Peninsula Health PO Box 52 Frankston Victoria 3199 Australia Telephone

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1 Peninsula Health PO Box 52 Frankston Victoria 3199 Australia Telephone July 2011 DRUGS AND CRIME PREVENTION COMMITTEE Inquiry into Violence and Security Arrangements in Victoria Hospitals Parliamentary Submission. Short Summary Paper Introduction Violence within the Health Care Industry has become increasingly problematic. Back in 1999 the Australian Institute of Criminology mentions that the Health Industry was the most violent industry in Australia. A definition of occupational violence is; any incident where an employee is physically attacked or threatened in the workplace. In addition to physical contact and threats, the Australasian College for Emergency Medicine (March 2004) adds to that by saying verbal and aggressive abuse are also defined as acts of violence. Violence and its aftermath significantly impacts on physicians, nurses, receptionists, Patient Service Assistants and other clients and visitors within public Emergency Departments. M. Kennedy (2005) state that Emergency Departments are among the highest risk settings for violence in the health workplace and identify a strong correlation between increased violence in societal settings and Emergency Department presentations requiring medical treatment for related injuries (pg. 1). Violence in the setting of healthcare facilities seems to take on a different focus. The violent behaviour of the aggressor is not seen as a display of power or dominance but is more likely to be excused on compassionate grounds. M. Kennedy (2005). This contributes to an ongoing problem of under-reporting in the healthcare setting by both health professionals and the general public. Other contributing factors for under reporting identify that episodes of violence have become so prevalent that it is now almost accepted by health professional as an every day occurrence and therefore normal business. Health professionals are becoming desensitized. They are no longer willing to report violent incidents unless physical injury or property damaged occurs. Various studies estimate that up to 70% of episodes of violence are not formally reported (M. Kennedy 2005 pg. 4). It is no surprise that Australian Registered Nurses rate second highest among employee groups for workers compensation claims as a result of violence. Mayhew & Chappell (2003) acknowledges that approximately ninety percent of Emergency Department nurses experience physical intimidation or assault at some point in their career, with all experiencing verbal abuse. This statistic highlights the difficulties in attracting and retaining Emergency Nurses into the workforce.

2 Causes of Violence Causes of violence in Emergency Departments are multi-faceted. A certain percentage of the population who seek Emergency Department assistance are often classified as being socio-economically at risk and vulnerable (M. Kennedy 2005). Risky and aggressive behaviours are frequently displayed by patients in a state of alcohol intoxication or under the influence of drugs. These behaviours compound the difficulty of simple communication between the Health Professional and the client. The Department of Health - Metropolitan Health Plan Technical Paper (May 2011 pg. 93) states that Frankston is in the top ten Local Government Agencies in Victoria for poor self-reported health. Within the State of Victoria this suburb ranks sixth for risky drinking. The paper goes onto record that across all of the Local Government Agencies in metropolitan Melbourne there are individuals that are at risk of short-term harm from alcohol consumption. It was identified that more than 15% of the community on the Mornington Peninsula were undertaking risky drinking. The timing of the occurrences of aggression and violence in Emergency Departments should also be considered. With regards to social patterns of drug use and alcohol consumption, it can be said that the escalation of occurrences of violence increases on evening shifts and weekends. Characteristically hospitals generally function with minimal staff numbers and are more likely to be over crowded at these times. Contrary to beliefs, waiting times and organic illnesses does not correlate to increased violence and violent episodes within Emergency Departments. A survey of 116 Australasian Emergency Departments found that restraints were used for a wide range of client circumstances. In particular, violent or aggressive behaviour requiring the use of restraints was not illness-related. In 52% of cases, psychosis attributed to 32% of violent episodes, and organic brain syndromes attributed to only 10% of violent episodes within Emergency Departments (M. Kennedy pg. 4). International Research and Australian Professional Bodies Internationally research shows that 79 institutions in America have security personnel present in the Emergency Department 24 hours a day. Preventative, risk-management approach that addresses environmental factors, training, policies, restraints, security arrangements, and the need for legal precedents have been recommended by many professional bodies. Prevention and mitigating management of violence in the workplace is a focus of such organisations as the International Labour Office, International Council of Nurses, World Health Organization and Public Services International. In Australia the Occupational Health and Safety Act 2004 (Victoria) states that employers have a duty of care to the health and safety of their employees. Standards and policy guidelines have been set by industrial and professional bodies such as the Australasian College for Emergency Medicine s 2004 policy and the Australian Nursing Federation s policy document entitled Zero Tolerance in Violence These policies all advocate for a safe and secure working environment. In 2005 the Nurse Policy Branch of the Department of Health Services established the Victorian Taskforce on Violence in Nursing (2006). Of the 29 recommendations, 5 2

