What you need to do
Complete a risk assessment
If there is a risk of violence and aggression, or challenging behaviour, you must assess the risks. This process will help you: identify hazards; evaluate risks; and, implement, monitor and review measures to reduce the risk.
The main factors that can lead to violent or aggressive behaviour and create a risk include:
- inherent aggression or mental instability;
- impatience (due to waiting, lack of information or boredom);
- frustration (due to lack of information or boredom);
- anxiety (lack of choice, lack of space);
- resentment (lack of rights);
- alcohol and drugs; and,
- poor design of premises.
What is a suitable and sufficient risk assessment?
The risk assessment process for managing the risks of violence and aggression may not be as straight forward as that of other risk assessments you have completed. You may need to have a number of different types of assessment in place, for example:
Generic risk assessments that consider the overall needs of the organisation, for example:
- The general risks to all staff from patients, service users and their relatives or visitors;
- The risks associated with the design of the work environment, ie layout of rooms, alarm systems, access to car parks at night;
- The risks associated with lone working, whether working in the community or alone in work premises;
- The identification of appropriate instruction, information and training.
Individual risk assessments where individuals pose a risk of violence and aggression. If the person is receiving care, the assessment should be completed and regularly reviewed as part of the care planning process. The assessment should consider:
- the mental, emotional and physical condition of the person;
- the effect of medical conditions or ingestion of drugs, alcohol or medicines
- their stress levels;
- whether they have a history of challenging, violent or aggressive behaviour; and,
- whether they consider others a threat.
All staff likely to be exposed to potentially violent individuals should know the potential trigger situations and the prevention measures identified by the assessment and care plan. Particular care is needed when:
- new members of staff or agency staff are involved;
- new persons are admitted, especially those with a history of challenging behaviour; and,
- there has been a change in a person's mental or physical state, medication, behaviour, mood etc.
Implementing control measures
Identifying appropriate control measures is part of the risk assessment process. There are a number of precautions that can help prevent and control violence. The following are examples, but this is not an exhaustive list and it is important to ensure the measures identified adequately control the risks:
Work arrangements and communication
- Consider the jobs staff do and how they are done. For example, do cleaners and caterers come into contact with persons that present challenging behaviour?;
- Provide clear instructions. These can be verbal or written;
- Ensure appropriate training at the right level to help staff work safely when dealing with potentially aggressive or violent people;
- Ensure suitable systems are in place for recording and exchanging information about patients, service users and potentially, their relatives (individual risk assessments, hand over briefings, indicators on care plans, prompts in bedrooms etc);
- Ensure adequate staffing levels according to level of risk. Do certain times of the day present a higher risk of challenging behaviour, ie bathing or meal times?
- Respond appropriately to incidents and record them appropriately.
- Consider how staff engage with people. People can get annoyed if information is not available or they feel as if they are being ignored.
- Manage new patients or service users – check you have the right information at referral regarding violent behaviour and share it early with staff
Personal Communication Devices
Employees may need to contact someone for assistance, for example, community-based staff such as midwives, district nurses, social workers and site-based staff working in isolated areas of premises. The provision of personal communication devices may form part of a number of reasonably practicable control measures to help manage the risk. These include; telephones, mobile phones, radios, automatic warning devices and emergency alarms.
Personal communication devices alone will not prevent incidents from occurring. However, if used correctly and in conjunction with robust procedures, they will improve the protection of lone workers.
The physical environment may affect the likelihood of violent incidents, and the ease at which people can respond to them. You must ensure the work environment is as safe and secure as possible to reduce the risk of violence and aggression. Risk assessments should consider:
- Space and layout – consider good visibility and avoid trapping points;
- Lighting, decoration and furnishings – it is important to create a relaxing environment but you should consider what furnishings could be used as weapons;
- Noise – banging doors, trolleys, PA systems can be stressful. Sound absorbing surfaces and materials may reduce the ambient noise levels
- Information – People can get annoyed if information is not available. Consider clear signage and visual displays to inform people.
- Staff security – consider building security, access to isolated areas and security systems such as CCTV, fixed alarms, personal alarms and communication systems.
