Assault Response Competency

AB508 and SB 1299 WorkbookDeveloped by:

Erin Zamora, LMFT, LPCC, Terry Rudd, RN, MSNKatie Wellins, Gary Toppins, Instructor Tai Chi Yang Long Form

© 2016 Key Medical Resources, Inc.

Version 3.0 12.2016

Key Medical Resources, Inc.   "Kindness Matters"

Training Center9774 Crescent Center Drive, Suite 505,

Rancho Cucamonga, CA 91730 909 980-0126 Fax: 909 980-0643

KMR@keymedinfo.com         www.cprclassroom.com

East-Wind Martial Arts School9720 Magnolia Avenue

Riverside, CA 92503

951 688-7220

www.east-wind.comwww.eastwindmartialartsca.com

Contents:

Topic PageIntroduction 3Disclaimer 3Objectives 3Background 4Minimum Training Requirements AB508 and SB1299 5Training Frequency 5Workplace Violence Statistics 6Recognizing Potential Workplace Violence; Active Shooter 7Consequences for the Healthcare Worker 9Workplace Violence Types 10Dignity and Respect 11The Assault Response Competency (ARC ) Model 13General Safety Measures 16Personal Safety 17Social Media 19Aggression and Violence Predicting Factors 20De-escalating Maneuvers - Verbal 23Other Patterns Leading to Assault 26Principles to Reduce the Threat 27The Crisis Stage 28Active Shooter 29Evasive Techniques, Basic Defense TechniquesEscalating and Life Threatening Situations

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Restraining Techniques 39Appropriate Use of Medications, Chemical Restraints 40Post Crisis Depression 42Employee Resources and Incident Debriefing 43Self-Care 44Appendix A: Legalities 48Appendix B: Title 22 Patient's Rights 50Appendix C: Patient's Rights Mental Health Facilities 51Appendix D: Erikson's Stages of Psychosocial Development 52Appendix E: Maslow's Hierarchy of Needs 54Appendix F: Assessment and Interventions for Psychiatric Patients 56Appendix G: Senate Bill 1299 Overview 60Appendix H: Comparison Matrix AB508, SB 1299, ARC 62

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Introduction:

Welcome to Assault Response Competency (AB508) and SB1299 Training. The purpose of this training is to provide you with the tools to prevent assaultive situations in the healthcare setting, and should they arise to appropriately manage without causing harm to the patient/client or yourself. Our goal is that you would utilize the tools learned in this training to verbally de-escalate the person you are working with so that no hands-on techniques would be necessary. Should hands-on techniques be utilized, they would be evasive maneuvers.

Disclaimer:

This packet is intended to provide information and is not a substitute for any facility policies or procedures. Legal information provided here is for information only and is not intended to provide legal advice. Each state or facility may have different training requirements or regulations. Participants who practice the techniques do so voluntarily . Practice techniques involve working with and other participants in the program for hands-on maneuvers. If you are unable to participate in these maneuvers notify your instructor immediately. Participants who cannot participate in all aspects of the course may be unable to successfully complete the course. Information has been compiled from various internet sources as indicated at the end of the packet.

ObjectivesAt the completion of this program, the learners will:1. Discuss Minimum Training Requirements and Law for AB508, SB 12992. Training Frequency for AB508, SB 12993. State 2 Workplace Violence Statistics4. Recognizing Potential Workplace Violence; Active Shooter5. Describe Consequences for the Healthcare Worker6. Identify 2 Workplace Violence Types7. Discuss Dignity and Respect as a Means for Diffusing Violence8. Describe The Assault Response Competency (ARC ) Model9. Identify 3 General Safety Measures10. Describe Personal Safety11. Discuss How Social Media May be a Risk12. List Aggression and Violence Predicting Factors13. State 3 De-escalating Maneuvers - Verbal14. State Other Patterns Leading to Assault15. Describe Principles to Reduce the Threat16. Describe The Crisis Stage17. List Interventions with an Active Shooter18. Demonstrate at least 3 Evasive Techniques, Basic Defense Techniques19. List 2 Escalating and Life Threatening Situations20. Discuss Restraining Techniques21. Describe Post Crisis Depression 22. Identify how to Access Employee Resources and Incident Debriefing23. List 2 personal Self-Care Activities24. Describe Legalities with Assault Response25. Identify 3 Title 22 Patient's Rights26. Describe Patient's Rights Mental Health Facilities27. Discuss Erikson's Stages of Psychosocial Development29. Discuss Maslow's Hierarchy of Needs30. Utilizing Role Play Demonstrate Assessment and Interventions for Psychiatric Patients31. Complete Testing Components at 75% Competency

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Background:

As a result of increasing violence in California hospitals, Assembly Bill 508 was chartered by assembly member Speier and AB508 was chartered in 1993. The California legislature declared the following:

(a) Violence is an escalating problem in hospital emergency departments throughout California and the nation.

(b) The emergency department is particularly vulnerable to violence because of its accessibility to all members of the public. The emergency department is open 24 hours a day, seven days a week, to anyone desiring care.

(c) During the past few years in California, deaths to nurses and other health care workers occurred in emergency rooms, psychiatric hospitals, and community mental health clinics.

(d) Actual incidence of the problem in all types of healthcare facilities is greater than documented because of failure to report or failure to maintain records of incidents that are reported.

(e) A 1991 national survey of emergency room nurses found that two-thirds reported at least one assault during their careers, and over a third had been assaulted at least once during the previous year.

(f) A 1992 survey of California hospitals reported that nearly 60 percent of hospitals in Fresno, Los Angeles, Sacramento, San Diego, and San Francisco reported injuries to staff, visitors, or patients. Over 40 percent of the incidents involved the use of a gun.

(g) Patients and emergency personnel should be assured of access to health care in a safe environment. Personnel training and appropriate safety controls should be implemented to minimize the risks and dangers affecting all people in emergency room settings.

(h) Many hospitals have undertaken numerous efforts to assure that patients and workers are safe from violence. These efforts will be enhanced by the enactment of this act.

In September 2014, SB 1299 was put in to place for a workplace violence prevention plan for hospitals and psychiatric facilities. The bill requires all employees to have training.

The California Occupational Safety and Health Act of 1973 imposes safety responsibilities on employers and employees, including the requirement that an employer establish, implement, and maintain an effective injury prevention program, and makes specified violations of these provisions a crime.

This bill would require the Occupational Safety and Health Standards Board, no later than July 1, 2016, to adopt standards developed by the Division of Occupational Safety and Health that require specified types of hospitals, including a general acute care hospital or an acute psychiatric hospital, to adopt a workplace violence prevention plan as a part of the hospital’s injury and illness prevention plan to protect health care workers and other facility personnel from aggressive and violent behavior. The bill would require the standards to include prescribed requirements for a plan. The bill would require the division, by January 1, 2017, and annually thereafter, to post a report on its Internet Web site containing specified information regarding violent incidents at hospitals. The bill would exempt certain state-operated hospitals from these provisions. Because this bill would expand the scope of a crime, the bill would impose a state-mandated local program. An overview of SB 1299 is in Appendix G.

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Minimum Training Requirements for AB508 in California

All hospital employees regularly assigned to the emergency department shall receive, by July 1, 1995, and thereafter, on a continuing basis as provided for in the security plan security education and training relating to the following topics:

(1) General safety measures. (2) Personal safety measures. (3) The assault cycle. (4) Aggression and violence predicting factors. (5) Obtaining patient history from a patient with violent behavior. (6) Characteristics of aggressive and violent patients and victims. (7) Verbal and physical maneuvers to diffuse and avoid violent behavior. (8) Strategies to avoid physical harm. (9) Restraining techniques. (10) Appropriate use of medications as chemical restraints. (11) Any resources available to employees for coping with incidents of violence, including, by way of example, critical incident stress debriefing or employee assistance programs.

Minimum Training Requirements for SB1299 in California

Personnel education and training policies that require all health care workers who provide direct care to patients to, at least annually, receive education and training that is designed to provide an opportunity for interactive questions and answers with a person knowledgeable about the workplace violence prevention plan.

The education and training shall cover topics that include, but are not limited to, the following topics:(1) How to recognize potential for violence, and when and how to seek assistance to prevent or respond to violence.(2) How to report violent incidents to law enforcement.(3) Any resources available to employees for coping with incidents of violence, including, but not limited to, critical incident stress debriefing or employee assistance programs.

A comprehensive overview is in Appendix G

Training Frequency

The AB508 law does not specify how the training is conducted, length or frequency. Facility policies vary. It is essential that you follow facility policies and procedures.

The SB1299 requires annual training.

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Workplace Violence Statistics

CDC - http://www.cdc.gov/niosh/topics/violence/training_nurses.html

From 1997 to 2009 there were 130 workplace homicides in the healthcare and social assistance industry.

In 2008, health care and social assistance workers overall had an incidence rate of 8.2 (out of 10,000 full-time workers) for injuries resulting from assaults and violent acts. The rate for nursing and personal care facility workers was 20.4

Data showed a rate of physical assaults at 13.2 per 100 nurses per year and at a rate of 38.8 per 100 nurses per year for non-physical violent events (threat, sexual harassment, verbal abuse)

80% of all nurses do not feel safe in their workplace. In a survey of 125 ED nurses, 82% of had been assaulted at work in one year. 25% of psychiatric nurses in a survey suffered disabling injuries from assaults. Studies show that between 35-80% of hospital staff has been physically assaulted at

least once during their careers. 53% of student nurses report being put down by a staff nurse (Longo, 2007). 57% of nurses report having been threatened or experienced verbal abuse from

coworkers (ANA, 2001). A study of 130 staff nurses revealed that 90% reported experiencing at least one

episode of verbal abuse during the past year (Manderino & Berkey, 1997).

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Recognizing Potential Workplace Violence/Active Shooter

U.S. Department of Labor, Occupational Health and Safety Administration, www.osha.gov.

RECOGNIZING POTENTIAL WORKPLACE VIOLENCE An active shooter in your workplace may be a current or former employee, or an acquaintance of a current or former employee. Intuitive managers and coworkers may notice characteristics of potentially violent behavior in an employee. Alert your Human Resources Department if you believe an employee or coworker exhibits potentially violent behavior.

Indicators of Potential Violence by an Employee Employees typically do not just “snap,” but display indicators of potentially violent behavior over time. If these behaviors are recognized, they can often be managed and treated. Potentially violent behaviors by an employee may include one or more of the following (this list of behaviors is not comprehensive, nor is it intended as a mechanism for diagnosing violent tendencies): • Increased use of alcohol and/or illegal drugs • Unexplained increase in absenteeism; vague physical complaints • Noticeable decrease in attention to appearance and hygiene • Depression / withdrawal • Resistance and overreaction to changes in policy and procedures • Repeated violations of company policies • Increased severe mood swings • Noticeably unstable, emotional responses • Explosive outbursts of anger or rage without provocation • Suicidal; comments about “putting things in order” • Behavior which is suspect of paranoia, (“everybody is against me”) • Increasingly talks of problems at home • Escalation of domestic problems into the workplace; talk of severe financial problems • Talk of previous incidents of violence • Empathy with individuals committing violence • Increase in unsolicited comments about firearms, other dangerous weapons and violent crimes

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The Challenge of Underreporting

As significant as the foregoing facts and figures may seem, many experts believe they represent only the tip of the iceberg and that most incidents of violence go unreported.