3 strategies were developed including; establishing a framework, raising awareness, justice interface, education, reporting and monitoring. Locally several Victorian metropolitan and regional public hospitals are currently involved in the The Building Better Partnerships Initiative program which is scheduled for completion in June An Incident Resolution Action Pack is being trialled as part of this program. This provides a framework for reporting incidents of occupational violence internally and to the police. Promoting early reporting, providing guidance on roles and responsibilities of Health Professionals, managers and the police, and provide action forms and a checklist to facilitate reporting to police. Further guidance on weapons management, gun safes, searching clients and Behaviour Assessment Rooms (BAR) will be made available on completion of this program. Aims The aims of implementing strategies to reduce the incidence of occupational violence in Emergency Departments include the following: o Targeting the social determinants of health and health related behaviours o Ensure equality of access. People attending an Emergency Department need access to urgent care unimpeded by exposure to or involvement in violence o Emphasising the need to fully implement and support prevention measures o Introducing a hazard/risk identification process o Identifying specific client groups and their characteristics with related appropriate interventions/controls o Changing attitudes towards under-reporting of violence in our Emergency Departments by Health Professional o Implementing a structural protection and security response system, including the presence of adequate security staff 24 hours per day dedicated to the department o Ensure that Health Professionals are provided with a safe working environment Peninsula Health Emergency Department Strategies Security arrangements and strategies within Peninsula Health vary throughout the hospital and across sites. Frankston Hospital has a 24 hour whole of hospital security management service. Within the Emergency Department, security services are accessed on demand. Fixed security devices such as duress alarms, triage window hydraulic pop-up screen protection and CCTV monitoring are currently in place. Computer alerts are generated using the hospital registration/medical records system for those patients who are known to exhibit aggressive behaviours. Active management plans of known frequent presenters are also developed by the Mental Health Service. Policies relating to physical restraint and armed violence (Code Black) situations are all in place with direct links to local police. Specially trained teams have been established to respond to unarmed situations, (Code Grey/Aggression Management Team (AMT). These teams play a vital role in everyday clinical management within the Emergency Department. 3

4 The Risk identification, Safety, Communication and Environment (RiSCE) program is a training program set up for all staff and has a focus towards those working in high risk areas of aggression, such as the Emergency Department. RiSCE aims to provide a leadership framework which supports the reduction of occupational violence, enhances the management of clinical aggression and behaviours of concern, reduces the use of physical restraint and where possible eliminate seclusion. This program is well entrenched in the culture of Peninsula Health staff and now makes up part of the mandatory annual training requirements for staff in the Emergency Department. In addition a new quality improvement program Management of Clinical Aggression Rapid Emergency Department Interventions (MOCA REDI) commenced in June This program is aimed at improving clinical responses to aggression and increase staffs confidence in dealing with aggressive behaviour for staff; it is anticipated by the RiSCE Coordinator that this new strategy will be merged into the current RiSCE program. Despite all of these strategies utilised at Frankston Hospital it must be acknowledged that not all are standard practice across other Peninsula Health sites. The limitations at other sites include the increased reliance on community police support along with private security patrols during and after business hours. Strategies implemented by Peninsula Health have been mostly in response to specific sentinel events and an increase in frequency. Yet, despite all these measures being implemented in the Emergency Department the number of violent occurrences has risen which leads to questions being raised about whether the current strategies put in place are no longer effective. Code Greys Incidents ED MH WARDS TOTOAL 0 Years ED-Emergency Department/ MH-Mental Health/ WARDS other than ED or MH at Frankston Hospital/ TOTAL-whole of Frankston Hospital. This graph displays the occurrences over a five year period of Respond Grey incidences at Frankston Hospital: Emergency Department, Mental Health, wards, and the remainder of Frankston Hospital. Within a five year period a total of 1,737 incidents of aggression/violence requiring a managed team approach occurred. This relates to an average of episodes per year. In relation to the increased management strategies within the Emergency Department over the past five years, the statistics have only remained as status quo and not declined as anticipated. 4

