Brodie Paterson, MEd, BA (Hons), RMN, RNLD, Lecturer, Department of Nursing

and Midwifery Studies, University of Stirling, Scotland, FK9 4LA.

E-Mail b.a.paterson@stir.ac.uk

David Leadbetter, M Sc, BA ( Hons), CQSW, Dip SW, Cert SW Ed, Cert MTD

CQSW, Dip SW, Cert SW Ed, Cert MTD Director, CALM Training Services,

Menstrie Business Centre, Elmbank Mill, Menstrie, Clackmannanshire

Gail Miller, BA, RMN, Consultant Nurse, Aggression and Violence Management,

South London and Maudsley NHS Trust, 113 Denmark Hill, London.

Title page

Workplace Violence in Health and Social Care as an International problem: A

Public Health Perspective on the 'Total Organisational Response'

Abstract

Violence in the health and social care workplace remains in some respects unexplored

with a knowledge base which although developing is often ambiguous, imprecise or

incomplete. The issue has however, attracted increasing attention over the last two

decades as indicated not just by a growing research literature but in the UK and

elsewhere the proliferation of training programmes very often focused on 'reactive'

strategies i.e. 'secondary' prevention and tertiary prevention rather than primary

prevention and a public health based approach. This paper reviews the basis for

international standards including definitions and reporting criteria and argues that a

radical shift in emphasis is needed which looks not just at the organisational but

societal roots of violence.

Key words

Violence, training, public, health, workplace, nursing, social, care

Introduction

The global economy is now an undeniable reality built on the principle of free trade.

However, the principle of untrammelled free trade which does not take into account

either the environmental or human costs of production has been severely criticised.

Corporate downsizing with increased pressures for productivity and the threat of

redundancy has raised the threat of violence by disgruntled employees. A number of

major international companies particularly those with production plants in the third

world have been forced to improve working conditions for their employees after

media exposes of poor salaries and unsatisfactory working conditions. Increasing

attention has therefore been drawn to the need to promote workers rights amongst

which is the right to a workplace safe from violence.

It is timely perhaps, then to suggest that we seek to develop an international

consensus on good practice in the area of workplace violence. This paper will

therefore review the basis for such a consensus and discuss approaches to workplace

violence with particular reference to the author's areas of practice, mental health and

learning disability services and child care in the United Kingdom. It will explore the

relevance of a public health model to workplace violence, argue the necessity for

comprehensive proactive organisational strategies to reduce workplace violence and

assert the need for these to be complemented by wider social initiatives to address the

roots of violence in our communities.

The Right to a Safe Workplace

The right to a safe workplace and to protection from abuse at work is increasingly

recognised internationally enshrined in several International Covenants The

International Covenant on Economic Social and Cultural Rights adopted by the UN

General assembly in 1966 binds the States party to the covenant to recognise the right

of citizens to “safe and healthy working conditions”. Women, particularly have been

identified as a group at risk of experiencing violence in the workplace especially in

the form of sexual harassment and the UN Convention on the Elimination of All

Forms of Discrimination Against Women adopted by the UN in 1979 (Chappel and

Di Martino 1998) requires states party to the convention to take “all legal and other

measures that are necessary to provide effective protection of women against gender

based violence”, (United Nations 1992:4).

The role of Legislation and Guidance

The situation within individual nation states varies considerably in terms of

legislation. Wynne et al (1997) discussing the results of a European Union Survey

suggest that most of the states surveyed deal with the issue of workplace violence

under health and safety legislation although sexual harassment and racism were

covered separately in some instances. Individual member states varied however, in

whether they provided further specific guidance on good practice. Wynne et al (1997)

suggest that in the absence of further guidance it is very unlikely that the issue of

workplace violence was being sufficiently recognised or addressed. In the UK both

general guidance on the issue of workplace violence (Health and Safety Executive

1991) and additional sector specific guidance exists. This covers a number of areas,

including the retail sector, banks and building societies and the Health Service (Heath

Services Advisory Commission 1987) where the guidance has been updated relatively

recently (Health and Safety Executive 1997). This approach is similar to that of a

number of other countries including the US where the issue of workplace violence is

recognised under Health and Safety Legislation and has received considerable

attention by the Occupational Health and Safety Administration who have published

both generic advice for employers and specific advice for a number of identified high

risk areas including Health and Social Care. (Occupational Health and Safety

Administration 1996).

Such laudable progress notwithstanding, in some respects violence at work continues

to represent a “largely unexplored area with a knowledge base which is often

incomplete, imprecise or contradictory” (Chappel and Di Martino 1998). Continuing

lack of recognition of the problem, inconsistencies in definition and endemic under

reporting in some settings, all combine to hinder attempts to understand and thus to

prevent, reduce or minimise the harm resulting from violence in the workplace. Never

the less much work has been done or is beginning in many areas. It is clearly

understood that work related violence can result in serious physical injury or death

and that working in an atmosphere of continuing threat may be profoundly damaging

to the confidence, morale and ultimately psychological health of staff exposed or

affected. Significant efforts have been made in many workplaces across the world to

reduce workplace violence but in some settings workers may continue to face an

unacceptable risk of work related violence.

Homicide is overwhelmingly the most dramatic aspect of workplace violence and the

loss of life at work is properly the source of justifiable concern (Bulatao and

VandenBos 1996). In some nations, for some occupations, homicide may be the most

frequent cause of work related death and the need for action to reduce the risk of such

incidents cannot be over emphasised (National Institute for Occupational Health and

Safety 1993). Fortunately it appears that the overwhelming majority of workplace

violence experienced is not fatal. However, while ‘non fatal’ violence attracts less

media interest than high profile work place homicides it represents a serious potential

risk to the welfare of employees which may be under reported particularly in settings

such as health and social care where incidents of verbal abuse, sexual harassment,

threatening behaviour and assault can be high (Occupational Health and Safety

Administration 1996).

Saying What We Mean: Violence

Bulatao and VandenBos (1996) note that both policy makers and researchers continue

to strive towards establishing definitions of both violence and workplace. Before

considering how we might develop standards we need to firstly consider and define

our terms. The term violence is used frequently and “as such would seem to have

considerable communicative value” (Siann 1985:1) However, there are marked

inconsistencies between various operational definitions of aggression and violence

used by writers, researchers and policy makers (Breakwell and Rowett 1989). The

terms aggression and violence are sometimes used interchangeably (Marsh and

Campbell 1992) but other authors assert that violence represents a unique subtype of

aggression, involving an attempt to inflict physical harm on another. Violence is

therefore distinguished from other forms of aggression such as the psychological. Yet

others extend the scope of the term violence beyond the ‘individual acts of abuse’ to

the political process (Audi 1971). To such authors violence includes the

institutionalised imbalance in power and economic inequality which may result from

the economic system, gender or racial bias (Audi 1971).