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Reasons for not reporting:

Consequences for Healthcare Workers

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Behavioral PsychologicalEmotional

Physical

Spiritual Cognitive

Workplace Violence Types

CDC - http://www.cdc.gov/niosh/topics/violence/training_nurses.html

Workplace Violence Types

Description For Example

Type 1 Criminal intent

In Type 1 violence, the perpetrator has no legitimate relationship to the business or its employees, and is usually committing a crime in conjunction with the violence

Type 2 Customer/client

Type 2 violence is the most common in healthcare settings. This course considers the customer/client relationship to include patients, their family members, and visitors, and will be referred to as CLIENT-ON-WORKER VIOLENCE. Research shows that this type of violence occurs most frequently in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings, but is by no means limited to these. Prevention of Type 2 violence is a primary focus of this course.

Type 3 Worker on worker

Type 3, violence between coworkers, is commonly referred to as lateral or horizontal violence. It includes bullying, and frequently manifests as verbal and emotional abuse that is unfair, offensive, vindictive, and/or humiliating though it can range all the way to homicide. Worker-on-worker violence is often directed at persons viewed as being "lower on the food chain" such as in a supervisor to supervisee or doctor to nurse though incidence of peer to peer violence is also common.

Type 4 Personal Relationship

In Type 4 violence, the perpetrator has a relationship to the nurse outside of work that spills over to the work environment.

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Dignity and Respect: Dignity and Respect Campaign

www.dignityandrespect.org

What does DIGNITY mean to you? What does RESPECT mean to you?

When I am treated with DIGNITY, I feel... When I am treated with RESPECT, I feel...

When I am not treated with DIGNITY, I feel... When I am not treated with RESPECT, I feel

Ways I can ensure others are treated with DIGNITY and RESPECT are

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30 Tips to Treating Everyone with

Dignity and RespectCheck them out! Practice one each day until it’s become a good habit. Then move onto another. The more you

practice, the more you’ll become aware of how your words and actions affect others. Get your friends and colleagues to join you. Together, we can work to achieve a more inclusive community.

I, ______________________________ will do my part to make our world a better place by treating everyone with dignity and respect.

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The Assault Response Competency (ARC) Model

© 2015 Key Medical Resources, Inc.

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Stressor

Assaultive Response

Bridge of Communication

Post Crisis Depression

Incident De-Briefing

Self-Care

The Assault Cycle

You and the client go through the same phases!

Baseline Behavior – The standard behavior observed with the client.

Trigger Event

Observe to spot changes in the client Quiet person may pace Pacing person may sit still If the triggering event is not dealt with, escalation occurs

Decompensation

Person thinks angry thoughts Body mobilizes for fight or flight Increased heart rate, respiration Person may pace, yell, throw things or Person may become tensely quiet. If left unchecked may escalate to crisis During the decompensation stage, assess the motive. Is the person fearful,

frustrated, manipulative or intimidating?

Diffusing Techniques

Listening is the hero of good communication. Empathize with their situation. Understand their perception of the situation. What do they want that they are not getting? Address their concerns Offer a solution or alternative

Crisis

Energy expenditure very high. Person cannot sustain this level of output for long As crisis passes, person will enter a stage of recovery. During the crisis stage you must keep the crisis communication ongoing and

observe the reasonable force guidelines. Remember due to the tremendous output of energy, the crisis will end.

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Recovery

Body and mind return to baseline levels. Person is still vulnerable and can re-escalate During the recovery stage, avoid lengthy conversations. Do not blame or chastise the person. Honor requests for being alone (with observation). The person could still re-

ignite and start back into the crisis stage. This is a poor time for medication because of the post-crisis depression that

follows.

Post Crisis Depression

Person is exhausted and body is below the baseline level. Pulse and respiration lower than normal. Depression accompanies fatigue. The post-crisis depression is a time where more engaging verbal techniques

may be used. Some people will not want to talk. Close supervision is required at this time. Medication could place a person at risk of too low of a blood pressure or

respiration. Return the person to the treatment plan.

Incident De-briefing

Review the incident with the team. Perform a debriefing with the client. Try to determine what could have been done differently.

Self-Care

Ensure you are taking care of yourself physically and mentally Find time for you Know when to seek help

Situations where assault pattern does not apply:

There are times when an assaultive event may occur without warning. This may happen with the client who has seizures, is on hallucinogenic drugs such as LSD, PCP, or mescaline or has a severe mental disorder. Anticipating the potential for these clients may prevent you from harm.

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General Safety Measures

“Don’t Make the Situation Worse”

Allow the client/patient to regain self-control.

Treat the person respectfully.

Preserve the client/patient's rights.

Assess and remove potentially harmful items in the environment (Contraband)

Common Contraband Items What Else Might be Contraband?

Compacts with glass mirrorsGlass containersPicture frames with glassHair dryersCurling ironsRazorsKeysMouthwash or cleansers that contain alcoholScissors.StaplesCardboard greeting card coversMetallic parts of greeting cardsPencilsPens, CombsEating utensils KnivesForks Spoons

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Position Yourself for Safety

“How Are You Positioned?”

Personal Space - Maintain a distance of at least two arms’ lengths between you and your aggressor. This will allow you reaction time from attacks such as grabs, strikes and lunges.

Stance - Angle your body about 45 degrees in relation to the individual. This stance not only reduces your target size in the event of an attack, but also prepares you to escape when necessary.

Hands -In front of your body in an open and relaxed position. This gesture appears non-threatening and positions your hands for blocking and counterattacking if the need arises. Avoid crossed arms, hands in the pocket, or arms behind the back since it not only puts you at a tactical disadvantage, but also can be interpreted as negative body language.

If possible, casually position yourself behind a barrier such as a sofa, desk, large chair, counter, table or other large object when possible.

Allow yourself an exit.

Personal Safety

“How Safe are You?"

Don’t wear items around your neck -Avoid ties, stethoscopes, jewelry and name badges that can be used as a noose.

Don’t divulge personal information about yourself.

Give yourself access to exit.

Have others around you.

Inform co-workers if there is a potential threat.

Isolate agitated persons (client, family, visitors)

Self Assessment

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Nails short?

Comfortable clothing and easy to move?

Functional shoes?

Keys in a safe place?

Please stand then sit when directed.......

How long did you stay standing for? What changes can you make?

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Social Media

Are you on........

Discuss how this may be a safety hazard?

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Aggression and Violence Predicting Factors

CDC - http://www.cdc.gov/niosh/topics/violence/training_nurses.html

Legalities - See Appendices A, B, and C

Appendix A: General TermsAppendix B: Title 22: Patient's RightsAppendix C: Rights for Patients in Mental Health Facilities

What constitutes assaultive behavior?

Assaultive behavior is NOT obnoxious behavior, name calling or ignoring.

Assaultive behavior IS an immediate risk of injury to you or the client that would require some form of medical attention. Behaviors such as hitting, kicking, scratching, biting, throwing objects or spitting (if the person has hepatitis or HIV) are considered assaultive.

The person assaulting must have the ability to injure another, be close enough to injure or show intent to injure immediately

There are three primary legal (moral and ethical) considerations when providing restraint and/or involuntary treatment for a client:

The rights and needs of the client, The duties of the health care providers, The responsibility for protection of involved third parties.

Clinical Risk Factors

The clinical setting is one of intensified emotions. Patients who are at risk of perpetrating violence include those who:

are under the influence of drugs or alcohol are in pain have a history of violence have cognitive impairment are in the forensic (criminal justice) system are angry about clinical relationships, e.g., in response to perceived authoritarian

attitude or excessive force used by the health provider have certain psychiatric diagnoses and/or medical diagnoses

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Environmental Risk Factors

Environmental risk factors are those that are attributable to the layout, design and amenities of the physical workspace. Environmental risks fall into four categories and include factors that:

Provide opportunity to gain access or avoid detection such as unmonitored entries or stairwells, insufficient lighting, blind corners, unsecured rooms or closets.

Increase stress such as signage that is confusing, poor weather conditions, difficulty parking or accessing a building, insufficient heat or air conditioning, and disturbing noise levels.

Provide opportunities to be used as weapons such as unsecured furniture, fixtures, decorative items, office or medical supplies.

Limit staff's ability to appropriately respond to violent incidents such as the lack of security systems, alarms, or devices.

Organizational Risk Factors

Organizational risk factors are those that result from the policies, procedures, work practices and culture of the organization. Such risk factors include:

Careless management and staff attitudes toward workplace violence prevention; Inadequate security procedures and protocols; Lack of staff training and preparedness; Cumbersome or nonexistent policies for reporting and managing crises; Low staffing levels, extended shifts, overtime requirements. There are a number of social and economic factors in communities and society that help

to create a climate in which violence is encouraged. These include: High concentrations of poverty Diminished economic opportunities Socially disorganized neighborhoods High levels of family disruption Low community participation Social and cultural norms that encourage violence Health, educational, and social policies that help to maintain economic or social

inequalities between groups in society

Social and economic risk factors create strains on health care systems and can lead to staffing shortages at a time when more people are seeking emergency services and can set the stage for violence.

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Other Aggression and Violence Predicting Factors

Clients Families

Parents

Hospital Medical

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Verbal and Other De-escalating Maneuvers

Listening is the hero of good communication.

Empathize with their situation.

Understand their perception of the situation.

What do they want that they are not getting?

Address their concerns

Offer a solution or alternative

Listening: Three Main Listening Skills:

Attending: Giving your physical attention to another person. Following: Making sure you’re engaged by using eye contact, non-intrusive gestures

(such as nodding of your head, saying okay or asking very infrequent questions). Reflecting: Paraphrasing, reflect back using the feelings of the youth (empathetically).

Other Verbal Suggestions

Use words or phrases that are neutral. Avoid cultural bias. Show respect for the individual "I-statements" in place of "you-statements."

"I see what you mean" “I hear what you're saying"

Be aware of body language

Expressions Posture Gestures

Defusing a Situation

Note when the situation first escalates Louder Voice Fidgeting, verbal sounds Build-up of energy

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Be proactive, not reactive.

Attend to the client before it gets out of hand. The staff needs to be in control by actively defusing the client, family or visitor.

Defusing Techniques

Avoid arguing or defending previous actions Avoid threatening body language Calmly but firmly outline limits

Watch for the Defense Phase

If escalating, the client will give more physical cues (louder, more agitated, verbalizations)

Staff interventions Reduce stimulation from setting – move to quieter area. Communicate information about delays or areas of concern.

Give choices

As emotions increase, auditory processing decreases. Focus on client, not rules They don’t care about JCAHO and other agencies Use phrases for safety, not rules or policies

Techniques

Plenty of personal space Allow a frustrated person time to vent Ignore personal verbal attacks

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Verbal De-escalation Procedure

Remain calm and friendly, be aware of your feelings Be mindful of your body language Breath slowly and deeply Maintain a safe distance and refrain from touching Utilize contact and cover principles Position yourself so that the client cannot block your access to an exit Keep your hands in front of your body in a non-threatening manner Only one provider should communicate with the client Maintain a soothing tone of voice Listen to client's concerns Empathize, use positive feedback Be reassuring and point out choices Be willing to slow down and disengage if appropriate Calmly set boundaries of acceptable behavior

Rules for Open Communication

Allow the distressed person to state the problem Hear the person out Request behavior changes only—what kind of change do you want them to

make? Be specific/ non-threatening Remember the Rule of Five—five words or less /five syllables or less. Understand

that they are angry, but this is what you want them to do right now Don’t ask him/her to feel differently or to change his/her attitude

Considerations

Personal space and body language communicate much of how we feel. Personal space refers to our comfort zone. This individual preference must be respected.

