Conflict Resolution Course Guidance Manual - Wirral University ...

Clinical Education & Development Team
Aggression Management Training
National NHS Syllabus
Conflict Resolution Course Guidance
Manual

FORWARD
In April 2004 the National Health Service (NHS) launched the biggest training initiative in its history,
with the aim of providing a minimum standard of training for all frontline staff (those who have contact
with patients and the general public) in the recognition, prevention and management of violence,
aggression and challenging behaviour.
Awareness training in conflict resolution will be delivered across the NHS to approximately seven
hundred thousand staff.
This conflict resolution training (CRT) course has been developed in order to assist NHS staff when
dealing with incidents that may have a potential for violence and aggression.
It is important that NHS staff have provisions in place for a safe and secure working environment, in
order to maintain excellence in standards for both personal and patient care.
CRT provides staff with recognition signs and prevention measures that relate to the escalation and
potential for violence and aggression.
INTRODUCTION
Wirral University Teaching Hospital (WUTH) NHS Foundation Trust’s Division of HR/OD have
provided this Workbook which is now your property to keep, as such it has been designed to both
compliment and assist in today’s National Syllabus Course on Conflict Resolution.
Today’s course is to provide you with an understanding of the nature of workplace conflict, and the
environmental and human factors that contribute to or influence it. Furthermore, the course will
provide an understanding of the impacts and effects of workplace conflict on individual attitudes,
behaviours and group performance both in and outside the workplace environment.
You will learn how are communication patterns and responses to conflict influence our ability to
resolve conflict and assist others. Through the use of communication models and the application of
contemporary approaches to addressing workplace conflict you will experience how others may
influence how we understand and act, and therefore ultimately how we deal with conflict.
Areas are provided throughout the Workbook for you to make your own notes, should you wish to do
so.
The workbook contains valuable information, which you should use throughout your National Health
Service career in order to assist you within your chosen workplace, in dealing with patients, visitors
and also colleagues.
Wirral University Teaching Hospital NHS Foundation Trust
Aggression Management Training
Clinical Education and Development Team
Clinical Excellence
HR/OD
2

COURSE OBJECTIVES
1. DEFINE THE COMMON CAUSES OF CONFLICT
2. DESCRIBE THE TWO FORMS OF COMMUNICATION
3. PROVIDE EXAMPLES OF HOW COMMUNICATION CAN BREAKDOWN
4. EXPLAIN HOW COMMUNICATION MODELS CAN ASSIST IN CONFLICT RESOLUTION
5. DESCRIBE PATTERNS OF BEHAVIOUR THAT MAY BE ENCOUNTERED DURING INTERARACTION
6. GIVE EXAMPLES OF IMPACT FACTORS
7. PROVIDE EXAMPLES OF WARNING AND DANGER SIGNS
8. DESCRIBE THE USE OF A REACTIONARY GAP WHEN DEALING WITH CONFLICT
9. DESCRIBE REASONABLE AND PROPORTIANATE FORCE APPLICABLE TO CONFLICT RESOLUTION
10. DESCRIBE DIFFERENT METHODS FOR DEALING WITH POSSIBLE SITUATIONS OF CONFLICT
CONTENTS
1. LEGAL DEFINITIONS OF CONFLICT
• DEFINITIONS OF VIOLENCE, AGGRESSION, CHALLENGING BEHAVIOUR
AND ZERO TOLERANCE
• COMMON LAW
• THE CRIMINAL LAW ACT 1974
• THE NHS ZERO TOLERANCE CAMPAIGN
• THE NHS COUNTER FRAUD SECURITY MANAGEMENT SERVICE
• THE HUMAN RIGHTS ACT 1998
2. COMMUNICATION
• COMPONENTS OF COMMUNICATION
• HOW WE COMMUNICATE
• IDENTIFYING NON VERBAL COMMUNICATION
(PICTURES AND CAPTIONS TO ASSIST COURSE CANDIDATES)
3. COMMUNICATION MODELS
• BETARIS BOX
• FIVE STEP APPEAL
• LEAPS
• CUDSA
4. REASONS FOR COMMUNICATION FAILURE
• TRANSMITTER TO RECEIVER INTERFERENCE
(MODEL FOR CANDIDATES TO PROVIDE REASONS TO WHY COMMUNICATION MAY FAIL)
• CULTURAL DIVERSITY
• PROXEMICS (DISTANCES)
• CONFLICT
• PERCEPTIONS (WHO’S TO BLAME)
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5. THE CONFLICT RESOLUTION MODEL
• PATTERNS OF BEHAVIOUR
• IMPACT FACTORS
• WARNING SIGNS
• DANGER SIGNS
• THE REACYIONARY GAP
• REASONABLE RESPONSE OPTIONS
6. SCENARIOS
7. CONCLUSION
8. REFERENCES AND FURTHER READING
9. ACKNOWLEDGEMENT
VIOLENCE - Defined as an physical act
Notes
LEGAL DEFINITIONS OF CONFLICT
AGGRESSION - Defined as an expressed emotion
Notes
CHALLENGING BEHAVIOUR - Any situation that denies access to or use of normal
everyday available facilities
Notes
ZERO TOLERANCE – non-acceptance of any form of verbal abuse, racial abuse,
threatening behaviour or use of violence and or aggression.