5 Recommendations It is a recommendation that the focus needs to be changed from incident management to risk management. Proactive prevention is the key. The physical and practiced strategies currently in place within the Emergency Departments should remain however more needs to be done in relation to the early identification of high risk indicators occurrences and active physical and behavioural screening. The presence of unarmed security staff in visible locations at the entrance of the Emergency Departments may be an effective deterrent to violent behaviours. This is particularly so when combined with other structural elements of a security system, such as cameras, restricted access and metal detectors (M. Kennedy pg. 6). In saying this, there needs to be less fortification of the environment and more unobtrusive barriers that promote effective communication and more engagement with the users of the service. This should aid with presentations of aggression and violence, by providing a sense of a more supportive and calm environment hopefully leading to a less threatening interaction. Risk identification including weapon detection using metal detectors or physical inspection is becoming more widespread according to M. Kennedy (2005. pg 6). The introduction of metal detectors should only be considered if their use is imbedded within a policy framework with clear communications with patients. It should also be recommended that the use of metal detectors only occurs in the presence of 24 hour trained security staff equipped with techniques and strategies that minimise escalation of violent behaviours and mitigate against its impacts. Strategies to reduce violence needs to work both ways. Community awareness and education must also be a strategy to ensure people understand acceptable and expected behaviour within a Healthcare facility. Whether it is through public advertising, such as posters, video presentations or information sheets in waiting rooms, or the use of the Health Care Charter Rights as explicit information about expected behavioural standards. Conclusion Despite strategies to mitigate violence within Healthcare facilities, the occurrence of violence will not diminish unless the promotion of a non-violent culture is adopted by society. This involves us all. A moral stance needs to take place that does not limit or restrict but encourages the acceptance that intimidating verbal and physical acts of behaviour can no longer be tolerated. Shamala Jones. Operations Director Emergency/ Access/ Demand Management. Peninsula Health. Nyree Parker. Clinical Nurse Specialist Emergency Department. Peninsula Health 5

6 References: Australian College of Emergency Medicine. Violence in emergency departments. Policy Document (21/5/11) Australian Nursing Federation. Harassment, victimisation and bullying in the workplace. Policy statement. (21/5/11) InformED Program. Emergency Departments promoting health. Welcome to the ED video production. Marcus P Kennedy Violence in emergency departments: under-reported, unconstrained, and unconscionable. MJA 2005; 183 (7): (21/5/11) MD Frank W Lavoie, MD Gary L Carter, MD Daniel F Danzl and Robert L Berg 1988 Emergency department violence in United States teaching hospitals. Annual of Emergency Medicine Vol 17 Issue 11 Nov 1988 pg Perone S. Violence in the workplace. Canberra: Australian Institute of Criminology, 1999.(Research and Public Policy Series, No.22.) Prevention of Occupational Violence in Hospitals Project DHS Rural Health Conference April Cheryl Thomas, Project Officer, Health & Aged Care. Victorian Consolidated Legislation. Occupational Health and Safety Act Sect (21/5/11). 6

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