promoting safe & therapeutic services preventing and ...€¦ · management of abuse,...

This policy document is subject to South London and Maudsley copyright. Unless expressly indicated on the material contrary, it may be reproduced free of charge in any format or medium, provided it is reproduced accurately and not used in a misleading manner or sold for profit. Where this document is republished or copied to others, you must identify the source of the material and acknowledge the copyright status.

Promoting Safe and Therapeutic Services - Preventin g and Managing Violence and Aggression Policy, Version 12.0 - Sept ember 2011

PROMOTING SAFE & THERAPEUTIC SERVICES

PREVENTING AND MANAGING VIOLENCE AND AGGRESSION POLICY

Version: 12.0

Ratified By: Service Quality Executive

Date Ratified: 7th September 2011

Date Policy Comes Into Effect: 7th September 2011

Author: Natalie Hammond, PSTS Nurse Consultant

Responsible Director: Director of Nursing and Education

Responsible Committee: Preventing and Managing Violence and Aggression Committee [PMVAC]

Target Audience: All Staff

Review Date: September 2014

Equality Impact Assessment Assessor: Natalie Hammond Date: 22/08/2011

HRA Impact Assessment Assessor: Cliff Bean Date: 29/08/2011

Promoting Safe and Therapeutic Services - Preventin g and Managing Page 1 of 37 41 Violence and Aggression Policy, Version 12.0 - September 2011

Document History

Version Control

Version No.

Date Summary of Changes Major (must go to an exec meeting) or minor changes

Author

1 March 2002

C. Adams

2 July 2005 G. Miller

11.0 September 2008

New monitoring section. Revised ‘responsibilities’

Major N. Hammond, PSTS Nurse Consultant

12.00 September 2011

Full policy review. Major N. Hammond, PSTS Nurse Consultant

Consultation

Stakeholder/Committee/ Group Consulted

Date Changes Made as a Result of Consultation

PMVAC 30/05 Major changes to both structure and content.

Plan for Dissemination of Policy

Audience(s) Dissemination Method Paper or

Electronic

Person Responsible

All staff A group email will be sent alerting staff to the policy and instructing them to download for local use

Electronic Natalie Hammond, PSTS Nurse Consultant

Promoting Safe and Therapeutic Services - Preventin g and Managing Page 2 of 38 Violence and Aggression Policy, Version 12.0 - Sept ember 2011

Contents

Section Page

1. INTRODUCTION 3

2. DEFINITIONS 4

3. PURPOSE AND SCOPE OF THE POLICY 5

4. ROLES AND RESPONSIBILITIES 6

5. LONE WORKING 9

6. REQUIREMENT TO UNDERTAKE APPROPRIATE RISK ASSESSMENTS

9

7. PREVENTION OF AGGRESSION AND VIOLENCE 10

8. RAPID TRANQUILISATION, PHYSICAL INTERVENTION, SECLUSION AND OBSERVATION

11

9. CALLS FOR ASSISTANCE 14

10. POST INCIDENT MANAGEMENT FOR STAFF 15

11. PHYSICAL CARE AND OBSERVATION OF THE SERVICE USER – RISKS IN RESTRAINT

16

12. AFTER THE INCIDENT REVIEW 18

13. INCIDENT REPORTING AND RECORDING 19

14. SPECIAL SITUATIONS AND CONSIDERATIONS 19

15. TRAINING 21

16. EXPECTATIONS OF SERVICE USERS/ CARERS/ SERVICE USER REPRESENTATIVES/ VISITORS

21

17. MONITORING COMPLIANCE 21

18. ASSOCIATED DOCUMENTATION 22

19. REFERENCES 22

20. FREEDOM OF INFORMATION ACT 2000 23

APPENDICES

APPENDIX 1: CAUSES OF VIOLENCE AND AGGRESSION 24

APPENDIX 2: PREVENTION OF AGGRESSION AND VIOLENCE 25

APPENDIX 3: STAFF PARTICIPATION IN RESTRAINT 27

APPENDIX 4: A GUIDE TO THE INITIAL RESPONSE FOR HOS TAGE, SIEGE, BARRICADE OR SUICIDE INTERVE NTION INCIDENTS

30

APPENDIX 5: EQUALITY IMPACT ASSESSMENT 32

APPENDIX 6: HUMAN RIGHTS ACT ASSESSMENT 34

APPENDIX 7: CHECKLIST FOR THE REVIEW AND APPROVAL O F A POLICY

36


1. INTRODUCTION

1.1 Policy background – ‘Promoting safer and therapeutic services’

Violence in healthcare has been subject to a number of national initiatives aimed at reducing the risk and ensuring appropriate support for staff and service users. The Trust is engaged in the development of best practice in this area to ensure safe and therapeutic services for service users, staff and visitors and believes that the majority of service users with mental health conditions or learning disabilities are not violent, nor should they ever be perceived as such. The causes of violence within these settings are complex and can be attributed to a range of factors – environmental and cultural, for example. (NHS SMS, 2005) However, it is clear that violence is a major concern for the safety of service users, staff and visitors.

‘.... patients feel unsafe on wards, yet the purpose of inpatient care is to provide a safe and therapeutic environment’ (NPSA, 2006).

Violence and aggression, whilst a part of the human condition is not inevitable in health settings and actions staff take, or omit to take, may markedly influence the frequency and severity of incidents. Whilst ordinarily no incident of violence is acceptable from one person to another, within our workplace we can do much to prevent and reduce it. The Trust promotes the Safer and Therapeutic Services initiative. This means it does not expect or accept violence or the threat of it, as an inevitable part of daily routine. This policy is part of an overall approach aimed at cultivating a culture where the prevention and reduction of violence is the aim. This is achieved by partnerships at all levels within and outside this organisation. The NICE Clinical Guideline 25, (2005) ‘Short term management of disturbed and violent behaviours in psychiatric In Patient settings and Emergency Departments’ sets out a number of recommendations for the positive management of violence, which underpins this policy. Recommendations are specific to:

• Prediction – Risk factors/antecedents and warning signs/risk assessment/ searching

• Prevention – De-escalation/observation. • Interventions for the management of disturbed/violent behaviour – Rapid

tranquillisation/physical intervention/seclusion • Carrying out post-incident review • Service users with varying special requirements – disabilities, pregnancy etc • Training Provision and Content

The Guideline can be viewed at http://www.nice.org.uk/guidance 1.2 The Care Quality Commission - CQC

The Trust upholds the essential CQC standards in providing quality and safety ensuring that people who use our services are protected from, or the risk of aggression and violence and their human rights are respected and upheld. The Trusts policy requires all staff to:

• Ensure that the use of restraint is always appropriate, proportional and reasonable and justifiable to that individual.


• Only de-escalate or restrain in a way that is respectful to dignity and where possible respects the preferences of people who use services.

• Understand how diversity, beliefs and values may influence the identification, prevention and response to aggression and violence.

• Protect others from the negative effect of any behaviour by people who use services.

