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Management Course Notes

In partnership with POC Management Limited.
In April 2004 the NaBonal Health Service (NHS) launched the
biggest training iniBaBve in its history, with the aim of
providing a minimum standard of training for all frontline sta
(those who have contact with paBents and the general public)
in the recogniBon, prevenBon and management of violence,
aggression and challenging behaviour.

Awareness training in conict resoluBon will be delivered

across the NHS to approximately seven hundred thousand

This conict resoluBon training (CRT) course has been

developed in order to assist NHS sta when dealing with
incidents that may have a potenBal for violence and

It is important that NHS sta have provisions in place for a

safe and secure working environment, in order to maintain
excellence in standards for both personal and paBent care.

CRT provides sta with recogniBon signs and prevenBon

measures that relate to the escalaBon and potenBal for
violence and aggression.

YOUR ORGANISATION NAME have provided this Workbook which is now
your property to keep, as such it has been designed to both compliment and
assist in todays NaBonal Syllabus Course on Conict ResoluBon.

Todays course is to provide you with an understanding of the nature of
workplace conict, and the environmental and human factors that
contribute to or inuence it. Furthermore, the course will provide an
understanding of the impacts and eects of workplace conict on individual
aVtudes, behaviours and group performance both in and outside the
workplace environment.

You will learn how our communicaBon paWerns and responses to conict
inuence our ability to resolve conict and assist others.

Through the use of communicaBon models and the applicaBon of
contemporary approaches to addressing workplace conict you will
experience how others may inuence how we understand and act, and
therefore ulBmately how we deal with conict.

Areas are provided throughout the Workbook for you to make your own
notes, should you wish to do so.

The workbook contains valuable informaBon, which you should use
throughout your NaBonal Health Service career in order to assist you within
your chosen workplace, in dealing with paBents, visitors and also colleagues.

Course ObjecBves
The aim of this course is to recognise dierent aspects of conict
that delegates may encounter and to understand and be aware of
dierent methods of resolving such conicts.

At the end of this course, delegates will be able to:

1. Describe common causes of conict.
2. Describe the two forms of communicaBon.
3. Give examples of how communicaBon can break down.
4. Explain three examples of communicaBon models that can
assist in conict resoluBon.
5. Describe paWerns of behaviour they may encounter during
dierent interacBons.
6. Give examples of the dierent warning and danger signs.
7. Give examples of impact factors.
8. Describe the use of distance when dealing with conict.
9. Explain the use of reasonable force as it applies to conict
10. Describe dierent methods for dealing with possible conict

This workbook has been designed to complement and assist with
todays course.

Legal DeniBons of Conict
VIOLENCE - Dened as a physical act

AGGRESSION - Dened as an expressed emoBon

CHALLENGING BEHAVIOUR - Any situaBon that denies access

to or use of normal everyday available faciliBes

ZERO TOLERANCE non-acceptance of any form of verbal

abuse, racial abuse, threatening behaviour or use of violence
and or aggression.

Common Law
Common Law gives each and every individual person a right to protect themselves from being
aIacked and also to act in the defence of others.

In order to be seen as lawful, any force that is used in defence of an aWack must be reasonable to
the circumstances and proporBonate to the actual or perceived threat. Circumstances may jusBfy a
person striking rst in defence of an aWack.

Common Law also recognises peoples acceptance and use of force against each other as say a
sporBng contest rather than a crime.

Common Law is therefore interpreted according to the following guidelines:

If force is used it must be reasonable in the circumstances.
Any force that is used must also be proporBonate to the threat.
Force may be jusBed in the prevenBon of serious evil.
Force can be used in defence of self and others.

Common Law also places responsibiliLes onto both the employer and the employee:

Duty of Employer: Employers have a duty of care to others. This means that they have to ensure
the safety of anyone who has access to their premises, as far as is reasonably pracBcable. This
means that there is a duty to ensure the safety of members of the public and to ensure that they are
not put at risk because of workplace violence.

Duty of Employee: Employees must take care for their own safety and the safety of others who may
be aected by their acBon or inacBon. The duty of employees does not in any way reduce the
responsibility of employers to comply with their duBes. As NHS sta, consideraBon must also be
given to the duty of care towards paBents.