Barret and Slaughter (1996:396) conclude that a universally “accepted model for

defining violence is lacking in the literature”. This lack of a consensus on definition

is however, a major obstacle to progress in this area where policy makers, researchers

and staff on the ‘shop floor’ may all have different operational definitions. In seeking

to develop a consensus around workplace violence we need firstly to establish our

terms of reference i.e. our definition of violence and by promoting its adoption

(Chappel and Di Martino 1998). This is a more complex task than it may first appear

for as Breakwell (1992:5) states there are "no simple definitions of violence which

stand detailed analysis". A number of conceptual, philosophical and pragmatic issues

must be considered. Amongst those are;

• Should the term violence be restricted only to those acts in which physical

violence directed towards another is involved?

• Should this include attempted, or only, actual harm?

• What about physical injury to self or physical damage to property?

• Should we further restrict the term to those acts in which the physical harm is

intentional and how do we define (and determine) intent?

What about the elderly nursing home resident experiencing dementia who lashes out

as a consequence of confusion and disorientation and perhaps the failure of care staff

to take sufficient care to orientate her to time and place before attempting to move

her. In one sense she might intend to cause harm but can she have ‘intent’ if she is not

considered legally competent and thus responsible for her actions. Is the intent to

cause harm a necessary element or can violence result from an accident. This issue

raises complex legal questions which may be interpreted differently in different

jurisdictions.

If we broaden the definition of violence beyond the physical act to include behaviours

such as ‘sexual harassment’ and ‘bullying’ as some authors suggest (Bowie 1996)

how do we determine and manage the boundaries of such concepts in the workplace?

What do we do about subtle variations of ‘passive aggression’ such as non-

compliance with requests, or failure to respond to telephone calls or e-mails which

may be acutely distressing to the recipient?

The examples of definitions of violence drawn from the literature and given below

reflect different perspectives on these questions.

“extreme aggression enacted on others aimed at serious injury” (Cox 1969 cited by

Blue and Griffith 1997:572).

An “escalated form of social conflict involving the violating of boundaries often

through the use of physical force” (Laue 1969:31).

“That which may include overt or covert threats and/or behaviour that is likely to

harm another person” (American Psychiatric Association 1984).

There have been attempts to develop definitions which might enjoy broader support.

The National Academy of Sciences in the USA have defined violence as; “behaviours

by individuals that intentionally threaten, attempt or inflict physical harm on another”,

(Reiss and Roth 1993:35). Unfortunately this definition whilst concise and including

threats of violence which is desirable, could be interpreted to exclude behaviours such

as verbal abuse, bullying and sexual harassment. These behaviours have obvious

potential to cause serious psychological harm to the recipient and together with

physical assault form part of the continuum of ‘abusive behaviour’ that employees

may experience in the workplace (Adams 1992, Wondrak 1989). It is extremely

important that all aspects of the continuum are recognised and an excessively narrow

focus on ‘the physical’ element of violence is thus arguably undesirable.

The WHO ( Krug et al 2002:5) have defined violence as “the intentional use of

physical force or power threatened or actual, against oneself, another person, or

against a group or community, that either results in or has a high likelihood of

resulting in injury, death, psychological harm, maldevelopment or deprivation”. This

definition differs from many in recognising the potential impact of violence on

development and must be welcomed. However, its focus encompassing community

violence is too broad for our purposes, further as has already been noted the question

of intent in settings such as health care where the most common perpetrators may be

elderly people experiencing dementia or people with severe learning disabilities poses

problems.

Chappel and Di Martino (1998) note that significant progress has been made towards

establishing a consensus definition of violence citing a working party of the European

Commission in 1995 who defined workplace violence as, “incidents where persons

are abused, threatened or assaulted in circumstances related to their work involving an

explicit or implicit challenge to their safety, well being or health”, (Wynne et al

1997:1). This definition reflects a developing awareness of the complex nature of the

issue of abusive behaviour at work and already enjoys European endorsement. It

allows a wide range of abusive behaviours which have reported in the workplace

such as verbal abuse, sexual harassment and “spreading negative rumours about

target individuals... , withholding information or resources needed by targets or even

purposely failing to return phone calls from them” (Folger and Baron 1996:52) to be

identified as unacceptable. The definition is not without problems the primary

objection which might be raised against its adoption as the basis for an international

consensus is that it is 'overly inclusive' and would not be useful for research purposes.

This criticism is however, easily addressed via the development of categories and sub

categories for research purposes. An example of such an approach is given below with

both incident type and source codes;

A PHYSICAL VIOLENCE

A1.1 Physical violence: Fatality no weapon

A1.2 Physical violence: Fatality weapon

A2.1 Physical violence : Serious assault requiring hospital admission no weapon

A2.1 Physical violence : Serious assault requiring hospital admission weapon

A3.1 Physical Violence: Serious Assault requiring medical attention no weapon

A3.1 Physical Violence: Serious Assault requiring medical attention weapon

A4.1 Physical Violence: Assault resulting in injury (bruise or abrasion) treated by

immediate first aid no weapon

A4.2 Physical Violence: Assault resulting in injury (bruise or abrasion) treated by

immediate first aid weapon

A5.1 Physical violence: Assault resulting in no significant physical injury no

weapon

A5.2 Physical violence: Assault resulting in no significant physical injury weapon

A6 Physical Violence: Self injury resulting in serious injury requiring medical

attention

A5 Physical Violence: Self injury resulting in injury treated by

immediate first aid.

A6 Physical Violence: Serious Sexual Assault including Attempted / Rape

A7 Physical Violence: Sexual Assault

A8 Physical Violence: Damage to property

B THREATENING BEHAVIOUR

B1 Threatening Behaviour: no‘weapon’

B2 Threatening Behaviour: ‘weapon’

C VERBAL ABUSE

C1 Verbal abuse. Racist

C2 Verbal abuse. Sexual

C3 Verbal Abuse. Generic

D PASSIVE AGGRESSION

D1 Passive aggression. Non- compliance with request

E VEHICLE RELATED INCIDENTS

E1 Vehicle related incidents.

F VIOLENCE INCIDENTS NOT OTHERWISE SPECIFIED

F1 Violence Incidents not otherwise specified

In each instance the ‘source’ of the aggression could be further coded such that we

could monitor whether the aggression was being perpetrated by a co-worker,

customer, in patient or visitor depending on the context and determine whether the

violence was being carried out during the committal of a crime such as an attempted

robbery.

