Management of Aggression & Violence – Conflict Resolution Training. - December 2013

1. Management of Aggression & Violence – Conflict Resolution Training. - December 2013

2. Aims: To provide a summary of the role of NHS Protect, local anti-crime roles & security management work in the NHS. To illustrate what constitutes conflict, how it arises, and how to be effective in reducing the risk of conflict occurring. To explore the role of communication in conflict and how to use it effectively. To outline the procedural, environment and legal context of violence in the workplace. To explain what is required of individuals and organisations after a violent incident. CONFLICT RESOLUTION TRAINING

3. NHS Protect NHS Protect has five high-level organisational aims. These are: (as per The NHS Standard Contract 2013: GeneralCondition 6.1 requires all providers to put in place and maintain appropriate counter fraud and security management arrangements prior to the commencement date of the contract). - To provide national leadership for all NHS anti-crime work by applying an approach that is strategic, co-ordinated, intelligence led and evidence based. - To work in partnership with the NHS, DH, NHS England and with our key stakeholders including with the police, CPS and local authorities to coordinate and deliver our work, to take action against those who commit offences against the NHS.

4. - To lead investigations into serious, organised and/or complex financial risks and losses including fraud, bribery and corruption within a clear professional and ethical framework. - To establish a safe and secure physical environment that has systems and policies in place to protect NHS staff from violence, harassment and abuse; safeguard NHS property and assets from theft,misappropriation, or criminal damage; and protect resources from fraud, bribery and corruption. - To quality assure the delivery of anti-crime work with stakeholders to ensure the highest standard is consistently applied.

5. “Incidents where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health”. DEFINITION OF WORK RELATED VIOLENCE.Adopted by: NHS Executive and RCN, in; Safer, (1998). RCN Publications.DOH Zero Tolerance (2000).

6. Definitions of assault.CFSMS – Secretary of State Directions on tackling violence against NHS staff and professionals Nov 2003 Non-physical assault – “The use of inappropriate words or behaviour causing distress and/or constituting harassment”. Physical assault – “The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort”.

7. ARA Issued Demographic Screen in the Patient Administration System Alerts recorded here are fed into Maxims and Oceano automatically

8. A red triangle appears for anyone with an alert Maxims Demographic Screen

9. Maxims Alert Screen Alert Details

10. Red triangle appears Oceano Demographic Screen

11. Expanded to see alert detail Expanded details of alert

12. Core Care PlanClinically Related Challenging Behaviours

13. FURTHER ASSESMENT OF PROBLEM Assess and document all underlying causes of clinically related challenging behaviour, for example: Infection Head injury Pain Medication Anxiety Acute Confusional State Manic episode Psychosis Hallucinations Dementia Sleep deprivation Alcohol and/or drug misuse High stimulus environment Disempowerment Recent altercation or receipt of bad news Document if these are short term and reversible or established longer term challenges. Consider the need for Safe and Supportive Observations as per Trust Policy.

14. RESTRAINT Assessment of Mental Capacity should be demonstrated as per Trust Policy when restraint is required - document the assessment and outcome in the evaluation sheet. Persons implementing restraint must reasonably believe that restraint is necessary to prevent harm and the level of restraint used is proportionate in response to the likelihood and seriousness of harm - document the identified risks and how many staff are required in the evaluation sheet. Staff applying restraint should be made aware of physical and emotional risks to the person being restrained, in particular including risk of positional asphyxia – document how this has happened in the evaluation sheet. The effectiveness of the practice in meeting its aims should be continually reviewed and the practice should continue only for as long as it remains both effective and necessary - document the review and outcome in the evaluation sheet.

15. ACTIONS Offer the person support and reassurance – document how this has happened in the evaluation sheet. Promote privacy and dignity at all times – document how this has happened in the evaluation sheet. Ensure all staff are aware of any risks and how to call for help when required – document how this has happened in the evaluation sheet. All incidents must be reported on DATIX and documented in the medical notes, including: A Mental Capacity assessment where appropriate Steps that were taken to de-escalate the situation prior to the use of restraint The duration of the restraint How many staff were involved The outcome of the situation Ongoing assessment and management of the patient with regards to violence, aggression and restraint

16. THE PERSON : Is the person facing high levels of stress ? Are the persons inhibitions reduced ? (Illness, drugs, alcohol, pain). Is the person Behaving abnormally ? Do they have a known mental health problem or Learning Disability ? Are they able to communicate effectively ? ASSESSING THE RISKS.Based on: Breakwell G M (1989). Facing Physical Violence. Routledge. (British Psychological Society). London.Royal College of Psychiatrists (1998). Management of Imminent Violence; Risk Factors Associated with Violence. Occ. Paper. R C P, L:ondon.

17. Has the person a history of violent or aggressive behavior ? Have they threatened to attack you or frightened you in the past ? (Does their gender, age or subculture, reflect a propensity for aggressive behaviour ?). Does the person consider you a threat, or as deliberately unhelpful ? (Threat to themselves or family. Do they have a negative view of the profession ?)

18. THE TASK: Are you having to give ‘bad news’ / tell them something they don’t want to hear ? Are you refusing to give the person what they want ? Do they see you as being helpful ? Have they unrealistic expectations of you ?

19. THE ENVIRONMENT / SETTING: Are you alone, without backup, or means of raising the alarm ? Are your colleagues aware of your where-abouts ? Are there weapons or cues for violence ? Are you familiar with the environment, your escape route, or how to get away ? Is the environment one, where aggressive behaviour might be rewarded ?