• Only use deprivation of liberty safeguards when it is in the best interest and in accordance with the Mental Capacity Act 2005. (CQC , 2009)

1.3 NHS Protect

NHS Protect has a national responsibility for tackling crime (inclusive of abuse, agression and violence) within the NHS. The aim is to protect NHS staff and resources from activities that would otherwise undermine their effectiveness and their ability to meet the needs of patients and professionals, its guidance on the prevention and management of abuse, aggression and violence is embedded within the Trusts policies and guidance (see Prosecution Protocol 2011).

• to educate and inform those who work for or use the NHS about crime in the health service and how to tackle it

• to prevent and deter crime in the NHS by removing opportunities for it to occur or to re-occur

• to hold to account those who have committed crime against the NHS by detecting and prosecuting offenders and seeking redress where viable.

(NHS Protect 2011)

1.4 NHS Litigation Authority [NHSLA]

The NHSLA handles civil legal liability claims and works to improve risk management practices in the NHS in England. The NHSLA has an active risk management programme to help raise standards of care in the NHS through Risk Management Standards for mental health and foundation trusts to reduce the number of incidents leading to claims Risk Management Standards include an assessment of the policies providers have in place covering violence and aggression in respect of good risk management, governance and assurance.

1.5 Health & Safety Executive

Health & Safety Executive enforces workplace health, safety and welfare legislation, underpinned by the Health and Safety at Work etc Act 1974 and the Management of Health and Safety at Work Regulations 1999. This statutory obligation underpins the prevention, reporting and management of incidents of aggression and violence.

2.0 DEFINITIONS

For the purposes of this policy, the Trust recognises the following definition of work related violence from the Health & Safety Executive: ‘Any incident, in which a person is abused, threatened or assaulted in circumstances relating to their work. This can include verbal abuse or threats as well as physical attacks.’

The NHS definitions of physical and non-physical assault, used for incident reporting purposes, are as below:


Physical assault

‘The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort.’ Non-physical assault

‘The use of inappropriate words or behaviour causing distress and/or constituting harassment.’

Incidence

Approximately 50% of all adverse incidences reported across the Trust are incidences of violence or aggression. On average 80% of violence and aggression is directed towards staff and 20% is directed at patients.

3. PURPOSE AND SCOPE OF THE POLICY

The purpose of this policy is to set out the arrangements for managing the risks associated with the prevention and management of aggression and violence, clinical settings. It also outlines the Trust values and strategic aims for promoting safe and therapeutic services.

3.1 Trust Values

‘Everything we do is to improve the experience of people using our services and to promote mental health and well-being for all’ (South London & Maudsley NHS Foundation Trust)

The Trusts Core Value above is underpinned by a key priority to provide high quality, safe and innovative clinical care and treatment. (SLAM Quality Strategy 2011-2014). The Trust recognises and accepts its responsibility in accordance with relevant legislation and best practice guidance. Accordingly, this policy is specifically aimed at reducing the risk of violence, whether verbal or physical to service users, staff and others.

3.2 The Trust Strategic Aim is to: reduce incidences of violence by 25% by 2015.

In implementing this policy, the Trust aims to: • To raise awareness amongst all staff, service users and others, about the

potential for work related violence and aggression and factors which may contribute to disturbed behaviour, and the need for: effective environmental and clinical risk assessment and risk management; and, incident reporting to support organisational learning and the implementation of effective risk reduction strategies.

• To promote a culture that focuses on early recognition, prevention and de-escalation of potential violence and aggression, using techniques that minimise the risk of its recurrence.

The Trust also aims to provide a care environment:

• Where staff and services demonstrate and encourage respect for racial and cultural diversity and recognise the need for privacy and dignity

• Where staff understand factors which may contribute to disturbed behaviour • Where service users are engaged by staff and kept fully informed in a way they

can understand, of what is happening and why. • Where a therapeutic relationship is developed between each service user and a

key worker • Which promotes a non-punitive, legal and skilled approach with any physical

interventions used as a last resort


• Where care is given to all service users to full potential, within the bounds of safety, even where aggression may have taken place.

• Where physical interventions are performed using only the force required to contain an incident and by appropriately trained staff

Organisationally the Trust aims to:

� Create a pro-security culture amongst staff, service users and the public where the responsibility for security is accepted by all.

� Further raise awareness and encourage all staff to report violent or other security incidents when they occur.

� Promote a learning environment where staff are routinely involved in the review of incidents in order to learn lessons and continuously improve practice.

3.3 Staff values

All staff should show respect and courtesy and involve service users in developing and evaluating practice and services. With regard to this policy, prevention is seen as paramount and service users’ perceptions of respectfulness are very important in this, as is the belief that the service user genuinely has influence in what is happening to them and some sense of control over their life. Service users who feel powerless and devalued are more likely to respond with aggression, and staff should carefully address the issue of not making people feel devalued, powerless or disrespected. Service users should: be given timely information; not made to wait undue periods; be treated with respect and courtesy; and, be enabled to make decisions within the current limits of their mental health condition and capacity.

3.4 Consultation & Communication with Stakeholders

Service user and Carer groups are consulted about and contribute to the development of policy and the delivery of training on the prevention and management of work related violence and aggression. The service users’ experience is an important component that will help staff to consider and reflect on what it might be like to receive the services they provide.

4. ROLES AND RESPONSIBILITIES 4.1 Chief Executive

The Chief Executive is ultimately accountable for the safety and welfare of staff, ensuring that systems and support are embedded within the Trust protecting staff from violence and aggression.

4.2 The Trust Board

The Trust Board recognise and accept its responsibility for the prevention and management of aggression and violence in accordance with relevant legislation and national best practice guidelines.

The Trust Board will take a lead within the organisation and ensure a strategic approach to promoting a Safe & Therapeutic organisation. The Trust Board have the responsibility to ensure that, in line with other comparable business decisions, the resources and support necessary to adequately implement and maintain the policy are made available.


The Trust Board will ensure that there are systems in place; • for the review of violent incidents and authorise staff to make changes as a

result of these reviews. (refer to Incident Policy) • for staff to receive training and refresher courses. The Trust recognises that

the provision of training in the prevention and management of aggression and violence is essential in ensuring that the policy can be implemented successfully. (refer to Education & Training Policy)

• to ensure adherence to health & safety legislation pertaining to the prevention and management of work-related violence.

• that ensure adequate staffing to prevent or manage violent incidents. • to provide support for service users, staff and others who have been involved

in violence. (refer to Incident Policy, Prosecution Protocol, Occupational Health policy, Being Open Policy)

4.3 Directors, Professional Heads and Senior Managers

Senior Trust staff additionally must: • Ensure structures within management systems allow concerns to be reported

and dealt with quickly. • Respond in a timely fashion when requests for advice or action are required. • Are compliant to the legal responsibilities defined by the Heath and Safety at

work act, Human Rights Act and Criminal Law Act. • Ensure information and support structures are in place for service users and

carers • Ensure support structures are in place for staff • Promote information sharing for the purposes of risk reduction that is compliant

with legislation

4.4 Line Managers

Line Managers are required to have systems in place to ensure; • All permanent clinical staff on in-patient units are PSTS trained [5 day]. • Risk assessments relating to potential violence and aggression are under taken,

those include risk assessment of the environment as well as risk assessments of individuals who use the service.