Touch is not a good way to comfort a distressed person. Most people want space. The only exception may be if the person is crying. Take cues from their facial expressions as well as their hand gestures, the way they approach, their size and appearance.

Your body language sends messages as well. Have an open stance. This lets people know you are listening.

If someone is agitated, be aware of your own safety. Have your hands free and at your sides. Stand at an angle, not facing the person straight on. Stand with one foot back and your knees slightly bent.

Other patterns leading to assault:

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Fear – will fight if safety concern.

Fearfulness can be reduced by approaching the person from the side angles and not head on or from behind.

Use a calm and reassuring voice. Stay at eye level and not above. Use crisis communication techniques such as short and direct speech. Keep your posture open and non-threatening. Speech patterns should be firm, reassuring and confident Explain your actions before doing anything! Avoid any surprises. You will increase chances of the client becoming physical if

your communication adds to their perceived threat.

Frustration – skin will be splotchy, loud voice.

Speak with confidence and control. Use good eye contact. Approach directly in front but outside striking range. You are helping the frustrated person to re-gain control. Speech patterns should be quiet, firm, low and repetitive. Use the broken record

technique. It takes practice but it does work. Avoid communication that demonstrates loss of control. This only increases the

chance that a person will become physical.

Manipulation – tantrum to escalate the situation

The manipulative person needs to be dealt with in a matter of fact way. Use little eye contact, since attention is one of the main payoffs. Use a “broken record” or “skipping CD” type of speech pattern. Just repeat the

expectation, such as, “It’s time to return to your home.” over and over again. Act detached and relaxed.

Intimidation – uses calculated threats to get what they want.

The intimidating person is handled in a matter of fact, emotionless manner. State consequences of his or her choices. Be clear and direct. Do not present ultimatums. Eye contact is used sparingly. Do not box yourself in the environment. Have an escape route. Your speech should not be condescending or sarcastic.

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Principles to reduce threat

Match your level of response to the dangerousness of the threat.

If an assaultive person is alone kicking and screaming, fatigue will eventually win out and an intervention is probably not necessary.

Crisis communication

Short, direct statements

Do not ask open ended questions.

Keep voice calm

Use the person’s name.

Evade - Get you and others out of the way

Restraint (a last resort)

Remember that as the person escalates, the capacity to think rationally and use good judgment rapidly

diminishes.

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Crisis Stage

Safety First

Intervene early at the first signs of escalation. Don't think that if you ignore them they'll go away!

Keep others away from angry people. Alert staff members and security guards to be close by. Avoid appearing to gang up on someone, but if necessary, a show of

numbers usually fosters compliance. Only one person should verbally direct the agitated person. However,

additional staff provides support by their presence. Allow angry people time and space. Remember "fight or flight," and allow them a graceful way out. Train staff members how to manage assaults for times when physical

containment is required. Realize that people with frightening hallucinations, paranoid delusions,

and/or who are under the influence of substances, usually are not receptive to verbal de-escalation. Medication and special interventions may be required

Physical maneuvers are used as the last resort and

only when all tactics have failed.

Never plan to fight an attacker and win;

do only what it takes to get away from them.

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Active Shooter

U.S. Department of Labor, Occupational Health and Safety Administration, www.osha.gov.

PROFILE OF AN ACTIVE SHOOTER 41

An Active Shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern or method to their selection of victims. Active shooter situations are unpredictable and evolve quickly. Typically, the immediate deployment of law enforcement is required to stop the shooting and mitigate harm to victims. Because active shooter situations are often over within 10 to 15 minutes, before law enforcement arrives on the scene, individuals must be prepared both mentally and physically to deal with an active shooter situation.

Good practices for coping with an active shooter situation

• Be aware of your environment and any possible dangers

• Take note of the two nearest exits in any facility you visit

• If you are in an office, stay there and secure the door

• If you are in a hallway, get into a room and secure the door

• As a last resort, attempt to take the active shooter down. When the shooter is at close range and you cannot flee, your chance of survival is much greater if you try to incapacitate him/her.

CALL 911 WHEN IT IS SAFE TO DO SO!

HOW TO RESPOND WHEN AN ACTIVE SHOOTER IS IN YOUR VICINITY

Quickly determine the most reasonable way to protect your own life. Remember that customers and clients are likely to follow the lead of employees and managers during an active shooter situation.

1. Evacuate If there is an accessible escape path, attempt to evacuate the premises. Be sure to:

• Have an escape route and plan in mind

• Evacuate regardless of whether others agree to follow

• Leave your belongings behind

• Help others escape, if possible

• Prevent individuals from entering an area where the active shooter may be

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• Keep your hands visible

• Follow the instructions of any police officers

• Do not attempt to move wounded people

• Call 911 when you are safe

2. Hide out

If evacuation is not possible, find a place to hide where the active shooter is less likely to find you.

Your hiding place should:

• Be out of the active shooter’s view

• Provide protection if shots are fired in your direction (i.e., an office with a closed and locked door)

• Not trap you or restrict your options for movement

To prevent an active shooter from entering your hiding place:

• Lock the door

• Blockade the door with heavy furniture

If the active shooter is nearby:

• Lock the door

• Silence your cell phone and/or pager

• Turn off any source of noise (i.e., radios, televisions)

• Hide behind large items (i.e., cabinets, desks)

• Remain quiet If evacuation and hiding out are not possible:

• Remain calm

• Dial 911, if possible, to alert police to the active shooter’s location

• If you cannot speak, leave the line open and allow the dispatcher to listen

3. Take action against the active shooter

As a last resort, and only when your life is in imminent danger, attempt to disrupt and/or incapacitate the active shooter by:

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• Acting as aggressively as possible against him/her

• Throwing items and improvising weapons

• Yelling

• Committing to your actions

HOW TO RESPOND WHEN LAW ENFORCEMENT ARRIVES

Law enforcement’s purpose is to stop the active shooter as soon as possible. Officers will proceed directly to the area in which the last shots were heard.

• Officers usually arrive in teams of four (4)

• Officers may wear regular patrol uniforms or external bulletproof vests, Kevlar helmets, and other tactical equipment

• Officers may be armed with rifles, shotguns, handguns

• Officers may use pepper spray or tear gas to control the situation

• Officers may shout commands, and may push individuals to the ground for their safety How to react when law enforcement arrives:

• Remain calm, and follow officers’ instructions

• Put down any items in your hands (i.e., bags, jackets)

• Immediately raise hands and spread fingers

• Keep hands visible at all times

• Avoid making quick movements toward officers such as holding on to them for safety • Avoid pointing, screaming and/or yelling

• Do not stop to ask officers for help or direction when evacuating, just proceed in the direction from which officers are entering the premises Information to provide to law enforcement or 911 operator:

• Location of the active shooter

• Number of shooters, if more than one

• Physical description of shooter/s

• Number and type of weapons held by the shooter/s

• Number of potential victims at the location

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The first officers to arrive to the scene will not stop to help injured persons. Expect rescue teams comprised of additional officers and emergency medical personnel to follow the initial officers. These rescue teams will treat and remove any injured persons. They may also call upon able-bodied individuals to assist in removing the wounded from the premises. Once you have reached a safe location or an assembly point, you will likely be held in that area by law enforcement until the situation is under control, and all witnesses have been identified and questioned. Do not leave until law enforcement authorities have instructed you to do so.

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Evasive Techniques

Developed by Gary Toppins, Instructor Tai Chi Yang Long FormChinese Kenpo 8th Degree Black Belt/ Shootfighting 2nd Degree Black Belt

Certified Kettlebell Conditioning Instructor

There are two very basic fundamental rules of self-defense (protecting yourself) if someone is attacking you. You can get out of the way (evasive move), or block and manipulate the attacker’s strikes or aggressive moves. In this program; the endeavor is to protect yourself without harm to you or your aggressor; the following moves will hopefully help in this effort. Always remember reaction time and awareness enhances your ability for success in your self-protection.

Remember to call (scream) for help!

Basic Defense Techniques (Evasive Maneuvers)

Running or lunging at you with both hands

(A) Variation: as person is running or lunging towards you with their hands outstretched, take one step forward or back with either foot, bending your knees to stabilize your position. Bring both arms up between persons arms before they grab you and drive their arms outward, push with both hands of your hands to the front of person’s shoulder’s, just enough to escape.

(B) Variation: as person is running or lunging towards you with their hands outstretched, take one step forward or back with either foot, bending your knees to stabilize your position. Bring both of your hands to the inside of person’s wrist and grab (pulling down slightly); immediately push person’s arms up and back towards their shoulders and escape.

One-handed arm grab

One-handed arm grab

(A) Variation: Right hand to left arm or left hand to right arm. Step forward at a slight angle (right foot if the right arm is being grabbed / left foot if left arm is being grabbed). Push forward slightly; then quickly bring your fist back towards you torso; this will apply pressure to the thumb and index finger breaking the grip. Slight push to the arms with both hands to create distance, then escape to exit.

(B) Variation: Right hand to right arm or left hand to left arm. Step forward at a slight angle (right foot if the right arm is being

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(continued) grabbed / left foot if left arm is being grabbed). Grab with free hand to persons forearm that is grabbing applying pressure to nerves and pressure points on top of persons forearm, this will cause discomfort allowing you to break grip and escape.

(C) Variation: left hand grabbing right arm or right grabbing left. If person is grabbing with left to your right arm, roll the hand of the arm being grabbed inward towards your body to counter grab while stepping across yourself at a 45 degree angle with left foot; apply pressure with opposite hand to persons elbow, breaking grip. This maneuver will also put you in a more favorable position.

Two-handed arm grab:

(A) Variation: Person grabbing you with 2 hands to one of your arms; step back with one foot while dropping your weight slightly as you bring your arms down, with free hand, grab over the persons arm and grab your own fist; then circle high and fast to put pressure on person wrist, breaking free. Note: It is also possible to slightly push persons arms at this time to gain a better position.

(B) Variation: Person grabbing you with 2 hands to one of your arms; step back with one foot while dropping your weight slightly as you bring your arms down, with free hand, grab under persons arm and grab your own fist; circle down and fast to put pressure on person grip, breaking free. Note: It is also possible to slightly push persons arms at this time to gain a better position.

Punches

Punches(continued)

(A) Variation: Person throw’s right punch, step forward at a 45 degree angle (slant); at the same time use both hands to redirect the punch by making contact with the palm of your hands at the person’s forearm and with the other hand slightly above the elbow. This should provide an opportunity to push person away and escape. Note: If person throw’s left punch, simply do the opposite.

