1 Page 1 of 18 (S) REVISED / REVIEWED SUMMARY This section is presented up front to facilitate the reader in knowing the chronology of changes to a policy and the nature of the change(s). Accordingly, only the last date revised / reviewed is carried in the title block. Version Date Comments / Changes 1.0 April 2006 Initial Policy Published Prevention and Management of Aggressive Behaviour 2.0 April 2008 Revisions made to the Prevention and Management of Aggressive Behaviour Policy 3.0 November 2013 INTENT / PURPOSE Violence Prevention Policy published. Supercedes the Prevention and Management of Aggressive Behaviour Policy This policy applies to all Fraser Health employees, physicians and volunteers and to those employees of Lower Mainland Consolidated Services that work in Fraser Health facilities and to all patient/clients/residents and their families/visitors. POLICY To ensure the provision of a safe workplace and health care environment, Fraser Health will not tolerate verbal, physical, psychological or sexual violence against any employee or by any employee. Fraser Health will provide the resources to create and maintain a safe workplace as arising out of policies enacted under the Workers Compensation Act Section 115, General duties of Employers; Section 116, General duties of workers; and Section 117, General duties of Supervisors as well as of the WorkSafeBC Occupational Health and Safety Regulation (OHSR). As part of an overall strategy to improve workplace health, Fraser Health will adopt initiatives that will eliminate and/or reduce the incidence and severity of workplace violence by:
2 Page 2 of 18 evaluating the risk of violence in all Fraser Health workplaces; implementing measures such as engineering controls, policies, procedures and education and training to eliminate or reduce the risk of aggressive and/or excessive behaviour; defining the responsibilities of Fraser Health employees and committees (e.g. Joint Occupational Safety and Health Committee, Fraser Health Regional Violence Prevention Committee); providing resources for dealing with Critical Incident Stress; monitoring and evaluating control measures on a regular basis; reviewing reports and statistics; communicating expectations for appropriate conduct in the workplace to employees and patients/clients/residents, families and visitors or other members of the public; providing a formalized response to violent behaviour at all Fraser Health premises by the use of a Code White team response. Fraser Health supports a practice of least restraint and utilizes a preventive approach to violent incidents. All non-physical means of responding to aggressive behaviour must be employed prior to any physical response. Employees and Physicians will respond primarily using techniques as per the Provincial Violence Prevention Curriculum for Healthcare in situations of disrespect or potential violence. Patients/clients/residents have the need and right to receive visitors of their choice to the greatest extent possible given their clinical condition and the operational requirements of the program, service or facility. However, it is Fraser Health s responsibility to provide a safe working environment as per WorkSafeBC Occupational Health and Safety Regulations and to ensure a balance between this need for patients/clients/residents to receive visitors and the safety of its workers and other patients/clients/residents and visitors. Patients also have the right to exclude visitors based on their own wishes.
3 Page 3 of 18 Visitors have a responsibility to manage their own conduct, treat others with respect and to preserve the dignity, safety and comfort of other patients/clients/residents, staff, physicians and volunteers. In situations where visitors exhibit behaviours which are disrespectful or violent, Managers or delegate are responsible for acting immediately to reduce risk and to protect the safety of others. If the behaviour does not meet these responsibilities Fraser Health reserves the right to address the behaviour in a manner that preserves a safe workplace and safe health care environment. (See Appendix A) Portions of this policy related to visitors are superceded by court orders including custody orders, orders made under other enactments relating to the specific patient/client/resident or visitor and by the Memorandum of Understanding with the B.C. Corrections and Lower Mainland Correctional Centres. STANDARDS A. Executive Directors/Directors - Clinical Programs Ensure the provision of the Fraser Health Violence Prevention (VP) program including policies and procedures for dealing with workplace violence. Ensure that Directors, Managers and Supervisors are aware of VP program requirements. Ensure the provision of violence prevention resources including education and training of employees and responders. Regularly reviews the VP policy and associated program materials. B. Site Directors Establish a site-specific Code White response. Code White teams at the acute sites must have a minimum of 3-5 trained responders (as per Provincial Guidelines) assigned to respond for all shifts. Code White teams and responses at community sites will be
4 Page 4 of 18 based on to the number of available staff to respond, patient/client/resident population and assessed level of risk at the site. Ensure mock codes/drills are conducted to provide for the trained Code White response when required. Ensure appropriate inspections and investigations are conducted at the site to validate required prevention activities are in place. Ensure that the Joint Occupational Safety and Health (JOSH) Committee has violence prevention as a standing agenda item. C. Managers and Supervisors Ensure employees are aware and understand that violence should not be accepted as part of the job. Ensure employees are aware of policies and procedures related to violence prevention (e.g. Violence Prevention, Code White, ALERT: Identification and Designation of Clients at Risk for Aggressive Behaviour, Working Alone, Response to Disrespectful or Violent Behaviours from Visitors, etc.). Ensure risk identification, assessments and resulting requirements are completed and implemented for their work area. Inform employees of any risks due to violence and ensures the VP program procedures are developed and communicated to employees. Ensure employees complete required education / training programs. Ensure all violent (verbal or physical) or potentially violent (near miss) incidents are reported to the Workplace Health Call Centre, are reviewed, that an investigation is immediately undertaken and that any necessary corrective measures are implemented. Corrective actions must address prevention. Ensure employees are aware of resources available to them after responding to violence (e.g. Critical Incident Stress Management, Employee and Family Assistance Program, Workplace Health, Protection Services, etc.).