Source code

S1 Employee : Co-worker

S12 Employee : Supervisor of victim

S13 Employee : Individual for who victim had supervisory responsibility

S14 Employees: Student

T11 Customer

T13 Customer: Health - In patient

T14 Customer health - Out patient

T14 Customer health - Visitor

U11 Individual committing a crime, e.g. robbery, criminal damage etc.

W1 Combatant. Armed conflict / civil unrest

Having suggested a form of words and proposed a means of recording and classifying

incidents, (which would require to be piloted to determine and improve validity and

reliability and identify further codes necessary before actual use) we need before

moving on, to think briefly about what we mean by ‘workplace’ in this context.

Saying What We Mean: The Workplace

The nature of the ‘workplace’ is increasingly diverse, for some workers it continues to

be the factory or the office but for others it might be the street or the customer's home.

Increasingly for many workers the workplace may be their own home for either some

or all of the time as the shift to home working develops in some industries. Any

approach to defining the workplace based on its physical boundaries is therefore

redundant. Bulatao and VandenBos (1996:3) have suggested that we should consider

“any incident of violence while working or on duty” as workplace violence. This

approach would however, not cover a suicide which occurred at home but which was

precipitated by excessive job stress (Bulatao and VandenBos 1996) further it could

depending on interpretation exclude the issue of domestic violence which can have a

significant impact on the welfare of employees who may be victims (Friedman et al

1996).

Given working definitions of both violence and workplace and suggestions as to how

such violence might be recorded what should we be doing about preventing it?

The Control Cycle

Chappell and Di Martino (1998:109) suggest that attempts to manage violence in the

workplace can be represented as a “Control Cycle” (See Figure 1.) This provides a

simple framework which any employer, in any setting, can use as the basis for

developing a violence prevention strategy. It stresses finding out whether a problem

exists and if so what is the nature and extent of the problem. Risk assessment, a legal

obligation in the context of Health and Safety legislation in the United Kingdom

demands that we identify

• ‘hazards’ which are simply things with the potential to cause harm

• ‘exposure’ i.e. who in the workforce is likely to be exposed to which hazards

• ‘harm’ what is the probability of exposure to the hazard causing harm

An environmental audit should form a routine part of the risk assessment exercise and

this consists of two elements. Firstly, an audit of the environments in which staff work

is necessary. Areas which serve high risk populations must be appropriately designed

and equipped and a security audit should routinely take place with the development of

security and violence policies proceeding in tandem. Security features such as security

patrols, police presence, CCTV personal alarms (or their absence) should be noted

and their effect or potential effect on risk considered. Secondly, an analysis of all

recorded incidents over as long a period over which data can be gathered. Whilst

acknowledging that problems with the reliability of reporting may mean that recorded

data is inaccurate, there is a tendency for more significant physical injuries to be

reported more accurately and recorded incidents are therefore still a valuable source

of data. On the premise that the best predictor of future behaviour is past behaviour

this analysis should establish; the frequency of recorded incidents, the severity of

recorded incidents, the site, location and time of incidents and the occupation, grade

and role of staff involved and/or injured.

In addition simple observation of clinical areas may allow the frequency of under-

reporting of near misses, threats, verbal abuse and less serious assaults which to be

estimated. Employees may however, be fearful of report some forms of violent

behaviour particularly 'lateral violence' such as bullying, and some form of

confidential questionnaire or hotline may therefore be necessary to supplement

whatever other measures are put in place.

This information should then inform the development of an appropriate risk

management plan which seeks to prevent violence within the organisation. Prevention

in this context must however, be multidimensional in nature. It has been suggested

Leadbetter and Paterson (1999,) that organisations have somewhat unfortunately

tended to adopt one of two responses to the problem of workplace violence neither of

which is helpful. The first is 'avoidance' i.e. simply to ignore the problem, this is

obviously problematic but was until comparatively recently a commonplace strategy

in many areas of health and social care. The second is to recognise a problem exists

but to frame the problem either solely or largely as a problem of individual staff skill

deficits which are remediable by 'training' (Paterson and Leadbetter 2004). Leadbetter

has suggested that in many organisations characteristically similar processes can be

observed over time. See Figure 2

Often however, the problem relates less to a staff skill deficit, which can be addressed

through training, and more to a performance deficit. Staff may know broadly how

they should act, but their responses to aggression are influenced by factors within the

organisation particularly service culture, lack of procedures, risk audits, poor

management, resource shortfalls and so on. These are organisational variables out

with the control of individuals. Training in such circumstances may only reinforce

reductionist explanations for violence which focus on the role of the individuals

concerned and feed into the cultures prevalent in many services of victim blaming and

overarching blame cultures many of us will be familiar with. Some victims report

that the response from managers and colleagues is often the most traumatising feature

of the assault experience. This can leads to the avoidance of stigma through under-

reporting, a practice which maintains the invisibility of the problem and validates lack

of action by managers to ascertain and resolve underlying contributory factors.

A Public health perspective on Violence Prevention: 1 Within the Organisation

A public health perspective on violence by contrast adopts an ‘ecological’ approach,

which recognises that violence involves an interaction between the assailant, the

potential victim and the context in which the interaction occurs (Satcher 1995). The

'context' includes not just the immediate setting but the beliefs, values and skills

which the individuals involved bring to any situation. It also encompasses aspects of

the physical environment, the prevalent culture for example within a service and

within a particular ward or children's home. Violence is therefore a complex, multi-

faceted phenomenon but conflict management training only affects one aspect of this

triangular interaction. Many NHS and social services, staff recognised as being at

high risk of exposure to violence support service users whose aggressive behaviour is

influenced by a range of factors, some of which are outside their control and arguably

unlikely to be influenced by the talking and non-verbal skills taught on a conflict

management training programme (Department of Health and Department for

Education and Skills 2002). Such settings can include learning disability services

where individuals' violent behaviour may be, learned and functional response to

managing their environment. There is therefore a need for a more sophisticated

approach to violence prevention which looks beyond how we can manage incidents

better and considers the prevention of violence at source.

