Juggling with justice

Managing violence and security risks in health and residential care services

Everyone is at risk from the consequences of violence in the workplace – organisations, workers, clients, and visitors, writes Trish Butrej.

How big is the problem?An opportunity for cost savings and harm minimisation

This article talks about violence and security risks in health and residential care facilities with a focus on the risk of violence. This article does not deal with bullying which requires an entirely different risk-management strategy. Here we refer to the range of behaviours encompassing verbal abuse, threats and intimidation, physical violence against property, and physical violence against persons with or without the use of weapons.

While many reports have been published, there is no single report that quantifies the human and financial costs of violence and security incidents in health and residential care services. One former NSW Area Health Service (now divided into two Local Health Districts) advised the NSW Nurses’ Association that the cost of violence-related workers compensation claims amounted to $11 million per annum. Add to this the cost of property damage, physical and psychological injuries to people who may be assaulted but who are not covered by workers compensation (e.g. clients*), treatment costs associated with injuries to non-employees, backfilling of injured staff, internal and external investigations, litigation by injured parties, prosecutions under work health and safety legislation, and poor public image where incidents are reported in the media. Now, multiply this several times across a wide range of health and residential care organisations and it is easy to see how the cost of violence in NSW healthcare facilities alone could exceed $100 million per annum.

Anecdotally, the problem of violence seems to be getting worse. How do we know? Our nurse and midwifery members are increasingly raising violence and security as issues that they want addressed to the point where it is the subject of the majority of work health and safety-related complaints that we receive and investigations we carry out. During the past 15 months, NSWNA received approximately one report per month of a serious assault against one of our members. This is significantly more than the average in previous years. Of those incidents, five involved stabbings or attempted stabbings (one fatal), and three incidents resulted in serious head injuries. Of the incidents involving knives as weapons, two occurred in emergency departments, one in a mental health rehabilitation unit, one on a general ward, and one in an aged care facility.

The consequences of failing to manage risks

Health and residential care organisations and officers individually are at risk of prosecution and litigation if they do not take proactive steps to manage the risks of violence and security. There have been a number of successful prosecutions after violent incidents in NSW under the previous occupational health and safety legislation.

These prosecutions have included a range of public healthcare facilities and disability services. The new harmonised work health and safety laws are even more stringent in many respects with higher fines and stricter obligations on officers of corporations.

In NSW, some key prosecutions can be summarised as follows. (For those who are interested, the full findings are available on the internet.)

• Department of Community Services and the Department of Ageing Disability and Home Care (dealt with collectively as the original Department of Community Services was later divided to form the Department of Ageing Disability and Home Care and the Department of Community Services) were prosecuted in 1999, 2002, 2005 and again in 2008 over incidents relating to assaults on staff in residential facilities. Fines ranged from $95,000 to $285,000 over incidents in which staff were assaulted by clients. Key issues were lack of safe havens, lack of means for calling for assistance (duress alarms) and no systems for responding to such emergencies.


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  Central Sydney Area Health Service fined $180,000 in 2002 after four nurses were assaulted in a psychiatric hospital. Key factors included inadequate duress response procedures and failure to replace breakable glass with safety glazing despite the known risk that patients may break glass and use glass shards as weapons.

  
  


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  Northwest Disability Services Incorporated was fined $7,500 in 2002 for an assault on a staff member by a client with a history of aggression and assaults.

  
  


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  Western Sydney Area Health Service fined $90,000 in 2003 after a series of incidents in the car park culminating in a serious assault on two security officers in May 2000. The car park lighting was known to be deficient, and the risk of assault in the vicinity of the car park was known to the employer as there had been previous incidents.

  
  


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  Hunter Area Health Service was prosecuted twice – in 2003 and again in 2005. Fines were $46,000 and $105,000 respectively for assaults by patients on staff. In one case the duress alarm system was faulty and had a history of malfunction. In the other, there was no duress alarm system by which the assaulted nurse could call for assistance.

  
  


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  Ramsay Health Care Australia was fined $74,750 in 2004 after a nurse was assaulted in a private mental health clinic. The staff station was an entrapment point and training in duress alarm use was inadequate.

  
  


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  The Department of Ageing Disability and Home Care was fined $227,500 in 2005 over an assault on a nurse at a large residential care facility for people with developmental disabilities. Key features were the failure to provide safe premises, adequate duress alarms and duress response.

