Industry • system of emergency processes occupational health and safety interim standards for • post-incident processes including access to support preventing and managing occupational violence and systems aggression in Victoria’s mental health services (Department • induction systems for all staff, including permanent of Human Services (Victoria) 2004). 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
25 Administrative controls (3) – Administrative controls (4) - resources occupational violence staffing for the prevention and management of considerations bullying in Victorian health services. How staff are managed can be important in preventing and There are a number of valuable resources, such as toolkits managing occupational violence (Department of Human and publications, currently available to Victorian public Services (Victoria) 2004). The organisation’s approach to health services to help prevent and manage bullying in the risk control in relation to staffing should cover: workplace. Of particular relevance are: • rostering and staffing ratios, for example, ratio of staff to • the various publications developed by the State clients should be adequate for the level of care needed Services Authority to help organisations respond to and also take into account range of required activities bullying and promote positive work environments • skill level, training and experience appropriate for duties • WorkSafe Victoria guidance note on Preventing and • where possible, staff should be permanent or regular responding to bullying at work. employees who are known to the clients and workplace On the following page you will find addresses for websites and • capacity to rotate staff into alternate duties to reduce links containing useful information and resources to assist with exposure developing strategies for preventing bullying in the workplace • procedures and back up for staff working alone or in and dealing with bullying when it occurs. A content synopsis isolation for each website and resource has been included. • regular support and supervision.
26 State Services Authority (Victoria) Developing conflict resilient workplaces – a report for www.ssa.vic.gov.au Victorian public sector leaders The State Services Authority (SSA) works to improve the This report is the companion document to the above performance of the Victorian public sector to enable it to guide. It provides the business case for changing the way provide services more effectively and efficiently. The SSA that conflict is managed in the workplace. website has an array of publications to support workforce People matter survey development, governance and culture in the Victorian public sector, including resources relevant to bullying The People matter survey measures a range of aspects prevention and management. of workforce culture and climate (including bullying) in the The following resources are available from the SSA website. Victorian public sector. The information from the survey Go to www.ssa.vic.gov.au and click on ‘products’ in the can be used by organisations to identify their strengths and top banner. Type the title of the required resource using the weaknesses and to measure their progress in embedding ‘find a product’ tab, or browse using the ‘a-z’ tab. the public sector values and employment principles in their organisation’s culture. how positive is your work environment? the organisational, management and individual WorkSafe Victoria perspective on making improvements at work www.worksafe.vic.gov.au This toolkit is of particular relevance to the prevention WorkSafe Victoria has a leading role in the promotion and and management of bullying. It includes a ‘quick check enforcement of health and safety in Victorian workplaces. tool’ that allows you to assess your work environment Two WorkSafe Victoria’s broad responsibilities are helping from three perspectives: organisational, management and to avoid the occurrence of workplace injuries and enforcing individual. It also provides practical tips on how to improve Victoria’s occupational health and safety laws. your workplace. As with the State Services Authority website, WorkSafe Ethics resource kit Victoria’s website also contains information to assist Victorian health services with the prevention and The Ethics resource kit contains a set of posters called the management of bullying within their workplaces. Value and employment principle posters. The set includes one poster entitled Respect and another entitled Fair and Bullying and occupational violence information can be reasonable treatment, both of which promote a workplace accessed at the website via the ‘Safety and Prevention’ free of bullying. link in the top banner. code of conduct for victorian public sector employees The following resource can be accessed at the website via the ‘Forms & Publications’ link in the top banner by This code emphasises the values contained in the Public entering the resource name in the ‘Quick Search’ field. Administration Act 2004. The values are relevant to the many and diverse operational settings in which Victorian Preventing and responding to bullying at work public sector employees work, including healthcare settings. This guide aims to ‘help employers to develop systems Developing conflict resilient workplaces that will prevent bullying, respond to reports of bullying and effectively meet their legal duties under occupational health An implementation guide for Victorian public sector and safety (OHS) laws’ (July 2009). 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.