(B) Variation: Person throw’s right punch, step forward at a 45 degree angle (slant); at the same time using the back of your right wrist to redirect punch, follow through with the palm of your left hand at persons shoulder to push away. This should provide an opportunity to escape. Note: If person throw’s left

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punch, simply do the opposite. Two-handed choke hold from the rear

(A) Variation: Step forward at a slight angle with either foot, at the same time circle arm (elbow pointing upward) up and over persons arms breaking grip. This should put you in a position side ways to person. Note: If you step with right foot you must use left arm; the same goes for other side. Technique can also be used if grabbed with two hands to the shoulders.

(B) Variation: Step forward at a slight angle with either foot, at the same time drive your forearm into the person’s wrist, following through with your other hand to persons forearm. Note: If you step with right foot you must use left arm; the same goes for other side. Technique can also be used if grabbed with two hands to the shoulders.

Two-handed choke hold from the front:

(A) Variation: with both hands, trap person’s right hand. Apply pressure downward while stepping across yourself at a 45 degree angle slightly leaning forward with your upper body, at the same time twisting person’s hand. In most cases person will lose balance and let go. This will expose the person’s side; give a slight push to escape.

(B) Variation: Trap person’s right hand with your right hand (all 4 of your fingers should be grabbing person’s small finger side of their hand) apply pressure by leaning forward with upper body, at the same time apply pressure with the fingers of your left hand to top of person’s right forearm while stepping across yourself at a 45 degree angle. In most cases person will lose balance and let go.

One arm or two arm choke hold from behind:

Step to a wide stance bending your knees for balance, at the same time put your chin down into your chest to protect your neck (reaction time, this needs to be done immediately). Grab with both hands; one hand at aggressor’s wrist, the other at his elbow, step left at a 45 degree angle and bend forward, this will put aggressor off balance, giving you a chance to escape.

Bear hug from the

Step to the side of the person, bending your knees for balance, at the same time bring your hand across their face; right foot steps

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front: person's arms underneath yours:

right grabs. (You can use the edge of your hand or middle or index finger to press the nerve underneath their nose). Press upward and back simultaneously; this will bring their head back releasing their grip.

Bear hug from behind: persons arms underneath yours:

Take a step sideways with one foot, bending your knees for balance. Drive your hips back into your aggressor, and then drive both of your elbows into your aggressor’s arms, attempting to break their grip (repeat if necessary). Grab right hand of aggressor with both hands (thumbs on top fingers on their wrist). Step with left foot at a 45 degree angle into a wide stances, apply pressure with thumbs to aggressor’s hand. This should put you in a position to escape.

Bear hug from the behind: your arms are pinned:

Drive your hips back into your aggressor, then drive your arms backwards into aggressor’s arm’s; this should release their grip (if not repeat). Then take a step forward with one foot turning into your aggressor, push with both hands to escape.

Biting your arm

(A) Variation: force your arm into the mouth of aggressor; with other hand, grab aggressor’s nose and push. This will make it difficult to breathe, as aggressor gasp for air, free your arm and escape.

(B) Variation: force your arm into the mouth of aggressor; make a fist with your other hand (don’t hit) but drive knuckles into aggressor’s I-T Band (side of the leg between the hip and knee) this should cause a significant reaction, causing the person to let go, and allow you to escape.

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ESCALATING AND LIFE THREATENING SITUATIONS:

These are situations that are more critical in nature, higher degree for injury to yourself, and perhaps worse. The individual being attract must determine immediately the severity of the moment and act accordingly.

Remember! Reaction time and awareness enhances your ability for success in yourself protection.

Bear hug from the front: your arms are pinned:

This may not appear that dangerous; but against a strong aggressor it is very difficult to break free; they could throw you to the ground (land on top of you), drive you against a wall, perhaps throw you over a table or chair etc. if you feel that you are in a critical position, and help has not arrive, you can do the following: Head butt to aggressor face, knee to groin, stomp to aggressor foot, knee to the thigh. When aggressor lets go, push with both hands and escape.

WEAPONS ATTACKS: THIS CAN BE A NUMBER OF THINGS, IT CAN BE A BLUNT OR SHARP OBJECT COMING FROM MULTIPLE DIRECTIONS.

Vertical one arm weapon attack:

Step forward at a 45 degree angle simultaneously bringing both arms upward to contact aggressor arm (never block a weapon, always the arm). With one hand grab aggressor’s wrist, with the other hand push against aggressor’s elbow as you step across your aggressor, this should bend them over and allow you to escape.

Vertical two arm weapon attack:

Step forward at a 45 degree angle simultaneously bringing one arm upward to contact aggressor arm (never block a weapon, always the arm). Grab aggressor’s arm with the hand of the arm that is blocking as you step with your back foot 180 degrees simultaneously bringing the other hand to aggressor’s elbow. This should bend them over, when this happens, push arm towards aggressor; this will create distance so you can escape.

Sideways one arm weapon

Step forward bending your knees for stability, simultaneously bringing both hands up to contact aggressor arm (use the edge of you hand, one hand at aggressor’s wrist the other above the

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attack: elbow). The hand at the wrist grabs the wrist while the other hand slides over the elbow and locks arm; apply pressure and step back with front foot, this will cause your aggressor to bend forward. When this happens, push arm towards aggressor, this will create distance so you can escape.

Sideways two arm weapon attack:

Block by driving shoulder into aggressor’s upper arm, immediately grab aggressor’s wrist with one hand (over their arm) and under their forearm with other hand. Step back with one foot turning hips and lean forward at the same time. This will cause aggressor to lose balance and allow you to escape.

Ground attack

You are on your back, aggressor is on top of you (choking, pinning your arms etc.) With both hands collapse aggressor’s arm at the inside of the elbow, at the same time put one foot over aggressor’s leg (same side that you are grabbing at the same time put one foot over aggressor’s leg (same side that you are grabbing). With one hand pin their wrist with other hand grab tricep. Drive your hips up as high and fast as you can (this is called a bridge) and roll towards the hand that you have trapped, at the same time push against the aggressor’s body with other leg; this should break their grip and reverse your position.

You are on your back, aggressor is on top of you, and one of aggressor’s arms is around your neck. Whatever side aggressors arm is; grab the side of your head and push your elbow in tight to trap aggressors arm, at the same time put one foot over aggressor’s leg (same side that you are grabbing). Drive your hips up as high and fast as you can (this is called a bridge) and roll towards the hand that you have trapped, at the same time push against the aggressor’s body with other leg; this should break their grip and reverse your potion.

Attack with a cord of some type:

Immediately protect your neck by putting your chin down into your chest. Bring your hands up to block weapon. Drive your hips as hard as you can into aggressor. Drop your center of gravity and try and twist free. This is life threatening, if you cannot get free, drive your heel into aggressor’s foot or inside knee, this should help you escape.

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Restraining Techniques

Escorting and Containment Techniques

Problem TechniqueStanding Restraint

Two persons on either side of the client, facing the same direction. Hold client’s arms, then bend forward.

Escort Client is standing upright. One staff person on each wrist walking on either side.

Floor Restraints

Require 5 persons. Not recommended as they place the person in a prone position. Especially not recommended for elderly persons.

Floor restraints and "take-downs" will not be practiced or demonstrated in this course. They are potentially dangerous maneuvers. The purpose of this course is to emphasize verbal de-escalation techniques and evasive maneuvers that do not harm the patient or the healthcare worker.

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Appropriate Use of Medications as Chemical Restraints

Medications are also considered a form of restraint. If a client’s behavior requires and intervention with drugs, the same protocols utilized for physical restraints apply. Seclusion: the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.

Restraint: any manual method or physical or mechanical device, material or equipment attached or adjacent to the client's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body.

Chemical restraint: a medication used to control behavior or to restrict the client's freedom of movement and is not a standard treatment for the client's medical or psychological condition.

The standard of use for seclusion and restraints: (these are general guidelines that may or may not apply to your facility or state).

Emergency situations if needed to ensure the client's physical safety less restrictive interventions have been determined to be ineffective in least restrictive manner and with safe techniques end at earliest possible time

Physician or Independent Licensed Practitioner ordered. Treating physician must be consulted as soon as possible (if did not order use).

Cannot be a PRN order

Time limits:o Written orders; 4 hours for adults- 2 hours for ages 9-17 and 1 hour for under

age 9. o May be renewed up to 24 hours.

In- Person evaluation of client:

Physician or Independent Licensed Practitioner must see and evaluate the need for use within 1 hour after initiation.

If client is no longer in restraints at end of verbal order the physician or independent licensed practitioner must still see and evaluate the client within one hour.

The client must continuously monitored. The client must be physically checked every 15 minutes.

Time out is a behavioral consequence written in the client’s Individual Program Plan (IPP) used to remove the client from reinforcement opportunities in the environment.

Clients’ right to avoid restraint: this is actually two different standards, one that applies to acute medical and surgical care, and another that applies to behavior management.

Acute medical and surgical care: restraint includes physical restraint and drugs used to restrain.

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Restraint can only be used when less restrictive interventions have been determined to be ineffective.

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Chemical Restraint Guidelines

1. Sedative agents may be used to provide a safe, humane method of restraining the violently combative client who presents a danger to themselves or others and to prevent the violently combative client from further injury while secured by physical restraints

2. These clients may include but are not limited to the following: Alcohol and or drug-intoxicated clients Restless, combative head-injury clients Mental illness clients Physical abuse clients (more humane than physical restraint)

Chemical Restraint Suggested Procedures

1. Assess the possibility of using physical restraint first; evaluate the personnel needed to safely attempt to restrain the client

2. Have sedative medication prepared for injection; prepare for possible hypotensive side effects

3. Contact Physician prior to administration and clearly state the need for sedation if you think it is necessary for safety or client care

4. Administer medication as ordered.

Vital signs should be assessed within the first five minutes and thereafter as appropriate

Haldol is often the drug of choice. If necessary, contact the Physician for additional sedation.

5. Assess the need for sedation carefully The violently combative client stands a lesser chance of injury when sedated Clients who are physically restrained and aggressively fighting their restraints

and head injury clients who are combative and compromising their airway and C-spine may be candidates for sedation

Chemical restraint precautions: Side effects of Haldol may include hypotension, tachycardia, and acute dystonic reactions. Treat symptoms of dystonic reaction with Benadryl as ordered. Watch for increased sedation

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Post Crisis Depression

Person is exhausted and body is below the baseline level. Pulse and respiration lower than normal. Depression accompanies fatigue. The post-crisis depression is a time where more engaging verbal

techniques may be used. Some people will not want to talk. Close supervision is required at this time. Medication could place a person at risk of too low of a blood pressure

or respiration. Return the person to the treatment plan.

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Employee Resources and Incident Debriefing

Post Incident Debriefing Review the incident with the team.

o Discuss the incidento Meet in a quiet place

Perform a debriefing with the client.o Assess safety o Discuss the triggering evento Look for a pattern

Try to determine what could have been done differently. Discuss with your manager or human resources if you need additional

assistance such as employee assistance.

Complete an Incident Report/Follow Facility Procedures

Document the event completely:

Documentation of the event is the legal record. It is important to be clear and accurate in the documentation. You must use words and descriptions within your scope of practice. After an assaultive episode, you must recover, relax and re-gain your thinking ability. Talk to the other staff and get an accurate account of the episode. Documentation must include what part of the care plan didn’t work and what “plan B’s” were attempted. The documentation will describe the event and then what was finally done to return the client to the primary treatment plan.

