University of Indianapolis
School of Nursing Graduate Program
Nursing and Health Systems Leadership Practicum II Fall Semester 2014
By
Brenda L. Hinz, RN, BSN
Quality Improvement Project:
Violence in the Workplace
Workplace Violence
Creating a safer work
environment for all
Community Health Network
employees and providers.
Why should we care about workplace
violence?
S.A.F.E. Task-force
Stop Aggression for Everyone
• Date established: April 30, 2014
• Sponsoring Group: Network Culture of Safety Steering
Committee/People Pillar
• Purpose of the committee: to insure safe, secure, violence-free
working and patient care environments throughout Community
Health Network including offsite network businesses.
COMMITTEE NAME:
S.A.F.E. (Stop Aggression For Everyone)
DATE
April 30, 2014
ESTABLISHED/REVISED:
SPONSORING GROUP: Network Culture of Safety Steering Committee- Jean Putnam, People PillarWayne Pack
PURPOSE OF THE
To create a safer work environment for all Community Health Network
COMMITTEE IS :
employees and providers.
The Committee Shall:
Decision-making
Authority:
Leader:
Core Team:
COMMITTEE
CHARTER
ESTABLISHED
Meetings:
Frequency,Time and
Place
Meeting Procedures:
Reporting:
1)Establish consistent methodology and terminology for reporting of aggression
and workplace violence (WPV) incidents across the network. 2)Train leaders to
conduct departmental risk assessments to help determine staff training needs.
3)Recommend WPV improvement strategies or policy input. 4)Review and relay
recommendations from Indpls. Coalition for Patient Safety on WPV prevention.
5)Establish need for incident debriefing. 6)Train dept. leaders to assess risk level
of WPV incidents. 7) Monitor employee injury rates, expenses, and turnover
related to WPV.
Recommendations will be made to the Network Culture of Safety Steering
Committee and the People Pillar.
Sherri Stinson and Lisa Weatherford are co-leaders
Candace Ballard CHA Occ Health, Nikki Brown CHS ED, Shawna Thomas CHS,
David Franz Network Security, Judy Hall CHN ED, Brenda Hinz RN CHVH, Karla
Kirby BHS, Michael Kuhn CHE ED, Candace Landmark BHS, Michael Lanning CHE
ED, Laura Leaming Family Rooms/Educator, Steve Linerode Howard Risk Mgmt,
Marsha Meckel CHA Quality Resources, Kevin Neumann Network Security,
Thomas O’Daniel Security Training, Patsy Poehler VEI Surgery, Stephanie Silver
Home Care, Dave Vandergrift CHE Security, Tamera Williams Center of Hope,
TBA CPN, TBA Human Resources. Information Technology, Clinical Education,
Performance Improvement & Legal representative will be included ad hoc.
Meetings will be held at CHE every 2 weeks initially for 1.5-2 hours. May
decrease to monthly once improvement strategies have been planned and
implemented. Bridgelines and Webex access will be provided.
Team will follow standard meeting management template. Agendas out 1-2
days in advance. Anyone can suggest a topic for the agenda by contacting Sherri
Stinson or Lisa Weatherford. Decision making will be by consensus. Minutes
and tools will be posted on SharePoint. A group distribution list was established
as *SAFE Team for sharing materials.
Reports to the Network Culture of Safety Steering Committee and People Pillar
Review and Changes to Charter will be reviewed annually and changes submitted to the Culture of
Charter:
Safety Steering Committee for approval.
Task-force Ground Rules
•
•
•
•
•
•
•
Respectful Communication
Meetings will be held at CHE every 2 weeks initially for 1.5-2
hours
Bridgelines and Webex access will be provided
Communication outside the bi-monthly meetings should take place
on the S.A.F.E. SharePoint site
Team will follow standard meeting management template
Agendas out 1-2 days in advance.
Task-force will be well represented but not allowed to get too
large to be productive.
Gantt chart (“Roadmap” or
“Timeline”)
• Established for S.A.F.E. QI project as a
graphic view of the project schedule
• Gantt chart table listed information about
each task and a bar chart displayed on a
timescale to show task durations, start and
finish dates, and critical tasks.