Prevention in this context can usefully be described with reference to the public health

model (Sethi et al 2004) as having three main dimensions:

• primary prevention : Action taken to prevent violence before it occurs

• secondary prevention: Action taken to prevent violence when it is perceived to

be imminent

• tertiary prevention: Action taken when violence is occurring and after it has

occurred to prevent or reduce the potential for physical and psychological

harm to the parties involved and to inform primary and secondary prevention

strategies. The notion of prevention in this context is in the public health sense

of preventing or reducing harm (Sethi et al 2004)

Primary prevention requires

• action at the level of the organisation,

• the staff team,

• the individual worker

• the patient

Action at the level of the organization;

These include establishing clear leadership via the appointment of a senior manager

with overall responsibility for the issue, the development, dissemination and

implementation of a policy on workplace violence, mandatory post incident reviews,

action to address underlying reasons for violence suggested by incident investigation

such as inconsistency in staffing, impoverished and physically unsuitable clinical

environments, low rates of engagement with service users, and finally the

development, implementation and evaluation of a training strategy. The training

strategy must however, embrace much more than 'crisis management' in considering

underlying skills deficit in direct care and other staff. These may include the need to

revisit in some instance what might already be expected to be in place i.e. core

professional values, collaborative approaches to care planning and the use of

structured risk assessment/management plans. In addition advanced training in

interventions such as Cognitive Behavioural Psychotherapy and Psycho Social

interventions should be considered. Staff must have the skills necessary to undertake

the focused, structured, evidence based interventions which have the possibility of

averting violence before it occurs and not just training in how to manage crisis more

effectively (Goldstein et al 1998). Assuming that such skills exist routinely in all

settings simply belies the reality of many in-patient settings and many children's

homes.

It has been suggested that what is required is a 'total organisational response' in which

a partnership between the organisation, employees, trade unions and individual

workers is necessary (Cox and Cox 1993). Figure 2 Illustrates a model developed by

one of the authors Miller (2003) which illustrates the multiple dimensions that

organisations must address in seeking to prevent violence and create 'safer services'.

The example relates to her practice setting i.e. mental health. Miller's work however,

takes the idea of a 'total organisational response' further in several respects. In her

model 'safer services' depends on a partnership between service users, clinical staff,

the wider organisation and other agencies involved such as criminal justice. She

stresses the need to recognise how elements within organisations perhaps not

typically seen as related to the problem of violence such as recruitment and retention

and potential problems encountered therein, can relate to the issue of violence because

of their impact on the consistency and experience of staff. Finally she emphasises the

role of good practice in promoting engagement with service users supported by

effective clinical supervision and personal development procedures.

Action at the level of the staff team; explicit attention to workplace culture

(Braithwaite 2001) is absolutely vital. Organisations in which staff feel devalued,

disempowered and disenfranchised are highly unlikely to be able to provide a suitable

therapeutic regime. If we deny individuals the means of satisfying their existential

needs which include, the need to feel effective, the need for stimulation and

excitement we should not be surprised if the result is malignant aggression (Fromm

1977). All to readily an invidious combination may be produced where staff members

legitimate desire for recognition and a degree of control in their professional lives

combines with displaced hostility towards an abusive organisation which is in effect

behaving violently towards its employees and finds its expression in regimes of care

which consist largely of control and coercion in which violence may sometimes be

deliberately provoked by employees to avert their boredom (Bowie 1998). The

Some users experience is of services in which "restraint of patients was the main

goal at all times" (Horton 2001) The resultant conflict can undermine any hope of

therapeutic collaboration and in extreme circumstances lead to staff effectively

disengaging from their client by finding things to do other than interact with patients

such as 'the paperwork'. A vicious circle can then result in which violence perpetrated

by services users at least partially as a function of boredom and conflicts over 'petty'

rules is blamed wholly on the service users. This reinforces the existing negative

stereotypes held by staff and produces yet more coercion and even less positive

engagement.

It has been suggested that violence even in psychiatric inpatient settings may not

represent a relationship between mental illness (or even specific symptoms) and

violence as much as; patients’ reactions to the experience of;

• Admission to the ward or service culture (Garnham 2001),

• To deliberate or unwitting provocation by other patients or staff (Powell, Cann

and Crowe 1994, Sheperd and Lavender 1999),

• To the lack of activities and staff patient interactions (Sclafani 2000)

• To the restrictions on liberty which may accompany admission (Sheridan et al

1990)

All of which have the potential to evoke conflict and thus violence. The likelihood of

any given conflict situation resulting in violence will however, be influenced by the

predominant beliefs within the participants cultures regarding how conflict should be

dealt but the perceived 'legitimacy' or otherwise of violence as a solution will also be

influenced by the 'local' culture i.e. of the ward or home which may have a greater

influence (Werner, Rose and Yesavage1983).

Among the most Common antecedents to violence in many settings is limit setting.

Training in non-confrontational limit setting can help staff set limits with, rather than

for, patients and help avert conflict. In addition promoting awareness of the

relationship in particular between inconsistent limit setting and violence enhances

understanding of the need for teams to establish and implement a consensus and

allows subtle forms of workplace abuse by which staff can be 'set up' by colleagues to

be recognized and challenged.

Action at the level of the individual worker. Until relatively recently, as Leadbetter

(1996:6) observes, “the tendency has been to individualise the question of the

management of challenging behaviour. To frame it simply as a matter of individual

staff competence with risk viewed simply as part of the job”. This perspective has

effectively de-emphasised the role and responsibility of the agency and resulted in the

interpretation of the problem of violence as essentially a lack of staff skill which has

in turn promoted responses based on staff training in conflict management and

physical intervention skills. A focus on training for staff in direct contact with patients

can however, neglects the significant training needs of managers. Managers need an

understanding of the organisational dimensions of violence such that they can co-

ordinate the range of activities necessary. Training may play a valuable role in

enhancing staffs abilities to recognise and avert conflict situations and to deal with

physical violence. A lack of central regulation has however, allowed an unregulated

market in training in the 'short term management of violence' to develop with marked

differences in course philosophy, content, duration, and assessment. ‘Systems’

developed in one context or country is sometimes aggressively marketed as 'one stop'

solutions to the problem of workplace violence in another. A review of the research

literature on aggression management training undertaken in the context of the joint

guidance by the DoH/DfES by Allen for the British Institute for Learning Disabilities,

concluded that such training could generate a range of positive outcomes including

reductions in violent incidents and injuries but,

"Unfortunately, the research indicates that none of the above outcomes can be

guaranteed from training, and negative results have also been observed in each of the

above areas. “ (Allen 2000:23)

Such results should not surprise us as even where the relevant model has 'face

validity' in the context, its effect may be marginal if the structural determinants of

violence within an organisation are not understood and addressed (Lindsay et al

2000). A review of the literature on violence in Psychiatry concluded,

"that wards with trained and experienced staff working well together with good

leadership (i.e. high morale wards) tend to be less violent".

(Royal College of Psychiatrists 1998:33).