  
  


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  North Coast Area Health Service was fined $150,000 in 2005 over the fatal assault on a patient and injury of nurses during an incident at Kempsey District Hospital in 2001.

  
  


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  South Eastern Sydney and Illawarra Area Health Service fined $100,000 in 2007 for an assault on a nurse in an acute mental health unit. Key factors raised in the case were inadequate lighting and an unsafe system of work.

  
  


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  Department of Community Services was fined $200,000 in 2008 after an incident at a centre during which a client stabbed one staff member and threatened others.

  
  

What risk? Who’s at risk?

Is the risk foreseeable? Absolutely it is! It is not possible to predict exactly where and when the violence will occur and who will be involved. However, it is foreseeable that violence will occur at some point in time given the large number of incidents that occur each year. The probability will, of course vary between facilities and units depending on the clients and other factors. In the interests of legislative compliance, quality of service to clients and cost containment,steps must be taken to prevent and mitigate that risk as far as practicable.

As you would expect, verbal abuse and threats are the most common events closely followed by violence towards property and physical violence towards persons resulting in no or minor injury. However, while fatalities are relatively rare, assault resulting in significant physical injuries and long-lasting psychological trauma are sufficiently frequent and costly to alert persons conducting a business or undertaking (PCBUs) that risk management strategies must be implemented.

Security of clients, staff and property is a related and important issue. Events can range from kidnap and murder of staff working alone (we refer to Sandra Hoare who was kidnapped from Walgett Hospital and murdered in 1994), through to theft of property, assaults in car parks, and the protection of clients who may, due to their clinical condition, be at risk in situations where others would not (e.g. clients with cognitive deficits).

Serious assaults in health and residential care settings appear in the media from time to time. Many of these incidents have shocking and tragic consequences. Four that come immediately to mind are the death of a mental health nurse stabbed by a patient at Bloomfield Hospital in NSW in January 2011; the stabbing of an emergency department nurse at Blacktown Hospital in July 2011; the death of a nursing home resident in Melbourne in 2007 (see below); and, the death of an elderly female patient in Kempsey District Hospital in 2001. All of these events attracted considerable media interest.

Everyone is at risk from the consequences of violence in the workplace – organisations, workers, clients, and visitors. From an organisation perspective violent incidents can result in costly and lengthy workers compensation claims, damages claims from injured clients or visitors, court proceedings, investigations by police and other authorities, and loss of reputation resulting in lost business and recruitment and retention difficulties.

Whose rights?

‘Do no harm’ is the common law premise on which much of the specific legislation that applies to health and residential care services is based. Staff and others in health and residential care workplaces have legislated rights to a safe and healthy environment under work health and safety (WHS) legislation. Additional protections are offered in the various state and commonwealth laws that regulate health and residential care services, and discrimination.

Organisations need to consider that the above plethora of laws is designed to protect individuals and that none of these laws give anyone the right to assault, threaten, intimidate or abuse others. Health and residential care organisations need ensure that, in an attempt to protect the rights of one client, they do not violate the rights of other individuals to work or live in a facility where their health, safety and wellbeing is not at risk.

There have been many serious assaults on staff and clients with the majority going unreported in the media. Nurses have the option of bringing their issues to their union or to the work health and safety authority in their state. On the other hand, many clients, particularly those in residential care services, largely suffer in silence.

One exception that was widely reported in the media is the following case of a nursing home resident who was assaulted and subsequently died. Organisations who do not take adequate steps to address the risks of violence, could find themselves in a similar situation.

The case involved the death of Mrs Anderina Sanderson at Central Park Nursing Home, Windsor, Victoria on 23 April 2007 after being assaulted a few days earlier by a male resident with a history of assaults. The Coroner Kim Parkinson determined that the nursing home had contributed to Mrs Sanderson’s death by:

• Failing to adequately supervise the behaviour of the resident known to be aggressive, or to isolate the resident in order to keep others safe.


• Failing to implement specific plans for addressing violent behaviour of the resident.


• Failure to take steps to prevent recurrence after the first assault.

Coroner Kim Parkinson also remarked: “Dementia specific training for staff is a useful tool, however, in a case such as this, involving significant repeated violence, training is not a substitute for careful planning and management and allocation of additional staffing resources to direct supervision.” Additionally, the Coroner stated: “Aged persons are entitled to at least the same protections as any other member of the community.”

