Prevention and Management of Violence and Aggression Training

Prevention and Management of Violence and Aggression Training
STEPHEN WHEELER

Are we at risk?

Prevention & Management of Violence & Aggression in the Workplace Aims
To enable an understanding of aggression and violence that may be encountered during the course of your employment. To offer a framework to be used when faced with an angry person. To recognise and respect the diversity within our environment, while promoting and delivering good practice in the safe prevention and management of violence and aggression.

to recognise and defuse potentially violent episodes.
Prevention & Management of Violence & Aggression in the Workplace Objectives to recognise and defuse potentially violent episodes. to avoid overreaction to episodes of violence. to maximise staff and client safety. to enable the confidence. to recognise what can be dealt with safety and what cannot. The aim of today’s training is Nothing is guaranteed totally painless but our aim is to minimise pain and to give options to be used according to personal and clinical judgement. Physical interventions are designed to promote confidence. When confidence is enhanced more time can be dedicated to de-escalation. Exercise [optional] Group introductions. Split the group into pairs. introduce yourselves to your partners, e.g.. name, where you work etc.. Take a couple of minutes each. When the group gets back together each person can tell the large group about the information you have about their partner. Time allocated: minutes.

Organisational Expectation
NHS Lanarkshire does not expect any of its staff to put themselves at undue risk from violence and aggression. Prevention of violence and aggression is the safest and preferred option. It is acceptable to acknowledge instinct and to explore alternative strategies. Not all risk comes from clients. Risk may come from the client, their family members, significant others or pets. If a pet is the problem you are entitled to ask it be secured for the duration of your visit. If a safety request of this nature is not upheld you may leave and make alternative arrangements for dealing with the person e.g. a clinic appointment. In many instances the safest action is to withdraw and return with a colleague/s. Don’t dismiss instinct, if your instinct tells you that something is wrong… Pay attention! Instinct is a combination of professional and life experience and you simply have not realised the detail. It is acceptable to remove yourself from a potentially violent situation if this is the safest action available.

Your Responsibilities.
Familiarise yourself and comply with: Organisational policies and procedures Local policies and procedures Health & Safety Control Book Complete accident reports for all incidents and near misses. Attend and participate in training

What Increases Risk? Can be used as a discussion or just shown if group are participating well.

What Increases Risk? Working alone
Working outside normal working hours Working within a community Handling valuables and medication Providing or withholding a service Exercising authority Working with people who are emotionally or mentally unstable Working with people who are under the influence of drugs and/or alcohol Working with people under stress Working with people who have to wait while in pain or discomfort. Can be used as a discussion or just shown if group are participating well.

What is Violence? The Health and Safety Executive (HSE) 2004 define violence as, “Any incident in which a person working in the healthcare sector is verbally abused, threatened or assaulted by a patient or member of the public in circumstances relating to his or her employment.” There are many definitions this is most recent from Health & Safety exec 2004.

What makes YOU Angry?

Perception What makes one person afraid or uncomfortable may be perfectly acceptable to someone else. It is necessary to take this ‘personal perspective’ into account. It is important to recognise that individuals will view incidents differently. It is important to recognise that individuals will view incidents differently

Obvious warning signs Group Exercise

FACE Sweat Skin Color changes Grimacing Sneering Clenched teeth EYES Pupils dilate. Staring Crying POSTURE Upright stance Invading personal space Neck and shoulder muscles tense VOICE Tone and pitch changes Volume and speed of speech increases. Speech content changes, obscenities, threats, insults, dismissive remarks and silences. Replies to questions abruptly often with aggressive Spitting out words Lost for words [can’t think straight] May become quieter. Uncommunicative BREATHING Breathing becomes faster and more shallow, HANDS White knuckles Clenched fists Obscene/gestures Throwing things Thumping fist on objects Slamming doors Pointing fingers Shaking fists Hidden hands [possible concealed weapon] Can be used as discussion or use flip chart to encourage participation. BEHAVIOUR Appear oblivious to surroundings Signs of confusion Signs of withdrawal Signs of delusions and/or hallucinations FEET Pacing Very still Kicking the ground

What causes Violence and Aggression?
A combination of factors: Anger Frustration Medical or Psychological conditions Influence of drugs and/or alcohol Power or control issues