5 Page 5 of 18 Provide support to employees/physicians who wish to pursue legal action if they are injured as a result of responding to violence. D. Employees/Physicians Respond appropriately to violent behaviours. Follow established procedures and protocols for aggressive incidents. Report all acts of aggression to the Manager/Supervisor and completes relevant documentation. Seek first aid if injured responding to a violence incident or attending to a violent patient. Contact the Workplace Health Call Centre for injuries (physical, psychological, sexual, near misses, etc.). Attend required education and training where applicable. E. Joint Occupational Safety and Health (JOSH) Committee Participate in a local, annual evaluation of the VP Program with Workplace Health. Make recommendations to improve the VP program. Review incident statistics on a regular basis. Participate in investigations of aggressive incidents where reasonably available. F. Fraser Health Regional Violence Prevention Committee Provide guidance for the Violence Prevention (VP) Program of Fraser Health. Liaise with internal and external stakeholders (WorkSafeBC, other Health Authorities, etc.) regarding development and evaluation of VP programs. Monitor and evaluate site and JOSH Committee activities in violence prevention through the annual reporting requirement.
6 Page 6 of 18 G. Protection Services Administer the VP Program in conjunction with Workplace Health. Facilitate the VP Program design as well as associated training and education. Ensure contracted security personnel are trained in the Provincial Violence Prevention Curriculum for Healthcare principles and techniques. Ensure that contracted security personnel deployed at Fraser Health sites respond STAT to all violence incidents. Provide statistical information on violence incidents to JOSH committees for review. Evaluate the VP Program annually in conjunction with Workplace Health and JOSH committees. Assist employees/physicians who wish to pursue legal action after a violent incident. H. Workplace Health Administer the Violence Prevention (VP) Program in conjunction with Protection Services. Provide advice and guidelines to Managers and employees to assist with compliance with VP program requirements. Ensure appropriate education and training is available for all employees and Code White responders. Facilitate VP Program design as well as associated training and education. Coordinate the delivery of standardized training and education programs. Evaluate the VP program annually in conjunction with Protection Services and JOSH committees. Make provisions for all new employees to receive orientation to the VP Program. Provide statistical information on aggressive incidents to JOSH committees for review.
7 Page 7 of 18 Assist employees/physicians who wish to pursue legal action after a violent incident. CODE WHITE RESPONSE A Code White response is a coordinated emergency team response to deal with situations where workers perceive themselves or others to be in danger of physical harm from someone who is violent, someone acting out in a way that is dangerous to self, others or the environment or the situation is rapidly escalating out of control where the staff present do not have the capability to de-escalate the situation. Each Executive Director, at the sites/facilities that they are accountable for, is responsible for ensuring that there are enough trained responders to safely respond to all potential behavioural emergencies. All Acute Care sites will utilize a Code White Level III Response Protocol. Community sites will also employ a Code White response based on the staffing levels, training and assessed risk of the site. Where there are not sufficiently trained responders working at a site, alternative measures must be implemented to ensure a safe, emergency response. Each site must ensure a site-specific procedure is developed, communicated and regularly reviewed. Each site-specific procedure must clearly describe who/which departments are responsible for providing trained responders to safely respond to all patient related behavioural emergencies or Code White calls 24 hours a day, 7 days a week (24/7) based on the assessed Code White response required by that area. Contracted security personnel will respond to all Code White calls. Code White team responders are trained in the Provincial Violence Prevention Curriculum (PVPC) for Healthcare Advanced Team Response module and should recertify annually. Code White team physical interventions are used as a last resort to safely control a person until they are able to regain control of their own behaviour. Code White teams must ensure the safety of the team and others and not intervene in any situation beyond their ability.