When implementing medication management, organisations need to be mindful of the legislation, policies, procedures and sensitivities around medicating clients with challenging behaviours. Restraint of clients who are mentally disordered or ill and a risk to themselves or others is a recognised clinical practice in situations where there is no other option. However, it is a last resort rather than an alternative to, for example, adequate skilled staff and a well-designed clinical environment. Nevertheless, before withholding medication, consideration needs to be given to whether in doing so the facility is denying a client legitimate treatment for psychiatric symptoms such as psychosis, paranoia or anxiety, as this could constitute a breach of duty of care and/or discrimination. In all cases, the decision to medicate or otherwise needs to be based on sound clinical judgement, and implemented in a way that is consistent with legislation and policy.

An additional security issue requiring vigilance from health and residential care services is ensuring the safety of patients who for reasons of illness or cognitive decline may come to harm in circumstances and environments which are not regarded as potentially harmful to the general community, e.g. roads. The security of babies and children also has to be considered – even unwell children can be masters of curiosity and adventure. One visiting toddler that ‘suddenly disappeared’ from sight was found inside a thermal food trolley with the door shut – fortunately before any harm had befallen him.

What can be done to manage the risk?

This article sets out some fundamental ‘must haves’ for a violence and security risk-management framework. Such a framework needs to be integrated into the core business policies, protocols and reporting systems for the organisation if it is to be effective. The approach is consistent with the harmonised work health and safety legislation and accepted international and Australian Standards for risk management. The information provided here assumes a basic knowledge of risk management principles and practice. For more information, we suggest that you refer to the many guidance documents listed here and/or contact your industry association and unions.

Consult

Consult with staff, clients and their representatives on risks and how to manage them. This can be done via the standard mechanisms of health and safety representatives, work health and safety committees,surveys and focus groups. Alternatively you may like to set up a special purpose working group.

Identify sources of risk

Don’t stop at naming the risk (violence) but think about root causes and what factors or situations might contribute to the creation of risk and the outcomes. With respect to outcomes, consider what could happen during and after a violent incident that might worsen the severity of injuries (e.g. delayed response). Triggers for risk identification include plans to making changes to premises, systems of work, equipment; and after an incident has occurred. All proposal documents and briefs should include a section assessing the health and safety impacts (for staff and clients) of the proposal.

Develop risk control strategies

Strategies include:

1. Risk assessment of clients, premises, systems, equipment and training. Risk assessment should be built into clinical practice and reflected in admission criteria, patient assessment, management plans, and treatment protocols. For example, staff should be well versed in how to recognise the early signs of delirium and what steps to take as a result. Any identification of escalating behaviours in a client or the occurrence of a violent incident should be the trigger for an immediate clinical review by an appropriate medical officer.


2. Clinical procedures that enable early identification and treatment of medical, psychiatric and congenital conditions that can cause violent behaviours. Ensure that these are documented, available, staff are skilled in implementation, and supportive supervision is present on each shift.


3. Methods of communicating the risks to staff and others who need to know (e.g. visiting clinicians). This includes systems for developing and reviewing client alerts, procedures for obtaining adequate information about clients prior to admission (where admissions are planned), and the development of management plans. Inclusion of a sheet summarising patient risks (clinical and behavioural) at the front of the file and referring to management plans is a useful practice.


4. Design premises to reduce risks, e.g. secure perimeters, separation of staff and patient areas, lighting, monitoring via CCTV. Technology is becoming increasingly sophisticated with the ability to integrate multiple systems so that they report to a single communication device worn by the staff member, for example a DECT unit that has duress alarm, telephone, nurse call, fi re alarm, pager and door alarm capabilities.


5. Install equipment to alert staff of incidents and potential breaches of security, e.g. duress alarms, patient alarms, door alarms.


6. Safe systems of work including staffing and skill levels. Staffing and skill mix should be sufficient to allow for adequate observation of clients and their behaviours and to provide a basic response to an incident including performing the restraint of an unarmed client. Doing this safely requires at least five properly trained staff that can get to the scene, preferably within 30 to 60 seconds.


7. Education of managers and staff in risk management including knowledge of related systems and procedures, clinical skills, the identification of escalating behaviours and warning signs, de-escalation, where the risks in a particular service – facility or unit warrant it, the physical restrain of clients, and when to call the police.