• Ensure a regular Health and Safety risk assessment should be carried out together with implementing a preventative strategy to ensure that all practical measures are taken to avoid violent incidents. Appropriate action must be taken when significant risks are identified. Risk assessments must be reviewed where there is reason to believe that they may no longer be valid, i.e. when there has been a violent incident that has resulted in harm. All Risk assessments must be reviewed regularly.

• Appropriate risk reduction measures are implemented and are inline with NICE Guidance 25, this policy, and the training needs identified.

• Incidents of violence, aggression and threats including near misses are reported, investigated and monitored in accordance with DATIX reporting and the Incident Policy.

• Reports of intentional physical assault on staff members are made to the police and there is an MDT response and debrief with the team and patient.

• Staff under their management, receive required training within the specified time frames.

• Systems are in place to implement practices taught in training sessions • The alarm system and response to alarm calls is safe and consistent • Staffing levels are robust enough to cover (potential) violence.


• Communication systems allow appropriate individuals to be informed of risks associated with service users.

• Damage to the environment is dealt with promptly. • Systems for reducing violence such as whereabouts books/boards, mobile

phones and panic alarms are checked regularly. • De-Briefing and other post incident support take place facilitated by suitably

trained and/or experienced individuals. • Learning from previous events is incorporated into practice. • Have an awareness of the dynamics occurring within the team/service, and the

effect of this on the potential for violence, intervening to effect change where this necessary.

• Ensure relevant policies and procedures are available and known to staff. • Are aware of the legal, ethical and professional aspects involved in the

therapeutic management of violence? • Aware of and linked with the available staff services, for example occupational

health, staff support to ensure prompt referral when required • Are aware of and facilitate access to financial support for staff in consultation with

human resources e.g. Temporary Injury Benefits, when necessary. 4.5 Employee Responsibility

Every member of staff has a responsibility for ensu ring his/her own safety and that of others and assisting as necessary.

• All employees are required to take responsibility for health and safety issues within the work environment, alerting line managers to potential hazards, including the risk of violence.

• All employees have a responsibility to prevent violence. However, some professional groups and managers have specific accountability and responsibility in the prevention and management of violence.

• Monitoring of incidents of aggression and violence is essential, and all staff members have a responsibility to ensure accurate and timely reporting of incidents as per the Incident Policy.

• All staff have a responsibility to contribute to a culture of respect, encouraging all to express any concerns about the safety of the care environment.

• Good communication underpins all aspects of enhancing safety. All staff must familiarise themselves with local communication systems and as a matter of priority.

• All staff should book, plan and undertake the appropriate training at the specified time intervals.

• No member of staff, finding themselves alone faced with a potentially violent incident should attempt physical intervention before adequate assistance has been obtained. The exception would be a situation where such inaction would endanger themselves or others and, there is no opportunity to remove themselves from the situation. Staff must weigh the impact of removing themselves from the immediate vicinity of an aggressor with their duty to care and therefore protect service users by taking appropriate steps to minimise risks to them.

• Additional assistance should be sought as soon as possible in an emergency situation. Staff should not wait to report the incident to the person in charge before calling assistance.

• All incidents of actual or potential violence including threats must be reported and documented as per local procedure as soon as possible.

• Staff must inform other members of the team of their whereabouts at all times.


• If a member of staff does not feel able to carry out their role in emergencies he/she must discuss this with their Line Manager as soon as possible to allow appropriate steps to be taken.

• Joint clinical risk assessments are good practice and should be completed in all instances.

• Any interventions utilised must be necessary and proportionate to the harm they are intended to prevent.

• Clinical staff are responsible for providing service users with care, support, information in a timely and responsive manner that will minimise the risk of aggression and / or violence. This should include a timely response to any requests or complaints.

5. LONE WORKING

Working alone can present unique health and safety problems. The Health and Safety at Work etc Act 1974 places a duty on the Trust to ensure the health, safety and welfare of its staff. There is a separate Trust policy and guidance regarding lone working which should be read in conjunction with this policy (see Trust Policy and Guidance on Lone Working 2011).

6. REQUIREMENT TO UNDERTAKE APPROPRIATE RISK ASSES SMENTS

There are different risk assessments that are required in order to identify factors which could indicate an increased risk of incidents of violence and aggression and an increased risk of harm as a result of violence and aggression. Risk assessment is an ongoing and dynamic process that should reflect changing environmental and service user needs.

6.1 Risk assessment of the individual patient

Clinical risk assessment of individual patients is the single most important element of risk assessment in the prevention of violence and aggression. Risk assessments should always occur when a service user first comes into contact with mental health services and within 72 hours of admission. Risk assessments should be reviewed; at CPA meetings, on each occasion where the risk might have changed significantly, whenever a service user is transferred from service to service, when there are significant changes to circumstances, or following an incident where risk behaviour has been reported, including incidents of violence and serious aggression. A risk assessment is only as good as the information on which it is based. Risk assessments should take into account all history available. It is recognised that often staff may have to rely on incomplete or unreliable information, but background materials should always be sought. Staff are advised to record sources of information, indicating where information is lacking and where records are unavailable.. A brief risk screen is to be completed for all patients. A full risk screen is to be completed where ‘significant risk’ is ticked in the brief risk screen. A full risk screen ‘case formulation/summary of risk’ box is to be completed. Crisis and contingency plans are to be completed for all patients on CPA. Where a risk of disturbed/violent behaviour has been identified as a possibility in the risk assessment, intervention and behaviour management strategies should be recorded as part of the care plan and care record.


6.2 Risk assessment of the clinical setting

Risk assessment of the clinical environment should be conducted within the context of the formal Health and Safety environmental risk assessment (Trust Policy – Health and Safety Risk Assessment). The responsibility for conducting the risk assessments of the clinical setting rests with the Service Manager, or their nominated representative. In the first instance, it may be appropriate to start the assessments through a “desk top” exercise by identifying: � the main “hazards and risks”, � those affected - employees, members of the public etc. � existing control measures - local codes of practice, Trust guidance, HSE guidance

etc. � any additional controls required over and above those already identified.

Following such an exercise, it may be necessary to verify the assessment through observation of the work process, walking around the environment and by discussions with employees. Alternatively, assessments may be conducted through a team approach. Such an assessment process would involve management and employee representatives, and as and when required specialist advice (Directorate Health & Safety Advisor). This approach usually produces a more effective and concise assessment. Identified “hazards” then need to be risk rated, using the Trust RAT tool to enable prioritisation of control. Consultation with employees is necessary to ensure an effective assessment. When agreed, assessed risks and hazards must be brought to the attention of all staff - management and staff - involved in the operation. Risk assessment of the clinical environment should be repeated when ever there are significant changes to; the operation policy of the service, the environment itself or the patient population using the service. Environmental risk assessment in the content of violence and aggression management will take into account hazards, lines of sight, alarm system, door entry and egress systems. Where alarm systems are fitted the following should be in place: � A regular and recorded programme of testing to ensure that it functions correctly � A robust response procedure in place. � Staff induction which include how to use the alarm.