8 Page 8 of 18 Untrained individuals are not to participate directly in a Code White response but may act in a supportive role. CODE WHITE ROLES AND RESPONSIBILITIES A. Nurse/Person Initiating Code White May become part of or Team Leader for Code White response team if currently trained in PVPC ATR otherwise must remain present throughout the entire intervention and relay information to the Code White team leader including: o Events leading up to incident o Actions that have been taken o Physical and emotional condition of aggressor o Alerts, risks and history with respect to violent potential of aggressor o Actions or goals of intervention for the Code White team (e.g. escort to room, medication, physical restraint, etc.) Removes persons in immediate danger to safety. Calls police if directed by Code White Team Leader Obtains medication or physical restraints if required Delegates staff member to call attending Physician for orders Documents incident on health record as related to the patient NOTE: If the situation is extremely dangerous and/or weapons are involved staff will call the police before the Code White Team arrives. B. Code White Team Leader Responds STAT to a Code White call. Receives report from the Nurse/person initiating the Code White.
9 Page 9 of 18 Assesses the patient/client/resident (potential, alerts, medical, physical and emotional status), team (e.g. is everyone currently trained and ready, willing and capable) and environment prior to intervention. Acts as spokesperson for the team and is the only person who speaks for the team. Only person communicating with the aggressor unless otherwise delegated. Plans the team intervention with input from the Nurse/person initiating the Code White. Directs team members in the intervention. Options may include: o o o o o Calming the aggressor utilizing verbal defusing skills and assisting them back to their room. Isolating the aggressor in a seclusion room (where available). Administering medication. Controlling with physical and/or mechanical restraints. Calling police if the situation is beyond the team s capabilities. Ensures that team members remove personal items which may cause injury or be damaged (e.g. pens, scissors, neck ties, lanyards, watches, cell phones, etc.) Ensures that team members participate in an informal debriefing after a Code White. Reports immediately to first aid and reports to the Workplace Health Call Centre if injured (physical/verbal) or potentially injured (near miss) during the Code White call incident. C. Code White Team Members/Responders Participates in both initial training (PVPC on-line modules, 4 hour basic PVPC program, 8 hour PVPC ATR program) and annual reviews. Responds STAT to a Code White call. Identifies self as a currently trained responder to the Team Leader.
10 Page 10 of 18 Observes universal precautions. Put on gloves prior to intervention. Removes personal items which may cause injury or be damaged. Participates in planned intervention following the instruction of the Team Leader. Uses the least restraint necessary in containing threatening or violent behaviour. Participates in debriefing immediately following the incident. Reports immediately to first aid and reports to the Workplace Health Call Centre if injured (physical/verbal) or potentially injured (near miss) during the Code White call incident. NOTE: If the aggressor leaves the facility the team will not attempt to follow but will notify the police. D. Unit Manager/Designate Assesses the emotional and physical well being of staff. Notifies the CISM Coordinator or designate if debriefing or defusing is required. Ensure that injured employees go to first aid immediately. Investigates the incident with the Code White responders and employees. Reviews, investigates and makes recommendations for corrective actions once a copy of a Workplace Health Call Centre incident report is received and implements the recommended corrective actions. DEFINITIONS Code White: A call for help for a violent or potentially violent situation. o Level I Code White response A basic response. Consists of one or more workers responding to a call for help.