The Typical Assault Cycle
( based on Kaplan and Wheeler (1983) Escalation Phase Crisis Phase Summit Post Crisis Depression Phase Excitable Transfer [possible additional assaults] Trigger phase Escalation shift Plateau or Recovery Phase Decent Assault Cycle The Assault cycle had five interrelated stages Baseline Behaviour that is normal everyday behaviour for that individual that is non-aggressive for most of the time. Trigger All clients have a normal or baseline set of non-aggressive behaviours. This is the point where the individual first indicates a movement away from how they usually behave. Unless you have detailed understanding of the client these possible early warning signs can be missed. Changes can be perceived in non-verbal, verbal behaviour e.g unwillingness to sit down. Inability to wait for you to finish your sentence Answer before the question is completed Failing to make eye contact. The less detailed understanding you have of the individual the more easily you can miss early warning signs. Try to implement interventions: time talking and listening Examples for trigger phase initiation Misunderstanding and suspicion Lack of space – privacy Alcohol, drugs tiredness Resistance to staff handling or attention Bad news Particular words or labels The main problem is their idiosyncrasy and the numerous minefields. Escalation Behaviour deviates more from the baseline if there is no intervention. Deviation will become increasingly more obvious and the person will become less amenable to diversion e.g: Pacing, Speed and volume of speech may increase . Queries may be ignored completely Individual may become overly focused on a particular issue and is less likely to responds to any form of rational intervention. Intervene as soon as possible. E.g. Counselling, removal from the immediate environment. Supply alternative task or anger management During this phase your actions are likely to be over -interpreted and posture and stance perceived as aggressive. Essentially the assailant is looking for anything negative to justify the attack Crisis Client [and the practitioner] becomes increasingly physically, emotionally and psychologically aroused. Control over aggressive impulses lessens and actual violent behaviour becomes more likely e.g. Kicking or overturning furniture, pushing or punching the practitioner, throwing crockery The least effective strategy to adopt for an intervention is one which presumes the individual can respond rationally. Control over impulses lessen. Verbal argument or confrontation is likely to exaggerate the agitation of the assailant. Most intervention errors occur due to quickly recovering to relive own anxiety and duty to help client recover from incident. Once the crisis phase has been reached it is advisable to focus on your own safety and the safety of the assailant or anyone else who may be threatened. Attempts to hold or touch the assailant are extremely dangerous at this stage and may precipitate more extreme aggression. It is important to focus on own safety your client and anyone else who might be threatened. Intervention may be to engage in physical restraint. Options available are limited Escape Seek help Physical restraint Physically protect yourself By this phase the assailant will normally have persuaded themselves that the attack is justified. Recovery Gradual return to normal baseline behaviour. It is at this point that most intervention errors occur. This a state of high arousal [adrenaline] can remain for a period of up to 1.5 hours after the incident. Attempts at intervention can lead to the renewal of the violent attack. Interventions should be carefully considered and timed. During this phase the individual is particularly sensitive to the sorts of trigger factors which have been described earlier. The phenomenon of a sudden steep change in aggression is something to watch closely for, the assailant does not retrace the path through the phases, offering no opportunity to think or manage. Post Crises Depression Phase The client regresses below baseline behaviour. Mental, physical exhaustion are common. Precipitated by psychological changes becoming tearful, remorseful, guilty, ashamed, distraught or in despair The individual may be receptive to interventions designed to relieve guilt, understand the incident and perhaps prevent its recurrence. Practitioner may parallel the feelings of exhaustion or fatigue. Both aggressor and practitioner experience high levels of physical or psychological arousal during episodes of aggressive behaviour. The crisis is over and interventions designed to relive guilt, promote understanding and maintain relationship with client. Supplementary Learning Disability Specific Behaviour everyday behaviour that is normal everyday behaviour for that individual that is non-aggressive. Emotional Transfer Emotional Transfer Baseline Behaviour

Self Defense You can act in self defence of another inScots Law and you can come to the assistance of a person under threat of imminent physical violence.

Use of Force A person may use force as is reasonable in the circumstances for the purpose of Self Defence Defence of another Defence of Property Prevention of a Crime The use of force must be both necessary in the circumstances and should be proportional to the threat

Understanding Fear & Anger
The Adrenaline Flows Glucose is released by the liver Breathing gets faster The heart beats faster Skin changes occur The pupils of the eyes open wider Blood is diverted from the digestive system The muscles tense for action And so the body is prepared for Fight or Flight. Glucose is released by the liver to help muscles work. Breathing gets faster, even gasping, so that the extra oxygen can transform the glucose into energy. The heart beats faster, as it needs to work harder to take the extra oxygen in the blood to the muscles. Blood is diverted from the digestive system to compensate for the above, so symptoms such as churning stomach and dry mouth occur. The muscles tense for action Skin changes occur due to the increased activity of the body: e.g. sweating, to cool the body. The pupils of the eyes open wider to make for clearer vision. So the body is prepared for FIGHT or FLIGHT But what help is that in doing your job? Glucose is released by the liver to help muscles work. Breathing gets faster, even gasping, so that the extra oxygen can transform the glucose into energy. The heart beats faster, as it needs to work harder to take the extra oxygen in the blood to the muscles. Blood is diverted from the digestive system to compensate for the above, so symptoms such as churning stomach and dry mouth occur. Skin changes occur due to the increased activity of the body: e.g. sweating, to cool the body. The pupils of the eyes open wider to make for clearer vision. The muscles tense for action

Points to note Being angry can be normal
An angry person will be looking for reasons to justify the way they feel and therefore, their behaviour. An audience may inflame the situation. Being grateful can minimise feelings of anger.