Training in skills such as risk assessment and proactive risk management may

however serve to reduce patient violence in drawing staff attention to the reasons for

an individuals violence and prompting staff engagement before aggression is

imminent (Needham et al 2004).

Action at the level of the service user. This relates principally to individual care/

program planning. Each patient has an individual care plan and where violence is an

issue this must identify underlying problems which assessment suggests are related to

their propensity to use violence and the circumstances in which violence is most

likely. This is when structured programs using psychosocial interventions, anger

management training, pro-social skills training, pro-social value training and

contingency management may be required. Intervention strategies may need

adjustment particularly for individuals with learning disabilities or other cognitive

impairments such as dementia.

Secondary Prevention

Depending on the context secondary prevention may be planned or unplanned. In

some situations violence by service users may involve highly predictable patterns of

responses. Knowledge of such patterns garnered via functional analysis can allow the

planning of proactive positive interventions to prevent violence. In addition however

where, violence may not be preventable it can allow planned 'reactive strategies' to be

devised and tested to provide guidance to staff such that where a patients behaviour

follows a pattern of escalation that imminent violence might be recognised early and

averted. In other instances service users may not be well known to organisations for

example in the case of a child recently admitted to residential care. In such situations

staff must follow broad guidance on strategies such as de-escalation while using

clinical judgement to identify as effective a response as possible compatible with

relevant legal and ethical principles including 'least restrictive intervention' (Paterson

et al 1999).

Tertiary Intervention

In this context violence is either happening or has happened we have been unable to

prevent its occurrence and are now focused on reducing the risk of violence causing

physical and psychological harm. Strategies to manage immediate violence will vary

depending on risk assessment and organisational policy but may include withdrawal

by staff, the removal of other services users who may be a risk and forms of physical

intervention such as 'blocking' or 'breakaway' strategies to enable staff to remove

themselves from the threat. Prolonged or more serious violence may necessitate

physical intervention in the form of restraint, physical or mechanical, seclusion or

medication. Interventions may involve immediate care staff, more senior personnel,

and a response team where such models are desirable and practicable, security staff or

the police. There must however be clear protocols in place detailing the nature of the

response expected by each member of the clinical team and each agency.

Once the immediate crisis has passed organisations needs to do several things;

review the incident such that whatever lessons need to be learned organisationally are

actioned in order to avert or manage better similar situations

review the care of the individual concerned such that whatever actions necessary in

relation to the individuals care plan are taken to avert future crisis and enhance the

management of crisis are taken

review the actions of staff involved in such situations such that any acts or omissions

which may have contributed to the incident or detracted from its successful

management are identified, recorded and addressed. This does not necessarily mean

an 'investigation' by management unless serious misconduct is alleged or suspected

and is sometimes best done where a supportive culture exists via peer review. We

know however, that in some instances "staff attitudes might themselves be a problem"

(Horton 2001:7) and any investigation of alleged wrongdoing should therefore

involve an external representative i.e. an advocate.

promote positive outcomes for the patient involved

Violence can evoke strong feelings in both victim and perpetrator creating a volatile

emotional situation. Immediate management will focus on ensuring safety and

preventing re-ignition of violence in a situation, which may remain volatile. When it

is judged appropriate however, a structured de-brief with the patient involved may be

conducted which seeks to explore the antecedents i.e. the relationships between

feelings, behaviour, and alternative coping strategies which might be used to deal with

similar situations in the future. These can then be practised later in controlled

simulations i.e. role plays forming part of primary prevention in order to help avoid

future crises (Neizo and Lanza 1984).

put in place flexible supports such that staff involved in incidents can access at their

discretion a range of supports which may include occupational health, telephone

support, peer debriefs. There are some suggestions that pre rather than post incident

support may be the most important determinant of whether an individual develops or

does not develop a pathological reaction to exposure to violence. There remains some

debate about how we can best support staff exposed to violence. What is however,

unquestionably not in doubt is that supports should be there!

A Public health perspective on Violence Prevention: 2 Violence Prevention in the

Community

The discussion so far has focused on violence as an intra-organisational problem. In

terms of prevention it has adopted a public health interpretation of the total

organisational response Figure 3 (Leadbetter 2004) illustrates the application of this

model explicitly identifying potential preventative strategies in terms of primary,

secondary and tertiary intervention and emphasising the need for approaches to reflect

a client centred focus.

There is however, potentially, a serious flaw in this approach; this is, in essence that

in looking only ‘inwardly’ organisations may neglect the relationship between the

problem of violence inside their organisation and the problem of violence outside it.

Many of the underlying contributory factors to violence by service users may lie

outside the service. In failing therefore to address violence as a community, not just

an organisational problem services risk neglect by default the devastating effect of

exposure to violence may have on the health of the communities they serve. Such

effects will almost invariably disproportionately impact upon disadvantaged and

marginalised communities (Krug, 1999). What are required are unified approaches

(Lett et al 2002) whereby intra-organisational strategies and community based

interventions to prevent violence, or minimise its impact complement each other.

The roots of violence may lie in no small part in social inequality. In both high

income countries (HIC) and low-to-middle income countries (LMIC), the highest

rates of violence "tend to occur in the poorest communities with the fewest resources

to cope with the financial, social and psychological strains produced by the resulting

deaths and disabilities" (Krug, 1999). Economic inequalities may result in a

discrepancy between an individuals expectations and their abilities which are in part a

function of their access to “opportunity structures” i.e. the means to gain career

advancement such as education (Peacock 2002:40). Feelings of inequity and

consequently entitlement may develop when individuals then judge their material and

social status obtained with those of others not similarly disadvantaged. Wilson and

Herrnstein (1985) suggest that these feelings may give rise to hostility but in a process

of 'reaction formation' this may come to be directed not against either the system

which maintains such inequalities or those who benefit most from these inequalities

but paradoxically at those within their immediate communities including their family.

Gilligan (2000:233) argues that the underlying mechanism is one of 'shame' observing

that the disproportionate amount of violence in many societies perpetrated by men is

a function of the male gender role, which "generates violence by exposing them to

shame if they are not violent" . Simultaneously however, the ascribed female gender

role while restricting female violence also promotes male violence. It encourages men

to treat women as passive sex objects and women to conform to the role but it

implicitly promotes a view of men as "violence objects" (Gilligan 2000:233) whose

violence against women who dishonour or 'shames' them by failing to observe their

role is given a perverse legitimacy.