11 Page 11 of 18 Workers must maintain a basic level of Violence Prevention training. (Check regional training recommendations) Responders keep people safe, clear the environment and initiate additional support (i.e. call 911/security) o o Level II Code White response An intermediate response. Consists of a trained group of 2-5 workers. Workers must maintain current certification in the Provincial Violence Prevention modules which minimally include the modules on Communication, De-escalation and Personal Safety. (Check regional training recommendations) Workers respond to Code White calls in a structured manner. Responders provide an initial show of support and presence. They do not physically intervene but continually assess the situation and use deescalation skills. Level III Code White response An advanced team response. Consists of a highly trained group of 3-5 workers. Workers must maintain current certification in the Provincial Violence Prevention modules which includes Advanced Team Response. (Check regional training recommendations) They are often called the Code White Team. This team is able to provide a show of presence, de-escalation, up to and including physical interventions. Code White Response or Procedure: A coordinated emergency team response to deal with unresolved threatening or violent behaviour from a patient/client/resident. Critical Incident Stress: Any situation faced by employees which causes them to
12 Page 12 of 18 experience unusually strong emotional reactions and which has the potential to interfere with their ability to function either at the scene or later. Least Restraint: Intervention used with a violent patient/client/resident which is the least restrictive possible. Patient: A term often used interchangeably with client or resident to refer to consumers of the healthcare system. Disrespectful and Violent Behaviours: Includes behaviours assessed/perceived as disrespectful, inappropriate, aggressive or violent (verbal or physical). Behaviours also deemed unacceptable include, but are not limited to, using abusive and/or foul language, apparent alcohol and/or drug intoxication and being disruptive or unresponsive to the direction of staff. Provincial Violence Prevention Curriculum for Healthcare: A standardized, safe, non-harmful, violence prevention education program developed in British Columbia, Canada with collaboration from B.C. Health Authorities, Healthcare Unions, WorkSafeBC and OHSAH with support from the Ministry of Health. Violence: Incidents where persons are abused, threatened or assaulted in circumstances related to their work involving a direct or indirect challenge to their safety, well-being or health. This includes any violent behaviour that is intentional, that is not intentional due to illness/injury and violent behaviour that is not intentional where the aggressor lacks the mental capacity to demonstrate intent, often called aggression. (Provincial Violence Prevention Curriculum for Healthcare, March 2011) REFERENCES Fraser Health s ALERT System: Designation, Identification and Review of Clients at Risk for Aggressive Behaviour Policy Fraser Health s Critical Care Indicators Policy
13 Page 13 of 18 Fraser Health s Management of Targeted Violence Policy Fraser Health Authority s Respectful Workplace Policy Fraser Health Authority s Workplace Health and Safety Policy Fraser Health s Working Alone Program and Procedures Guidelines: Code White Response, A Component of Prevention and Management of Aggressive Behaviour in Healthcare, Health Association of BC, WorksafeBC, OHSAH Ministry of Health Policy Communique, October 24, 2012, Response to Visitors Who Pose a Risk to Health or Safety in Health Care Facilities Preventing Violence in Healthcare - Five Steps to an Effective Program, WorkSafeBC WorkSafeBC Occupational Health and Safety Regulation, Working Alone, Workplace Conduct and Violence in the Workplace Regulations, Sections , , APPENDICES Appendix A: Response to Disrespectful or Violent Behaviours of Visitors
14 Page 14 of 18 APPENDIX A RESPONSE TO DISRESPECTFUL OR VIOLENT BEHAVIOURS FROM VISITORS PURPOSE This procedure outlines the steps for dealing with disrespectful or violent behaviours (e.g. verbal and/or physical aggression or violent acting out) of visitors. PROCEDURE In situations where visitors exhibit behaviours which are disrespectful or violent, Managers or delegate are responsible for acting immediately to reduce risk and to protect the safety of others. It is important to note that family members/visitors may be under stress and a supportive and compassionate approach may be helpful in decreasing the intensity of the situation. Criteria as per the Aggressive Behaviour Risk Assessment form as per the ALERT policy apply to the risk assessment of visitors. When appropriate, staff and management must make efforts to ensure the communication of risk from a visitor is documented as per the ALERT policy and on the relevant data systems (e.g. Meditech, PARIS, etc.). SPECIFIC RESPONSES TO VISITORS EXHIBITING DISRESPECTFUL OR VIOLENT BEHAVIOUR Contact 911 for immediate police assistance where an immediate risk is present or for situations where a weapon is present or being threatened.