Begi nni ng Date:
Apri l 29, 2014
Projected Compl etion Date: October 1, 2014
Improve workplace violence and agression for Everyone
A
May- October 2014
Research to Support
Responsible Person
Status
Task-force group
Complete
Timeline
1 Al l pockets of ri sk need to be i dentifi ed
Assess the trai ni ng tool s that the vari ous l ocations currently use so that
we are not dupl i cating efforts and so that we can possi bl y streaml i ne
them. Exampl es: AVADE; VA tool ; Behavi oral care tool …. Updated
WPV/Emp Harassment Pol i cy
Week 1
4/30/14
Week 1
4/30/14
Kevi n Neumann
Complete
3 Determi ne resource needs
Week 1
4/30/14
Task-force group
Complete
4 Determi ne team rol es
Week 1
4/30/14
Sherri & Li sa
Complete
5 A charter needs to be set up
Week 2
5/15/14
Week 2
5/15/14
2
6
Set up a SharePoi nt si te so that di rectors and those i nvol ved can share
i nformation effi ci ently.
Sherri
Complete
Janet Roberts
Complete
Brenda
Complete
7 Li terature Revi ew
Week 2 - 3
A timel i ne needs to be establ i shed and agreed upon by the taskforce so
8
we can proceed and stay on track.
Week 4
6/10/14
Brenda - see Gantt chart
Compl ete
9 Revi ew EBP and what other faci l i ties are doi ng regardi ng thi s i ssue
Week 4
6/10/14
Sherri & Laura presented i nfo from
IU mtg
Compl ete
Week 4
6/10/14
Behavi oral Heal th Rep
Compl ete
Week 4
6/10/14
10 Research evi denced based tool s
11
Revi ew pre-i mpl ementation patient satisfaction scores, i ncl udi ng key
dri vers. Patient feel safe when they come to communi ty?
B
Development of WPV Tools
1
2
Devel op A3 to determi ne root cause/gap anal ysi s See:
http://www.shmul a.com/the-toyota-a3-report/363/
A good rul e-ofthumb i s that you haven’t reached the root cause until you’ve asked
“why?” at l east fi ve times i n seri es.
Devel op a process fl owchart (To ensure that the process does not go
astray and stays on track ensuri ng that qual i ty i s not compromi sed upon)
5/15-5/29/14
Compl ete
Week 5
6/24/14
Brenda (s ee c a us e/effec t di a gra m)
Compl ete
Week 5
6/24/14
Brenda
Compl ete
Draft Heal thy Campus 2020 MAP-IT Framework to hel p our S.A.F.E. group
track our progress. It wi l l be used to pl an and eval uate publ i c heal th
i nterventions and to achi eve Heal thy Campus 2020 objectives.
Speci fi cal l y, i t wi l l hel p us pl an regul ar eval uations to measure and track
our progress over time and determi ne i f our action pl an has been
effective i n achi evi ng our goal s.
http://www.heal thypeopl e.gov/2020/Impl ement/defaul t.aspx
* Impl ement
3
Week 8
7/8/2014
Task-force group
Compl ete
4
Revi ew onl i ne course for workpl ace vi ol ence prevention trai ni ng for
heal thcare workers retri eved from:
http://wwwn.cdc.gov/wpvhc/Course.aspx/Sl i de/Intro_1
Note:
task-force l i ked the vi deos i n thi s course but the course overal l i s way too
l engthy to requi re staff to revi ew. The vi deos gave our task-force the
i dea of vi deo tapi ng empl oyee vol unteers who wi l l gi ve testimoni al s to
Week 8
WPV exposure. Thi s i nfo wi l l then be presented at the Feb 2015
presentation to the steeri ng commi ttee. The group feel s bri ngi ng thi s
personal pi ece to the presentation wi l l hel p bri ng to l i fe the WPV i ssues
that exi st and for the steeri ng commi ttee to buy i n to the necesi ty of the
AVADE 4 hour trai ni ng program that wi l l be requi red goi ng forward.
7/8/2014
Task-force group
Compl ete
5
Revi ew Effectiveness of anonymi sed i nformation shari ng and use i n
heal th servi ce, pol i ce, and l ocal government partnershi p for preventing
vi ol ence rel ated i njury.
Week 12 8/7/2014
Task-force group; Kevi n and Dave
Compl ete
6
Di scuss usi ng The Indi anapol i s Coal i tion for Patient Safety's - Framework
for Interpersonal Vi ol ence Prevention.