7. PREVENTION OF AGGRESSION AND VIOLENCE

7.1 Causes of Violence

Many incidents of violence arise from the individual feeling vulnerable, frustrated or disregarded and expressions of anger or attack can result. While the causes of violent outbursts are not always easy to ascertain a number of causes have been identified. Please see [Appendix 1] for a summary of these. By considering the individual situation in conjunction with the intervention and the service users’ presentation, staff can start to anticipate the likelihood of violence and construct plans to reduce the risk.


7.2 Prevention of Violent Incidents

All staff have a responsibility to prevent situations arising which increase risks to service users, the public and staff. A multi faceted approach is required to prevent violence, including being aware of both the physical and emotional states and the environment (including the need for staff to be self-aware of how their own behaviour may impact on the behaviour of others.

7.3 Advance Directives

Service users identified to be at risk of disturbed/violent behaviour should be given the opportunity to have their views and wishes recorded in the form of an advance statement. They should be encouraged to identify as clearly as possible what interventions they would and would not wish to be used, as well as what interventions are effective for them. This should be subject to periodic review. Collaboration with the service user to develop crisis plans and advance directives is good practice.

7.4 Sensitivity to Service Users

Violence can be a reaction to (perceived or actual) feelings of lack of sensitivity to individual needs. Staff faced with potential or actual violence must bear in mind any physical, sensory or communication deficits the person is experiencing and takes this into account when managing the situation. Similarly cultural and gender issues must influence the staff response to (potential) violence e.g. ensuring staff deployed to manage the situation are from both genders. Assumptions regarding an individual’s likelihood to be aggressive or indeed co-operative should not be made, based on culture or ethnicity but must be made according the presenting risk and previous history of risk events (NICE 2005).

7.5 De-escalation of Potential Violence

De-escalation is the preferred intervention when confronted with potential violence. This should only be superseded when delaying the use of other interventions would result in physical harm. In order to de-escalate an aggressive or potentially violent situation staff should aim to present in a calm and interested manner and display empathy to the service users’ perspective. Non threatening body posture and active listening skills can reduce the risk of a violent response. It is important for members of staff to feel confident in the use the appropriate verbal and non-verbal skills when a client presents with potentially violent behaviour (refer to appendix 2 for verbal/non-verbal skills).

8.0 RAPID TRANQUILISATION, PHYSICAL INTERVENTION, S ECLUSION AND OBSERVATION

Rapid tranquillisation, physical intervention, seclusion and observation should be used only where de-escalation and other strategies have failed to calm the service user.(see Rapid Tranquilisation Policy, Supervised Confinement Policy, Observation and Engagement Policy). These interventions are management strategies and are not regarded as primary treatment techniques. They should always be used in conjunction with further efforts at de-escalation, and must never be used as punishment or in a punitive manner.


Any such intervention must be used in a way that minimises the risk to the services users’ health and safety and that causes the minimum interference to their privacy and dignity, while being consistent with the need to protect the service user and other people. When determining which interventions to employ, clinical need, safety of service users and others, and, where possible, statements made by service users who are subject to compulsory powers under the Act about their preferences for what they would or would not like to happen if a particular situation arises in future, should be taken into account. This includes legally binding advance decisions to refuse treatment. (Chapter 17, Code of Practice Mental Health Act 1983).

8.1 Consent

To ensure an individual’s rights are not infringed staff should attempt a full explanation of the effects and side effects of any intervention offered. In an emergency situation it may not be possible to gain informed consent but this should be sought as soon as possible after the incident for subsequent interventions. If informed consent is not given staff should consider the use of the Mental Health Act (1983) which provides staff with an ongoing legal basis for restraint (and the service user with a legal basis for appeal). In cases where the service user is under eighteen or has dependent children, the provisions of the Children’s Act 1989 should be considered.

8.2 Physical intervention (Code of Practice Mental Health Act 1983)

Managing aggressive behaviour by using physical interventions should be done only as a last resort in an emergency when there seems to be a real possibility that harm would occur if no intervention is made. The most common reasons for needing to consider such interventions are: • Physical assault • Dangerous, threatening or destructive behaviour • Self harm or risk of physical injury by accident • Extreme and prolonged over-activity that is likely to lead to physical exhaustion • Attempts to abscond, where the service user is detained under the Act.

The purposes of physical intervention where de-esca lation has failed are to:

• Take immediate control of a dangerous situation • End or reduce significantly the danger to the service user or others around them. • Contain or limit the service user’s freedom for no longer than is necessary.

Any physical intervention used must be:

• Reasonable, justifiable and proportionate to the risk posed by the service user. • Used for only as long as is absolutely necessary. • Involve a recognised technique that does not depend on the deliberate application of

pain. • Be carried out by staff who have received appropriate training.

A single member of staff should lead and control the situation and the service user should be approached where possible and agreement sought to stop the behaviour. Where possible an explanation should be given to the service user of the consequences of refusing the request from staff to desist. The special needs of service users with sensory impairments should be considered –approaches to deaf or hearing-impaired people should be made within their visual field.


During physical intervention one team member should be responsible for protecting and supporting the head and neck, where required. They should take responsibility for leading the team through the physical intervention process, and for ensuring that the airway and breathing are not compromised and that vital signs are monitored. A number of physical skills may be used in the management of a disturbed/violent incident. Every effort should be made to utilise skills and techniques that do not use the deliberate application of pain, which has no therapeutic value and could only be justified for the immediate rescue of staff, service users and/or others. It is important that restraint through the use of physical intervention is seen within the overall spectrum of approaches for dealing with violence and aggression. Disengagement from a violent or potentially violent situation is preferable. Occasions may occur when the safety of self or others may supersede this. Staff will develop a clear understanding of factors that may contribute to disturbed behaviour and dealing with violence and aggression through local induction procedures, advice and instruction from Managers on the policy and through their attendance on mandatory Promoting Safe & Therapeutic Services Training. Staff likely to be involved in restraining through the use of physical interventions must be suitable trained by attending the relevant course as set out in training matrix of this policy. Violence that occurs very suddenly and without time to de-escalate or summon help may require immediate physical intervention. The use of such intervention is acceptable in law providing the amount of force is reasonable to stop the attacker, and/or stop injury to the person being attacked or injury to the attacker. Disengagement from a violent or potentially violent situation is preferable, but also recognises that at times safety of self or others may supersede this. Where staff have not been trained in physical inter vention , they should only be involved in extreme circumstances where they, or others are in immediate danger. The following guidance should be used: Wherever possible, restraining service users on the floor should be avoided. If the floor is used, this should be for the shortest period of time and for the primary reason of gaining control of the situation. In exceptional situations where the service user is in a prone position (face down) this should be for the shortest possible period of time to bring the situation under control, and the service user moved into the supine position (face up).