Health & Safety At Work (etc.) Act 1974
Workplace violence is dened by the Health & Safety ExecuBve (HSE) as:

Any incident in which a person is;
(Verbally) Abused;
in circumstances relaLng to their work

There is no special law relaBng specically to workplace violence and the issue is dealt with under
the Health & Safety at Work (etc.) Act 1974 (HASAW) and under Common Law in the same way as
any other hazard that might be faced in the workplace.

HASAW Act 1974 lays duBes onto both employer and employee:
Duty of employers (SecLon 2 HASAW Act 1974)
To ensure the health, safety and welfare of their sta, as far as is reasonably pracBcable.
To do everything reasonable and pracBcable to eradicate or minimise the risks of harm from all
hazards to health, including violence.
Where a violent incident (a hazard) is foreseeable, an employer must idenBfy the nature and
extent of the hazard and devise measures that will provide a safe workplace and a safe system
of work.
This is done by undertaking risk assessments which allow employers to idenBfy hazards, how
severe they are and how likely they are to occur and, having done this, to put processes and
procedures in place to eliminate the risks or, at the very least, minimise them.

Duty of employees: (SecLon 7 HASAW Act 1974)
To ensure that they are aware of the risk assessment process.
To follow the processes and procedures put in place by their employer to ensure both their own
safety and that of their colleagues.

Criminal Law

A person may use such force as is reasonable in the
circumstances in the prevenBon of crime, or in the eecBng or
assisBng in the lawful arrest of oenders or suspected oenders
or persons unlawfully at large

s3 of the Criminal Law Act is always considered when there has
been a use of force for a lawful purpose. As with the Common
Law use of force, the word reasonable is used. What does this
really mean?

Make notes below on your interpretaBon of the word:

Other LegislaBon and

The Human Rights Act describes workplace violence as:

Any incident where sta are abused, threatened or assaulted
in circumstances related to their work

This can involve an explicit (direct) or implicit (unspoken)
challenge to a persons safety, well-being or health


In October of 1999 the Minister of State for Health launched
the NHS Zero Tolerance Campaign in order to provide NHS
sta with the knowledge and training in dealing with violence
and aggression, and also to provide a mulBagency approach
to dealing with oenders.

When considering a use of force, think PLAN. It helps you to ensure
your acBons fall within all of the legislaBve rules and guidance
surrounding its use. Knowledge of your basic powers under the law
is an essenBal part of formulaBng a response to a confrontaBonal

Using the minimal amount of force

to counter the aWack or threat. The
way to remember this is Dont use
a sledgehammer to crack a nut.
Is the use of force legal? For

example, is it covered by Common
Law or s3 of the Criminal Law Act
1967? If not, you must not use

Whenever you have used force,

even if you think nothing of it at the
Bme, you MUST make a record.
Within the NHS this should be done
by compleBng an incident form.
Is the use of force necessary? Could
N NECESSARY it be avoided by changing tacBcs, or
by removing yourself from the
situaBon. This is always the
preferred opBon.
Causes of Conict
There are several causes for conict that apply to the NHS arena:

Long waiBng Bmes
PaBents being refused entry to NHS sites that are locked
Slow or poor service (it does unfortunately happen).
Drunk or otherwise intoxicated paBents.
EmoBonal friends and relaBves visiBng paBents.
PaBents being asked for personal informaBon

Think of any examples of when you have had to deal with conict,
or list other factors that may lead to conict:

Dealing with Conict
PuVng factors such as long waiBng Bmes aside, how can you
prevent conict from occurring in the rst instance, or
deescalaBng the situaBon if it has occurred?

Use the box below to list methods that you would use to achieve

Risk ReducBon
Policy, procedure & guidance

Physical measures

Training is an important part of risk reducBon, which is why you
are taking part in this lesson!

Good Service

Basic elements of communicaBon
CommunicaBon is basically about geVng an idea from your head into another persons
head. This seems to be quite a simple process, but it can be very dicult to convey the
exact idea you want to get across to the other person.

The diculty comes when sending the message. You need to put it into words that the
other person can understand. This part of the message is called encoding.

You then actually send the message. This is typically made up of a combinaBon of
words, tone and non-verbal messages.