15 Page 15 of 18 Utilize a preventive and progressive approach using de-escalation techniques and limitsetting (as taught in the Provincial Violence Prevention Curriculum for Healthcare) to try to achieve compliance where assessed as safe to do so. Take all threats seriously. Remove yourself and/or others from the immediate area. Call security (where available) and a Code White and/or 911 where appropriate. Document the incident, inform the Manager and report the incident to the Workplace Health Call Centre and PSLS. Manager or delegate contacts Workplace Health and Protection Services to discuss the incident and implement risk controls. Manager or delegate may contact the contracted security site Supervisor or Protection Services to request a threat assessment where warranted. Interventions and controls that may be considered by the care team may include the following for consideration: Explaining the visitor times and policies and standards of behaviour expected to the visitor and requesting compliance. It would be recommended to have the Manager/delegate present and/or representation from Protection Services or the site Security Supervisor. Provide written warnings of the potential for periodic or absolute restrictions on access to the facility if inappropriate behaviour re-occurs. These warnings and restrictions must be reviewed by the team within a reasonable time frame as determined by the Manager and care team. Supervision for the visitor when visiting their friend/family member (i.e. security standby). Enforcing limitations to visiting times for periods when staffing numbers are higher or when security assistance/stand-by s are available.
16 Page 16 of 18 If restrictions are put in place for the visitor, facilities must document the steps they have taken to resolve the issues including the progressive process used and receive approval from senior administration before implementation. The Manager must document in the Patient Safety and Learning System event record the progressive escalation processes used, discussions and approval from senior administration. Staff experiencing/receiving the disrespectful or violent behaviour must report the incident to the Workplace Health Call Centre Provide the visitor with the contact information for Client Relations should they want to appeal the visitation limitations.
17 Page 17 of 18 SAMPLE BEHAVIOURAL AGREEMENT (Date) Dear Mr./Mrs./Ms.: (Name of Wife; Husband; Son; Daughter; Friend, etc.), Fraser Health staff and Physicians work hard every day to demonstrate the values that are most important to us: Respect, Caring and Trust. Persons in care have the need and right to receive visitors of their choice to the greatest extent possible given their clinical condition and the operational requirements of the program, service or facility. However, it is Fraser Health s responsibility to provide a safe working environment as per WorkSafeBC Occupational Health and Safety Regulations and to ensure a balance between the need for clients to receive visitors and the safety of its workers and other patients/clients/residents and visitors. Visitors have a responsibility to manage their own conduct, treat others with respect and to preserve the dignity, safety and comfort of other patients/clients/residents, staff, Physicians and volunteers. In situations where visitors exhibit behaviours which are disrespectful or violent, Managers are responsible for acting immediately to reduce risk and to protect the safety of others. It is important to note that family members/visitors may be under stress and a supportive and compassionate approach may be helpful in decreasing the intensity of that situation. Our experience to date here on (site/dept) makes it necessary to discuss Fraser Health s Violence Prevention Policy and outline our behavioural expectations while you are visiting with (Name of Patient/ Client/Resident).
18 Page 18 of 18 BEHAVIOURAL EXPECTATIONS: Expected Behaviour 1 (outline specific expected behaviour(s) for the visitor ex no videotaping; non interference with care etc) 2 Example: (Visitor name) will behave in a respectful and calm manner while on hospital premises. Disruptive behaviours such as swearing, yelling and threatening physical actions will not be tolerated. Please let us know if there are ways that we can interact with you so that these behaviours are not demonstrated Staff Response on Non-Compliance (outline the actions staff will take when visitor does not comply with expected behaviour; include specifics of interventions including de-escalation tactics, notification to PCC/ manager; when to call security. Also include directions to staff regarding documentation of event in patient chart) Example: Staff will give one verbal warning and document incident in nursing notes on patient chart. If behaviour continues they will: 1. Contact security for removal from site 2. Document the incident in nursing notes on patient chart. PSLS 3. Notify their Unit PCC, Manager and/or Site Leader 3 4. Report to the Workplace Call Centre if you were hurt, threatened, or felt at risk (Visitor Name) (Name, Clinical Manager (Name), Site Director Date Date Date Copy of Violence Prevention Policy provided to Visitor: Contact information:(provide Name, Contact Number for Visitor to direct questions etc) COPIES OF COMPLETED AGREEMENT TO BE GIVEN TO VISITOR AND FILED ON PATIENT/CLIENT/ RESIDENT CHART
Page 1 of 10 1.0 PURPOSE The ALERT System will provide a systemic and formal process which alerts employees to a potentially aggressive client as per regulatory requirements. 2.0 DEFINITIONS Aggression
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