• The process of breathing must not be impeded. • Pain must not be inflicted. • Vulnerable parts of the body e.g. neck, chest and sexual areas should be

avoided. • Hold only long bones e.g. forearms, upper arms and legs. • Monitor for signs of distress or injury and terminate the intervention as

appropriate.

Staff trained in physical intervention should take over as soon as is practicable. 8.5 Use of Seclusion

Seclusion is the supervised confinement of a service user in a room, which may be locked .Its sole aim is to contain severely disturbed behaviour which is likely to cause harm to others (see Code of Practice Mental Health Act 1983). It has a place to play in the spectrum of interventions available to support the management of violence and aggression. See Supervised Confinement Policy.


8.6 Rapid tranquillisation

Rapid Tranquillisation is the use of medication to calm the service user, reduce the risk to self and/or others and achieve an optimal reduction in agitation and aggression, thereby allowing a thorough assessment to take place and allowing comprehension and response to spoken messages throughout the intervention. Rapid Tranquillisation should only be considered once de-escalation and other strategies have failed to calm the service user, and should be considered as a management strategy and not a primary treatment technique. See Rapid Tranquillisation Guidelines. Physical intervention may be used in order to administer medication to an unwilling service user where there is legal authority, whether under the Mental Health Act 1983 (amended by the Mental Health Act 2007) or Mental Capacity Act 2005 or otherwise, to treat the service user without consent. Physical interventions may not be used to treat an informal patient who has the capacity to refuse treatment and who has done so.

8.7 Observation

Increased levels of observation may be used both for the short-term management of disturbed behaviour and to prevent suicide or serious self-harm. See Engagement & Observation Policy.

8.8 Mechanical restraint

The use of mechanical restraint is not permitted. However the employment of mechanical restraints may be undertaken by the Metropolitan Police Service and/ or Security Trained staff. This might include Velcro strapping, handcuffs etc. In these incidences continuing observation of patient well being and communication of patient risk is required by our clinical staff present. Please refer to Joint Working protocols with the MPS.

9. CALLS FOR ASSISTANCE

Calls for assistance should be made via the local procedure. This may be via localised alarm systems. Where telephone requests are made details such as the number of people involved, the exact location, the nature of any weapons and the senior member of staff on duty to whom they should report may be required. A member of staff should be designated to meet those arriving to help and direct them to where they are required. Staff arriving should be given relevant information to allow them to assist.

9.1 Assistance from non-clinical staff and other ag encies

Assistance from non-clinical staff such as porters or security guards or other agencies such as the police may be required. This should be sought as early as possible before a potentially violent situation can escalate. The person in charge of the area must liaise with any helpers who arrive and be clear about what help is required from them.

9.2 Police assistance

Procedures are in place to summon police support and the Joint Working Protocols should be read in conjunction with this policy. The Trust will support staff in contacting the Police for help in a violent situation in order to help regain control where all internal resources have been deployed and are unable to manage safely the situation. Each episode of joint police working should follow protocol, be reported and discussed as required through liaison meetings.


9.3 Incidents where dangerous weapons are present Staff should not attempt to physically disarm any person who is acting in a hostile manner with any kind of dangerous weapon. Urgent Police assistance should always be requested. Where staff are threatened with a weapon attempts should not be made to disarm the individual. Those present should attempt to keep the situation contained and call the police for assistance. In situations involving weapons staff should evacuate service users and themselves to a safe are and dial 9999 for police. Explicit information regarding the location of the incident, the weapon involved and a description of the assailant will assist the police risk assessment process and allow a prompt response.9999 calls receive a graded response and clear information is required.

9.4 Police will not restrain service users for the purpose of clinical intervention

• e.g. enforced administration of medication. Police will attend and intervene to prevent a breach of the peace or to prevent a crime.

• The Trust will also support any management decisions to call the Police in order to support a complaint being made following a violent incident. This applies to staff, service users and visitors to the Trust. (see Prosecution Protocol)

• The Senior Manager should be informed immediately and an urgent review carried out.

10 POST INCIDENT MANAGEMENT FOR STAFF

• Timely, post-incident support is good management practice, to limit wherever possible the effects of exposure to distressing workplace events.

• Responding quickly to the needs of staff who have been through a distressing experience is important and the use of recognised methods will provide an opportunity for staff to feel supported and to talk about and work through their experience.

• Any member of staff who has been involved in a violent incident should be offered these supportive processes and their right to this should be respected regardless of the manager’s view of the incident.

10.1 Shift Evaluation

• This is the process of discussing an incident or series of minor incidents at the end of the working shift/day if staff wish. The team manager or person in charge of the shift should initiate it.

• The purpose is to provide an immediate outlet for staff to voice their thoughts and feelings following a difficult period of working. It does not replace debriefing, which may still be held, depending on the severity of the incident and the feelings of those involved.

10.2 Debriefing

• This is an enabling process whereby staff and service users can talk about their experiences and feelings after an incident. Debriefing can be used with individuals, but is usually used with groups of people who have commonly experienced an emotionally distressing workplace event. It cannot prevent reactions from occurring, but can provide a framework for the individual to contain them and provide opportunities to take further action to resolve distress.

• Debriefing aims to prevent the development of further adverse reactions and minimise the occurrence of unnecessary psychological and emotional suffering.


• Consideration must also be given to other people who may have witnessed the incident.

10.3 Staff issues

• A review of whether staff require medical treatment, sick leave or temporary relief from duty must be carried out by the Manager and appropriate arrangements made.

• Staff may wish to be referred for counselling via the relevant Occupational Health Department or alternatively could choose to access the Staff Counselling Service (see guide for employees, Occupational Health Service).

• A review and assessment of working practices and security measures must be carried out and appropriate changes made where required. Where changes are required, but cannot be implemented, these must be reported to the Director/Senior Manager immediately.

• The Manager should discuss the issue of pursuing a prosecution against the assailant, and offer to accompany the member of staff to the police if necessary. Advice and support can be provided by the LSMS.

• If the member of staff requires sick leave, the Manager should establish how frequently the member of staff would like to be contacted. Staff may feel very isolated if they are away from work, and unable to discuss the events. Managers should also check how the staff are feeling when they return to work, and at intervals following the incident. See Policy for Managing Sickness Absence.

• Advice and support can be sought from the Human Resources Department as appropriate.

11. PHYSICAL CARE AND OBSERVATION OF THE SERVICE US ER – RISKS IN RESTRAINT

11.1 During restraint/physical interventions • Verbal de-escalation should continue throughout the intervention, and negotiations

with the service user to comply with requests to stop the behaviour should continue where appropriate.