Interview or Treatment Rooms
- When designing treatment and interview rooms, you need to consider:
- the selection of furniture and fittings which are difficult to use as weapons;
- the ease with which staff can escape;
- the provision of suitable alarm systems;
- the need for easy communication between staff, while retaining privacy.
Lone working - Community workers
Lone workers can face additional risks. It is difficult to change the working environment, so it is especially important to consider working arrangements carefully.
Generic assessments of the risks of visiting particular areas or client groups may help employees decide on the precautions to take for specific visits; for example, by identifying particular types of visit which should not be carried out during the evening or night, or by a lone member of staff.
On an individual basis, the potential risk of violence should be assessed before any home visit. Such assessments need to consider:
- information passed on at referral;
- information from other agencies, such as the police, health or social services;
- past history of violence (person receiving care or relatives);
- the effect of staff uniforms on people or their relatives; and,
- recent medical and personal history.
It is useful to set up systems to ensure exchange of information and co-operation between all agencies that might visit people in the community.
If there is not enough information to make a suitable assessment, consider the following precautions for visits where there may be a risk of violence:
- meeting the patient or client in another location;
- two or more staff visiting together;
- arranging for security staff or others to provide an escort;
- provision of alarm and/or communication devices; and,
- special liaison with local police/other agencies (possibly a combined visit).
It is sensible if arrangements require employees who carry out home visits to prepare plans of their movements and to report back to base periodically. Reporting back might be appropriate after identified visits, and at the end of the day or shift. The movement plans need to be kept by someone responsible, who knows what to do if the person involved does not call in when expected.
Training in the prevention and management of violence/aggression can provide employees with appropriate skills to reduce or diffuse potential incidents. It should be available to all staff, including ancillary staff, such as cleaners and maintenance, and temporary or agency staff.
The right level will be identified through the risk assessment process. Basic training in the principles of managing challenging behaviour should include:
- causes of violence;
- recognition of warning signs;
- relevant interpersonal skills, ie verbal and non-verbal communication skills;
- de-escalation techniques;
- details of local working practices and control measures; and,
- incident reporting procedures.
In England NHS Protect provides specific guidance on the training requirements for NHS staff.
All staff who have the potential to be involved in an aggressive incident should receive the basic level of training. However, you must ensure the level of training provided to staff reflects the specific needs of the work activities, for example:
- staff caring for persons who present a low risk of aggressive behaviour may only require basic training.
- staff caring for persons with dementia may also need specific dementia awareness training as well as basic training.
- staff caring for persons that present a serious risk of physical aggression may also need training in physical intervention techniques, as well as basic training.
Confidence and capability are important when dealing with a potentially aggressive or violent incident; Staff will need refresher training from time to time to update their skills.
You need to ensure that procedures are in place for responding to incidents; and that they match the level of risk. Managers who set staffing levels need to ensure there are always enough suitably trained staff to cope with any foreseeable violence.
Staff exposed to the risk of violence need training on procedures in the event of an incident, and on what they have to do. It is important that they are aware of the criteria for initiating procedures, and are free to do so when they feel under threat.
Are incidents of violence reportable under RIDDOR?
Acts of non-consensual violence to a person at work that result in death, a major injury or being incapacitated for over-seven-days are reportable. A physical injury inflicted on one employee by another during a dispute about a personal matter, or an employee at work injured by a relative or friend who visits them at work about a domestic matter, is not reportable. For detail on what incidents are reportable under the RIDDOR visit the RIDDOR webpage.
Many staff accept incidents of violence and aggression as "part of the job" and may need encouragement to report, particularly incidents that don't cause serious injury such as hair pulling, pinching or verbal abuse. It is important that staff report all incidents and understand why this is important. For example, quite often a number of minor incidents can escalate to a major incident.
Helping staff after an incident
It can be useful to bring staff together after an incident to discuss what happened. This process of debriefing has two potential functions: to establish details of the event and to provide emotional help and support. It is sometimes appropriate to supplement debriefing with confidential counselling.