The other person receives the message and then has to decode it and work out your
original idea.


Misunderstandings occur for many reasons most of them are related to the fact that
each of us sees our world in a very dierent way. Consequently, when you encode your
message, you should try to make it as clear as possible, and most importantly, check the
receiver has understood the message as you intended.

Channels of CommunicaBon
In conversaBon the message is passed from one person to another through three

Words; The actual words spoken.

Tone; The intonaBon of the voice, i.e. the way the words are spoken
Non-Verbal; The stance, gestures and expressions used.

Channel Percentage
of meaning
Words (verbal) 7%
Tone (verbal) 38%
Non-Verbal CommunicaBon 55%
Many studies have been done about communicaBon and it is generally accepted
that in a face-to-face situaBon the receiver gains the meaning of the message as
shown above.

We can easily use body language which signals anger, frustraBon or aggression
without realising that we are doing so. It is important to be aware of our stance,
posture, eye contact and gestures to avoid giving the wrong signals.

Similarly, we need to monitor the body language of the person we are
communicaBng with for signs of aggression.

Blocks to CommunicaBon
A number of things can get in the way of eecBve communicaBon. These are
termed as blocks. A block is anything that can cause the communicaBon between
two people to break down or become dicult.

The environment
The environment in which you are
communicaBng can contain things that will
have an eect upon the success of the
communicaBon. They are usually obvious
although you do not always recognise the
eect they are having. They include:
Loud Noise
Lots of people crowding together
Physical discomfort feeling hot/cold,
hungry, Bred, etc.

EmoBon and Feelings

When you are feeling angry, frustrated, or
unhappy, the emoBons generated will have a
d i r e c t i m p a c t u p o n y o u r a b i l i t y t o
communicate eecBvely.

You are more likely to nd it dicult to hear
and correctly interpret words and tend to rely
much more on the tone and body language to
develop an understanding.

Blocks to CommunicaBon
Alcohol and Drugs
Alcohol has a depressant eect, which results
in slower reacBons to normal sBmuli. It tends
to reduce peoples inhibiBons and can make
them unreasonable and unpredictable. Drugs
have similar eects, and can also induce
hallucinaBons and act as a sBmulant.

When you are communicaBng with a person
who is under the inuence of alcohol, or drugs:

Talk slowly and calmly.
Adopt a non-aggressive
Maintain space between
them and you.

The greatest communicaBon diculty is the

unpredictability that can arise in people who
have taken drugs or are under the inuence of
alcohol, and the fact that their world be very

Blocks to CommunicaBon
Mental Health Problems
A person may behave in a certain way because of
mental health problems. Mental illness can take
many forms, and most people with mental health
problems will not be problemaBc or a threat to
you. It is important to be aware of the possibility
of dealing with a person suering from mental
health problems, as you may need to adapt the
way you communicate with them.

A person who is very unwell could become aggressive for any of the following reasons:

Fear and confusion (e.g. caused by noise or people) leading to desperaBon and the feeling
that the only way out is to ght.
Paranoia (feelings of being persecuted) may be directed towards certain groups in society,
for example NHS employees or Police Ocers, and could have been caused by bad
experiences with them in the past.
Anger at being provoked by other people.


dealing with people who have a mental illness:

Give them plenty of space.
Talk clearly and calmly to ensure they understand you.
Make sure they know you mean them no harm.
Be reassuring. Tell him or her what you are doing and
Keep your hands open and in full view.
Reduce distracLons that will alarm or confuse.
If you are with a colleague, only one of you should talk
to the person.
Blocks to CommunicaBon
People with disabiliBes
People with disabiliBes, be it a physical disability or a learning disability, experience the same
emoBons as other people and may become upset or angry when they are in an unfamiliar
environment, especially when in pain or discomfort.

Things to remember:

Speak clearly and do not over complicate language.
Be sure to signal non-aggression.
Consider the use of other communicaBon methods i.e. symbols/pictures, wriWen text if
hearing impaired etc.
One person should communicate calmly and clearly to avoid an audience or crowd that may
confuse or anger the person.
Reassure the person that you are trying to help them remember, to them you are a stranger.
Empathise and be sensiBve to their needs.
Do not touch the person unless invited. For example, if someone is lost and scared they may
want to hold onto you, whilst others may not welcome physical contact.