De-escalation De-escalation is based on core values and skills.
We communicate a great deal about ourselves by our non-verbal behaviour, which seems more important than what we say. Although most non verbal behaviour is unconscious and automatic we can take control.

De-fusion & De-escalation
When faced with a potential violent incident, de-fusion and de-escalation should be attempted as a first option where possible. De-fusion & De-escalation are influenced by the attackers ability to understand what is being said. Where this ability to understand is absent defusing and de-escalation is affected. Those with learning disabilities, head injuries, dementias, intoxication etc. may be unable to understand verbal input. Use simple, clear language.

GROUP WORK

Assessing Risks Assessing Risks Spectrum of Dangerousness
No problem A bit iffy [could go either way] Difficult [all your skills] Dangerous [all your skills plus luck] “aaaargh”! [the wrong place at the wrong time]

Prevention and Management of Violence and Aggression Waiting for the GP.
How does the patient feel? Physical Emotional Assault cycle reference back What warning signs would be evident? Body language,actions,spoken word

Actions Safety takes precedence Give obvious assistance.
Make friendly gesture Make a Concession MAKE A DELIBERATE FRIENDLY GESTURE This is another way of breaking a conflict situation is to meet antagonism with a friendly gesture. e.g.... “come into my office and we’ll talk about it”; “let me get you something to drink”. It is not important what the gift is but the fact that we are offering puts us in the donor role. Its difficult to be annoyed and grateful at the same time. Make sure the gesture is safe. e.g hot tea may not be the ideal gesture! MAKE A CONCESSION If one side yields a little the other side often does too. Again it is difficult to be annoyed and grateful at the same time. DEMONSTRATE INTEREST IN WHAT THE CLIENT IS SAYING. This is done by reflecting back to check whether we have understood correctly. e.g.... “so someone said they would contact you today “- this lets the person know we are listening and that we understood their information. Statements like “I want to make sure I have understood this properly can also help to reinforce this. It is also a good thing to reflect our judgement of the persons feelings both in retrospect e.g.... You were probably quite angry waiting for someone to call and then not” and in the here and now.” I can see you are very upset”. It is often possible to sympathise “ If I were you I would be angry too”- this can often be a useful way of winning the person over.

Receptionist Scene one
The receptionist is really busy, especially as his colleague has had to slip out for an hour.He also has been given typing to do which is urgent. The clinic didn’t start on time and is now running late . A queue has built up. What would the receptionist do ? About her work load About the patients waiting What could the receptionist say ? What would she be looking for About the patients turning up for appointments

Actions Apologise Talking and/or listening should be tried in the first instance. Hear Communicate clearly Use words appropriate to the violent person’s level of understanding. Demonstrate an interest in what the person is saying.

Receptionist Scene 2 The next patient is obviously annoyed at having to wait for attention. Swaying slightly, he says aggressively: “I’ve been waiting ten minutes in this queue. Its’ just not good enough How would the receptionist present herself body language,posture? What would the receptionist be looking for What would she say.(Deescalation ,Defusion) What might she miss What could influence her assessment of the situation Could she get it wrong How could she get it wrong Assault cycle Does everything she can BUT

Actions De-personalise issues. Divert the focus Personalise yourself.
Turn you into a “real” person. Empower the client. Acknowledge that if you work together you can both find a solution.

Receptionist Scene Three
The telephone beside the receptionist rings: “Excuse me”, he says to the patient, and answers the telephone,he then has to go and find some information. He completes the telephone conversation and then turns his attention again to the patient: “ Where were we? What was it again?” Should she have answered the phone? She was polite There are other demands on her time Did she deal with the situation well What could she have done,said Assault cycle Would that have eased the tension lowered the arousal levels? Body language good or bad? Verbal via body language

Tone Pitch Volume Accent Actions: Voice
Avoid being provocative or patronising, Pitch Volume Accent Can cause an escalation. VERBAL TECHNIQUES Voice Give example of how changing accent can change the meaning of a sentence AVOID PROVOCATIVE PHRASES It may be tempting to tell a client just what you think of them by using phrases like “don’t be silly” or “there’s people much worse off than you” or “pull yourself together”- probably on of the most common phrases used “calm down” - how do you feel if someone says those things to you? ALLOW THE PERSON TIME AND SPACE Someone who is angry often needs to get it off their chest, and anything that conveys the message that we don’t have time to listen to their complaint or worry may inflame them further. Phrases such as “Please tell me what is bothering you” “Let’s sit down and you can tell me about it” “I’D like to hear about your concerns” “I’ve got plenty of time, just you go ahead and tell me what the problem is” “Start at the beginning and then take your time and tell me what has made you feel this way” Give the person space and permission to give their own account. CONVEY OUR DESIRE TO REDUCE DISTRESS “I’m sure we’ll be able to sort something out”- this type of phrase encourage the person to calm down by assuring them that some helpful action will be performed. The hope is that the person will be less angry not only because of practical help offered but also that they have been allowed to put their case forward.

