Other strategies

Crime Prevention Through Environmental Design (CPTED)

Research suggests that the design of a workplace may either diffuse or aggravate a potentially violent situation.

Crime Prevention Through Environmental Design (CPTED) aims to enhance the design of buildings to discourage criminal activity, and is implemented using the specialist expertise of engineers, builders, architects and gardeners.

CPTED focuses on both physical design factors, but also studies on how people respond to things like colour schemes, lighting and room temperature.

It seeks to strike a balance between creating a welcoming and non-threatening environment for clients and customers, and ensuring the safety of staff.

Below are examples of CPTED designs used commonly in the health sector. Some of these designs may be applicable to other sectors. They include:

  • using personal emergency alarms, panic buttons
  • separating reception areas and nursing stations from the public via safety glass and/or high counters
  • arranging furniture to ensure staff will not be trapped
  • making waiting areas comfortable (eg having a TV, water, climate control)
  • providing secure, separate bathrooms for staff
  • placing curved mirrors in hallways, intersections and concealed areas
  • using metal detectors to screen patients in psychiatric facilities
  • creating “time out” rooms for agitated patients
  • adding large windows with no curtains so people passing by can see into the waiting room

Education and training

Education and training is seen as critical to reduce, prevent and manage workplace violence against professionals in rural and remote locations. Research suggests at least some education and training on preventing workplace violence should be provided in the induction period.

There is no ‘one size fits’ all approach to education and training on workplace violence. Education and training should be tailored to the particular role and location. However, the content of education and training may include:

  • understanding violence
  • recognising and diffusing violent and aggressive behaviour
  • managing clients that may have a psychological disorder or substance abuse problems
  • self-defence techniques and personal protection
  • interpersonal skills and conflict management training
  • communication skills
  • use of communication devices
  • cultural sensitivity
  • workplace violence prevention policies and procedures, including reporting procedures
  • industry guidelines, codes of practice and standards.

While education and training may not necessarily reduce violent incidents in the workplace, it may equip staff to better respond to workplace violence and in turn help them feel safer in the workplace.

Ninety-six criminal justice professionals in the United States and Canada attended training in violence risk assessment. The course included 54 contact hours across 8 days and focused on:

  • principles of violence risk assessment and management
  • mental disorder symptoms and the association between mental disorder and violence
  • assessment of risk for various forms of violence
  • general violence, sexual violence, stalking, child abuse and neglect, group violence, and school and workplace violence
  • assessment of threats
  • report writing and testimony.

An evaluation was conducted to look at whether the training increased criminal justice professionals’ “knowledge about violence risk assessment concepts, violence risk assessment skills, and attitudes regarding competence at assessing violence risk”.

A comparison between the pre-training and post-training research found that, following the course, participants:

  • showed increased knowledge about risk assessment
  • showed significant improvement in using the risk assessment skills they had learnt in an applied manner
  • showed improvements in case-management recommendations post-training
  • reported improved confidence, competence and knowledge following the course.

(Storey J et al (2011) ‘Evaluation of a violence risk (threat) assessment training program for police and other criminal justice professionals’; Criminal Justice and Behaviour 2011 38:554)

Communication procedures when off-site

Working off-site or conducting home visits presents risks for workers, but particularly those in rural and remote locations who may have to travel long distances on country roads, or visit isolated locations where few support services are available to assist them if they find themselves in danger.

Research suggests an effective communication procedure is one strategy for mitigating this risk. The procedure should take into account the particular circumstances of the workplace and location. In one location, for example, supplying staff with a mobile phone may be a suitable mitigation strategy, but in another location, this may be unsuitable due to poor or no coverage.

Some mitigation strategies employers may wish to consider in developing a communication procedure include:

  • a system to record the address of the place visited, time of departure and expected time of return
  • follow-up checks after visits
  • scheduled telephone calls
  • the issuing of mobile or satellite telephones
  • the issuing of personal alarms or sprays.

In addition to having communication procedures, it is advisable for employers to develop clear guidelines on when home visits are safe and reasonable, and the circumstances in which visits will take place (eg in some cases, a home visit may only be acceptable if a worker is accompanied by a police officer).