Week 12 8/7/2014
Sherri and Laura
Compl ete
7
Revi ew WPV tool s wi th stakehol ders to i dentify opportuni ties for
addi tions or removal s
Week 12 8/7/2014
Task-force group
Compl ete
8
Fi nal i ze WPV
week 18 9/16/2014
Task-force group
Compl ete
Week 23
10/2/14
Task-force group
Compl ete
Week 23
10/2/14
Compl ete
Week 23
10/2/14
Compl ete
3
Prevention
*Acknowl edge i ntol erance of al l workpl ace vi ol ence and necessi ty to put
measures i n pl ace to prevent i t from happeni ng i n the fi rst pl ace.
*Rai se
awareness of the cul ture of acceptance and promote the i mportance of
recogni zi ng escal ating si tuations and i nterveni ng earl y. *Understand the
barri ers to an effective prevention program.
*Fl ag medi cal
record of previ ous offenders.
Week 23
10/2/14
Compl ete
4
Policy
*Management commi tment
of coonduct (Professi onal i sm)
vi ol ence
*Restri cted movement
*Incorporate pl ai n l anguage i nto al l al erts
Week 23
10/2/14
Compl ete
5
Education
*El earni ng
*Pol i cy
*Code of conduct
*Ri sk
factors that cause or contri bute to assaul ts
*Earl y
recogni tion of escal ating behavi or or recogni tion of warni ng si gns or
si tuations that may l ead to assaul ts
*Ways to
prevent or di ffuse vol atil e si tuations or aggressi ve behavi or, manage
anger and appropri atel y use medi cations as chemi cal restrai nts, empathy
trai ni ng.
*Active shooter (real or
threat of vi ol ence) scenari o based trai ni ng.
Week 23
10/2/14
Compl ete
6
Employer response following acts of violence
*Comprehensi ve treatment for empl oyees who are vi ctimi zed personal l y
or may be traumatized by wi tnessi ng a workpl ace vi ol ence i nci dent.
*Injured staff shoul d recei ve prompt treatment and psychol ogi cal
eval uation whenever an assaul t takes pl ace, regardl ess of i ts severi ty.
*Identify the barri ers to swi ft, effective and safe response to an
occurrence.
*Fol l ow
up wi th empl oyees who have been assaul ted. Del i neate options:
empl oyee assi stance programs, change i n envi ronment/assi gnment, fi l e
charges, etc. Provi de fol l ow up after thi s i ni tial counsel i ng to determi ne
outcome.
Week 23
10/2/14
Compl ete
C
Create a detai l ed work pl an that i ncl udes concrete action steps
assi gned to speci fi c peopl e wi th cl ear deadl i nes and/or timel i nes.
Share responsi bi l i ties across coal i tion members but consi der havi ng a
si ngl e poi nt of contact to manage the process to ensure that thi ngs get
done. Check i n wi th coal i tion members by usi ng the Coal i tion Sel fAssessment to see i f your process i s runni ng smoothl y.
Heal thy Campus 2020 Tool : Coal i ti on Sel f-Assessment (Downl oad
Worksheet - Word Document)
tool (s)
Action Plan
Fol l ow the Indi anapol i s Coal i tion for Patient Safety - Workpl ace Vi ol ence
Prevention Workgroup Mul ticenter Recomme ndations for i mprovi ng
patient and staff safety and reduci ng workpl ace vi ol ence.
1
2
D
1
Assessment
*Workpl ace secui ty survey tool
*Cul ture survey
Reporting system
*Combi ne external and i nternal events
*Moni tor trends and anal yze i nci dents
*Col l ect departments, uni ts, job titles, parties i nvol ved, time of day
*Code
*Lateral
*Active shooter
Evaluation
Metri cs the SAFE team wi l l be moni tori ng, awai ting team feedback:
CHNw exi sting metri cs -1) secul ri ty dept ri sk assessment; 2) cul ture of
safety survey; 3) securi ty servi ces survey.
Task-force recomme ndations: 1) Mi das reports of WPV to be added to
Gi nger Breech's workl i st to match securi ty reports.
Week 31
11/25/14
In Progress
What is Workplace Violence?
Workplace violence is hostility/violence or threat of
violence against workers.
It can occur at or outside the workplace and can range
from physical assault to verbal abuse.
Root Cause Analysis - RCA
Use the RCA –
To Answer the Critical Questions
• What happened (or is still happening)?
• How did it happen?
• Why did it happen?
• How can we prevent it from happening again?
• What can we learn from this?
WHY??????