Receptionist Scene Four
But the patient retorts: “ If that phone rings again before you’ve dealt with me, I’m going to teach you a lesson you’ll never forget.”

Actions Convey a desire to reduce distress
Acknowledge concerns and feelings. “I can appreciate how worried you must be…………..” “I can see the difficulty you have…….” Check understanding. Recap

Receptionist Scene Five
The phone rings again and the patient immediately thrusts his hand across the desk. “ Right, you’ve been warned. I’m going to have you.”

Actions Give the person time and space. Safety strategies
Safe environment Alerts

Receptionist Scene Six
WRONG PLACE WRONG TIME

Proximity and angle to the other person Body Buffer Zone
Actions Facial Expression Gestures Posture Proximity and angle to the other person Body Buffer Zone Personal space WHAT DO YOU THINK WOULD BE INCLUDED HERE BRAINSTORM We communicate a great deal about ourselves by our non-verbal behaviour, which seems more important than what we say. Non-verbal behaviour is largely unconscious and people are often surprised when they see themselves on video interacting with others. Although most non verbal behaviour is unconscious and automatic we can take control of many aspects of these behaviours. Like other skills they can be rehearsed and practiced until we become proficient. Here are a few aspects which may merit some special attention. (DEMONSTRATE) Facial Expressions Gestures Posture Proximity and angle to the other person BODY BUFFER ZONE- We all have our zone of personal; space around us, if someone comes too close, and invades that zone we tend to feel uncomfortable, crowded and perhaps threatened. It is therefore useful to avoid intruding on a clients personal space by keeping a reasonable distance from them and allowing them space. It is difficult to get this right as people differ some cultures e.g..... Eastern cultures tend to stand closer than Westerners. People who are habitually violent have a much larger body buffer zone. It is best to err on the side of safety that way we will be out of arms reach.

Actions: Eye Contact Staring Squaring up Confrontational
Taking notes can promote natural limited joint eye contact. EYE CONTACT The pattern of eye contact during an aggressive exchange is as follows · initially normal eye contact takes place . The person listening looking at the person talking roughly twice as much. Spells of joint eye to eye contact are limited to a second or two. · as aggression develops both parties tend to avoid eye contact. · stage three is where at least one of the involved- the aggressor- indulges in steady, staring aggressive eye contact, and will sometime demand eye contact from the other. Our task is therefore to endeavour to stay at the first stage- the normal stage or as close as possible. There are two things that can help us, when things are getting heated. Do not have chairs facing one another if the chairs are at an angle to each other it makes it easier to look away and maintain normal eye contact. Another thing you could do is take notes about the persons grievance. It shows concern on our part and that we are taking the person seriously- it also gives us the opportunity to turn our gaze away. AVOID SQUARING UP A head on face to face position is challenging and confrontational and is rarely adopted in normal interaction between males in the UK. (though it is by females). It is however the stance adopted by those seeking to be actively aggressive, regardless of gender. Our task is then to introduce an angle- even a small one between you and the aggressor; this is a powerful thing to do, if we can achieve it, because it greatly lessens the sense of and reality of threat.

De-escalation Techniques Non-verbal
Mirroring is a subtle, non-verbal interaction, which encourages mimicry by others Can be calming in some situations. MIRRORING Researchers agree that verbal interaction is used primarily to convey information, while non verbal interaction is used for conveying and negotiating interpersonal attitudes, and in some cases replaces verbal interaction. When ever we get a `gut` feeling about another person, what we are really interpreting is that the other persons verbal communication is not consistent with their Non verbal communication. Research has shown that when a leader of a group uses certain gestures and positions, the rest of the group will copy them. Therefore we can see the effect that non-verbal body language has on our ability to communicate. When people are interacting they tend to adopt the same physical position. When one leans forward the other does the same. If two people are standing and one sits the other is likely to do the same. Research has shown that people who mirror one another get along better than those who don’t. This is normally an automatic phenomenon, we can use the effect deliberately in order to improve the quality of our interactions. We have to be subtle to avoid obvious mimicking, mirroring the way the other person is sitting or standing will tend to make the client feel more at ease

Remember We have no control over what people say or the way they act, but we do have control over the way we behave and respond to their behaviour. The angry person may have been justified.

Prevention and Management of Violence and Aggression Training

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