• Physical monitoring is especially important: • During (where possible) and following a prolonged or violent struggle. • If the service user has been subject to enforced medication or rapid tranquillisation. • If the service user is suspected to be under the influence of alcohol or illicit

substances. • If the service user has a known physical condition which may inhibit cardiopulmonary

function e.g. asthma, obesity. Service users subject to restraint should be physically monitored during restraint.

• Observations for maintain safety and well being for the service user check and record pulse rate and respiratory rate every 5 minutes. If the restraint lasts over 10 minutes then blood pressure should be recorded every 15 minutes. If the respiratory rate goes below 10 or above 25 breaths per minute, the pulse oximetry rate drops by 3%, or the pulse rate is below 50 or above 120 beats per minute, a doctor must be called and the restraint released.

• If it is unsafe to release the restraint, then a doctor must be called and the method of restraint used must be reassessed by the most senior member of staff available and trained in physical interventions. If, after release or reassessment, the observations do not improve, an ambulance or urgent medical assistance must be called. If consent and co-operation for these observations is not forthcoming from the service user, then it should be recorded in their clinical record why the observations could not be performed and what alternative actions have been taken. Care of other service users


• A member of staff should take the lead in caring for other service users and moving them away from the area of disturbance.

• Staff not involved in the physical intervention should leave the area quietly. 11.2 Post Physical Intervention – Observation & Car e

• The senior member of staff on duty will co-ordinate the activities of others post- incident.

• A member of staff will be delegated to remain with the person for a time after release.

• A review of Mental Health Act status and observation level will take place. A medical review of the individual’s mental and physical state will also take place as soon as possible. National Institute of Mental health England (NIMHE 2004) recommend within 2 hours.

• The patient’s care plan will be reviewed and risk assessment / risk event updated. • Any physical observations must be carried out as agreed and reported if outside of

expected limits. • For inpatients, staff will review the appropriateness of the current environment and

make referrals as required. NIMHE (2004) recommend that physical observations should be checked 2 hourly for 24 hours post-restraint.

• All episodes of restraint must be recorded as per the incident reporting procedures. • All incidents of violence against staff must be reported via the Trusts DATIX reporting

system then to the Local Security Management Specialist as per Secretary of State Directions (2003/4).

The following should be monitored by the Nurse in Charge:

• Pulse rate • Respiration rate • Blood pressure • Temperature • Oxygen saturation via pulse oximeter (for 15 minute observations only unless

abnormal) • Fluid and food intake and output • Level of alertness and consciousness • Staff should also look out for: • Verbal complaints of pain and discomfort • Non-verbal clues to pain or discomfort (especially if verbal communication is

identified as difficult) Each set of observations should be assessed and discussed with medical staff if out with range of normal (see Rapid tranquilisation guidelines). If at anytime there is concern over the health of the service user a doctor must be called and if this continues an ambulance or urgent medical assistance must be called. If consent and co-operation for these observations is not forthcoming from the service user, then it should be recorded in their clinical record why the observations could not be performed and what alternative actions have been taken.

11.3 Debriefing the service user

The service users care plan should be reassessed and they should be helped to reintegrate into the ward environment. The debriefing of the service user should take place as soon after the event as is possible, but at a time appropriate to the service user. They should be given the chance to write up their account of what happened in their clinical record. It is desirable that the debriefing is undertaken by a member of staff who was not involved in the incident, and the staff member should speak with the service


user about what led to the incident. The debriefing discussion will be recorded within the service user’s clinical record and should include:

• How the service user felt about the action taken by staff? • If there is anything they feel could have been done differently? • Is there anything the staff perhaps could have done differently?

12 AFTER THE INCIDENT REVIEW

Once a situation has been brought under control, consideration needs to be given as to the longer term care needs of the service user(s) involved. Options to be considered by the multi disciplinary team are:

• The need to move a service user to another unit area to prevent a further occurrence. Consideration of risk and refer if appropriate to the Patient Leave, Conveyance & Escorting Policy.

• The need for the service user to be nursed in seclusion for a period of time. See Policy for the use of Supervised Confinement.

• The need for a service user to be transferred into a more secure area such as a Psychiatric Intensive Care Unit (PICU).

• Review of treatment and medication aims and effectiveness. • The need for the service user to be nursed on special observations. (refer to

Engagement & Observation Policy) 12.1 Treatment withdrawal

The Trust will support clinical teams and staff in consideration of the withdrawal of treatment for service users where there has been evidence of wanton, deliberate aggression and violence. Clinical teams and staff will be supported in their consideration of the need to withdraw treatment from service users where there has been an appropriate risk assessment undertaken. The team must ensure a comprehensive risk assessment has been completed for each individual service user. The reasons why the withdrawal of treatment is considered the best option should also be documented and alternatives to treatment offered. The Trust’s Local Security management specialist must also be involved in these considerations so that the appropriate legal guidance and duty of care considerations are incorporated. This also will ensure that the Trust is supporting teams in this difficult area. Teams must consider alternative options of treatment delivery, which may include different provider organisations in serious cases (refer to Prosecution Protocol).

12.2 Visiting

Trust staff are responsible for the health and safety of any visitors who are on Trust premises. In the event that visitors are in the vicinity when an incident occurs they should be removed to a safe area immediately. Witnessing a violent incident can be distressing, so staff should explain why the visitors are being removed, when the incident has been dealt with, and when it is safe for them to return to the area from which they have been removed. If relevant they should be offered involvement in any debriefing process.

13 INCIDENT REPORTING AND RECORDING

Staff must report all incidents of violence and aggression as soon as possible after the incident by completing and submitting an Electronic Incident Form via the DATIX reporting system. See Incident Policy.


These incident reports are reviewed by the Consultant Nurse in PSTS, the Local Security Management Specialist (LSMS) and the Lead Tutor for PSTS, any concerns are passed on to the relevant Manager. It is a requirement that all incidents of physical assault are reported – whether intentional or not.

13.1 Recording of Physical Intervention

Where physical interventions are used staff must: • Record the decision and the reasons for it and complete • Document and review every episode of physical intervention, which should

include a detailed account of the restraint. • Document the debriefing discussion with the service user • File the service user’s written account (where provided) of what happened • All the above will be kept in the service user’s clinical record. • Where service users are brought in by the Police, staff must establish if the

Police have physically restrained the service user and the discussion with the Police should be recorded in the service user’s clinical record. The Police should be asked to countersign the clinical record to confirm if they have or have not already restrained the service user.

13.2 Responding to complaints

Any complaint made against staff as a result of a violent incident will be dealt with quickly and fairly and investigated as per the Complaints Policy. Staff are also encouraged to consult their own professional association or Trade Union for advice.

13.3 Pursuing criminal proceedings

Following a serious assault the process set out in the Prosecution Protocol must be followed. The LSMS will provide advice and support to Managers and staff as required.

