In this section you will learn to:
- Challenge behaviours of concern and clearly outline options and opportunities to change with positive encouragement
- Confirm using clear, calm and objective language the implications of continuing behaviours of concern
- Follow procedures to ensure personal safety of self, the individual, colleagues and others
- Select strategies and response for their potential to provide role models for confident and assertive behaviour
- Carry out interventions based on an analysis of the situation and organisation policies and procedures
Supplementary materials relevant to this section:
- Reading D: Experiences that Inspire Hope: Perspectives of Suicidal Patients
Previously, you were introduced to various behaviours of concern and how to respond effectively to clients presenting with behaviours of concern. In this section, greater focus will be placed on aggression, violence, and suicidal behaviour.
When challenging behaviours of concern, workers should adhere to various principles that prioritise safety and effective communication with the client. Overall, these principles encourage workers to ensure safety while offering the client with choices and opportunities to change with positive encouragement.
Principles of Responding to Aggression and Violence
When responding to aggressive and violent behaviours, workers should consider the following principles.
Safety
Safety should be prioritised when responding to aggression. Workers should take precautions to prevent risk and harm. Workers may maintain physical safety by increasing personal space from the client to about two arms lengths away from the client presenting with aggressive behaviour. When approaching the client, workers should demonstrate calm verbal and non-verbal language. This includes having a clam and neutral facial expression and maintaining appropriate eye contact. Workers should use simple, clear, and respectful language with a gentle tone.
If aggressive behaviour escalates to violence, workers should be aware of the organisation’s policies and procedures on workplace violence. Generally, it is recommended that workers remove themselves from the dangerous situation and seek support. Duress alarms may also be used to alert the relevant safety and emergency services.
De-escalation
If there is no immediate risk to safety, workers may de-escalate aggressive behaviour. De-escalation aims to reduce the tension in the situation and improve the relationship between the client and worker. De-escalation also involves offering the client choices and alternatives to address their concerns.
The following are steps that workers may go through during the de-escalation process (Stinger, 2015):
When approaching the client, workers should first introduce themselves and provide a client as to why they are being approached. Workers may state that they want to ensure the safety of everyone and that they are concerned about the client’s behaviour.
Workers should invite the client to share their perspective. During this step, workers should allow the client time to share their concerns and focus should be placed on listening and understanding the client’s situation.
As the client is in heightened state of emotions, workers are encouraged to use short and simple sentences throughout the de-escalation process.
Workers may directly ask the client for their needs. This can be achieved using open questions that encourage clients to elaborate on their needs. For example, the worker may ask “What do you need at the moment?”.
Workers may observe the client’s verbal and non-verbal communication to identify what the client is feeling. Workers may empathise with clients by communicating to clients that they acknowledge what the client is feeling.
Listening carefully involves being fully attentive to the client and checking your understanding of the situation. Workers may summarise the client’s concerns and check in with the client if they have understood that correctly.
When listening to the client, workers may agree on the facts of the situation to reduce confrontation. This includes agreeing and validating the client’s emotions and their needs that may not have been addressed, thus leading up to the aggressive behaviour. For example, the worker may agree with the client that they are feeling stressed or frustrated as they have waited for a long time to get the support they needed.
Workers should communicate their perspective and professional boundaries to the client. Workers may set boundaries by outlining the behaviour expectations of the organisation and communicate how the client’s behaviour is preventing the worker from providing support. “I” statements can be used to lessen blame put towards the client. For example, when responding to a client who is raising their voice, a worker may state “I need you to stop shouting, so I can help you out.”
When clients are presenting with aggression or threatening violence, they are in heightened state and may feel that their only choices are fight or flight. Workers may offer the client a variety of support and choices within the scope of the worker's role. For example, the worker may offer the client a safe and quiet space to talk, refreshments, or a preferred activity according to the client’s support plan.
The patient-centred approach may be applied here as it encourages workers to collaborate with clients to identify choices that best align with the client’s needs.
Workers may offer hope and encouragement to the client that workers are ultimately there to provide support to the client. This signals to the client that the worker is willing to make the necessary improvements to their situation.
Principles of Responding to Suicide
When a client presents with suicidal ideation, their safety should be prioritised. The following principles should be considered when responding to clients presenting with suicidal ideation.