Employee assistance and mentoring programs

Employee assistance programs involve assisting employees with personal and work problems, often through confidential counselling, educational material, or referrals to different services. Research suggests such support is critical in helping workers develop resilience and judgement, which in turn can assist workers to manage risks to their personal safety and wellbeing.

Peer support or mentoring programs may also be useful for workers in rural and remote Australia. For example, a mechanism through which newly arrived rural/remote workers can communicate or share concerns with a long-term community member may help new workers better understand their community, including the risks and challenges the community and its members face.

Recognising and de-escalating aggressive behaviour

Recognising and de-escalating aggressive behaviour is seen as critical to reducing workplace violence.

Research suggests it is important for workers, particularly in sectors such as health, law enforcement and education, to be aware of potential risk factors for aggression (eg young age, a history of violence, severe mental illness and substance abuse), and to recognise signs of escalating frustration and anger (eg body language such as staring, frowning, clenched fists, crossed arms, pacing, finger pointing).

When recognised, early aggressive behaviour can often be de-escalated using strategies at individual and system levels.

Research by Sim et al (2011) suggests responses at the individual level may include:

  • remaining calm and respectful
  • approaching the person in a warm and open manner
  • avoiding a confrontational approach including confrontational body language (eg crossed arms)
  • using simple language
  • not raising your voice
  • maintaining non-threatening eye contact
  • nodding to convey understanding
  • giving the person your full attention and not being distracted by other things
  • acknowledging the person’s frustration
  • giving a clear message that you want to help and you understand their point of view.

Sim et al (2011) note that responses at the system level will vary depending on the sector and workplace. In the health sector, for example, system-level responses may include:

  • training for staff on effective communication
  • adopting processes that are likely to reduce frustration that may lead to aggression (eg different ways of scheduling appointments, a way of messaging patients to alert them of delays)
  • ensuring a comfortable waiting area for patients (eg with a television or magazines for adults and books/toys for children.

Strategies in the health sector

Parts of the health sector have adopted a number of specific strategies to try and minimise the risk of violence from patients, their friends/family and other community members. Research suggests that while these strategies can be effective, they may not be effective or ‘realistic’ in some environments, including some rural and remote communities.

Strategies specific to the health sector are outlined below:

Zero tolerance policies

Zero tolerance policies have been adopted or endorsed by some governments, unions, industry bodies and workplaces in Australia.  The Australian Nursing Federation has adopted a zero tolerance policy which expressly states violence against nurses is unacceptable and nurses do not have to tolerate it. The Western Australian Department of Health has defined the zero tolerance response as meaning that following all violent incidents, appropriate action will be taken to protect staff, patients and visitors from the effects of such behaviour.

Zero tolerance policies have supporters, but they also have detractors. While zero tolerance policies can send a strong message to the community that violence will not be tolerated, some argue that their value is limited because they do not address the cause of the violence. Detractors question the value of punishing someone who, for example, may not appreciate the consequences of their violent action due to severe mental illness.

The Australian Nursing Federation (Victorian Branch) has said that cooperation and support from police is critical to the effective implementation of zero tolerance policies. In rural and remote communities, such cooperation may be complicated by the fact that police may be located some distance away.

Flagging violent individuals

Some in the health sector manage workplace violence by ‘flagging’ the files of patients who have been violent in the past, and providing colleagues with as much information as possible to assist them to assess a client’s potential for violence. The RACGP advises that workplaces considering this strategy need to ensure practices comply with Australian laws, including anti-discrimination, privacy and  defamation laws. Click here for more information on flagging the files of violent individuals in the general practice setting.

Behaviour contracts and restriction of practice

A behaviour contract generally relates to a specific individual, and outlines the behaviour that will not be tolerated, as well as the consequences of such behaviour. For example, a behaviour contract may say that a consequence of certain behaviour is that the practice will no longer provide services to the client.

While the theory behind behaviour contracts may be sound, it is argued that, in reality, practices have a duty of care to a patient when immediate medical assistance is required. In some rural and remote locations, where there are limited health services, the clinic or the staff that have been threatened to the point that they have issued a behaviour contract may feel they have no option but to treat the patient.