Notes
4

COMMON LAW – CRIMINAL LAW
COMMON LAW:
Common Law is each and every individual person’s right to protect him or her from being
attacked 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 attack must be reasonable to the
circumstances and proportionate to the actual or perceived threat.
Circumstances may justify a person striking first in defence of an attack.
Common Law also recognises people’s acceptance and use of force against each other as say a
sporting 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 proportionate to the threat.
• Force may be justified in the prevention of serious evil.
• Force can be used in defence of self or others.
Notes
SECTION THREE – CRIMINAL LAW ACT 1967:
“A person may use such force as is reasonable in the circumstances in the prevention of crime, or in
the effecting or assisting in the lawful arrest of offenders or suspected offenders or person’s
unlawfully at large”
Legislation on the reasonable use of force is the key facts that will be decided in each individual case
were force has been used for lawful reason.
Notes:
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THE NHS ZERO TOLERANCE CAMPAIGN
In October of 1999 the Minister of State for Health launched the NHS Zero Tolerance
Campaign in order to provide NHS staff with the knowledge and training in dealing with
violence and aggression, and also to provide a multi – agency approach to dealing with
offenders.
Notes:
THE NHS COUNTER FRAUD SECURITY MANAGEMENT SERVICE
In January 2003 the House of Commons ordered a report on Protecting NHS Hospital Staff.
The National Audit Office were commissioned to carry out the report, The N.A.O. produced the report
on the 24 th March 2003.
It states:
“From April 2003, the new Counter Fraud and Security Management Service, which was established
as a Special Health Authority in January 2003, will take over responsibility for all policy and
operational matters relating to the management of security in the NHS including leading the work on
reducing violence and aggression against NHS staff”
The C.F.S.M.S. policy guidelines state that all NHS Trusts should:
“Take a more strategic approach to induction and other Aggression Management training, based on
an annual training need analysis for all clinical and support staff”
Notes:
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THE HUMAN RIGHTS ACT 1998
Human Rights describe workplace violence as:
“Any incident where staff are abused, threatened or assaulted in circumstances related to their
work”
“This can involve an explicit (direct) or implicit (unspoken) challenge to a person’s safety, well-being
or health”
Notes:
COMPONENTS OF COMMUNICATION
7%
NVC's
Vocals
Spoken Word
8%
55%
NOTES:
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COMMUNICATION
COMMUNICATION
NON – VERBAL
(BODY LANGUAGE)
VERBAL
(SPOKEN)
NON - VERBAL COMMUNICATION (NVC)
Signals that each person sends through use of body language that is interpreted above spoken
words by one another
Notes:
IDENTIFYING NON – VERBAL COMMUNICATION
I’m not angry
or aggressive
Comments:
I’m listening
and I agree
Comments:
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I’m interested,
I want to help
Comments:
I’m fine I’m
not worried
Comments:
BETARIS BOX
MY My ATTITUDE Attitude My
YOUR BEHAVIOUR
MY BEHAVIOUR
YOUR ATTITUDE
Your attitude or emotions if perceived by another to be hostile will be displayed in your behaviour.
This will affect the attitude or emotions of the person you are communicating with, the affect will be
noticeable through their behaviour.
This will then further affect your attitude and behaviour and so on.
You must recognise this cycle and take responsibility for breaking it in order to move forward with
communication.
Notes:
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FIVE STEP APPEAL
A mediation system that can be used when a person’s resistance persists or increases during
communication
STEP ONE - SIMPLE APPEAL
Notes:
STEP TWO - REASONED APPEAL
Notes:
STEP THREE – PERSONAL APPEAL
Notes:
STEP FOUR - PRACTICAL APPEAL
Notes:
STEP FIVE – FINAL APPEAL
Notes:
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LEAPS
When applied in an appropriate manner the LEAPS communication model will provide a useful and
professional aid to resolving differing situations of conflict within the working environment.