Keep asking why until the answer is no longer
within the boundary of the analysis or no
longer makes sense in relationship to the
event.
Cause and effect diagram
Situation
Goal: To insure safe, secure, violence-free working and
patient care environments throughout Community Health
Network including offsite network businesses.
Background
Workplace violence is commonplace. There are several important facts to consider
regarding prevention including security, staffing, training, and equipment. According
to a U.S. Department of Justice report on non-fatal violence:
Healthcare workers are more likely to be attacked than prison guards or police
officers.
Healthcare workers are 4X times more likely to be victims of non-fatal assault and
be victimized by Workplace Violence.
Physician incidents – 16.2 per 1,000
Nurses – 21.9 per 1,000 (Female Nurses are the most vulnerable)
Mental Health Care Workers – 68.2 per 1,000
All other work-groups – 12.6 incidents per 1,000
Statistics
 2013 CHNw sponsored nursing symposiums on Workplace Violence in response to the #1 reported nursing
concern: Workplace Bullying.
 2011- 2013 CHNw Security Incident Activity Problem Intervention, Verbal Intervention, Standby and Restraint
Year
Security Incident Activity
 2011
8,394
 2012
9,629
 2013 YTD - Oct
7,253
Behavior Mgt. Incidents*
7,274
6,717
6,138
Subtotal % of Incident
86.6%
69.7%
84.6%
Assessment
Leadership challenges




Area crime and violence varies by region with East being the highest crime area followed by North region.
2013 YTD more than 150 events of harm to network caregivers due to WPV from patients.
2012 Contracted Security Management Services International, Inc. (SMSI) to perform Security Assessment
Consultant SMSI Performed Network-wide assessment finding an excellent program, but recommended:
o Security Awareness Training for all EE’s (Workplace Violence Prevention)
o Visitor Badging at public entrances
o Dispatcher minimum staffing 2; Recommend 3 Dispatchers as the Standard
o License plate recognition cameras
o New Central Station software platform
o PPM Incident Reporting Software
o HR Screening process (Gap & Credit Checks)
o Bike Patrol (coincide with area school schedule)
o TI Security Simulator Training
o Replace GE Access Control & CCTV Platform
o Refresh Key & Lock System at East
o Install Taser Video Cam
What Else do you Need to
Know?
• What are the gaps in the information?
Why did each step in the process occur?
• What do you need to know to fill in the gaps?
• Where can you get the information?
•
Data-to-Decision cycle
Research occurs then data are converted to information,
information is transformed to knowledge, and that
knowledge supports actions and decisions for improved
performance.
Literature Review
Author
Lannaco, J.D., Dixon, J., Whittemore, R. and Bower,
L.
Kable, A., Guest, M., & McLeod, M
Year Published
Type of Source
Source Rank
Validity/Reliability Assessment
2011
Peer-reviewed journal
I. A
Published, integrative source
2011
Peer-reviewed journal
I. A
Published, integrative source
Hurvitz, K., & Simon, T.R.
2014
Peer-reviewed journal
I. A
Published, integrative source
King, K.
2014
Peer-reviewed journal
I. A
Published, integrative source
Bruce, M.D., Nowlin, W.A.
Hartley, D., Ridenour, M., Craine, J. & Costa, B.
2011
Peer-reviewed journal
I. A
Published, integrative source
2012
Peer-reviewed journal
I. A
Published, integrative source
2012
Peer-reviewed journal
I. A
Published, integrative source
2001
Peer-reviewed journal
I. A
Published, integrative source
2014
Peer-reviewed journal
I. A
Published, integrative source
2014
Peer-reviewed journal
I. A
Published, integrative source
2012
Peer-reviewed journal
I. A
Published, integrative source
2011
Peer-reviewed journal
I. A
Published, integrative source
2012
Peer-reviewed journal
I. A
Published, integrative source
2011
Peer-reviewed journal
I. A
Published, integrative source
Kowalenko, T., Cunningham, R., Sachs, C., Gore, R.,
Barata, I., Gates, D., Hargarten, S., Josephson, E.,
Kamat, S., Kerr, H., McClain, A.
Loomis, D., Wolf, S., Runyan, C., Marshall, S., and
Butts, J.
Gale, C., & Swain, N.
Magnavita, N.
Waschgler, K., Ruiz-Herhandez, J., Llor-Esteban, B.,
& Garcia-Izquierdo, M
Somes, J. et al.