People from dierent cultures/language barriers

If you want to communicate eecBvely with someone who is from another cultural or ethical
background to yourself, then it is important to respect the values of that culture and try to
communicate in a way that embraces those values as much as possible.

Dierent cultures hold dierent values and aVtudes to dene the way they live and interact with
others. There are no rights or wrongs where culture is concerned one culture is not beWer
than another, just dierent.

When communicaBng consider:
Use of alternaBve methods of communicaBon i.e symbols, hand signals, using other speakers
of their language as interpreters etc.
When using hand signals and gestures, consider how it may be received. In come cultures,
they can mean something very dierent to your own.
Remember that there are ouen dierences in values that are dicult to accept for some

Blocks to CommunicaBon
Think about your area of work and consider the cultural and
diversity issues that might aect you when trying to
communicate with people.

Verbal communicaBon,
TransacBonal analysis
In the 1950s, a great deal of research was carried out by psychoanalysts, one of whom was
Eric Berne. He developed a theory that claimed we all have three basic ego states making
up our personality. He stated that each Bme we interact with people, our ego states aect
the way we act, interact or react in any situaBon. The ego states govern our personality
and behavioural paWerns. Having the skill to recognise these dierent ego states in others
may help you to respond appropriately when defusing conict situaBons.

It is important to note that this theory is not about the relaBonship between a parent and
their child, but about the way in which people of all ages adopt certain behaviours (ego
states) when interacBng with others.

The chart on the next page gives some examples of the comments and behaviours that are
typical of people in each ego state.

Verbal communicaBon,
TransacBonal analysis

brow Condescending
PARENT Ought to
PoinBng Judgemental

NURTURING Benevolent
smile Caring
PARENT Well done
Pat on the Permissive

When? Relaxed Open-minded
Where? AWenBve Interested

ADAPTED Vigorous Compliant

Please can I?
CHILD Ill try harder
head nodding Deant
Whiny voice Complaining

FREE CHILD Uninhibited Curious

I feel great! Laughing with Fun-loving
someone Spontaneous

IdenBfying Non-Verbal
Enter your comments below

CALM model of CommunicaBon
The following is a model of communicaBon that can be used to
avoid conict when communicaBng with others, and can also be
used to de-escalate situaBons that have turned into conict.

C the Issue

Communicate directly with

Address the person you are in conict

Listen to Hear what the .

Manage your Explore soluBons and decide

on a .

PEACE Model of CommunicaBon
Another model that can be used it PEACE. Discuss what each
leWer may represent and ll it in:

More commonly known as personal space or distances between people. Distances are used to
allow us Bme to think and react, in certain condiBons it would be natural for us to allow some
people closer, while we will keep others at a distance.

Performing your role within the working environment can be the excepBon to the above rule as
condiBons dictate that we maintain a close proximity in order to provide quality care or carry out a
necessary procedure.

A reacLonary gap is the name given to the distance we should try and maintain when dealing with
conict. The distance for this is just outside of the extremity of the aggressors reach, which
includes any weapons they may have!

Understanding how violence can lead to aggression

The highest level of

Violence and the other party is physically assaulted by the


At the next level, the

Aggression through voice level, tone, verbal and non-verbal

The next level is a deeper level of emoBon and
will be fairly
Anger at the other party but the individual will be less

and this forms the lowest level of arousal. It may
FrustraBon not be evident or obvious and the individual can
keep it very much under control

Signs of Aggression
You should always monitor the body language of the person you are dealing with, looking for
warning signs of the conict escalaBng into physical violence. Below are lists of warning signs,
showing anger and aggression, and danger signs, which suggests a physical aWack may be
imminent. In this case posiBve acBon is crucial in order to avoid the risk of injury.

Generally, a human will try to dehumanise their opponent before using physical violence,
and the danger signs below give an indicaBon that this is happening.