13.4 Damage to personal property

The Trust will consider reasonable claims for compensation in respect of damage caused to personal property as a direct result of a violent incident involving the employee who is owner of the property provided that the employee has taken all reasonable precautions to avoid the damage. All claims should be made to the Line Manager as soon as is reasonably possible after the incident and the appropriate documentation completed. Individual members of staff will not be held liable for damage to property of the Trust incurred during a violent incident provided that the employee has taken all reasonable precautions to avoid the damage.

14. SPECIAL SITUATIONS AND CONSIDERATIONS

14.1 Gender/sexual safety

There may be occasions where the staff team, confronted with an aggressive service user, face the potential problem of gender/sexual issues, such as an all male team needing to manage a female service user or an all female team having to manage a male service user. On these occasions an attempt should be made to ensure there is a staff member of the same sex as the service user at the scene to observe the management of the situation. There should be no attempt to change the responding nurse team into one of mixed gender unless it is safe to do so and the person stepping in is trained in physical interventions.


14.2 Service users with disabilities

Service users with disabilities, including physical or sensory impairments and communication difficulties, should have specific instructions in their care plan concerning the preferred method of dealing with incidents, which may require specific interventions. The care plan should set out the responsibilities that each member of staff has in relation to the actions required.

14.3 Pregnant service users

Where it is known that a service user is pregnant, advice should be sought from the PSTS Lead Tutor and team and/or from Obstetrics and Gynaecology, and special provisions made where interventions may be required. The agreed interventions must be documented in the service user’s care plan.

14.4 Managing service users with communicable disea ses

If staff are aware that a service user has a potentially infectious condition, the advice of the infection control team should be sought. Upon their guidance, protective clothing and equipment will be made available. Any special provisions to be implemented with service users should be clearly written up in their care plan. If a member of staff or a service user is involved in an incident which involves a risk of infection, where the skin is broken, blood is spilt, or there has been direct contact with body fluids, then advice from the Infection Control Team should be sought. Policies on differing infections are available on the Trust Intranet.

14.5 Service users brought in by the police who may have been restrained

Where service users are brought in by the Police, staff must establish if the Police have physically restrained the service user, and if so, should commence recording their observations. The discussion with the Police should be recorded in the service user’s clinical record and the Police should be asked about length of restraint and resistance shown for risk awareness for the service user and this inputted into the clinical record.

14.6 Incapacitant Spray (CS Gas)

Incapacitant Spray has been used very occasionally in mental health settings by the police. It may have been used on a person who is then admitted to the Trust. Staff should follow the appropriate procedure to ensure measures to minimise the effects on the service user; staff and any others present are adhered to. If police employ the use of CS Gas they should advice as to how to minimise and manage the effects of such. The service user exposed to CS Gas should be monitored closely for effects and be assessed for pre-existing medical problems relating to lung capacity, breathing difficulties or known asthmatic. Police should be asked for information and advice in managing this situation.

14.7 Taser

Tasers are used by the Police as a means of managing behaviour in the event of extreme violence or where weapons are held. This equipment has been made available to specially trained officers only, and the decision to deploy will be made by them. The deployment of TASER is considered to require a medical response for removal of barbs and may require the patient to be transferred by ambulance to an A+ E department. Police have to be prepared to commence immediate basic life support if required. All staff should follow instruction from the police about clearance of area and when to be involved. It is imperative that clear concise information about risks known or suspected are communicated to the police by staff. Joint risk planning should include medical staff present.


14.8 Persons under 18 years of age

In the exceptional circumstance that a person under 18 years of age is admitted to an adult ward, due consideration should be given to the involvement of parents or carers.

15. TRAINING

Trust staff receive violence and aggression training as per the SlaM Training Needs Analysis. The processes for checking staff identified in the TNA complete relevant training, and for following up those who fail to attend relevant training, are described in the SlaM Education and Training Policy.

16. EXPECTATIONS OF SERVICE USERS/ CARERS/ SERVICE USER REPRESENTATIVES/VISITORS

Service users, family members, carers, visitors and service user representatives are expected to : • adhere to a behaviour code that includes not involve abusing others either verbally or

physically. • be aware that the display of aggression and violence may lead to action by others

such as additional medication, restraint and/or contact with the criminal justice system.

• communicate any concerns to the Key-worker/Care co-ordinator and/or Multi-disciplinary Team.

• contribute to reviews such as CPA meetings. • work with staff on the basis of informed consent. • develop knowledge of the services the group is advocating on behalf of. • work with other service users, staff and managers to promote a safer and therapeutic

service.

17. MONITORING COMPLIANCE

What will be monitored i.e. measurable policy objective

Method of Monitoring

Monitoring frequency

Position responsible for performing the monitoring

Group(s)/committee(s) monitoring is reported to, inc responsibility for action plans

Requirement to undertake appropriate risk assessment of the individual patient for the prevention and management of violence and aggression

Audit Annual Assistant Director Patient Safety

Clinical Risk Committee

Requirement to undertake appropriate risk assessment of the

Audit Annual Health and Safety Advisor

Health and Safety Committee


What will be monitored i.e. measurable policy objective

Method of Monitoring

Monitoring frequency

Position responsible for performing the monitoring

Group(s)/committee(s) monitoring is reported to, inc responsibility for action plans

clinical area for the prevention and management of violence and aggression

Organisational expectation in relation to staff training as identified in the training needs analysis

Audit. Annual Deputy Director Education and Training Committee

Education and Training Committee

18. ASSOCIATED DOCUMENTATION

� Trust Framework for the Management of Risk and Harm � Trust Health and Safety Risk Assessment Policy � Trust Policy & Guidance on Lone Working � Trust Incident Policy � CPA Policy � Clinical records policy � Prosecution Protocol � Supervised Confinement Policy � Joint working protocols with MPS � Rapid Tranquillisation guidelines � Trust Policy & Guidance on Lone Working

19. REFERENCES

� Nice Clinical Guidelines (2005) � The Blofeld Inquiry into the death of David Bennet (2004) � Department of Health (2000). Zero Tolerance Pack. Department of Health.

Leeds. � Health and Safety Commission Violence and Aggression to Staff in Health

Services: Guidance on Assessment and Management, (HSE 1997). � Department of Health (1999a) Addressing Acute Concerns: Report by the

Standing Nursing and Midwifery Advisory Committee. London, HMSO � Department of Health (1999b) Effective Care Coordination in Mental Health

Services: Modernising the Care Programme Approach. London, DoH. � Department of Health (2000) Safety, Privacy and Dignity in Mental Health Units.

London, DoH. � Department of Health (2003) Inside Outside: Improving Mental Health � Department of Health Guidance on Restrictive Physical � Interventions for people with learning disability and autistic spectrum disorder, in

health, education and social care settings. (2002) � Gournay K., Ward M., Johnson S., Thornicroft and Wright S (1998) Crisis in the

Capital; Inpatient Care in Inner London Mental Health Practice 1, 5, 10-18.


� Lewisham and Guys NHS Trust (1999). Preventing and Management of Aggression Policy Lewisham and Guys NHS Trust.