Daffern, M., Day, A., & Cookson, A.
Florence, C., Shepherd, J., Brennan, L., Simon, T.
Who Commits Workplace
Violence?
•
•
•
•
Strangers
Customers
Co-workers
Domestic Partners
Who is Vulnerable?
Workers With Increased Vulnerability
Positions that:
Exchange money with the public
Deliver passengers, goods, or services
Work alone or in small groups, work late night or early
morning hours
Work in high-crime areas
Have extensive contact with the public… utility
workers
Types of Workplace Violence
•
•
•
•
Bullying
Threats
Harassment
Assaults
Behavioral Warning Signs
•
Threatening Behavior includes physical actions short of actual contact/injury. Examples:
moving closer aggressively, general oral or written threats to people or property, "You
better watch your back" or "I'll get you" as well as implicit threats "you'll be sorry" or
"this isn't over".
•
Violent Behavior includes any physical assault, with or without weapons; behavior that a
reasonable person would interpret as being potentially violent. Examples: throwing things,
pounding on a desk or door, or destroying property, or specific threats to inflict physical
harm [a threat to shoot a named individual].
•
Disruptive Behavior disturbs, interferes with or prevents normal work functions or
activities. Examples: yelling, using profanity, waving arms or fists, verbally abusing others.
Abuser -Workplace Violence
Warning Signs
•
•
•
•
•
Sudden change in behavior
Decrease in productivity
Sudden withdrawal from
friends and co-workers
Vandalizes or steals from co-workers
New usage of abusive language or
unacceptable behavior
Domestic Violence
Why does it occur at work?
• Abuser knows where victim can be
found
• Domestic violence is about control
• The victim isn’t under the immediate
control of the abuser
Policy
PURPOSE: to provide guidelines for management of harassment, threats and violence in the workplace.
POLICY STATEMENT:
1. Any employee who believes that they have been harassed, threatened, injured by another
person at work, or has knowledge of such behavior in the workplace must notify their
supervisor, Safety and Security, Human Resources, or Legal Services.
2. All workplace violence incidents must be reported to and reviewed by Safety and Security.
1. All complaints of harassment, threats, or violence will be investigated in a timely and
confidential manner.
Ineffective Rules, Policies and
Procedures
If the policies and procedures were not used,
what got in the way of their usefulness to the
staff?
• What rules are used to make decisions?
•
Select Actions
Redesign of the process?
• Minor change?
• Development of a new process?
Are the chosen interventions:
• Cheap
• Easy to do
• Likely to succeed
Actions cont.
• Can they be tested prior to implementation?
Do the people who own the process concur?
• Do those who reported the error concur?
• What could be the unintended consequences?
• Who needs the information on the process change?
•
Steps to Reduce Workplace
Violence
• Zero Tolerance Policy on workforce
violence
• Take action to minimize/eliminate
workplace violence
• Become familiar with and recognize
warning signs
Reducing and
Action Plan
Follow the Indianapolis Coalition for Patient
Safety - Workplace Violence Prevention
Workgroup Multicenter Recommendations for
improving patient and staff safety and reducing
workplace violence.
Step 1
Assessment:
• Workplace security survey tool
• Culture survey
Step 2
Reporting system
• Combine external and internal events
• Monitor trends and analyze incidents
• Collect departments, units, job titles, parties involved,
time of day
Step 3
Prevention
• Acknowledge intolerance of all workplace violence and
necessity to put measures in place to prevent it from
happening in the first place
• Raise awareness of the culture of acceptance and promote
the inportance of recognizing escalating situations and
intervening early
• Understand the barriers to an effective prevention program
• Flag medical record of previous offenders
Step 4
Policy
• Management commitment
• Code of conduct (professionalism)
• Lateral violence
• Active Shooter
• Restricted movement
• Incorporate plain language into all alerts
Step 5
Education
•
Elearning
•
Policy
•
Code of conduct
•
Risk factors that cause or contribute to assaults
•
Early recognition of escalating behavior or recognition of warning signs or
situations that may lead to assaults
•
Ways to prevent or diffuse volatile situations or aggressive behavior, manage
anger and appropriately use medications as chemical restrains, empathy training
•
Active shooter (real or threat of violence) scenario based training.