27 Administrative controls (5) – occupational violence post incident response hierarchy The 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.
28 Key related policies or documents Other documents The following documents are some of the key related • NSW Health, Zero tolerance response to violence in the NSW policies or standards, in addition to this policy, that health health workplace – policy and framework guidelines (2003) services should be mindful of as they discharge their • WorkSafe Victoria, Preventing and responding to bullying at responsibilities to provide a safe and healthy workplace work (June 2009) free from occupational violence. • WorkSafe Victoria, Information pack for WorkSafe Victoria’s intervention on occupational violence in hospitals (Health Department of Health and Aged Care Team. Public Sector and Community • Staff safety in the workplace: guidelines for the Services Division November 2005) prevention and management of occupational violence • Australian Nurses Federation (Vic Branch), Zero tolerance for Victorian child protection and community-based policy and toolkit (November 2002) Juvenile Justice staff (Office for Children, 2005) • Victorian WorkCover Authority. Labour hire agencies: • Industry occupational health and safety interim standards managing the safety of on-hired workers (June 2006) for preventing and managing occupational violence and • Health and Community Services Union, Occupational aggression in Victoria’s mental health services (2004) assault: a health hazard…or is it ‘just part of the job?’ • Public hospital sector occupational health and safety Health and Community Services Union, Victoria Number 2 management framework model (2003) Branch of the Health Services Union. Undated • Creating safety; addressing seclusion practices, project • State Services Authority, Tackling Bullying, Public Sector report (Victorian Quality Council and Chief Psychiatrist’s Standards Commissioner (2010) Quality Assurance Committee 2009) • Victorian Health Incident management policy guide. (2011)
29 Appendix 1. Restraint, force and self-defence
The following is an extract from Staff safety in the Part 5, Division 3 of the Mental Health Act 1986, s. 44 workplace: guidelines for the prevention and management of the Intellectually Disabled Persons’ Services Act 1986 of occupational violence for Victorian Child Protection and [repealed], and ss. 256 (a), (b), and (c) of the Children and community based juvenile justice staff (pages 35–36). Young Persons Act 1989 [repealed] provide specific detail on the use of restraint and seclusion in those settings and Restraint, force and self-defence should be consulted and complied with in relation to the use of restraint and seclusion for such clients. The department has a duty of care to ensure staff are provided with adequate training, resources and Please note these acts might have recently been amended appropriate systems of work to enable them to respond and care should be taken to ensure the most recent appropriately to situations of assault. Mechanisms, such as version is consulted. restraint, time out and sedation, should not be the primary Self-defence and defence of others approach to minimising the risks of assault in departmental workplaces. Such mechanisms should only be used to This is permitted where a direct care worker (or someone provide the necessary protection for staff and clients where in care) is attacked or has a reasonable belief there is the process of risk assessment and control have identified about to be an attack. Training in self defence techniques, and put in place the range of appropriate controls, but including evasive self-defence, provides employees with some risk of assault still exists. controlled physical intervention when all other non-physical strategies have failed. Services and programs in which staff Physical restraint should only be used where an immediate work with clients who might display aggressive behaviour risk of injury exists and no other option for resolving the should provide adequate training for staff in containment situation is available. The physical restraint used should and self-defence techniques. be the minimum required. Reasonable force is the force that is sufficient to stop the Reasonable force assaulting person causing injury or harm to themselves or The person responsible might be liable for prosecution for others-and no more. assault if an incident of aggressive behaviour occurs under In addition to civil law where staff are provided with a provisions set down in the Victorian Crimes Act 1958. The duty of care to clients which justifies the use of physical main defence against assault actions available to staff is restraint, staff owe a duty of care to protect clients self-defence. Staff behaviour should therefore be defensive from being assaulted or assaulting others. The use of rather than aggressive, controlling rather than punitive, and reasonable force sufficient to prevent this is acceptable. use no more force than is necessary in the given situation. This includes situations where there is an overriding The justification of ‘self-defence’ relies on the argument necessity to protect someone. that the level of force used is reasonable given the threat faced. The level of force considered appropriate for self- The ‘emergency’ or ‘rescue’ powers given to departmental protection or to ensure the safety of others will remain workers provide the right (and responsibility) to rescue a a matter of judgement, depending on the context of the person from a dangerous situation. There are situations the specific persons and the situation involved. law ‘excuses from being assault’, such as: Appropriate responses Implied consent Appropriate responses to aggressive incidents are: Everyday activities of caring for clients require some physical contact between individuals. The department’s • crisis communication and negotiation where staff are clients have consented to the care provided and therefore being verbally abused or verbally threatened to the physical contact involved in that caring. However, • evasive self-defence to the threat of assault and battery, consent to such physical contact is not consent to restraint such as where physical contact or injury might occur or seclusion. • physical intervention and controlling self-defence to aggravated assault only where serious injury might be inflicted.