If you ever have to give a deposition or go to court about an assaultive event, your documentation is the legal record of it. If asked what happened during the episode, read your documentation. Do not rely on memory. Documentation will demonstrate your efforts at preserving the client’s civil rights.

1. In what manner was your client violent? Record client’s comments verbatim. 2. Did you feel threatened? Why?3. Were you concerned about your client's outcome without emergency medical interventions? Why?4. Could you treat your client appropriately without the use of restraints? 5. What Law Enforcement Officer was present? 6. What physician provided the order? Who was on-line medical control?7. Document the frequency of respiratory and mental status change assessments. * 8. If your client was physically restrained, was he prone or supine? 9. What kind of restraints did you use? 10. Where on your client were these restraints placed?

Constant evaluation of your client's airway status and documentation of such is extremely important.

Those who work in the healthcare industry are in situation were clients and families are stressed, impaired or frightened. These situations place workers at risk for assaultive situations. Early detection of behaviors, utilization of verbal de-escalation techniques can help avoid harm to the client or the healthcare professional.

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Self-Care

http://www.uky.edu/StudentAffairs/VIPCenter/downloads/self%20care%20defined.pdfSome information adapted from RAINN.org, UK Violence Intervention and Prevention Program

Self-care includes any intentional actions you take to care for your physical, mental and emotional health. Good self-care is a challenge for many people and it can be especially challenging for those that spend their days caring for other people. It can also be an important part of the healing process. Self-care is unique for everyone. Below are some ideas to get you started in developing your own self care plan. It can be overwhelming to consider taking on many new things. It may be helpful to start with a couple of ideas and build on that.

Physical self-care is an area that people often overlook.

Food • Food is a type of self-care that people often overlook. People are often so busy that they don’t have time to eat regularly or that they substitute fast food for regular meals. • It’s not always reasonable to expect people to get 3 square meals a day (plus snacks!) but everyone should make sure they get adequate nutrition. Goal:

Exercise • Exercise is one of the most overlooked types of self-care. The CDC recommends at least 30 minutes of exercise 5 times a week. • Exercise, even if it’s just a quick walk at lunchtime, can help combat feelings of sadness or depression and prevent chronic health problems. Goal:

Sleep • Although everyone has different needs, a reasonable guideline is that most people need between 7-10 hours of sleep per night. Goal:

Medical care • Getting medical attention when you need it is an important form of physical self-care. • Some people put off getting medical care until problems that might have been relatively easy to take care of have become more complicated. Goal:

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Emotional self-care will mean different things for different people. It might mean:

Counseling • This could mean seeing a psychologist, a clinical social worker, or therapist. Goal:

Keeping a journal • Some people find that recording their thoughts and feelings in a journal or diary helps them manage their emotions after an assault or abusive situation. Goal:

Meditation or relaxation exercises • Relaxation techniques or meditation help many people with their emotional self-care.Goal:

Socializing with friends and family • Nurture relationships with people that make you feel good about yourself• Make spending time with friends and family a priority Goal:

Find time for fun leisure activities • Get involved in a sport or hobby that you love!! Find other people who are doing the same thing! Knowing that people are counting on you to show up can help motivate you. • Make a date night and stick with it, either with a partner, a friend or a group of friends. • Treat leisure appointments as seriously as business appointments. If you have plans to do something for fun, mark it on your calendar! Goal:

Make your self-care a priority, not something that happens (or doesn’t happen!) by accident.

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Self-Care Exercises

Body and Chair Exercise www.sagepub.com/upm-data/47041_05_Mindfulness_exercises.pdf

Take your seat on a chair. With eyes closed or just half-closed, allow your attention to rest on your experience of your body in the chair.

Notice the areas of contact between your body and the chair. Notice the support the chair is offering to you right now. Become aware that the chair is supporting your body right now by carrying most of your physical weight. Allow this to happen, allow a comfortable sense of heaviness to spread through your body, supported and carried by the chair.

Notice the rise and fall of the breath. Notice any tension you are holding within your body, the neck, shoulders, down the arms, the weight of the head. Notice any tension in your back down the spine, into your buttocks, legs, ankles and feet. Notice any tension in your belly or chest. Each time you notice any tightness or difficulty in these different parts of your body allow it to drain into your chair, be absorbed by your chair.

Just rest in this experience of being supported by the chair for a few minutes.Whenever you are feeling anxious, unsupported or lonely, return to this practice which helps to build a nourishing reciprocal role such as caring or supporting in relation to being cared for or supported.

Happy Places/Thoughts:Write or draw people, places, events, pets, memories….anything that would give you a sense of comfort, peace or joy. Be detailed with colors, smells, sounds, tastes, etc.

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The Do’s and Don’ts of Self-Care:

Do Don’t Express yourself. Try to build

bridges rather than barriers; a quick chat with a friend may be all that you need.

Pamper yourself. Take time out during the day just for you.

Talk to your supervisor Seek professional help, if

necessary. Recognize the danger signs and take action

Don’t bottle up your anger or frustration. This can lead to destructive behavior. If necessary, and if possible, shout, scream or punch a pillow.

Don’t overeat or use drugs, drink or tobacco as ways of running away from your problems

Don’t allow work to take over your life. Take time to plan a balanced lifestyle.

Don’t be afraid to ask for help when you need it from family, friends or professionals.

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APPENDIX A: LEGALITIES GENERAL TERMS

Assault is defined as 1) an unlawful physical attack upon another; 2) an attempt or offer to do violence to another, with or without battery, as by holding a stone or club in a threatening manner.(5) Thus, "threat" – alone – can be considered an "assault."

Battery is defined as an unlawful attack upon another person by beating, wounding, or even by touching in an offensive manner. Checking a person's pulse without their permission may be considered "battery" by some clients. Members of some religions consider it extremely offensive to be touched by a person of the opposite sex; or for anyone to touch the head of a child. Thus, simply touching persons, without first obtaining permission to do so, may be considered "battery."

False imprisonment is defined as restraint without legal justification.False imprisonment is considered a civil law and does not require violent abduction. Its equivalent in criminal law would be "kidnapping." The mere threat of confinement, combined with only an apparent ability to accomplish confinement, and some limitation of movement (i.e.; a closed door), is sufficient to uphold a charge of false imprisonment. However, false imprisonment cannot be claimed if the client consents to being confined.

Simple assault - if the person threatens and is close, has the ability, has the intent and the outcome of the assault will likely require no medical attention other than first aide. Threats to slap, pinch or scratch are examples.

Simple assault and battery - person then carries out the threat and makes contact. No medical attention other than first aide is required. Simple assaults may be diffused by distraction or walking away. Hands on interventions as a rule start at the aggravated assault level. In other words, if a client threatens you but hasn’t touched you, you cannot touch the client.

Aggravated assault - if the person threatens harm and makes contact such that medical attention is needed. Examples are eye gouging, hitting, and choking.

Competence - the capacity or ability to understand the nature and effects of one's acts or decisions. And, for all practical purposes, a person is considered to be competent until proven otherwise.Laws governing competence and the right to refuse medical treatment vary widely from state to state.Universally, however, the determination of competence generally depends upon four observable abilities:

The ability to communicate a choice. The ability to understand relevant information. The ability to appreciate the situation and its consequences. The ability to weigh the risks and benefits of options, and rationally

process this information, before making a decision.51

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There are situations in which the interests of the General Public ("State Interests") outweigh an individual's right to liberty:

The individual is threatening self-harm or suicide. The individual presents a threat to the community because of

contagious disease or physical dangerousness. The individual presents a specific threat to other people (third parties). In these cases, individuals may be restrained and treated against their

will.

Consent is defined as the voluntary agreement of a person possessing sufficient mental capacity to make an intelligent choice to do something (or not do something), in response to a proposition posed by another.(2) Consent is generally considered to be either expressed or implied.

Expressed Consent is defined as positive, direct, unequivocal, voluntary verbal or physicalized agreement, and is a more absolute and binding degree of consent. Implied consent is defined as signs, facts, actions or inactions, which support the presumption of voluntary agreement. Thus, a client who personally calls 9-1-1 could be considered as having implied a consent for evaluation and care.

Responding to assaultive behaviors means the primary care plan objectives are not being met. It means whatever plan B was, is not effective. The goal is to get the client to regain self-control and re-enter the primary care plan objectives while protecting the client’s civil rights.

Assaultive behavior response is not an isolated set of techniques. If staff is constantly dealing with assaultive situation, then the staff needs to seriously review the primary care plans.

It is essential that you respond in a manner to protect injury to yourself and the client. You have to use techniques that are preventative and evasive. If you use techniques that cause harm to the client, you may be liable for assault, battery, loss of license and legal action.

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APPENDIX B: TITLE 22 - PATIENT'S RIGHTS (CALIFORNIA)

http://www.abhow.com/sm_files/CaliforniaStateRegulatoryPatientsBillofRights.pdf

The Patient Has the Right: (This is summarized - please see link)

1. To be fully informed of admission, services and charges for services.

2. To be fully informed by a physician of health status.

3. To consent or refuse any treatment or procedure.

4. To receive information necessary to accept or refuse treatment.

5. To be transferred or discharged only for medical reasons or patient welfare.

6. To be encouraged to exercise rights as a patient and citizen.

7. To manage personal affairs.

8. To be free of mental and physical abuse.

9. Confidential treatment, financial and health records.

10. To be treated with consideration, respect, dignity, privacy.

11. Not to perform services for the Facility tht are not therapeutic.

12. To communicate privately with persons of their choice, not open mail.

13. to meet with others and participate in activities of social, relgious and community groups.

14. If married, privacy and if both in facility to share a roo.

15. To have daily visiting hours established. To have visits from family, friends, clergy.

16. To have reasonable access to telephones and make confidential calls.

17. to be free from psychotherapeutic drugs and physical restraints for purpose of discipline, chemical restraint unless in an emergency.

The Patient Has the Right To:Other Rights (Summarized)

Refuse treatment (exceptions based on emergency or holds. Refuse to take part in research, electroconvulsive therapy. Refuse to take antipsychotic medications except in emergency. Informed consent Humane care, free from abuse or neglect, social activities and recreation, education,

religious freedom and practice. To be free from discrimination, Clothing, money, visitors, storage space, personal possessions, telephone, mail, writing

materials. Note: can be denied for good cause such as injury to person, others, damage to facility.

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APPENDIX C: RIGHTS FOR PATIENTS IN MENTAL HEALTH FACILITIES (CALIFORNIA)

http://www.dsh.ca.gov/Publications/Patients_Rights/docs/RightsHandbook_English.pdf

About Being Involuntarily Detained (This is summarized please see link)

“5150” 72-Hour Hold or

When a person, as a result of a mental disorder, is adanger to himself/herself or others or is gravely disabled,a peace officer, a member of the attending staff, oranother professional person designated by the countymay with probable cause take the person into custodyand place him or her in a facility for a 72-hour treatmentand evaluation.

