Claire Bentley and Simon Lindsay review the NICE guidance in relation to violent and aggressive behaviour in people with mental health problems
Patients can present with very challenging and sometimes violent behaviour in many healthcare settings. There were 68,683 reported assaults on NHS staff in England between 2013 and 2014. 69% of these occurred in mental health or learning disability settings involving service users and the families or carers of service users. Most violent or aggressive incidents in mental health settings occur in inpatient units and most acute hospital assaults take place in emergency departments.
It is widely recognised that the recovery rate and wellbeing of all service users are directly affected by the way challenging behaviour is managed. In addition, violence against NHS staff has a huge impact on staff morale and wellbeing and it is also a significant drain on NHS resources in terms of absenteeism, extra security, personal injury claims and legal costs. Violence also affects public opinion about services and service users.
In May, the National Institute for Health and Care Excellence (NICE) updated its guidance on the short-term management of violent and aggressive behaviour in people with mental health problems.
The previous guidance related only to people age 16 and over in adult psychiatric settings and emergency settings. The updated guidance now covers a broader range of settings and new recommendations now also cover children and young people aged under 16, family members and carers.
The guidance covers the short term management of violence and physically threatening behaviour in:
Since the publication of the previous guidance in 2005, there have been significant advances in:
These issues are reflected in the new guidance.
The new guidance focusses on:
1. Training staff to anticipate and reduce the risk of violence and aggression
Staff who work in services in which restrictive interventions may be used should be trained in psychosocial methods to avoid or minimise such interventions. Training will give staff:
2. De-escalation. Staff should receive training in how to recognise early signs of irritation, agitation, understand the likely causes of aggression, both generally and for each service user and use techniques for distraction, calming and ways to encourage relaxation.
3. Managing aggression in emergency departments. If a mental health service user becomes aggressive they should not be excluded from the emergency department and seclusion should not be used. The situation should be regarded as a psychiatric emergency and the service user should be referred for a psychiatric assessment within 1 hour.
4. Managing aggression in community and primary care settings. Staff should be trained in methods of avoiding violence including anticipation, prevention, de-escalation and breakaway techniques without the use of restraint.
5. Managing violence and aggression in children and young people. Staff should be trained in a way specifically designed for those working with young people and programmes should include the use of psychosocial methods to avoid or minimise restrictive interventions wherever possible.
6. Physical restraint. If all other methods of preventing or calming the situation have failed, physical restraint can be used but only as a last resort. When using physical restraint the head and neck of the person should be supported and nothing should interfere with the person's breathing, circulation or ability to communicate. Such restraint should not be used for more than 15 minutes. Restraining a person on the floor should be avoided but if it is absolutely necessary the persons back should be on the ground. In the event that face down restraint is unavoidable, it should be for as short a time as possible.
7. Medication for promoting de-escalation. The guidance sets out best practice in relation to using pharmaceutical interventions to promote de-escalation.
8. Searching. Organisations should develop an operations policy on the searching of service users and carry out searches in accordance with policy.
It is not always possible to avoid violence but physical restraint should be used only as a last resort if all other methods of calming the situation have failed. It is essential that there are safe staffing levels, that staff are trained in how to de-escalate potentially violent situations and that there are clear systems in place if more assistance is necessary. If an incident takes place, always hold a post incident review and a formal external post-incident review should take place as soon as possible and no later than 72 hours after the incident.
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