30 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.
31 Appendix 2. Summary of firearms and non-firearm weapons
Weapon type Definition/examples Legislation Authorisation
Firearms `Firearm’ is defined in section 3 of the Firearms Act Firearms Act 1996 Any person wishing to 1996 as any device: possess, carry or use • whether assembled or in parts; a firearm must obtain a • whether or not temporarily or permanently permit for each firearm they inoperable or incomplete; and possess and must hold a licence under this Act. • which is designed or adapted to discharge a bullet or other missile; or • which has the appearance of an operable firearm.
Non-firearm weapons The Control of Weapons Act 1990 divides non- Control of Dependent on category of firearm weapons into three defined categories: Weapons Act non-firearm weapon. • prohibited weapons, 1990 and Control • controlled weapons, and of Weapons Regulations 2000 • dangerous articles. Details of the specific weapons are set out in the Control of Weapons Regulations 2000.
Non-firearm weapons Prohibited weapons are particularly dangerous and Control of Persons wishing to 1. Prohibited weapons should not be available in the community, except Weapons Act possess and use these to persons able to display a specific need for such 1990 and Control weapons must obtain weapons. The list of prohibited weapons consists of Weapons a Governor in Council of 47 different items including certain prescribed Regulations 2000 Exemption or a Chief knives such as: Commissioners Approval. • 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.
32 Weapon type Definition/examples Legislation Authorisation
Non-firearm weapons Controlled weapons are potentially very dangerous Control of A person can only legally 2. Controlled weapons but more common weapons, which can only be Weapons Act possess, carry or use a possessed, carried or used with a lawful excuse. 1990 and Control controlled weapon if he or These weapons include: of Weapons she has a lawful excuse Regulations 2000 to do so. A lawful excuse • knives (other than those prescribed as prohibited would include employment weapons) related activities; sport, Other prescribed items including: entertainment or • spear guns • bayonets recreational pursuits; • batons • cattle prods. 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 Dangerous articles are other items either adapted Control of Dangerous articles can 3. Dangerous articles for use as a weapon or carried with the intention Weapons Act only be possessed or for being used as a weapon. These articles 1990 and Control carried in a public place include, for example: of Weapons with a lawful excuse, • a baseball bat deliberately fitted with nails so Regulations 2000 including the use of the that it can be used as a weapon article for the purpose for • a pair of scissors or a syringe when carried for which it was intended. use as a weapon.