Notes:
L
Notes:
E
Notes:
A
Notes:
P
Notes:
S
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CUDSA
CUDSA is a communication model that has been specifically designed for dealing with conflict
Notes
C
Notes
U
Notes
D
Notes
S
Notes
A
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REASONS FOR COMMUNICATION FAILURE
BODY POSTURE-Aggressive Stance, Facial Expression
VOICE- Tone, Volume
COMMUNICATION- Lack of Information (waiting times), Technical Terminology, Language
Differences, Stereotyping
ENVIRONMENT- Boredom – TV, Magazines, Literature, Under High Levels of Stress, Background
Noise, Exposed to Strange Environments, Affected by Alcohol/Drugs, Experiencing Pain. An
Enjoyment for Confrontation, Subject to Rapid Mood Swings, A History of Mental Disorder.
The itemised list is not exhaustive and each individual situation may present differing problems when
attempting to effect communication.
Understanding what situations may lead to communication failure will assist in the prevention of the
recognised causes of potential conflict.
Notes:
TRANSMITTER TO RECEIVER INTERFERENCE
During verbal or non- – verbal communication interference can take place between the person who
receives the message, and the person who is sending or transmitting the message.
MESSAGE
TRANSMITTER
RECEIVER
MESSAGE
Use the box below to list the various forms of interference that may prevent a transmitter message
from being correctly received:
Notes:
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CULTURAL DIVERSITY
The diversity within cultures is noticeable through the use of body language perceptions. Some
cultures will avoid direct eye contact as an individual sign of respect, while other cultures may
perceive this action as conflicting with anything verbal and therefore see the person as untruthful.
In some cultures the invasion of an individual’s personal space by a stranger would be viewed as a
totally inappropriate action, while other cultures would find it totally acceptable.
In greeting a person some cultures will place a kiss on the cheek followed by an embrace of the
person, while in other cultures a nod of the head or handshake would be viewed as appropriate.
Body language can therefore be perceived as different from that which is actually spoken or intended
to be said.
Use the box to provide examples:
Notes:
PROXEMICS - DISTANCES
Distances are used to allow us time to think and react, in certain conditions 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 exception to the above rule as
conditions dictate that we maintain close proximity in order to provide quality care or carry out a
necessary procedure.
INTIMATE ZONE
CLOSE FAMILY - PARTNER
LESS THAN 18 INCHES
PERSONAL ZONE
FRIENDS AND COLLEAGUES
18 INCHES TO 4 FOOT
SOCIAL ZONE
ALL OTHER PEOPLE
4 FOOT TO 12 FOOT
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Notes:
CONFLICT
It must be stressed that there is no singular 'right response' for any given situation. The decisions of
each and every person at an incident are governed by their individual perception at that time, as each
person may perceive the person's behaviour in a different way.
Because of the differing factors in relation to the behaviour of the person, each involved individual
may perceive the risk or threat to be either higher or lower than that of colleagues. The differing
physical abilities of each person involved in an incident will also have an impact on individual actions.
Therefore, the same set of circumstances may be met in many different individually perceived ways.
The aspects of communication that we have so far covered provide recognition of the different
elements of conflict and the knowledge required in order to avoid escalation of conflict, however,
when communication appears to be failing a person should consider other appropriate response
options within personal limitations and requirements.
Provide a list of other appropriate response options:
Notes:
PERCEPTIONS - WHO'S TO BLAME
Anne had been involved for three months with the voluntary drug support team, although Anne was
new to the work and unqualified she enjoyed it and wanted to be well regarded by the rest of the
team. The team was allocated to cover a large run down housing estate where unemployment,
violence, and drug abuse were common problems.
Tom, an experienced voluntary worker had himself been brought up in a similar disadvantaged
housing estate. Tom prided himself on his ability to 'tough out' even the most difficult, confrontational
situations, having been a team leader since the project had started he always encouraged his team
to adopt the same attitude as himself when dealing with confrontation.
Phil was a known long-term drug user. His behaviour had, over the years led to his removal from a
number of GP' lists, given his use of violence and intimidation to get his own way. Following another
recent incident over a drugs prescription, Phil was again in danger of being struck off from a surgery
practice by the GP.
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Worried about his imminent lack of support, Jane, the Community Psychiatric Nurse, who covered
the practice, wrote a brief note referring him to the Drug Support Team.
Upon receiving the note, Tom asked Anne to take the referral.
Prior to making a home visit, Anne casually mentioned the referral to her colleague Steve, Who
incidentally knew the family well, laughing; Steve suggested that she might find the visit a 'lively one!'