Identifying suicidal ideation
Workers should be aware of the common signs of suicide. Through observation methods that were previously discussed, workers can identify signs of suicidal ideation. The table below are examples of verbal and non-verbal warning signs that be presented by a client (Carpenter et al., 2020):
| Verbal Warning Signs |
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|---|---|
| Non-Verbal Warning Signs |
|
Depending on organisation policies and procedures, workers may have to assess the level of suicide risk the client of presenting with. This risk assessment is often carried out with a validated assessment tool.
Workers should also refer to the client’s case notes or previous records to identify which may contain information on whether the client is at risk for suicide. Workers should be aware of the relevant policies and procedures in place related to client confidentiality when accessing information on client history.
Non-judgmental and Empathetic Communication
When communicating with a client presenting with suicidal ideation, workers should maintain an empathetic and non-judgemental space for the client to express themselves. Workers should avoid making presumptions about the client’s intent. For example, workers should not assume that the client’s suicidal thoughts are for “attention seeking”.
Instilling Hope
Hope was found to buffer individuals against suicidal ideation (Huen et al., 2015). Experiencing hope and compassion through interactions with healthcare workers was found to improve a client’s ability to cope with suffering (Vatne and Nåden, 2018). When communicating with client presenting with suicidal ideations, workers should offer aim to instil hope. This involves encouraging goal-directed determination and planning ways to meet goals. Accordingly, workers may instil hope in clients through collaborating with the client to create new goals. Workers should adopt a recovery approach when supporting clients with suicidal ideation. This involves the worker highlighting and reinforcing the client’s existing strengths and social support.
Reading
Reading D: Experiences that Inspire Hope: Perspectives of Suicidal Patients
This reading is a study on how instilling hope through the interactions with clients as a worker can help reduce suicidal ideation. Through gathering the experiences of clients who had experienced suicidal ideation, it aims to gain a better understanding of what clients perceive as meaningful interactions with workers.
Appropriate referral
Early identification of the warning sign of suicidal ideation allows worker to plan for the appropriate referral for further support and assessment. Workers should be aware of their role and responsibilities within the organisation as long-term management of suicidal ideation may not be in the work’s scope of practice. Referrals may be made to mental health services, such as psychiatrists, psychologists, or counsellors, to better meet the needs of clients.
Workers should remain calm and assertive when communicating the implications of continuing behaviours of concern. Clear and objective language should also be used as clients presenting with behaviours of concern are generally in a heightened emotional state, which may interfere with cognitive processing.
Firstly, workers should establish a connection between the client and the behaviour of concern. This enables the client to make the personal connection that they are currently presenting concerning behaviour. Workers may address the client by their preferred name or title and describe the behaviour to the client. When describing the behaviour, workers should be specific and avoid vague statements.
Then, the worker may communicate the implications of the client continuing the behaviour of concern. Implications of clients continuing the behaviour of concern generally include negative impacts on the safety and service provision. In terms of safety, aggressive behaviours may lead to both physical and psychological harm to workers and other staff members. Workers who are repeatedly exposed to aggressive behaviour may experience stress and burnout, which impacts their well-being and ability to provide support to clients. This further highlights the importance of communicating these implications to clients.
Below is an example of a statement workers may use to communicate the implications of behaviour concerns to clients:
“Tom, you are raising your voice at the staff members, I do not feel safe in this situation, and it is making it difficult for me to provide you with support.”
This statement addresses the client’s behaviour in a clear and objective manner and links the behaviour to how it impacts service delivery. Furthermore, the statement also uses elements of assertiveness as the worker communicates their feels and perspectives by using “I” statements.
Case Study
Imagine that you are a support worker at an aged care facility. As you are supporting clients in a common area, you notice that Paul, who is one of the clients, appears agitated. Upon approaching him, he complaints about the crowdedness of the common room. When you suggested to him if we would like to move to a different location, he raises his voice and states that the other clients should leave instead. You also notice that the surrounding clients appear frightened by his behaviour.
How might you communicate the implications of continue this behaviour to Paul?
Workers need to be aware of the legal and ethical considerations that underpin organisation policies and procedures relating to addressing behaviours concerning safety.