33 Appendix 3. Suggested key elements of a health service firearms and non-firearms policy
Robust and integrated local operational policy and 5. Include as a condition of entry that clients will consent procedures should articulate the following aspects of to a search if required. A person who refuses to consent detecting, deterring and managing firearms and non- to a search can be asked to leave, and a subsequent firearm weapons within the specific health service setting: refusal to leave upon request may amount to the summary offence of trespass [Section 9(1)(d), Summary 1. Policy context and aims that: Offences Act 1966 (Vic)]. • apply to the whole health service community, that is, 6. Include specific procedures (separate policy) for no- clients, visitors and staff contact screening activities that may be employed, • include a clear rationale for deterring and controlling noting that this may only occur with consent. 4 weapons 7. Identify the specific processes for negotiating entry to • ensure primacy of ‘safety first’ health services by police and other officers authorised • promote establishment of a health service–police to carry and use firearms, and firearm control. partnership 8. Identify standards and requirements for documentation, • include clear proactive deterrent messages (such as reporting and monitoring of local policy and procedures entry with a weapon prohibited or refusal of entry - including client records, incident management and see point 4 below). security records. • identify opportunities to inform the public and 9. Identify the specific processes for recognising and reinforce the messages using positive language managing dangerous articles in health services. (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.
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.
34 Appendix 4. Establishing compliance with amendments to the Firearms Act 1996 and the Control of Weapons Act 1990.
All Victorian public health services will The changes and implications for health ensure that: service employers and employees their local weapons management policies and What are the new sections in the Firearms Act procedures are developed and/or reviewed in 1996 and the Control of Weapons Act 1990? consultation with their local police and legal counsel A new section 54AA has been inserted into the Firearms to ensure joint agreement about how weapons will Act and a new section 7A has been inserted into the be managed within their specific environment, taking Control of Weapons Act. These new sections should be into consideration variables such as access to gun read in conjunction with other relevant sections. safes (or agreed alternatives) and proximity of police (particularly in rural environments) What are the exemptions? there are clear policies and procedures that identify Section 54AA of the Firearms Act exempts specified health which workers are specified as exempt in the Firearms service workers, in specific circumstances, from committing Act and the Control of Weapons Act, including through an offence when ‘possessing’ a firearm. Section 7A of the contractual arrangements (for example, external security Control of Weapons Act exempts specified health service contracts or ‘agency’ staff), as well as the specific workers from committing an offence when ‘possessing’ a circumstances under which the exemptions apply controlled weapon, prohibited weapon or dangerous item. relevant policies and procedures include information What are the specific circumstances? about what is meant by a ‘prohibited person’, as set out in section 3(1) of the Firearms Act The specific circumstances under which the exemptions employment processes are in place to keep the health apply are that the health service worker, in the course of service informed of any current or potential employees carrying out his or her duties, takes possession of a firearm or other weapon that is either: who are ‘prohibited persons’ (and therefore not exempt from the specific breaches of the Acts), and that these a) given to them by a patient; or employees and their managers are aware that the b) removed from a patient; or exemptions do not apply to prohibited persons c) found in the vicinity of the patient; or affected staff members are aware of their d) given to them by a health service worker who has taken responsibilities under the Firearms Act and Control of possession of the firearm or weapon in one of the above Weapons Act and that policies and procedures reflect circumstances. and support lawful actions Which health service workers are exempt? these legislative changes are included on the agenda of the organisation’s Police and other key agencies The exemptions only apply to the health service workers collaborative committee (however titled) specified in the new sections of the Firearms Act and Control of Weapons Act. The specified health service workers are: joint agreements with local police are in place regarding the processes for safe storage of weapons • health professionals (registered nurses and midwives, while awaiting collection by the police and the safe registered medical practitioners, registered psychologists) disposal of weapons • health service security guards (defined in the Firearms processes are in place for accurate reporting and Act and Control of Weapons Act as ‘a security guard reviewing of incidents where health care workers need licensed under the Private Security Act 2004 when to take possession of a firearm or other weapon in the working in a health service facility as a contractor or an employee’) course of carrying out their duties. • ambulance workers (defined in the Firearms Act and Health services are encouraged to consult their Control of Weapons Act as ‘an operational staff member of the ambulance services as defined in the Ambulance local police and legal counsel when developing or Services Act 1986’). reviewing policies and procedures that are affected by these legislative changes. Note: The exemptions do not apply to a health service worker who is a ‘prohibited person’.
35 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.
36 References
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37 Preventing occupational violence A policy framework including principles for managing weapons in Victorian health services