Warning Signs Danger Signs

Direct prolonged eye contact Fists clenching/unclenching

Changed facial colour

Head held back Lips t

Maximises Head dropping forward to protect the throat

Kicking the ground/stamping Eyebrows eyes

Exaggerated movements Hands moving to above the waist

Accelerated breathing rate

Abrupt stopping and starBng of nervous Stance changing to side on or ghBng stance
behaviour such as tapping of ngers
Glancing at

Lowering of enBre body before launching


Reasonable response to aggression
When dealing with a person displaying the warning signs discussed, you must ensure
that you maintain your self-control, and:

Signal non-aggressive body language (PALMS)

Request a change of their behaviour
Be asserBve
Use tacBcal communicaBon
Remind aggressor what they have to lose
Use diversionary techniques
Only as a last resort, when all other opBons have been exhausted,
should you resort to laying hands on to the person.

Other consideraBons to make regarding your response are:

Do not be drawn into arguments

Do not retaliate to abusive or threatening language
Remember the 4 As
Show empathy and acBvely listen

Do not get
Angry Manage buse A

4 As
Maintain a
Be sserBve
Signalling non-aggression
The importance of signalling non-aggression:

This is one of the most important areas to understand when defusing a situaBon where people
are becoming aggressive.
The more emoBonal someone is becoming the less they can hear and raBonalise what is being
said to them. However, they will insLncLvely respond to body language and tone of voice.
Aggressive signals are easy to spot. As someone becomes angrier they tend to turn square on,
stare xedly and clench their sts. When they are about to resort to actual violence, they will
then move to avoid eye contact, drop their chin, and dehumanise you.
To signal that you are not aggressive, do the opposite. Turn slightly to one side, one shoulder
turned away, display open palms, and establish and maintain a normal eye contact.

The AVtude and Behaviour Cycle

Your aVtude or emoBons if perceived by another to be hosBle will be displayed in

your behaviour. This will aect the aVtude or emoBons of the person you are
communicaBng with, the aect will be noBceable through their behaviour.
This will then further aect your aVtude and behaviour, and so on.

You must recognise this cycle and take responsibility for breaking it in order to
move forward with communicaBon.
Avoiding Conict
Always react in a posiLve way, never let your feelings show.
There is a constant need to carry out a dynamic risk assessment when dealing with conict. The
stages of this can be remembered using the SAFER and POP acronyms, shown below:

Do not rush in, think rst.

IdenBfy dangers using POP
If necessary, you are part of a team
Take your chosen course of acBon, but
Respond be prepared to change. Constantly re-


Impact Factors
Impact factors are the consideraBons we must idenBfy when dealing with any conict like
carrying out a mini risk assessment of the situaBon we are in. You must assess your impact
factors and include what you consider the other persons impact factors to be.

For example: The person you are talking to is tall, appears t and healthy and is well-built.
He is becoming agitated and louder. You are much shorter, lighter in build and have a wrist
injury. You have knowledge of marBal arts. If the situaBon became physical, could you deal
with it? Are you the best person to deal with this man?

Now consider that this person is on crutches with a plaster cast on his arm
and leg. Have the impact factors changed? Could you now deal with this

Avoiding Conict Open PALMS

Allow exit routes, do

P not block them in.

Display a posiBve and

AVtude helpful aVtude.

Normal contact,
L and listen acBve .

Maintain a comfortable
Make distance.

Shoulders relaxed and

Stance turned away.

Fight or Flight

This is the name given to a to a danger or
threat. It occurs when someone is frightened or angry.
It is the bodys way of
for signicant muscular eort, by releasing a massive
amount of adrenaline. It can happen for the following

Their personal space is invaded.
They feel threatened.
They have no means of escape

It is important to recognise the eects the adrenaline
rush may have

non-aggressive body language, and do not block their
exits, will help to reduce the risk of this happening.

Exit strategies
Despite all of our best eorts, someBmes conict cannot be resolved, and the
situaBon leads to a point where for your own safety you need to take acBon to
remove yourself from the incident.

GeVng away from a high risk situaBon:
When you are in a situaBon which you recognise as high risk, it may be
necessary for you to exit from the situaBon. This will take you out of
immediate danger and allow you to think raBonally about how to deal with
the incident.
People ouen nd it dicult to get out of such situaBons without losing face
and, therefore, stay longer that it is safe to do so.
An exit strategy is a pre-prepared way of gehng yourself away from a
dicult situaLon.