The experience of violence, often within the family, is a risk factor for violence in

mental health service users to which insufficient attention is often paid. While it may

be less significant than the combination of substance dependency and psychoses

together with them it forms an invidious triumvirate (Swanson et al 2002). Hiday

(1997) argues that beliefs supporting violence as a means of conflict resolution may

be more prevalent in communities which have been disproportionately affected by

unemployment, where social disorganisation and poverty function as stressors, and

individuals or groups can become disassociated from the values of the wider

community. Growing up in such an environment is likely to increase an individuals

risk of being a victim of violence in comparison to more affluent areas (National

Research Council 1993). Over time as Stueve and Link (1997:329) observe this may

come to “foster mistrust and suspicion of others, an outlook that psychosis

exacerbates”. An individuals behaviour as an in-patient is thus not just a function of

their immediate pathology but a product of the interplay between themselves as an

individual, their experience of community and family violence and the culture of the

ward mediated by differences in gender, race, ethnicity, sexuality and class.

As Peacock (2002:41) reminds us, even in violent societies “not all individuals resort

to violence”. The behaviour of individuals will be influenced not just by structural

influences but also mediated by their unique experiences of family and or parenting

and the social groups to which they either belong or aspire to belong. The role of

positive parenting may also be crucial (Sanders1999) as inappropriate parenting styles

such as 'coercive parenting' may inadvertently teach children that aggression 'works'

(Patterson et al 1975).

An understanding that the roots of violence may lie in our communities at least as

much as in individual pathology should however, awaken interest in tackling violence

proactively at a social level. As Gilligan (2000:236) observes "if we wish to prevent

violence, then, our agenda is political and economic reform". There is now an

increasing emphasis on the primary prevention of violence. At a macro level it could

be argued that the Blair governments 'social inclusion' project seeks to target some of

the root causes of violence in UK society by addressing underlying economic and thus

social marginalisation. A range of strategies have however, emerged which seek to

prevent violence either directly or may have an indirect effect on the roots of

violence. (See Figure 4). Interventions vary in nature many being multi-component

however, broadly they fall into the three main types we have already discussed with

reference to intra-organisational strategies i.e,

Primary Interventions. Prevention is aimed at large groups of people often whole

population interventions, e.g. seeking to promote the acquisition and utilisation of

conflict resolution skills in whole school settings (Orpinas et al 2000, Durant et al

2001).

Secondary Interventions Prevention aimed at those presenting a 'higher risk' of

perpetrating violence targeting individuals at risk of offending e.g. cognitive skills

and values based programs for young offenders (Giuliano1994, Goldstein, et al 1998).

Secondary interventions may however, also target particular problems e.g. domestic

or sexual violence in terms of primary prevention i.e. preventing victimisation

(Anetzberger et al 2000, Conte1985, Foshee 1998 Wolfe and Jaffe 1999). Violence

prevention may also target particular problems such as violence associated with

alcohol usage in licensed premises. The Cardiff Violence Prevention Groups (2004:1)

research has clearly demonstrated that "the proper management of violence in

licensed premises depends upon input from NHS Accident and Emergency services

about physical injuries as well as what are recognised as incomplete police violence

records".

Tertiary Interventions Tertiary prevention strategies focus on treating individuals

exposed in order to minimise the adverse effects of violence but also on preventing

repeated victimisation (Dunford 2000)

Conclusion

Workplace violence in health and social care is a significant problem for many

workers. Action within many organisations is however, still over emphasising training

in the short term management of violence (i.e. secondary prevention) and staff support

post incident (i.e. tertiary prevention). There is a need for a major cultural shift which

recognises the structural reasons for violence both inside and outside organisations

and seeks to address them organisationally. The focus needs to be much more on

primary prevention.

Sorting out the problem of violence within services may sometimes seem an

insurmountable problem in itself. As the old adage observes ' when you're up to your

neck in alligators its hard to remember your original objective was to clear the

swamp'. Ecological objections to this metaphor aside, the emerging message from the

brief exploration of community based initiatives is plain, it is no longer enough for

health and social care organisations to seek to improve the protection we offer our

staff from violence and to work with the victims of violence. The message of Zero

Tolerance is that violence is unacceptable but if the roots of violence lie in social

inequality then surely by implication such inequality must be intolerable. As Heath

(2002:707) pointedly reminds us "violence is unacceptable, not primarily because it

undermines health, but because it is, in itself, demeaning cruel and unjust".

We need therefore to actively engage with the reasons which gave rise to such

violence in the first place. The 1998 Crime and Disorder Act established Community

Safety Partnerships in England and placed a duty on health authorities to work

towards reducing violent crime in conjunction with representatives from local

authorities and the police. There are already excellent examples developing of

collaboration between health care and other sectors to identify the nature of the

problem (Howe and Crilly 2002) and to develop preventative strategies (Cardiff

Violence Prevention Group 2004).

Nearly ten years ago violence was declared a public health emergency in America

(Fontanarosa 1995). Violence remains a scourge our society which wrecks lives, and

undermines the quality of life in many of our communities. Amongst its victims are,

all too often, those who are the most vulnerable in our society women, children and

older people (Krug et al 2002). We should also not forget that violence can also blight

the life of its perpetrator (Rivera et al 995). There is however, real cause for optimism

to be found in emerging research about how we can tackle the problem of violence

more effectively (Drug Strategies 1998). In many organisations recognition that

tackling the problem of violence requires action not just within their organisation but

via interagency partnerships is now growing (Australian Institute of Criminology

2003). Committed, partnerships using evidence based interventions are the answer to

tackling violence in the future both in our services and in our communities.

References

Adams A (1992) Bullying at Work: How to confront and overcome it, Virago,

London.

Allen, D (2000) Training Carers in Physical Interventions: Research Towards

Evidence Based Practice. Kidderminster: British Institute for Learning Disabilities

Anetzberger GJ, Palmisano B, Sanders M et al. (2000). A model intervention for elder

abuse and dementia. Gerontologist, 40(4): 492–497.

Audi R (1971) on the meaning and Justification of Violence, in, (Ed) Shaffer JA

Violence, David Mckay, New York, p45-99.

Australian Institute of Criminology (2003) The public health approach to crime

prevention A I Crime Reduction Matters, Number 7, Australian Institute of

Criminology

Barret ES and Slaughter L (1996) Mental Illness and Violence, Current Opinion in

Psychiatry, 9, 393-397.

BowieV (1996) Coping with Violence, Whiting & Birch, London.

Bowie V (1998) Workplace Violence. Paper presented at the Australian Institute of

Criminology Conference, Crime Against Business, Melbourne, June.

Breakwell G (1989) Facing Physical Violence, The British Psychological Society,

Leicester.

Breakwell G, Rowett C (1989) Violence in Social Work, in (Ed) Browne K, Human

Aggression Naturalistic Approaches, Routledge, London.