Having no information, which suggested particular difficulties and not wanting to appear anxious or
over concerned, Anne said nothing.
During the interview Phil became evasive about many aspects of his social history.
Concerned to undertake a competent first assessment, Anne persisted in her questioning although
Phil was clearly becoming agitated.
As Anne continued to question Phil, he became increasingly verbally abusive until, losing control
completely he picked up a large glass ashtray, and with considerable force struck Anne across the
face with it.
WHO IS TO BLAME
THE CONFLICT RESOLUTION MODEL
PERSON’S
BEHAVIOUR
IMPACT
FACTORS
REASONABLE
RESPONSE
OPTIONS
RESPONSE
OPTIONS
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PATTERNS OF BEHAVIOUR
This is a list showing a scale of possible behaviours that may be encountered during conflict.
A. Compliant behaviour
‣ The person is confrontational but complies with requests.
B. Verbal with gestures
‣ The person refuses to comply verbally or by their body language.
C. Passive behaviour
‣ The person sits or stands and will not move.
D. Active behaviour
‣ The person pulls or pushes but makes no attempt to strike out.
E. Aggressive behaviour
‣ The person physically attacks the member of staff.
F. Serious or Aggravated behaviour
‣ The person commits an assault, which presents the possibility of serious injury or death.
‣ This resistance may include the use of weapons.
‣ The person offending may exhibit these behaviours in a progressive pattern.
‣ It is not unusual for a person to jump several stages in the scale if the occasion demands it.
‣
Notes:
IMPACT FACTORS
The following is a list of possible Impact Factors:
• Relative sex, age, size of member of staff and person
• Relative strength of member of staff and person
• Relative skill level of member of staff and person
• Exhaustion or Injury
• Number of people involved
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• Special knowledge
• Alcohol or Drugs
• Mental state
• Weapons
• Perceived imminent danger
• Being in a position of perceived disadvantage
• Perception on obtaining help or assistance
Notes:
WARNING SIGNS
As a general rule people who are going to attack another person engage in actions known as
'Ritualised Combat'.
This may be because they fear being injured themselves.
Identifying these non-verbal signals may give staff a significant advantage.
They are:
♦ Direct prolonged eye contact
♦ Changed facial colour
♦ Head held back
♦ Maximises height by standing tall
♦ Kicking the ground
♦ Exaggerated movements near you especially with the hands
♦ Accelerated breathing rate
♦ Abrupt stopping and starting of nervous behaviour such as tapping of fingers
THIS IS NOT AN EXHAUSTIVE LIST.
In addition to the above behaviour the person may indicate that they perceive a particular member of
staff as being the problem, they will then direct any aggression toward that person.
This is known as 'Personal Identification' or personalisation of anger.
When this personal identification takes place it is usually a strong indication that the person may be
approaching the point of violence.
At this point staff should manage and maintain the 'Reactionary Gap'.
The 'reactionary gap' is the distance from the extremity of the member of staff's reach to the extremity
of the person's reach
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DANGER SIGNS
As the word danger implies the signs listed here have a much higher impact potential than the
warning signs.
WHEN THESE SIGNS OCCUR, ATTACK MAY BE IMMINENT, THEREFORE POSITIVE ACTION
IS CRUCIAL IN ORDER TO AVOID OR REDUCE THE RISK OF INJURY.
Neglecting or ignoring these signs MAY place a person at a serious disadvantage.
They are:
Fists clenching/unclenching
Changed facial colour
Lips tightening over teeth
Head dropping forward to protect throat
Eyebrows dropping to protect eyes
Hands moving to above the waist
Shoulders tensing
Stance changing to side on or fighting stance
Glancing at intended target areas
Lowering of entire body before launching an attack
THERE MAY BE OTHER SIGNS.
On witnessing these signs staff may opt for the following positive option:
‣ Disengaging in order to establish an effective reactionary gap.
The option may have both positive and negative aspects and the choice must be made on your
individual perceptions of the most appropriate response, taking into account all of the circumstances.
Notes:
REACTIONARY GAP
The distance we should use when dealing with conflict.
The distance between the extremity of your reach and the extremity of an aggressor’s reach
Notes:
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REASONABLE RESPONSE OPTION
Maintain self-control and:
Signal non aggressions
Request behaviour to stop
Be assertive
Use tactical communication
Remind the aggressor what they have to lose
Use diversionary techniques
Hands On - as a last resort
Notes:
SCENARIOS
The aspects of communication that we have so far covered provide recognition of the different
elements of conflict and the knowledge required in order to avoid escalation of conflict, however,
when communication appears to be failing a person should consider other appropriate response
options within personal limitations and requirements.