Have a ready made reason to exit:
An exit strategy is quite simply a sensible reason for leaving the
situaBon you are in. You need to have a reason ready so that it
comes to mind quickly. It needs to be something that will not make
the situaBon worse.
It could be something like Im afraid I cant make that decision, Ill
have to go and speak with my manager about it.

Discuss with the class some examples of exit strategies that could apply
to your parBcular area of work:

Recording Incidents
ReporBng all incidents, however minor or everyday they may seem, is essenBal in order
for the NHS to protect sta against risk as:

The NHS relies upon quality informaBon to establish eecBve strategies and
ReporBng incidents of workplace violence is a duty under Health and Safety

Under reporBng is chronic throughout many organisaBons, and the NHS is no excepBon.
There are a variety of reasons for this, but the main factors are that people feel there is a
lengthy and complicated reporBng procedure, and there is a lack of understanding about
what should be reported.

For the Cluster, the DaLx reporBng system is designed to promote reporBng based
upon the two reasons above. It is a structured, simple form to ll out, which should not
take long. Any incident which felt out of the norm should be reported.

Ensure that you know how to access this system. It can ouen be found via a link from
the Intranet page.

There are guides available to help you use the system, as well as sta members such as
your LSMS, or the Risk Team, who can also assist. An example of the guide can be

When compleBng any incident form, ensure that you give precise details, including:
Facts about yourself and any other parLes involved
Background informaLon
DescripLon of behaviour
Level of force used

Simply staBng that the person was abusive or violent is not enough, use specics,
including the exact words and movements involved.

Knowledge Check
1. Non verbal communicaLon is a key element of how we communicate, but what
percentage of our message does it form?
7% 38% 55% 93%
2. Which of these could lead to a breakdown in communicaLon?
Stress Cultural Dierences Alcohol All of these

3. What are the missing words from SecLon 2 of the HASAW Act 1974: It shall be the
duty of every employer to ensure as far as reasonably pracLcable the health,
at work of all his employees.
Safety and welfare Safety and wellbeing Security and welfare Security and wellbeing

4. What does the S stand for in the SAFER risk assessment model?
Safety Send for help Security Step back
5. Which ONE of the following is the MOST appropriate non-verbal behaviour used to
confront unacceptable behaviour?
Open Hands Loud Voice Strong eye contact Head juVng forward
6. To defend yourself, the law states that you can use as much force as is in
the circumstances.
RaBonal Responsible Respectable Reasonable
7. The 3 ego states in transacLonal analysis are Parent, , Child?
Carer Grown-up Adult Mature

8. According to Betaris Box, my ahtude aects what?

My Bmekeeping My behaviour My driving My mood

9. Which of the ve dierent ego states is this comment indicaLve of: Can we try to
avoid any misunderstanding?
Adult CriBcal Parent Adapted Child Free Child

10. From the PALMS model of avoiding conict, what does the M represent?

Make space Move out of the Mature Manage

We have learnt how to:

Describe common causes of conict.

Describe the two forms of communicaBon.
Give examples of how communicaBon can break down.
Explain three examples of communicaBon models that can assist in conict
Describe paWerns of behaviour we may encounter during dierent
Give examples of the dierent warning and danger signs.
Give examples of impact factors.
Describe the use of distance when dealing with conict.
Explain the use of reasonable force as it applies to conict resoluBon.
Describe dierent methods for dealing with possible conict situaBons.

As a nal exercise, go back to the start of the workbook, and look at the
personal example you gave of dealing with conict. Would you change the way
you dealt with the situaBon with the knowledge you have gained today? How?

We hope you have enjoyed the course, and gained new skills and
knowledge that you can apply to your work environment and even
your home life. Thank you for your parBcipaBon today.
References & Further reading
NHS Security Management Service: Conict ResoluBon
Training ImplemenBng the NaBonal Syllabus SMS Ref:
Your local NHS Managing Violence & Aggression in the
Workplace Policy
A safer place to work: ProtecBng NHS hospital and
ambulance sta from violence and aggression.
NHS CFSMS: A professional approach to managing security
in the NHS. hWp://
NHS SMS: Conict ResoluBon training workbook

Created by John Lambert, Senior Consultant & Trainer - POC Management Limited.