8. Emergency response procedures including duress response teams.

Report and review

Report and review systems, incidents and risk management strategies. Implement user-friendly reporting systems. Many violent incidents have both clinical and non-clinical aspects and needs to be reflected in reporting systems. Implement a system for regular review of policies and procedures to ensure their ongoing effectiveness. Regular auditing of risk management strategies should also be carried out. Incidents should be triggers for clinical review where they involve a client, and for review of risk management strategies including facility design.

Conclusion and key messages

While the health and residential care sectors have made progress over the past 15 years or so, there is still a lot more that can be done especially in some industry subsectors.

There take home messages for health and residential care managers are:

• The risk of violence towards staff and clients is very real and has the potential to result in significant costs and negative outcomes for organisations.


• The cost of negative outcomes following a serious assault can far outweigh the cost of implementing and maintaining risk control strategies. It is better to increase the budget for prevention and maintenance than to spend more on negative outcomes such as workers compensation, fines and litigation. Money well invested in prevention and harm mitigation can result in positive cost benefits.


• Staff and clients have the right to work and live in an environment that supports their health safety and welfare. The rights of challenging clients never override the rights of other clients, visitors, or staff.


• While it may not always be possible to eliminate all risks, steps can be taken to reduce the likelihood that incidents will occur, and to minimise the amount of harm if they do occur.


• Neglecting to address the risk of violence potentially breaches a number of state and federal laws and potentially breaches duty of care requirements.

* The term ‘client’ is used in this article to describe the various health care relationships including ‘patient’, ‘resident’ and consumer’.

Resources

There are many resources that are freely available on the internet. Favourites are listed below. Many originate from NSW Health. However, the information is easily adaptable to other health and residential care services.

In addition to documented guidance, facilities are encouraged to contact their respective industry associations and unions particularly when planning new facilities or renovations, when proposing to make significant changes to staffing levels, skill mix, systems of work or equipment.

• NSW Health, 2003, Protecting People and Property: NSW Health policy and guidelines for security risk management in health facilities. This is a somewhat encyclopaedic tome. However, it contains much useful advice and is a wonderful reference. Not all chapters will be relevant to all organisations but it is readily adaptable: www.health.nsw.gov.au/ resources/policies/manuals/pdf/protecting_people_ property.pdf
  


• NSW Health, 2003, Zero Tolerance Response to Violence in the NSW Health Workplace, PD2005_315. Includes strategies such as patient alerts and management plans, and a cascade of responses to aggressive behaviours by patients and others: www.health.nsw.gov.au/policies/ PD/2005/pdf/PD2005_315.pdf
  


• NSW Health, 2005, Employee Assistance Programs: NSW Health Policy and Best Practice, PD2005_568: www.health.nsw.gov.au/policies/pd/2005/pdf/ PD2005_568.pdf
  


• NSW Health, 2005, Incident - Effective Incident Response Framework for Prevention & Management in the Health Workplace, PD2005_234


• NSW Health, 2007, Incident Management, PD2007_06: www.health.nsw.gov.au/policies/ pd/2007/pdf/PD2007_061.pdf
  


• Australasian Health Infrastructure Alliance and University of NSW (Centre for Health Assets Australia), 2009, Australasian Health Facility Guidelines: www.healthfacilityguidelines.com.au
  


• NSW Health, 2012, Violence Prevention and Management Training Framework for the NSW Public Health System, PD2012_008: www.health.nsw.gov.au/policies/pd/2012/PD2012_008.

Trish Butrej

Trish Butrej is a Professional Officer working for the NSW Nurses’ Association and specialising in the field of work health and safety. Trish has a Master’s degree in Occupational Health and Safety from the University of Sydney and is a Fellow of the Safety Institute of Australia. She has worked in healthcare WHS for 22 years. During this time she has actively participated in a number of committees and working parties at Commonwealth and State levels developing legislation, Standards, codes of practice, policies and procedures.

The NSW Nurses’ Association is a professional and industrial organisation representing nurses with more than 56,000 members. Members include executive, managerial, supervisory and clinical nurses, all of whom are able to request the advice or assistance of the Association. In her role with the NSW Nurses’ Association, Trish provides advice to nurses and to staff with responsibilities for nurses’ safety, and investigates complaints from members about WHS.

Communications and inquiries about this article are welcome – email tbutrej@nswnurses.asn.au.