“5250” 14-Day Certification for Intensive Treatment

If a person is detained for 72 hours under the provisionsof Section 5150of the Welfare and Institutions Code andhas received an evaluation, he or she may be certified fornot more than 14 days of intensive treatment related to amental disorder or an impairment by chronic alcoholismunder the following conditions:

1. Evaluation services that the person is a danger to himself/herself or others or is gravely disabled.

2. Person has been advise dor need for, but has not been willing or able to accept treatment on a voluntary basis

"5260" Re-certification for Intensive Treatment

If during the 14-day certification you attempted orthreatened to take your own life and if you remain an imminent threat of taking your life, your doctor may place you on an additional 14-day hold, which is known as a re-certification.

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APPENDIX D: ERIKSON'S STAGES OF PSYCHOSOCIAL DEVELOPMENT

Every person has his own unique identity. This identity is composed of the different personality traits which can be a combination of positive and negative. Personality traits can be innate or acquired; thus, it actually varies from one person to another based on the degree of influence that the environment has on the individual. The bottom line is that as humans, we possess many characteristics and these are honed in many different aspects which eventually define the totality of a person.

Erik Erikson emphasized the sociocultural determinants of development which are represented in eight stages of psychosocial conflicts that an individual must overcome or resolve in a successful manner so that they will be able to adjust well to the environment. Erikson described that at each of the eight stages, the person encounters a certain crisis that contributes to his psychosocial growth. Whenever the person experiences such crisis, he is left with no choice but to face it and think of ways to resolve it. However, failure to overcome such crisis may lead to significant effects that contribute to the person’s psychosocial development.

ERIKSON'S STAGES OF PSYCHOSOCIAL DEVELOPMENT

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ERIKSON'S STAGES OF PSYCHOSOCIAL DEVELOPMENT Stage One – Trust versus Mistrust

Infants must learn how to trust others who care for their basic needs. The infant should feel that he is being cared for and that all his needs are met. The newborn is like a helpless being and therefore, might view the outside world as threatening. Depending on how he is treated by people around him, the sense of threat will be replaced by trust so that the infant can have a sense of security and will be able to build trust for people around him. The first and most important person to teach this virtue of trust is the mother. Mothers are expected to take good care of the child and attend to his every need rather than ignore and let the child be helpless. More specifically, the parents should be able to provide food, shelter, sustenance and make the child feel very comfortable so that he will feel secured and that he will trust that people around him truly cares for him.

Stage Five – Ego Identity versus Role ConfusionDuring adolescence, the child is expected to develop his or her sexual identity. This is gained through the discovery of oneself and in the course of finding meaning to their personhood. This is also a time when adolescents experience identity crisis because of the transition stage going to adulthood. Most adolescents may find it confusing in carrying out activities as to whether it is more appropriate for them or for an adult. Crisis at this stage may also be brought about by expectations from themselves and from other people.

Stage Two – Autonomy versus ShameAt this phase, children should be taught the basic ways of taking care of themselves like changing clothes and feeding themselves. If this is not met, the child will only continue to rely on other people and when compared with other kids of the same age, they might eventually feel shameful and may even doubt their own abilities to carry out simple tasks. Therefore, children at this stage should learn the basic ways of hygienic practices or other tasks that require good motor skills.

Stage Six – Intimacy versus IsolationIntimacy versus Isolation is very apparent for people who are at the age of 30. People at this stage become worried about finding the right partner or spending the rest of their lives alone. Young adults are most vulnerable to feel intimacy and loneliness because this is the phase where a lot of interactions with other people occur. However, it is not always a success story for every young adult to find someone whom they can share a lifelong commitment. Some may choose to spend the rest of their lives as singles.

Stage Three – Initiative versus GuiltThis is the stage when preschoolers would like to explore and do things on their own. At this age, the child is able to learn new concepts introduced in school and they are expected to practice these lessons in real life. Children are expected to do some basic decision making for their own good; and failure to do these simple things expected of them may develop feelings of guilt. Since they have knowledge of the value of right or wrong, they know that there are tasks that they can accomplish on their own therefore, inability to do basic things may lead them to ask assistance from other people and this leads them to feel guilty.

Stage Seven – Generativity versus StagnationAdults who are in their 40’s or 50’s tend to find meaning in their work. They feel like at this point in their lives, they should be able to contribute something meaningful to the society. Having children and simple work does not give them satisfaction anymore. It’s more of leaving a legacy that will culminate their career life. If they are not able to achieve this sense of satisfaction, they feel like they have been an unproductive member of the society.

Stage Four – Industry versus InferiorityAs the children grow in age, they mature and raise their level of self-awareness. Children are able to easily understand logical reasoning, scientific facts, and other matters that are usually taught in school. Erikson also viewed this stage as critical for elementary students to develop a sense of self-confidence because at this stage, they should be able to competitively achieve some things as compared to children of the same age. During the elementary age, children exert effort to develop self-confidence but otherwise, they become inferior if they feel that they are incapable of acquiring achievements or something that they can show off to their parents.

Stage Eight – Ego Integrity versus DespairSenior citizens or those who are past the age of 60, experience this kind of psychosocial crisis. This is the age when people retire from work and what gives meaning to their lives is that when they look back, they feel a sense of fulfillment knowing that they have done something significant during their younger years. It is incomparable to anything when a person at this age feels very happy and contented that they have lived life to the fullest. However, if they recall life events and feel disappointed and underachieved, it is most likely that they experience feelings of despair. It is at this stage when they should feel well-accomplished and because of these achievements, they feel satisfied and that they have gained wisdom.

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APPENDIX E: MASLOW'S HIERARCHY OF NEEDS

Maslow wanted to understand what motivates people. He believed that people possess a set of motivation systems unrelated to rewards or unconscious desires.

Maslow (1943) stated that people are motivated to achieve certain needs. When one need is fulfilled a person seeks to fullfil the next one, and so on.

The earliest and most widespread version of Maslow's (1943, 1954) hierarchy of needs includes five motivational needs, often depicted as hierarchical levels within a pyramid.

This five stage model can be divided into basic (or deficiency) needs (e.g. physiological, safety, love, and esteem) and growth needs (self-actualization).

The deficiency, or basic needs are said to motivate people when they are unmet. Also, the need to fulfil such needs will become stronger the longer the duration they are denied. For example, the longer a person goes without food the more hungry they will become.

One must satisfy lower level basic needs before progressing on to meet higher level growth needs. Once these needs have been reasonably satisfied, one may be able to reach the highest level called self-actualization.

Every person is capable and has the desire to move up the hierarchy toward a level of self-actualization. Unfortunately, progress is often disrupted by failure to meet lower level needs. Life experiences including divorce and loss of job may cause an individual to fluctuate between levels of he hierarchy.

Maslow noted only one in a hundred people become fully self-actualized because our society rewards motivation primarily based on esteem, love and other social needs.

Obtained from: http://www.simplypsychology.org/maslow.html

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Maslow (1968): Some of the characteristics of self-actualized people

Although we are all, theoretically, capable of self-actualizing, most of us will not do so, or only to a limited degree. Maslow (1970) estimated that only two percent of people will reach the state of self-actualization. He was particularly interested in the characteristics of people whom he considered to have achieved their potential as persons. By studying 18 people he considered to be self-actualized (including Abraham Lincoln and Albert Einstein) Maslow (1970) identified 15 characteristics of a self-actualized person.

Characteristics of self-actualizers:1. They perceive reality efficiently and can tolerate uncertainty;2. Accept themselves and others for what they are;3. Spontaneous in thought and action;4. Problem-centered (not self-centered);5. Unusual sense of humor;6. Able to look at life objectively;7. Highly creative;8. Resistant to enculturation, but not purposely unconventional;9. Concerned for the welfare of humanity;10. Capable of deep appreciation of basic life-experience;11. Establish deep satisfying interpersonal relationships with a few people;12. Peak experiences;13. Need for privacy;14. Democratic attitudes;15. Strong moral/ethical standards.

Behavior leading to self-actualization:(a) Experiencing life like a child, with full absorption and concentration;(b) Trying new things instead of sticking to safe paths;(c) Listening to your own feelings in evaluating experiences instead of the voice of tradition, authority or the majority;(d) Avoiding pretense ('game playing') and being honest;(e) Being prepared to be unpopular if your views do not coincide with those of the majority;(f) Taking responsibility and working hard;(g) Trying to identify your defenses and having the courage to give them up.

The characteristics of self-actualizers and the behaviors leading to self-actualization are shown in the list above. Although people achieve self-actualization in their own unique way, they tend to share certain characteristics. However, self-actualization is a matter of degree, 'There are no perfect human beings' (Maslow,1970a, p. 176).

It is not necessary to display all 15 characteristics to become self-actualized, and not only self-actualized people will display them. Maslow did not equate self-actualization with perfection. Self-actualization merely involves achieving ones potential. Thus someone can be silly, wasteful, vain and impolite, and still self-actualize. Less than two percent of the population achieve self-actualization.

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APPENDIX F: ROLE PLAY: ASSESSMENT AND INTERVENTIONS FOR PSYCHIATRIC PATIENTS

Assessment and Intervention Approaches for Psychiatric Patients Role PlayAdapted from Clinical Companion for Psychiatric-Mental Health Nursing by Fontaine, Kneisl, Trigoboff, Pearson Publication

Aggressive Client: Physical/VerbalAssessment Cues Interventions

Verbal- threats of harm, abrupt silence, pressured speech, yelling, screaming

Behavioral – clenched jaws, frowning, glaring, flushed face, pacing, pounding fists

Open and direct questions Violence history, Substance abuse Observe escalating behavior

Protect client and others from harm Set limits Accept client, reject aggressive behavior Active listening techniques, rapport Communication calm, clear, concise Avoid touching the client PRN med options

Angry Client – experiencing feelings of anger and expressing with feelingAssessment Cues Interventions

Speaking in loud, agitated tones Nostril flaring, fist clenching, muttering Loss of control with objects could predict violence to

others Fearful looks Loss of control Change from baseline behavior (even withdrawal)

Ask open-ended questions Protect client and others from harm Set limits Identify antecedents or triggers Provide support and empathy Give space, avoid touching Communication calm clear, concise

Anxious ClientAssessment Cues Interventions

Moderate – occasional shortness of breath, gastric symptoms, facial twitches, trembling lips

Severe – frequent shortness of breath, elevated vital signs, dry mouth, anorexia, body trembling, fearful facial expression, tense muscles, restlessness

Panic – shortness of breath, hypotension, dizziness, chest pain, nausea, agitation poor muscle coordination, felling of losing control, fear of dying

Moderate to severe – distraction techniques, journaling, teach muscle relaxation, deep breathing exercise

Panic – calm approach and stay with person. Speak slowly in a gentle voice. Use short, simple sentences.

Cognitively Impaired Client – altered abstract thinking, judgment, complex tasks, memoryAssessment Cues Interventions

Cannot process or remember new information Misjudges distances and falls, injures self Difficulty recognizing everyday objects Believes to be younger, like a child Assess ability to follow a multi-stepped process, process

new information Assess falls, injuries Assess ADL’s (sleep, appetite, hygiene and grooming)

Protect from harm Support self-care Assist with glasses, hearing aids Educate family Manage behavior, meds as needed Allow to wander within limits Re-orient as needed without arguing

Delusional Client – holds false beliefs about environment or self even if not confirmed.Assessment Cues Interventions

Talks about special powers or abilities Attend seriously to the client with caring and respect

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Insists upon a particular, irrational view. Believes global events are referring to him Cannot distinguish between the delusion (I am the

president) or preference (it would be interesting to be president)

Assess for belief in having special powers. Assess for persistent, irrational views] Assess for inability to differentiate between delusion and

preference.