Step 6
Employer response following acts of violence
• Comprehensive treatment for employees who are victimized personally
or may be traumatized by witnessing a workplace violence incident
• Injured staff should receive prompt treatment and psychological
evaluation whenever an assault takes place, regardless of its severity
• Identify the barriers to swift, effective and safe response to an
occurrence
• Follow up with employees who have been assaulted. Delineate options;
employee assistance programs, change in environment/assignment, file
charges, etc. Provide follow up after this initial counseling to determine
outcome.
Employees ask What Can I Do?
Everyone Must Report ! See Something Say Something!
• Unsafe situations
• Security Infractions
• Suspicious Activity
• Policy Violations
• Domestic Violence
• Crimes In Progress
Report To…
•
•
•
•
•
Supervisor
Manager
Security
Human Resources
Police
Report To…
1. Report harassment, threats, or violence to manager, Safety and Security, Human Resources, or
Legal Services as appropriate to the situation.
2. Anonymous reporting may be done by contacting the following:
a. The Alert-line at 1-800-638-5071.
b. Safety and Scurity at 317-355-5296
c. The Network Employee Incident E-Report System through InComm.
Evaluation
• Measure the effectiveness not just the
implementation of the action.
• What are the unintended consequences?
Evaluation
Metrics the SAFE team will be monitoring,
awaiting team feedback:
CHNw existing metrics -1) security dept. risk assessment;
2) culture of safety survey; 3) security services survey.
Task-force recommendations: 1) Midas reports of WPV
to be added to Ginger Breech's work list to match security
reports.
Together we can reduce…
Violence in the Workplace
References:
Lannaco, J.D., Dixon, J., Whittemore, R. and Bower, L. (2011). Measurement and
monitoring of health care worker aggression exposure. Online Journal of Issues in
Nursing. 18(1). 1-20.
Kable, A., Guest, M., & McLeod, M. (2011). Organizational risk management of resistance
to care episodes in health facilities. Journal of Advanced Nursing. 1933-1943.
Hurvitz, K., & Simon, T.R. (2014). Healthy people 2020 objectives for violence prevention
and the role of nursing. The Online Journal of Issues in Nursing. 1-10.
King, K. (2014). Violence in the school setting: A school nurse perspective. The Online
Journal of Issues in Nursing. 19(1) 1-10.
Bruce, M.D., Nowlin, W.A. (2011). Workplace violence: awareness, prevention, and
response. Public personnel management. 40(4) 293-308.
References cont.
Hartley, D., Ridenour, M., Craine, J. & Costa, B. (2012). Workplace violence prevention for healthcare
workers – an online course. Rehabilitation Nursing. 37(4) 202-206
Kowalenko, T., Cunningham, R., Sachs, C., Gore, R., Barata, I., Gates, D., Hargarten, S., Josephson,
E., Kamat, S., Kerr, H., McClain, A. (2012). Violence: Recognition, management, and prevention. The
Journal of Emergency Medicine. 43(3) pp 523-531.
Loomis, D., Wolf, S., Runyan, C., Marshall, S., and Butts, J. (2001). Homicide on the job: Workplace
and community determinants. American Journal of Epidemiology. 154(5) 410-417.
Gale, C., & Swain, N. (2014). A communication skills intervention for community healthcare workers:
Perceived patient aggression is reduced. International Journal of Nursing Studies. 1-5.
Magnavita, N. (2014). Workpace violence and occupational stress in healthcare workers: A chickenand-egg situations: Results of a 6-year follow-up study. Journal of Nursing Scholarship. PP 1-11.
References cont.
Waschgler, K., Ruiz-Herhandez, J., Llor-Esteban, B., & Garcia-Izquierdo, M. (2012). Patients’
aggressive behaviorus towards nurses: development and psychometric properties of the hospital
aggressive behavior scale - users. Journal of Advanced Nursing. (18) 1418-1427.
Somes, J. et al. (2011). Controlling aggressive behavior in the geriatric patient. Journal of Emergency
Nursing. 37(3) 275-277.
Daffern, M., Day, A., & Cookson, A. (2012). Implications for the prevention of aggressive behavior
within psychiatric hospitals drawn from interpersonal communication theory. International Journal of
Offender Therapy and Comparative Criminology. 56(3) 401-419.
Florence, C., Shepherd, J., Brennan, L., Simon, T. (2011). Effectiveness of anonymised information
sharing and use in health service, police, and local government partnership for preventing violence
related injury: experimental study and time series analysis.
BMJ pp 8-9