Duty of Care
Duty of care refers to the legal obligation workers must uphold the rights of a person and prevent harm to another person. In addition to not carrying out acts of violence or aggression, workers must ensure that they are complying with workplace policies and procedures for preventing and responding to behaviours of concern. For example, organisation policies may outline the worker’s responsibility to assess level of risk and implement the appropriate interventions, such as the use of de-escalation.
Individual Rights and Equality
While workers have the duty of care to prevent harm and uphold safety, workers should balance this with client’s rights. These include the client’s rights as an individual and right to equality.
Clients have the right to autonomy and self-determination. This suggests the need for workers to practise patient-centred care when responding to behaviours of concern. This encourages workers to consider the patient’s rights to make informed decisions about their care and have their views respected.
When responding to behaviours of concern, workers need to uphold the client’s right to equality. This means that workers should ensure fair treatment to clients and to treat clients without discrimination.
This encompasses culturally competent care, where workers adapt their responses based on the client’s cultural and linguistic needs.
Constraint and Imprisonment
The use of constraints when responding to behaviours of concern refers to the restriction of the client’s freedom of movement. Similarly, imprisonment or seclusion refers to placing an individual in a room which they cannot leave themselves. These practices are used to prevent the client from harming themselves or others.
This requires the worker to carefully balance safety and the client's right to self-determination and autonomy to make decisions about their care. Furthermore, workers need to have sufficient training to be aware of when to and how to use constraint and imprisonment. According to the Australian Commission on Safety and Quality in Healthcare (n.d), the use of restraint is governed through state and territory legislation, or mandatory policy. Workers may refer to the Seclusion and Restraint Report, which is an annual report detailing the use of constraints and imprisonment across different states and territories (Australian Institute of Health and Welfare, 2023).
Abuse
When workers respond to behaviours of concern, they are susceptible to abusive behaviour from clients. This is especially so when a client is presenting with aggressive and violent behaviour. workers should follow the relevant organisation policies and procedures on workplace abuse to ensure personal safety. For example, organisations generally have a zero-tolerance policy for worker abuse which gives workers the right to refuse services to abusive clients.
When responding to behaviours of concern, workers should model confident assertive behaviour to clients. The following strategies can be used to assist workers and improve confidence when responding to behaviours of concern.
Emotional Regulation
As workers de-escalate behaviours of concern, such as aggression or violence, workers should approach the situation in a non-confrontational manner using emotional and self-management techniques (Nutmeg & Dickens, 2017). Furthermore, practicing emotional regulation allows workers to model calm verbal and non-verbal behaviour to clients.
Self Reflection
Consider a time where you had gotten into a disagreement with another person. Did you notice a change in your emotional state? Consider how negative emotions could impact our ability to resolve disagreements with another individual.
Modelling Assertiveness with Confident and Non-Confrontational Language
When modelling assertive behaviour, workers should avoid the use of threats or uncertain statements (Nutmeg & Dickens, 2017). For example, workers may avoid statements that invite dissatisfaction, such as “You may not like this but…”. The use of qualifiers such as “I guess”, “sort of” or “maybe” should be minimised.
Instead, workers are encouraged to use “I” statements to state their perspective in a non-threatening manner. Workers should also clear and concise statements when setting behaviour expectations. This allows workers to communicate their perspective and offer support in a way that is not overbearing or threatening, thus modelling assertive communication to the client.
Workers should also be mindful of their body language. Workers may model calm body language to the client, which will help redirect the client in a calmer emotional space.
Case Study
Imagine that you are a health assistant at a hospital. You are supporting Carol, who is currently staying at the hospital ward. As you were preparing her meal, she angrily shouts at you and states that you had forgotten to give her medication. However, you are aware that Carol no longer requires medication according to her patient records.
How might you communicate to Carol that she no longer requires medication in a manner that models calm and assertive behaviour?
When responding to behaviours of concern, workers should analyse the situation according to organisation policies and procedures. Analysing the situation enables workers to ensure that they can offer support that best meets the client’s needs.
Underlying Reasons for Behaviours of Concern
As all behaviour serves a function, analysing the cause of behaviour will enable workers to better adapt their interventions to minimise behaviours of concern. The behaviour function scale can be used to support workers when analysing the function of clients’ behaviour. The scale consists of five elements (Limbu et al., 2021):
- External environment: This includes environmental factors such as noisy and crowded areas that can be overwhelming.