According to the Royal Australian College of General Practitioners (RACGP), there is evidence that acceptable behaviour agreements can change behaviour, but the RACGP suggests these agreements are not suitable for universal application. The RACGP states acceptable behaviour agreements have been found to be most effective in clinics with the following characteristics:

  •  a proportion of patients suffer from drug/alcohol abuse related conditions, drug seeking behaviours, or mental instability
  • the practitioners who use such agreements are highly experienced in dealing with patients having drug/alcohol addiction and related conditions or mental instability, and
  • the circumstances are such that the patient can be persuaded that there is a trade off, beneficial to the patient, in agreeing to modify behaviour as a condition of continuing treatment.

The RACGP states acceptable behaviour agreements are not appropriate and are more likely to trigger aggression where:

  •  the practitioner is inexperienced in dealing with patients having drug/alcohol addiction and related conditions or mental instability
  • recourse to an acceptable behaviour agreement is an overreaction to a trivial incident, and
  • in an emergency situation.

‘Refusing to Treat’ or discontinuing care

Similar to acceptable behaviour agreements, some health workplaces may respond to violent patients by issuing a “refuse to treat” directive, being a directive to discharge or prevent a patient from receiving non-life threatening treatment if the patient displays certain behaviours towards staff, such as violence. “Refuse to treat” directives, still raise some of the practical and ethical issues outlined in relation to acceptable behaviour agreements.

The RACGP cautions that practices must consider anti-discrimination laws when discontinuing care, stressing that patients cannot be excluded on the grounds of illness (eg mental illness) or disability. Click here for more information.

Intervention orders

If there is a continuing threat of violence, workplaces may consider an intervention or restraining order. The legislation governing such orders varies between states and territories in Australia. However, these orders are designed to restrict the perpetrator’s behaviour in relation to the victim, in order to protect the safety of the victim (eg the order may say that the perpetrator cannot go near the victim’s workplace or home).

This section has been informed by the following:

Australian Nursing Federation (Victorian Branch) (2001 reviewed 2006); Zero Tolerance (Occupational Violence and Aggression Policy).

Chappell, Duncan (n.d); Literature review into best practice for preventing and managing customer aggression; prepared for ComCare, Australian Government.

Ferguson, Heather (2005); ‘The danger out there’ published in Australian Doctor (www.australiandoctor.com.au) 13 January 2005.

Mayhew, Claire (2000); Preventing Client-initiated Violence: A Practical Handbook; Australian Institute of Criminology, Research and Public Policy Series, No.30.

National Health and Medical Research Council (NHMRC) (2002); When it’s right in front of you: assisting health care workers to manage the effects of violence in rural and remote Australia

Perrone, Santina (1999); Violence in the Workplace; Australian Institute of Criminology. Research and Public Policy Series No 22.

Premier’s Department of New South Wales (2003); Occupational Stress: Hazard Identification and Risk Management Strategy; September 2003.

Rowe, L and Kidd, Michael R; ‘Increasing violence in Australian general practice in a public health issue’; Medical Journal of Australia 187 (2): 118-119.

Sim, Moira G; Wain, Toni; Khong Eric (2011); ‘Aggressive behaviour: Prevention and management in the general practice environment’; Australian Family Physician Vol 40, No 11, November 2011.

Storey, Jennifer E; Gibas, Andrea L; Reeves, Kim A; Hart, Stephen D (2011); ‘Evaluation of a violence risk (threat) assessment training program for police and other criminal justice professionals’; Criminal Justice and Behaviour 2011 38:554.

The Royal Australian College of General Practitioners (RACGP) (2010); Standards for general practices; 4th edition; October 2010.

The Royal Australian College of General Practitioners (RACGP) (2009.b); General practice – a safe place: tips and tools; published March 2009; reprinted April 2011.

Tolhurst, Helen; Baker, Louise; Bell, Pam; Murray, Gillian; Sutton, Amber; Dean, Sara (2003); ‘Rural general practitioner experience of work-related violence in Australia’; Australian Journal of Rural Health (2003) 11, 231-236.

Western Australia Department of Health (2004); Prevention of workplace aggression and violence: policy and guidelines

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