Respond to how the client is feeling and have them talk. Reassure of their safety. Validate reality – what is actually happening in their

environment Monitor relapse Educate about medications and compliance

Demanding Client Assessment Cues Interventions

Demands of others rather than requests. Demanding statements such as “you”, “you better give

me what I want”. Demands made in an impatient, harsh tone. Nor recognition of caring that the demand places a

strain on others

Assess outcome on your interactions. If client’s demands escalate, comply within reason and discuss the matter later when the client is not agitated.

Ask client to express needs rather than making demands.

Teach alternative interactions. Explore why demands rather than expresses.

Depressed Client – often experience loss of interest in life, dejection, negative thinking.Assessment Cues Interventions

Decreased interaction with others Mood of despair or desolation, Feelings of guilt, focus

on failures Poor self-image Change in appetite Crying or inability to cry Poor hygiene, Assess ADL/s

Assess for suicidal thoughts and plans Help identify repetitive negative statements abut self. Begin activities with one person and then add Assist in setting attainable goals, Allow time to verbally

respond to questions. Set limits and boundaries in dwelling on the negative.

Fearful ClientAssessment Cues Interventions

Overly sensitive to opinions of others, hurt by criticism. Devastated by the slightest hint of disapproval Exaggerated need for acceptance Fear of refection and abandonment Lacks self-confidence

Approach that client ins a partner in their treatment and have a right to choose their own course in life.

Focus on role function and adapting. Help clients maintain hope. Assist with social skills, assertiveness training. Role play Discuss abilities and limitations.

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Hallucinating Client – experiences sensations that are not real in one of five senses, especially hearingAssessment Cues Interventions

Auditory – moving eyes back and forth as if looking for someone, listening intently to a person who is not speaking, engaging in conversation with an invisible person

Visual – suddenly startled or terrified by another without stimulus, suddenly running in to another room

Olfactory – smelling parts of the body, smelling while walking toward another

Tactile – slapping self as if putting out a fire, pushing invisible things like bugs off the body

Gustatory – describing bad taste, spitting or scraping tongue

Assess moving eyes, listening intently to someone who is not specking.

Conversations with invisible persons, Grinning and laughter threat is inappropriate.

Set limits and boundaries Reduce excess external stimuli Listen, deal with emotions or feelings, not content of

hallucinations. Reinforce reality testing Educate and encourage medication treatment

compliance.

Manic Client –manic phase of bipolar extremes of emotion alternating with depressed mood.Assessment Cues Interventions

Interest in all activates – seeking fun and excitement Mood is unstable, euphoric and irritable. Doesn’t experience guild, may have brief episodes of

crying Grandiose beliefs about self Delusions of grandeur, Increase sexual activity Assess for intense attachments, grandiose beliefs Assess unstable moods and flight of ideas Assess changes n ADL’s, decreased eating or sleeping.

Set limits, reduce external timeline Assist in cause and effect of behaviors Don’t argue with delusions Medication compliance

Manipulative Client – exploits other people for personal gainAssessment Cues Interventions

Nonverbal – excessive smiling touching crying, whining I public, drawing attention, giving gifts to others, selective forgetting

Verbal –compliments or flatters others, sarcasm, threats, inducing guilt n others, bargaining for privileges, wanting to be exempt from rules, lying

Use a team approach, set limits Be consistent Confront behavior, explain consequences Interact with client when client is not acting out Focus on positive behavior Support others around who may be victims of this client

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Substance Abuse Client: In RecoveryAssessment Cues Interventions

Assess symptoms of substance abuse. Symptoms leading to relapse – fatigue,

rationalizing, impatience, arguing, negative thinking, frustration, self-pity, cockiness (“I’ve got this problem licked”), complacency, letting up on recovery program, using mood-altering chemicals.

Group intervention – present facts, consequences.

Self-help groups Discuss coping strategies and avoid self-

destructive behavior. Substance Abuse Client: In Withdrawal

Assessment Cues Interventions Alcohol – may not show physical signs

immediately. Mild 6-12 hours after last drink.o Hallucinations and seizures marks the

onset of major withdrawal (2-3 days following the last drink.

o Nausea, anxiety, irritability, tachycardia, sweating, increased blood pressure, orthostatic hypotension, tremors hands, tongue eyelids, agitation

Barbiturates/sedative hypnotics – 24 to 72 hours after.

o deep sleep, decreased respiration, weakness, tachycardia, anxiety, depression, orthostatic hypotension, coarse tremors of hands, tongue, eyelids, painful muscle contractions, seizures up to 2 weeks after, hallucinations

Opioid (heroine, morphine, codeine, methadone) – most have withdrawal symptoms. Will see few hours to 2 to 3 days.

o Flu like symptoms, crave drug, dilated pupils, runny nose, fever, restlessness, muscle and joint pain.

o Babies have high pitched dry, irritable, fever, tremors

Cocaine – 24 hours to 2 to 4 days.o Anxiety, depression, fatigue, agitation,

irritability, depression.o Babies have irritability tremors, muscle

rigidity. Amphetamine (dexadrine, methamphetamine)

o Depression, fatigue, disturbed sleep, restlessness, disorientation.

General – may be suicidal. Withdrawal needs complicated and needs experienced and trained staff.

o Attend to life threatening physiologic symptoms first. Monitor vital signs, respiratory and cardiovascular function. Decrease stimulation.

o With hallucinations acknowledge they are seeing and are frightened but they are not there.

o Adequate nutrition, intake and output.

Alcohol – need lots of fluids. Magnesium sulfate to decrease muscular irritability. Vitamins, benzodiazepines, Narcan

Opioids –look for symptoms 1-3 days after stabilized on methadone. Administer clonidine until symptoms are alleviate (up to 14 days)

Cocaine – Diazepam, imipramine, monitor vital signs.

Amphetamines – diazepam, chlorpromazine. General hospital Client – alert primary

healthcare provider for possibility of withdrawal. Labs

Suicidal Client –has purposeful self-destructive thoughts, plans, or actionsAssessment Cues Interventions

Assess lethality by directly asking whether the client intends suicide, has had thoughts as well as a plan

Determine access to the method planned – gun rope, pills

Giving away valued items Assess for losses, rejection and increasing stressors

Set limits and boundaries (agreement to speak with staff)

Ensure patient safety Establish a behavior contract of not harming self May need to observe 1:1, access outside sources or

legal holds such as 5150

APPENDIX G: SENATE BILL 1299: WORKPLACE VIOLENCE PREVENTION PLANS; HOSPITALS

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Senate Bill No. 1299 Chapter 842http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB1299

An act to add Section 6401.8 to the Labor Code, relating to occupational safety and health.[ Approved by Governor September 29, 2014. Filed with Secretary of State September 29, 2014. ]

LEGISLATIVE COUNSEL'S DIGESTSB 1299, Padilla. Workplace violence prevention plans: hospitals.Existing law regulates the operation of health facilities, including hospitals.

The California Occupational Safety and Health Act of 1973 imposes safety responsibilities on employers and employees, including the requirement that an employer establish, implement, and maintain an effective injury prevention program, and makes specified violations of these provisions a crime.

This bill would require the Occupational Safety and Health Standards Board, no later than July 1, 2016, to adopt standards developed by the Division of Occupational Safety and Health that require specified types of hospitals, including a general acute care hospital or an acute psychiatric hospital, to adopt a workplace violence prevention plan as a part of the hospital’s injury and illness prevention plan to protect health care workers and other facility personnel from aggressive and violent behavior. The bill would require the standards to include prescribed requirements for a plan. The bill would require the division, by January 1, 2017, and annually thereafter, to post a report on its Internet Web site containing specified information regarding violent incidents at hospitals. The bill would exempt certain state-operated hospitals from these provisions.

Because this bill would expand the scope of a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.

BILL TEXT THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:SECTION 1. Section 6401.8 is added to the Labor Code, to read: (a) The standards board, no later than July 1, 2016, shall adopt standards developed by the division that require a hospital licensed pursuant to subdivision (a), (b), or (f) of Section 1250 of the Health and Safety Code, except as exempted by subdivision (d), to adopt a workplace violence prevention plan as a part of its injury and illness prevention plan to protect health care workers and other facility personnel from aggressive and violent behavior.

(b) The standards adopted pursuant to subdivision (a) shall include all of the following:

(1) A requirement that the workplace violence prevention plan be in effect at all times in all patient care units, including inpatient and outpatient settings and clinics on the hospital’s license.

(2) A definition of workplace violence that includes, but is not limited to, both of the following:

(A) The use of physical force against a hospital employee by a patient or a person accompanying a patient that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury.

(B) An incident involving the use of a firearm or other dangerous weapon, regardless of whether the employee sustains an injury.

(3) A requirement that a workplace violence prevention plan include, but not be limited to, all of the following:

(A) Personnel education and training policies that require all health care workers who provide direct care to patients to, at least annually, receive education and training that is designed to provide an opportunity for interactive questions and answers with a person knowledgeable about the workplace violence prevention plan. The education and training shall cover topics that include, but are not limited to, the following topics:

(i) How to recognize potential for violence, and when and how to seek assistance to prevent or respond to violence.

(ii) How to report violent incidents to law enforcement.

(iii) Any resources available to employees for coping with incidents of violence, including, but not limited to, critical incident stress debriefing or employee assistance programs.

(B) A system for responding to, and investigating violent incidents and situations involving violence or the risk of violence.

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(C) A system to, at least annually, assess and improve upon factors that may contribute to, or help prevent workplace violence, including, but not limited to, the following factors:

(i) Staffing, including staffing patterns and patient classification systems that contribute to, or are insufficient to address, the risk of violence.

(ii) Sufficiency of security systems, including alarms, emergency response, and security personnel availability.

(iii) Job design, equipment, and facilities.

(iv) Security risks associated with specific units, areas of the facility with uncontrolled access, late-night or early morning shifts, and employee security in areas surrounding the facility such as employee parking areas.

(4) A requirement that all workplace violence prevention plans be developed in conjunction with affected employees, including their recognized collective bargaining agents, if any.

(5) A requirement that all temporary personnel be oriented to the workplace violence prevention plan.

(6) Provisions prohibiting hospitals from disallowing an employee from, or taking punitive or retaliatory action against an employee for, seeking assistance and intervention from local emergency services or law enforcement when a violent incident occurs.

(7) A requirement that hospitals document, and retain for a period of five years, a written record of any violent incident against a hospital employee, regardless of whether the employee sustains an injury, and regardless of whether the report is made by the employee who is the subject of the violent incident or any other employee.

(8) A requirement that a hospital report violent incidents to the division. If the incident results in injury, involves the use of a firearm or other dangerous weapon, or presents an urgent or emergent threat to the welfare, health, or safety of hospital personnel, the hospital shall report the incident to the division within 24 hours. All other incidents of violence shall be reported to the division within 72 hours.