Provide a list of other appropriate response options:
Notes:
SECONDARY CARE NHS ACUTE TRUSTS
A patient arrives by ambulance to Accident and Emergency and is placed in a cubicle for treatment to
take place, when a group of friends arrive and demand to see him; they surround a member of staff
and begin shouting.
Notes:
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Upon arriving for duty, you see two male youths outside the entrance you must use to get to Accident
and Emergency.
As you get closer you notice that both males are bleeding from facial injuries, and that one male is
verbally abusing people as they try to get past him into the department.
Notes:
A patient who has waited two hours to see a doctor has approached a colleague and wants to know
how much longer he will have to wait.
The patient claims that he is being victimised, and deliberately left to wait by your colleague due to an
earlier encounter in which the conversation became heated, your colleague is offended by the
patient’s attitude and reacts by aggressively arguing back.
Notes:
A concerned father has gone to park his car after dropping both his wife and ill daughter off at the
entrance to Accident and Emergency.
Mother and daughter are told to take a seat in the waiting area and do so; they are immediately
harassed by a group of three teenage males.
The father arrives, angry to see his wife and daughter upset he say’s that if know one will do anything
about it then he will and threatens the teenagers with violence, they immediately respond by taunting
him.
Notes:
AMBULANCE TRUSTS
You arrive at a road traffic accident and having checked all those involved, you start to treat an
elderly female who is sat in the driving seat of one of the vehicles involved.
A younger female demands that you stop what you are doing and that you see to her friend in
another vehicle, she then attacks the elderly driver shouting that it was her fault in the first place.
Notes:
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A GP has called you to an elderly couple’s house to take a patient to hospital.
The husband is crying and refuses to listen to the doctor’s explanation that his wife needs urgent
medical care.
The husband stands between you and the patient with a raised walking stick and demands that you
leave.
Note:
You arrive outside a nightclub following an anonymous phone call, to find a man with severe head
injuries, a group of drunken friends don’t see the serious of his condition and claim he just needs to
sleep of the beer that he has drank.
One friend seems prepared to listen, but the others refuse to allow you to take him to hospital and tell
you to leave, your colleague goes to the ambulance and calls control.
The group surrounds you and become offensive and verbally aggressive.
Notes
Having just escorted a patient into hospital, you are returning alone to your vehicle at the main
entrance when you see a female searching inside the parked ambulance.
As you approach she turns to face you and you see she is holding a knife, she demands to know
where the drugs are kept and threatens self harm if you don’t tell her.
Notes:
CONCLUSION
‣ We have looked at how to recognise the different ways in which people may communicate.
‣ We have learnt how to recognise different warning and danger signals and what they mean.
‣ We have learnt about different communication models and methods to know when to use
them.
‣ We have looked at the importance of how different impact factors can affect behaviour.
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‣ We have studied distances and how they should be applied when dealing with conflict.
‣ We have discussed the law as it applies to reasonable and proportionate force.
‣ We have learnt to recognise that no two incident will be the same and will therefore be viewed
differently by each person involved.
WUTH NHS Foundation Trust thank you for your participation in today’s course, and sincerely hope
that you benefit from all the elements of what has been examined regarding conflict resolution.
Should you have any comments regarding this course or wish to participate in further aggression
management training, please contact:
Joe McLaughlin LSMS
Aggression Management Training
Clinical Education and Development Team
Clinical Excellence
Division of HR/OD
Clinical Skills Centre
Arrowe Park Hospital
Upton
Ext. 2779. Bleep 4471
REFERENCES AND FURTHER READING
• Criminal Law Act 1967 - Section 3: (1)
• Molan’s “Criminal/Common Law” - 10 Edition (1996/97)
• Baillie, D. “Practice” – Human Rights Act 1998
• CFSMS “A professional approach to managing security in the NHS”
• NAO “A safer place to work”
• Centrex Trainers Development Programme
• Argyle, M. “Bodily Communication” - Methuen (1975)
• Birdwhistell, R.L. “Human Communication”
• Clayton, P. “Body Language at Work” – Hamlyn (2002)
• Hall, E.T. “Silent Language and Proxemics” – Doubleday (1954)
• Axtell, R. “Gestures: Do’s and Taboos of Body Language” – John Wiley
•
ACKNOWLEDGEMENT
On behalf of Wirral University Teaching Hospital NHS Foundation Trust the course instructor both
acknowledges and thanks Christopher McCarthy from Merseyside Police for all his respected advice
and gratefully received assistance with the personal development of aggression management
training.
Joe McLaughlin
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