Bulatao E and VandenBos GR (1996) Workplace Violence: Its Scope and the Issues,

in VandenBos GR and Bulatao II (Eds.) Violence in The Workplace, American

Psychological Association, Washington

Cardiff Violence Prevention Group (2004)

http://www.crimereduction.gov.uk/cardif.htm

Chappel D and Di Martino V (1998) Violence At Work, International Labour Office,

Geneva.

Conte JR (1985). An evaluation of a program to prevent the sexual victimisation of

young children. Child Abuse and Neglect, 9: 319–328.

Cox T. and Cox S. (1993) Psychosocial and organisational hazards: Control and

Monitoring. Occupational Health Series, no 5, Copenhagen, World Health

Organisation (Europe).

Drug Strategies (1998) Safe Schools, Safe Students: A Guide to Violence Prevention

Strategies, Drug Strategies, Washington DC.

Dunford FW (2000). The San Diego Navy Experiment: an assessment of interventions

for men who assault their wives. Journal of Consulting and Clinical Psychology,

68(3): 468–476.

Durant RH, Barkin S, Krowchuk DP (2001). Evaluation of a peaceful conflict

resolution and violence prevention curriculum for sixth grade students. Journal of

Adolescent Health, 28(5): 386–393.

Folger R and Baron RA (1996) Violence and Hostility At Work, A Model of

Reactions To Perceived Injustice, in VandenBos GR and Bulatao II (Eds.) Violence in

The Workplace, American Psychological Association, Washington.

Fromm E ( 1977) The Anatomy of Human Destructiveness, Penguin Harmondsworth

Gilligan J (2000) Violence Reflections on Our Deadliest Epidemic, Jessica Kingsley

Publishers, London.

Fontanarosa PB (1995) The Unrelenting epidemic of violence in America, Journal of

the American Medical Association, 273, 1792-1793.

Friedman LN, Brown, ST, Neville PR and Imperial M (1996 ) The Impact of

Domestic Violence on the Workplace, in VandenBos GR and Bulatao II (Eds.)

Violence in The Workplace, American Psychological Association, Washington.

Foshee VA (1998). An evaluation of safe dates, an adolescent dating violence

prevention programme. American Journal of Public Health, 88(1): 45–50.

Garnham P (2001) Understanding and dealing with anger, aggression and violence,

Nursing Standard, 16(6), 37-42.

Giuliano JD (1994). A peer education program to promote the use of conflict

resolution skills among at-risk school age males. Public Health Reports, 109(2): 158–

161

Goldstein AP, Glick B and Gibbs JC (1998) Aggression Replacement training: A

Comprehensive Intervention for Aggressive Youth, Research Press, Illinois.

Health Services Advisory Committee (1987) Violence to staff in The Health Service,

HMSO, London.

Health and Safety Executive (1991) Violence To Staff, Health and Safety Executive,

London.

Health and Safety Executive (1997) Violence and aggression to staff in health

services Health and Safety Executive, London.

Heath I (2002) Treating violence as public health problem, British Medical Journal,

325,726-727.

Hiday VA (1997) Understanding the Connection Between Mental Health and

Violence, International Journal of Law and Psychiatry, 20(4), 399-417.

Horton J (2001) No Protection, Guardian Society Pages, July 25,7

Howe A and Crilly M (2002) Violence in the community: a health service view from

a UK Accident and Emergency Department, Public health, 116, 15-21.

Krug EG, Dahlberg LL, Mercy JA et al., (Eds) (2002). World report on violence and

health. Geneva, WHO.

Lanza M (1996) Violence Against Nurses In Hospitals, in VandenBos GR and

Bulatao II (Eds.) Violence in The Workplace, American Psychological Association,

Washington.

Laue JH (1969) Social Change dissent and violence, In, (Ed) Crawford FR, Violence

and Dissent in Urban America, Southern Newspapers Publishers Association

Foundation, Atlanta.

Leadbetter D (2004) " Surviving the Nightmare, Seizing the Dream", Keynote

address presented at International conference on Reducing the use of Physical

Restraint - Dallas, Texas, April.

Leadbetter D (2004) CALM Associates Training Manual, CALM, Menstrie.

Lett R, Kobusingye O, Sethi D (2002). A unified framework for injury control: the

public health approach and Haddon’s Matrix combined. Injury Control and Safety

Promotion, 9: 1–7.

Miller G (2003) Safer Services, paper presented at the Therapeutic management of

Aggression and Violence Conference, Royal Scottish National Hospital, Larbert

September 4th 2003.

National Research Council (1993) Understanding and Preventing Violence, National

Academy Press, Washington D.C

National Institute for Occupational Health and Safety (1993) NIOHS Alert: Request

For Assistance in Preventing Homicide in the Workplace, US Department of health

and Human Services, Washington D.C.

Needham I, Aberhalden C, Meer R, Dassen T, Haug HJ, Halfens RJg and Fischer JE

(2004) The effectiveness of two interventions in the management of violence in acute

mental in-patient settings: Report on a pilot study, Paper presented at European

Violence in Psychiatry Research interest Group (EViPRiG), Berne, May 2004.

Neizo B. A. and Lanza M (1984) Post Violence Dialogue: Perception Change

Through Language Restructuring, Issues In Mental Health Nursing, 6, 245-254.

Occupational Health and Safety Administration (1996) Guidelines For Preventing

Workplace Violence for Health and Social Service Workers, US Department of

Labour, Washington D.C.

Orpinas P, Kelder S, Frankowski R et al. (2000). Outcome evaluation of a multi-

component violence-prevention program for middle schools: the students for peace

project. Health Education Research, 15(1): 45–58.

Patterson GR, Reid JB, Jones RR and Conger RE (1975) A Social Learning

Approach to Family Intervention, (Vol 1) Castalia, Oregon.

Paterson B, Leadbetter D and Tringham C , (1999) Critical Incident Management ,

Aggression and Violence Case Study, in Mercer D, Mason T, McKeown M, McCann

N (Eds.) Forensic Mental Health Care Planning, Directions and Dilemmas, Churchill

Livingstone, Edinburgh.

Peacock R (2002) Macro and Micro Links Between Interpersonal Violence and

Violence in Broader Society: An Integrated Etiological Perspective, Acta

Criminologica, 15(3), 39-44.

Powell G, Cann W and Crowe M (1994) What Events Precede Violent Incidents In

Psychiatric Hospitals? British Journal of Psychiatry, 165, 107-112.

Reiss A and Roth J (Eds.) (1993). Understanding and Prevention Violence. Volume 1,

National Academy Press, Washington.