(c) By January 1, 2017, and annually thereafter, the division, in a manner that protects patient and employee confidentiality, shall post a report on its Internet Web site containing information regarding violent incidents at hospitals, that includes, but is not limited to, the total number of reports, and which specific hospitals filed reports, pursuant to paragraph (8) of subdivision (b), the outcome of any related inspection or investigation, the citations levied against a hospital based on a violent incident, and recommendations of the division on the prevention of violent incidents at hospitals.

(d) This section shall not apply to a hospital operated by the State Department of State Hospitals, the State Department of Developmental Services, or the Department of Corrections and Rehabilitation.

(e) This section does not limit the authority of the standards board to adopt standards to protect employees from workplace violence. Nothing in this section shall be interpreted to preclude the standards board from adopting standards that require other employers, including, but not limited to, employers exempted from this section by subdivision (d), to adopt plans to protect employees from workplace violence. Nothing in this section shall be interpreted to preclude the standards board from adopting standards that require an employer subject to this section, or any other employer, to adopt a workplace violence prevention plan that includes elements or requirements additional to, or broader in scope than, those described in this section.

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APPENDIX H: COMPARISON MATRIX AB508, SB1299 AND ARC Title 8 (a) Scope and Application

(3) The employer shall provide all safeguards...PPE, training, and medical services at no cost to the employee, at a reasonable time and place for the employee an during the employees work hours. ### = Employer Oversight *** = Key Medical/Assault Response Competency +++ = MABPRO Inclusions

Topics Topics Topics SB1299 MABPRO-KMR

ARC - KMR

Patient risk factors Drugs, alcohol, psychiatric condition, confusion, history of violence

X X X

Workplace Violence Any act of violence at work: threat, trauma, stressIncident - use of weaponWorkplace violence types (4)

XXX

X X

Communication Between shiftsReportingCommunicating concern without reprisalHow concerns will be investigated

XXXX

X X

Procedures to identify risk factors

Assessment tools, algorithmsType 2 - visitorsType 1 - workplacePatient - mental status, treatment, meds, history violence

X X X

Post-Incidence Response

X X X

Initial Training ### ###Violence Prevention plan XInitial Training ### Explanation of the Plan XInitial Training ### Hazard Identification XInitial Training General and personal safety

measuresX X X

Initial Training ### Communication of concerns XInitial Training ### Employer addressing workplace

violence incidentsX

Initial Training ### How employees can participate to revise plan

X

Initial Training Recognizing potential for Violence Escalation X X XInitial Training Recognizing potential for Violence Counteract X X XInitial Training Recognizing potential for Violence Seeking

assistanceX X X

Initial Training Strategies to avoid physical harm X X XInitial Training Reporting to law enforcement X X XInitial Training Employee resources Critical incident

stress debriefing

X X X

Initial Training ### Employee resources Employee assistance programs

X

Initial Training ### Opportunity for questions interactive with a person knowledgeable with the plan

X

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Topics Topics Topics SB1299 MABPRO-KMR

ARC - KMR

Additional training ### New equipment XAdditional training ### New workplace practices XAdditional training ### New workplace violence hazard

identifiedX

Additional training ### Employees who respond General and personal safety measures

X X X

Employees who respond

Aggression and violence predicting factors

X X X

Employees who respond

The assault cycle

X X X

Employees who respond

Characteristic of aggressive and violent patients and victims

X X X

Employees who respond

Verbal and physical maneuver to defuse and prevent violent behavior

X X X

Employees who respond

Strategies to prevent physical harm

X X X

Employees who respond

Restraining techniques

X

Employees who respond

Appropriate use of medications as chemical restraints

X X X

Employees who respond

Opportunity to practice maneuvers and techniques

X X X

Employees who respond

Debriefing of practice sessions

X X X

Employees who respond ***

Active Shooter X X

Employees who respond ***

Assessment and Interventions for Psychiatric Patients

X X

Employees who respond ***

Communication Techniques Role Play

X X

Employees who respond ***

Consequences of working in a high stress environment

X X

Employees who respond ***

Dignity and Respect Campaign X X

Employees who respond ***

Erikson, Maslow X X

Employees who HCAHPS Indicators

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Topics Topics Topics SB1299 MABPRO-KMR

ARC - KMR

respond ***Employees who respond ***

Legalities X X

Employees who respond ***

Patient's Rights in Mental Health Facilities

X X

Employees who respond ***

Self-Care Strategies X X

Employees who respond ***

Social Media Risk X X

Employees who respond +++

12 Elements of Active Listening X

Employees who respond +++

Methods for a Successful Negotiation

X

Frequency SB1299 AnnuallyFrequency SB1299 AnnuallyFrequency AB508 Not Defined

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Assault Response Competency (ARC) : AB508 Guidelines - Post-Test 2015Please place answers on the sheet provided.

Choose the Single Best Answer for the Following Questions and Place Answers on Form:

1. In some states, such as California, it is required for hospital personnel to:a. Document assault only if there is personal injury.b. Notify local law enforcement within 72 hours if there is any assault or battery.c. Initiate training for assault response training once an event has occurred.d. Train only security personnel in techniques for assault prevention.

2. Which statement listed below is not true:a. Emergency room personnel rarely have experienced assault in their career.b. The team approach is very important when working with the assaultive client.c. Hospital workers can be at increased risk for assaultive incidents. d. Assault can occur from clients and families.

3. Which of the following statements are true related to general safety measures:a. Maintain personal space about approximately one arm’s length.b. Allow the client to regain self control.c. Allow yourself an exit.d. All of the above are good safety measures.

4. Which item listed below IS NOT considered contraband?a. Keysb. Scissorsc. Compacts with glass mirrorsd. Hearing aid

5. Which description below could pose a threat to the healthcare worker with a potentially violent client?

a. A stethoscope around the neck.b. Short nailsc. Having others around you.d. Comfortable shoes.

6. Which description below IS indicative of assaultive behavior?a. Obnoxious behaviorb. Name callingc. Client scratchingd. Client ignores what you say

7. Which description below best defines assault?a. Restraining someone without legal justification.b. An attempt or offer to do violence to another with our without battery.c. Calling someone a name.d. Allowing someone to take your blood pressure.

8. With potentially violent individuals, which concept is MOST important for the healthcare worker?a. Restraining the client to protect you.b. Prevent and protect injury to yourself and the client.c. Harm the client only if there is a threat to others.d. Restrain the client until help arrives.

9. What is the most common occurrence to begin the assault cycle?a. A triggering event.

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b. A crises that occurred in their past.c. Recurrent depression.d. Admission to a medical facility.

10. During the crises period of the assault cycle, which statement is true?a. Behavior escalates.b. The person is exhausted and returns to baseline levels.c. Energy expenditure is very high.d. Depression is manifested.

11. Which situations listed below does the assault pattern not apply?a. Person with seizuresb. Individual using hallucinogensc. The person who is a psychopathd. All of the above

12. A most effective ways to prevent injury to yourself during a potentially assaultive situation is to:a. Confront the assaultive person.b. Get you and others out of the way.c. Tell the person to please sit down and relax.d. Tell the person who is angry that this must be a very difficult situation.

13. The most therapeutic goal for the client after crisis is to:a. Reach a higher level of functioning than before the crises.b. To not shout or scream.c. Is to establish a level of functioning that was present at the onset of the crisis.d. Communicate with their families about how awful the crisis was.

14. Which of the following are reasons that persons in the hospital setting might express anger?a. Their cognition is impaired from medications.b. They are worried about what might happen to them.c. They have fear of the unknown.d. All of the above could trigger anger.

15. Which of the following is true?a. Angry persons will always raise their voice.b. Most communication is nonverbal, the healthcare worker should assess nonverbal cues for

anger.c. It is easy for the healthcare worker to identify the angry person.d. There are predictable ways in which persons express their anger.

16. Which techniques, listed below is an important defusing technique?a. Focus on the client, not the rules.b. Stand close to the client.c. Ask the client to stop talking so that they may listen to what you have to say.d. Use threatening body language to encourage the client to stop the behavior.

17. Which of the following is the most important strategy to avoid physical harm?a. Safety first.b. Allow angry persons space.c. Train staff members on the techniques.d. When possible physically restrain.

18. Physical maneuvers to diffuse violent behavior is:a. A preventative first step.b. The last resort and used only when other tactics have failed.c. The preferred method to prevent injury to others.d. Should be attempted before verbal de-escalation methods have been tried.

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19. An appropriate techniques to use if someone is biting you is to:a. Pull away and shout for help.b. Bite the client back.c. Move towards the bite.d. Hit the client firmly on the arm.

20. When someone is grabbing you, release the grab by:a. Pulling the arm or wrist up and twisting out of the grab.b. Providing a forceful blow to their hand.c. Biting the hand.d. Pulling away as hard as you can.

21. A chemical restraint is defined as:a. A medication given for pain.b. A general anesthetic.c. A restraint on the wrist.d. A medication used to control behavior or restrict the client’s freedom.

22. Chemical restraints MAY NOT:a. Be a PRN order.b. In any way control the client’s behavior.c. Be used with other interventions.d. Be discontinued sooner than 48 hours after initiation.

23. After a violent incident occurs, the healthcare worker must:a. Take the rest of the shift off.b. Complete an incident report.c. Talk with others about the event.d. Talk with the client who harmed them within 24 hours.

24. Post incident debriefing includes:a. Reviewing the incident with the team.b. Try to determine what might have been done different.c. Discussion with your manager or Human Resources if you need assisting in dealing with

the situation.d. All of the above.

25. Which items should be included in documentation of a violent incident?a. Description of the client’s behavior.b. Respiratory and mental status change assessments.c. If used, what types of restraints were used.d. All of the above.

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ASSAULT RESPONSE TRAINING (ARC) AB 508 COMPETENCY ASSESSMENT 2015

Name: ________________________________ Date Completed: ______________ Score____

Place of Employment ________________________ Department__________________

I have completed the skills that apply:__________________________________Employee Signature

Employee has completed skills: _____________________________Manager or Educator Signature

Method of Observation: E=Exam O=Observation V=Verbal Response R=Return DemoCRITICAL ELEMENTS METHOD OF

OBSERVATIONINSTRUCTOR

INITIALSDEPARTMENT SPECIFIC COMPETENCIES

1. Events Leading to Escalation Date Observed: Initial

a. Is able to verbalize 2 situations that place client’s at risk for aggressive behavior. V

b. Is able to verbalize a situation where aggressive behavior may occur without warning. V

c. Is able to describe 2 client behaviors that may indicate escalation of behavior. V

2. Verbal De-Escalation Techniques Date Observed: Initial

a. Given a scenario, is able to utilize 2 techniques to help de-escalate behavior. O

b. Is able to verbalize two factors which may place the healthcare worker at risk. V

c. Is able to verbalize two safety measures when working with potentially escalative clients. V

3. Hand-On Techniques Date Observed: Initial

a. Is able to demonstrate the technique to evade a choke hold (without hurting the client) R

b. Is able to demonstrate a safe release of a grab of the arm. R

c. Is able to demonstrate safe release of a hair pull. R

ASSAULT RESPONSE TRAINING (ARC) AB 508 COMPETENCY ASSESSMENT

Post Test Passing is 75%. 18 or more Correct Score __________

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18. _____19. _____

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