- Internal environment: This refers to the individual’s emotional state, which generally includes feelings of anxiety, uncertainty, and frustration.
- Expression of volition: This refers to individuals expressing that their demands or needs have not been met.
- Characteristics associated with intellectual disability: Characteristics of Clients with intellectual disability may manifest as behaviours of concern when they are unable to communicate their needs.
- Specific activities/events: Examples of specific activities or events that could trigger behaviours of concern include a change of staff members during handover, family visits, change in appointment time or change in routine.
Clients with Special Needs
When a situation involves supporting clients with special needs, workers need to be aware of specific statutory requirements related to treatment of people with special needs and requiring special support. The Disability Discrimination Act 1992 prohibits discrimination against individuals with disabilities. Accordingly, workers should ensure fair and equal treatment towards clients with special needs.
The various Mental Health Acts depending on State and Territory also protect the rights of clients with mental health disorders that impact their capacity to make decisions. Mental Health Acts generally promotes the recovery of the client in a way that is the least restrictive of the rights and liberties of the client to the extent required to protect the client’s safety and welfare.
Analysing Level of Risk and Critical Incidents
Workers should also be analysing the level of risk and be aware of critical incidents when responding to behaviours of concern. Critical incidents refer to events that pose serious risks to the client’s life, health, and safety. Examples of critical incidents include, serious injury, a missing client, sexual assault, high risk of suicide or harming another person, or incorrect medication.
In the event where there is a need for urgent medical care or an immediate risk and harm to the client and others, workers should contact emergency services on “000” immediately. Such situations include a person suffering a serious injury and requires medical attention, alleged or suspected crime, or ongoing danger. Organisations should have the relevant procedures to support the worker through the process of calling emergency services.
Workers should adhere to organisation policy and procedure when responding to critical incidents. This would provide workers with a guide on how to contact the appropriate emergency service to ensure the health and safety of the client. Workers are required to report all critical incidents. This will be further discussed in the following section on reporting requirements.
In this section, you have learnt how to respond to clients presenting with aggression, violence, and suicide. You have learnt the various principles and techniques that affirm professional boundaries and safety, while continuing to respect and value the client’s perspective. This section has also covered the importance of analysing the situation by determining potential reasons for behaviours of concern and level of risk.
Australian Commission on Safety and Quality in Health Care. (n.d.). Action 5.35. Australian Commission on Safety and Quality in Health Care. Retrieved May 8, 2023, from https://www.safetyandquality.gov.au/standards/nsqhs-standards/comprehensive-care-standard/minimising-patient-harm/action-535
Australian Institute of Health and Welfare. (2023, April 27). Seclusion and restraint - Mental health - AIHW. Australian Institute of Health and Welfare. Retrieved May 8, 2023, from https://www.aihw.gov.au/mental-health/topic-areas/seclusion-and-restraint
Carpenter, D. M., Lavigne, J. E., & Colmenares, E. W. (2020). Community pharmacy staff interactions with patients who have risk factors or warning signs of suicide. Research in Social and Administrative Pharmacy, 16(3), 349-359. https://doi.org/10.1016/j.sapharm.2019.05.024
Huen, J. M.Y., Ip, B. Y.P., Ho, S. M.Y., & Yip, P. S.F. (2015). Hope and Hopelessness: The role of hope in buffering the impact of hopelessness on suicidal ideation. PLoS One, 10(6), e0130073. https://doi.org/10.1371/journal.pone.0130073
Limbu, B., Unwin, G., & Deb, S. (2021). Comprehensive Assessment of Triggers for Behaviours of Concern Scale (CATS): Initial development. International Journal of Environmental Research and Public Health, 18(20). https://doi.org/10.3390/ijerph182010674
Nutmeg, H., & Dickens, G. L. (2017). De-escalation of aggressive behaviour in healthcare settings: Concept analysis. International Journal of Nursing Studies, 75, 10-20. https://doi.org/10.1016/j.ijnurstu.2017.07.003
Vatne, M., & Nåden, D. (2016). Experiences that inspire hope: Perspectives of suicidal patients. Nursing Ethics, 25(4), 444–457. https://doi.org/10.1177/0969733016658794