Rivera FP, Shepherd JP, Farrnington DP and Cannon P (1995) Victim as offender in

youth violence, Annals of Emergency Medicine, 26,609-614.

Royal College of Psychiatrists (1998) Guidelines for the Management of Imminent

Violence. Royal College of Psychiatrists, London

Sanders MR (1999). Triple P-Positive Parenting Program: towards an empirically

validated multi-level parenting and family support strategy for the prevention of

behaviour and emotional problems in children. Clinical Child [and] Family

Psychology Reviews, 2: 71–90.

Satcher D (1995) Violence as public health issue, Bulletin New York Academy of

Medicine, 72, 45-46.

Sclafini MJ (2000) Developing a Clinical Violence Prevention and Intervention Plan

for psychiatric Mental Healthcare Settings, Journal of Health Care Quality, 22(2), 8-

12.

Sethi D, Marais S, Seedat M, Nurse J, Butchart A. (2004) Handbook for the

documentation of interpersonal violence prevention programmes. Department of

Injuries and Violence Prevention, World Health Organization, Geneva.

Sian G (1985) Accounting for Aggression: Perspectives on aggression and violence,

Allen and Unwin, Herts

Shepherd M and Lavender T (1999) Putting aggression into context, an investigation

into the contextual factors influencing the rate of aggressive incidents in a psychiatric

hospital, Journal of Mental Health, 8(2), 159-170

Sheridan M, Henrion R, Robinson L and Baxter V (1990) Precipitants of Violence in

A Psychiatric Inpatient Setting, Hospital and Community Psychiatry, 41(7), 776-780.

Stueve A and Link BG (1997) Violence And Psychiatric Disorders Results From An

Epidemiological Study Of Young Adults In Israel, Psychiatric Quarterly, 68(4), 327-

342.

Swanson JW, Swartz MS, Essock SM, Osher FC, Wagner HR, Goodman LA,

Rosenberg SD and Meador KG (2002) The social-environmental context of violent

behaviour in persons treated for severe mental illness, American Journal of Public

Health, 92(9), 1523-1531.

United Nations (1992) Report of the Committee on the Elimination of Discrimination

Against Women: Eleventh Session, In Official Records of General Assembly 47th

Session, Supplement 38, A/47/38. United Nations, New York.

Wilson JQ and Herrstein RJ (1985) Crime and Human Nature, Simon and Schuster,

New York.

Wolfe DA, Jaffe PG (1999). Emerging strategies in the prevention of domestic

violence. Future Child 9(3): 133–144.

Wynne R, Clarkin N, Cox T, Griffiths A (1997) Guidance on The Prevention of

Violence At Work, European Commission, DG-V, Ref.CE/V-4/97-014-EN-C.

Wondrak R (1989) ‘Dealing with verbal abuse’, Nurse Education Today, 9, 2776-280.

Werner PD Rose TK and Yesavage JA (1983) Reliability, Accuracy and Decision

Making Strategy In Clinical Predictions of Imminent Dangerousness, Journal of

Consulting Clinical Psychology, 51(6), 812-825.

World Health Organisation (2003) Joint Programme on Workplace Violence in the

Health Sector, Guidelines on Workplace Violence in the Health Sector: Comparison

of major known national guidelines and strategies: United Kingdom, Australia,

Sweden, USA (OSHA and California) International Labour Office ILO International

Council of Nurses ICN World Health Organisation WHO Public Services

International PSI, Geneva

Figure 1. The Control Cycle from Chappell and Di Martino 1998

1 Find out if there is a problem 7 Evaluate and monitor 2 Determine the relevance of the problem 6 Implement the Strategy 3 Describe the Problem 5 Design a Preventative Strategy

4 Analyse the reasons for the violence

Figure 2 Organisational Responses to Violence and/or Challenging Behaviour (CALM Associates Training manual 2003) Employing organizations tend to go through similar historic processes when addressing the problems of occupational violence and/or challenging behavior:- 1. Denial : - An “If you can't stand the heat get out the kitchen”; “Blame” culture. Staff who raise concerns are often seen as over anxious and/or incompetent. “Whistle blowers” and activists are often scapegoated. Violent incidents are seen as isolated events, predominantly caused by individual failure, or by chance. No agency policies exist. Responses are haphazard and ad hoc. 2. Ignoring:- The risks of service user violence is perceived but not addressed. This

is often due to unhelpful beliefs and ideologies and or fear of exposing the problem. Recording and reporting are not encouraged and active measures to suppress the debate may be imposed. High absenteeism/sickness absence. Focus on crisis management, rather than strategic service delivery.

3. Awakening: - Risks are acknowledged, but within an “it’s part of the job”

culture. Resistance to formal action and a fragmented agency response. Causal connections are not perceived. No overall management responsibility. The problem is “owned” by front line staff and, often the agency training section. Victims can share experiences and “whistle blowers” can speak out. Support systems are criticized. Consultants become involved. Policies are developed. These are often vague, unrealistic and focus on what staff cannot do, rather than the specification of acceptable responses “Reductionist” training introduced. Training “Gurus” are given credibility. Lack of routine post incident “debriefing” limits agency and individual learning.

4. Break through:- Management studies costs and consequences & concludes a different approach is required. One co coordinating manager assumes responsibility Policies are developed but remain fragmented. A more rational approach to the problem is adopted. Diversification of training, holistic training. Training “Gurus” lose credibility. Outcomes assume importance. 5. Management:- Practices & procedures are amended. Integration of different policies. Attention is given to warnings and causes & increased understanding of causal chains results. Management responsibility assumed. 6. Integration:- Safety is integrated in all activities. Pro-active approach at all levels. Aggression is seen as directly related to work tasks, rather than individual staff qualities. Effective liaison with service users. A Total organizational response model is implemented. Figure 3 Safer Services Model (Miller 2003)

Safer Services Model

COMMUNICATION

SAFERSERVICES

TRUST

CONFIDENCE

Post Incident Support &Review

Recruitment & Retention

Therapeutic Environment

Criminal JusticeLiaison. - Prosecution - Police intervention

Organisational Boundaries # & clear documentation

Joint PolicyDevelopment- search-exclusion-violence prevention-sedation-seclusion

Information sharing

CollaborativeRisk Management

Robust ComplaintsProcess with follow upactions

Service users & carer involvement

Staff Training& Education

Clinical Support & Supervision

Figure 4 A Public Health Perspective on the Total Organisational Response (Leadbetter 2004)

Clinical Support & Supervision

Risk Assessment

Post Incident Support& Review

Robust Complaints Procedures

Figure 5 Violence Prevention in the Community

Education

Social Capital

Victim Prevention Programs