20. YOU: (self awareness) Are you aware of how you might react in an aggressive / violent situation or considered what you might do if attacked or threatened ? Have you a raised awareness of your own communication skills / what you are communicating ? Are you aware of where you may be on the assault / arousal cycle ? Can you de-escalate the situation ? Do you need to leave ? What credible / plausible excuse can you make ?

21. BASELINE BEHAVIOUR THE ASSAULT / AROUSAL CYCLE Kaplan & Wheeler 1983 / Responses to different stages of cycle, adapted from Turnball et al 1990. RECOVERY PHASE CRISIS PHASE ESCALATION PHASE TRIGGER PHASE POST-CRISIS DEPRESSION

22. BASELINE BEHAVIOUR THE ASSAULT / AROUSAL CYCLE RECOVERY PHASE CRISIS PHASE ESCALATION PHASE TRIGGER PHASE POST-CRISIS DEPRESSION

23. DE-ESCALATION “The concept of de-escalation, sometimes also referred to as ‘defusing’ or ‘talk-down’, is simple. It refers to a set of verbal and non-verbal responses which, if used selectively and appropriately, reduce the level of a person’s hostility; by reducing anger and the predisposition to assaultive behaviour”. Turnbull J et al (1990). Turn it around: short term management of aggression and anger. Journal of Psychosocial Nursing, 28, 6-12.

24. communication Spoken word 7% Paralanguage 38% Kinesics/body language 55% Communication skills - managing angry, aggressive and violent behaviour. P Boatman (2001)

25. L - listen E - empathise A - ask P - paraphrase S - summarise (G Thompson - verbal judo)

26. Ask Reasonable appeal (explain why) Personal appeal (options) Final appeal (is there anything else I can say or do) Action 5 step appeal dealing with aggression or violence

27. Click here to view De-escalation Scenario 1

28. Click here to view De-escalation Scenario 2

29. Mood match. Mirror, ‘subtly’. Maintain ‘normal’ eye contact. Sit when appropriate. Have a relaxed and open posture. Use open and calming gestures. Sit or stand at an angle. Allow personal space. Diversity awareness Be aware of any tension or anxiety creeping in to the way in which you are communicating. Appear relaxed and calm. Be self aware. DE-ESCALATION: NON-VERBAL SKILLS / TECHNIQUES.

30. DE-ESCALATION: VERBAL SKILLS / TECHNIQUES. Allow the person space and time. Show concern and understanding. Acknowledge the persons feelings. Make a token concession. Make a deliberately friendly gesture. Avoid provocative phrases. Communicate clearly. Paraphrase / direct the dialogue / open ?

31. Depersonalise issues. Personalise yourself. Empower the person. Acknowledge that together you need to find a solution. (Ensuring solutions are realistic/ achievable).

32. Definition of the law of Self Defence, Defence of another, Defence of property. “A person may use such force as is reasonable in the circumstances, in the prevention of crime or effecting or assisting in the lawful arrest of offenders or suspected offenders or persons unlawfully at large.” Sec. 3 Criminal Law Act 1967

33. Common Law • “A defendant is entitled to use reasonable force to protect himself, others for whom he is responsible and his property. It must be reasonable” - Beckford v R AC 130, 1988 (Lord Griffin)

34. Further Information NHS Protect www.nhsbsa.nhs.uk www.nhsprotect.nhs.uk/reducingdistress Jon Wiggans – Management of Aggression & Violence – Lead, Learning & Development, Royal Cornwall Hospitals NHS Trusts Ian Davies – Management of Aggression & Violence – Specialist Trainer. Jon.Wiggans@rcht.cornwall.nhs.uk Ian.Davies@rcht.cornwall.nhs.uk Learning & Development Dept – 01872 255148 Training@cornwall.nhs.uk

35. CONFLICT RESOLUTION TRAINING - test. 1. What is meant by an ARA and what type of behaviour does it apply to ? 2. Where should you record an incident of violence or aggression ? 3. When assessing risk of aggression or violence, name five observable signs of the risk being high. 4. When assessing risk of aggression or violence, identify five other factors that may contribute to this risk.

36. 5. Identify five effective communication skills or techniques, that could be used in the de-escalation process ? 7. When dealing with an aggressive individual, what ethnic / cultural diversity issues do you need to consider ? Name two. 8. What happens to personal space, when an individual becomes aggressive ? 9. If required to be invasive of personal space (eg personal care) where best should you be in relation to the person, in order to reduce risk of impeding personal space, and maintaining some safety ? 10. What makes the use of force in protection of ones self (or others) ‘reasonable’ ?

38. Heading titles Body text with indent already set.

39. CONFLICT RESOLUTION TRAINING – EVALUATION of LEARNING 1. What is meant by an ARA and what type of behaviour does it apply to ? An ARA is – Behaviour - 2. Where should you record an incident of violence or aggression ? Report – And - 3. When assessing risk of aggression or violence, name five observable signs of the risk being high. 1 - 2 - 3 - 4 - 5 - 4. When assessing risk of aggression or violence, identify five other factors that may contribute to this risk. 1 - 2 - 3 - 4 - 5 -

40. 5. Identify five communication skills or techniques, that could be used in the de-escalation process ? 1 – 2 – 3 – 4 – 5 - 7. When dealing with an aggressive individual, what ethnic / cultural diversity issues do you need to consider ? Name two. 1 – 2 – 8. What happens to personal space, when an individual becomes aggressive ? Personal Space - 9. If required to be invasive of personal space (eg personal care / treatment) where best should you be in relation to the person, in order to reduce risk of causing further distress, and maintaining some personal safety ? In relation to person - 10. What makes the use of force in protection of ones self (or others) ‘reasonable’ ? - - - Name: Date: