Providing training to prevent and manage violence in health care

Preventing and managing aggressive behavior in health care settings is an educational and training area that has been neglected in Canada. The Workers’ Compensation Board of British Columbia published a handbook called Preventing Violence in Health Care: Five Steps to an Effective Program in 2000. A key reference for all health care settings, it uses a five-step approach:

Step 1   Establish a violence prevention working group and enlist support
Step 2 Conduct a risk assessment
Step 3 Develop and implement control measures
Step 4 Provide education and training
Step 5 Conduct an annual review 

The provision of education and training integrates with all the other steps, especially risk assessments.

Generic training and further risk-specific training need to be integrated so that all staff operate from the same assumptions. This suggests a “pyramid” training approach, as illustrated in the figure.

Given the reality of competing priorities for scarce resources in health care, a tiered training program along the following lines is suggested.

Level 1. Personal safety education and training

This consists of generic prevention and management of aggressive behavior training. The term personal safety refers to verbal, non-verbal, and behavioral skills that are designed to defuse aggression and to avoid being assaulted. It is not self-defence training.

This level of training can be provided as a 1-day workshop and includes practical personal safety training (including breakaway techniques) and a written test. The training program developed by the Crisis Prevention Institute (CPI) meets this level of training need. The CPI course, with its philosophy of care, welfare, safety, and security for staff and patients, can also serve as a best practice standard for this level of training. Call the CPI at 1 800 558-8976 for further information.

Most health care professionals, in particular those who work in emergency departments, walk-in clinics, mental health clinics, and in psychogeriatric settings, should remain current in Level 1 training in the prevention and management of aggressive behavior.

Level 2. Control and restraint training

This can be provided as a 1- or 2-day workshop and includes basic self-protection training, plus a written test and practical exam. Code white (behavioral team control) training could be included for participants taking both Level 1 and 2 together (i.e., in a 2-day training workshop format). Self-protection refers to personal safety plus the acquisition of defensive physical skills. It includes what is often referred to as self-defence, although focusing only on the use of non-deadly force.

Current full compliance (with supporting documentation) in certain generic programs (e.g., CPI, Management of Assaultive Behavior, Professional Assault Response Training, Basic Security Training) may qualify as a Level 1 equivalent for those seeking Level 2 training.

Level 3. Team control training

This level of training is more specific and is suitable for designated code white or behavioral emergency response teams and for security staff working in health care settings. This training is essentially an application of Level 2 training and can be provided in 1-day, 2-day, or maintenance classes, preferably in a continuous training and learning format.

While there is no currently accepted best practice standard in BC for Level 2 and Level 3 training, a review of the health care literature from the US, Britain, Australia, New Zealand, and Canada strongly suggests that physical control and restraint should only be used by a trained team and that the use of force be “the least restrictive and most appropriate.” Generally, this should not involve pressure points and painful joint locks or strikes.

As a code white trainer, I am presently working with Sheree Hudson (a community health nurse and workplace violence trainer) and others to articulate a standard for health care control and restraint training. This will reflect a best practice approach and, we hope, will help set a standard for British Columbia. A review of seclusion and restraint policies and procedures is also in the works.

For information on training or to provide input into helping to develop a best practice standard for control and restraint training in health care, please contact Joe Noone at (604) 875-5283 or by e-mail at

—Joseph Noone, MD, LRCP&SI, FRCPC 
Chair, Committee on Violence

Level 1 training in violence prevention in health care settings

As effective education and training needs to be provided by an appropriate messenger to be received and accepted, close attention to the selection of a small cadre of training staff with the requisite knowledge, skills, and attitude and a diversity of clinical and behavioral management experience is required. A professional health care trainer should be present at all training. Train the trainer programs can also be provided.

It is suggested that Level 1 training involve a course outline similar in most respects to the following example.

1. Introduction   Summary data on health care violence, operational definitions of aggression and violence, and so on.
2. Authority for the use of force Define the use of force continuum in situations of aggression and differentiate between insufficient, reasonable, and excessive force.
3. Key concepts An overview of the literature on aggression and violence with key concepts highlighted, including the modified frustration aggression hypothesis, social learning theory, dehumanization, and mood versus predatory aggression.
4. Risk factors and triggers Identify risk factors for violence and differentiate between predisposing and precipitating precursors to violence.
5. Crisis communication  The keys to effective crisis communication, including personal space, body language, and vocal factors and verbal techniques and their critical impact on defusing potentially violent individuals. Techniques covered may include dislocation of expectations (Noone), counter-projective speech (Havens), verbal judo (Thompson), and verbal self-defence (Elgin). Aspects of non-verbal and verbal communication can lead to a discussion of how to manage verbal aggression.
6. The professional edge Encourage a calm, confident, non-anxious approach in managing aggression. This is achieved through coverage of counter-transference issues, attitudinal mental set, and stress management strategies for use before, during, and after a violent act.
7. Debriefing and quality improvement  Debriefing as a tool promotes quality improvement and workplace safety. Include a brief introduction to critical incident stress management.
8. Personal safety Demonstrate and practise personal safety techniques for assaultive situations. After a brief warm up, participants practise distancing, stance, and movement skills including the evasive side step, deflections, and distractions to avoid being struck and to deal with being grabbed.
9. Summary and evaluation Highlight safe practice principles for participants with a course summary, followed by an evaluation by participants. A test may be incorporated.

Level 2 training differs from Level 1 training principally in its emphasis on skill development to the level of safe control and restraint of patients rather than just avoidance of, or escape from, assaultive behavior. Depending on the level of competence achieved, such training is suitable for clinical staff who will be restraining and controlling agitated persons, for dedicated code white teams, and for health care security professionals.

Joseph Noone, MD, LRCP&SI, FRCPC. Providing training to prevent and manage violence in health care. BCMJ, Vol. 43, No. 7, September, 2001, Page(s) - BCCDC.

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