� National Audit of Violence ww.rcpsych.ac.uk/.../centreforqualityimprovement/nationalauditofviolence/navnationalreports.aspx – 32k

� National Confidential Inquiry � http://www.medicine.manchester.ac.uk/suicideprevention/nci/ � The National Institute for Mental Health in England (NIMHE) – interim guidance

‘Developing Positive Practice to Support the Safe and Therapeutic Management of Aggression and Violence in Mental Health Inpatient Settings: Mental Health Policy Implementation Guide’ (2004)

� National Institute of Clinical Excellence (2005) short-term Management of Violent (Disturbed) Behavior in Adult Psychiatric In-patient Settings Guideline 25 (2005) o NHS SMS strategy document “A Professional Approach to Managing

Security in the NHS” (December 2003). � R-Dash policy on work related Violence (2008) � Royal College of Psychiatrists (1998). Management of Imminent Violence. Royal

College of Psychiatrists. London. � Royal College of Nursing (1998) Dealing with Violence Against Nursing Staff

Royal College of Nursing. London. � Wessley S., Rose S., Bisson J (1989) A systematic review of brief psychological

interventions (“debriefing”) for the treatment of immediate trauma related symptoms and he prevention of post traumatic stress disorder. Cochrane.

� West London Mental Health Trust PMVA Policy (2006)

Other significant reports and initiatives include:

� Health and Safety Commission Violence and Aggression to Staff in Health Services: Guidance on Assessment and Management, (HSE 1997).

� Department of Health (1999a) Addressing Acute Concerns: Report by the Standing Nursing and Midwifery Advisory Committee. London, HMSO.

� Department of Health (1999b) Effective Care Coordination in Mental Health Services: Modernising the Care Programme Approach. London, DOH.

� Department of Health (2000) Safety, Privacy and Dignity in Mental Health Units. London, DOH.

� Department of Health (2003) Inside Outside: Improving Mental Health � Health Care Commission – Staff Survey (2005) � RCN Breaking Point Survey (2005)

20. FREEDOM OF INFORMATION ACT 2000

All Trust policies are public documents. They will be listed on the Trusts FOI document schedule and may be requested by any member of the public under the Freedom of Information Act (2000).

Policy for the Development and Management of Trust- wide Procedural Page 24 of 38 Documents Version 4 – July 2011

APPENDIX 1 – CAUSES OF VIOLENCE AND AGGRESSION

• Restriction of freedoms • Limitations on behaviours • Past experience of violent behaviour • Lack of meaningful activity • Lack of personal space • Loss of privacy & dignity • Frustration at the system • Dignity and respect affronted • Lowered threshold of tolerance to other people • Loss of respect for health care staff • High density living environments • Psycho-active and behavioural effects of illicit drugs use • Irritability and craving due to drug/alcohol/tobacco dependency • Sustained exposure to stimuli in disturbed ward environments • Threat from others • Fear, uncertainty and boredom • Misinterpreting communication or hearing voices • Not feeling in control of one’s own situation • Hot humid environment • Tensions between service users • Staff are perceived as inaccessible or over controlling • Staff responses are inconsistent • Staff communication with each other is poor

It is known that health and social care workers are at increased risk of violence because they deal with the public and the likelihood of aggression increases when staff:

• Fail to meet immediate needs of service users • Refuse reasonable requests • Are perceived to ignore service users • Are perceived to disrespect service users


APPENDIX 2 – PREVENTION OF AGGRESSION & VIOLENCE

• The provision of a ‘homely’ environment in terms of furnishings and the ongoing maintenance of its decoration and furniture renewal are key to creating an atmosphere where violence is discouraged. This is balanced with security features such as appropriate lighting, immovable furniture and screens (in reception areas) and so on, where required.

• The provision of a smoking area with adequate space is important. (see Trust Smoking Policy)

• Staff must be sensitive to service users need for access to open space and fresh air and balance this with consideration of actual or potential risk(s).

• The ongoing review and maintenance of equipment such as panic alarms, mobile phones, and pagers and any other systems, which allow staff to call for help, may stop violence from occurring or, escalating.

• Staff must be sensitive to service users’ desire for privacy especially when attending to personal hygiene or conversing with friends and relatives, in person or by phone. Again, actual or potential risk(s) in facilitating this freedom need to be considered, recorded in care plans and any restrictions regularly reviewed.

• The provision of information such as signage, verbally, and in leaflet form also contribute to reduction in violence.

• Staff should routinely assess and identify any potential difficulties in their area and take steps, wherever possible, to reduce the likelihood of such an incident.

• The only reliable predictor of violence is a known history of violence including threats and near misses and contact with the legal system, which did not result in conviction. This history must be made known to all persons who need to know. The assessment and management of risk is covered by a separate document and should be read in conjunction with this policy.

• Staff should be aware of service users with a history of aggression and have in place a plan for dealing with the situation should it arise, collaboration with the service user to develop crisis plans is recommended good practice.

• If it is decided that a client should be isolated this should be in a designated area. The restriction of free movement of patients is a separate document that should be read in conjunction with this policy. (see Restriction of Free Movement Policy)

• Procedures for searching and removing items that are considered to be dangerous are in line with preventing violence (to self or others). This is covered by a separate document and should be read in conjunction with this policy. (see Search Policy)

• As far as possible, staff must facilitate the ability for service users to exercise choice in their care and treatment. This includes informing service users of the possible options and helping him/her to weigh the benefits.

• The provision of appropriate meaningful activities balanced with periods of rest should be facilitated by staff for individuals and groups.

Staff should pay particular attention to the management of activities known to be consistent with increased levels of violence such as mealtimes. The deployment of appropriate staff in number and skill, to carry out the task while being alert to the possibility of violence-and having the skills to deal with it-is crucial in prevention.

Verbal skills

Attempt to convey that their situation is understood by helping the person to talk about whatever it is that is troubling them by firstly adopting an unhurried approach and;

• Using the person’s name


• Focus on the emotional content, use a soft tone of voice if possible • Only use facts, don’t make promises that can’t be kept • Ask the person to put down (not hand over) any potential weapons if safe to do so • Personal risk assessment should determine if it is safe to negotiate or if withdrawing

self and others from a situation involving weapons is necessary • Help the person address the reasons for the outburst step by step • Offer alternative solutions to the problem • Avoid making the person lose face • Build on the service user’s strengths helping them take control of their actions • Remind the person throughout the conversation of your name and relationship with

them – you are there to help • Create space in time – do not rush the person into agreement • Always be prepared to compromise • Do not resort to status issues

Non-verbal skills

The following skills can be used in conjunction with the verbal skills above; • Avoid /reduce ‘audiences’ e.g. ask the person if you can discuss their concerns in

private • Be aware of opportunities in the environment for exit (own and other person’s) • Be aware of opportunities in the environment for the use of weapons • Avoid sudden movements • Avoid sustained eye contact and standing directly opposite the person • Avoid cornering the person • Show warmth and continued support • Create space by moving furniture or stepping back • Use an open posture • Sit beside the person if possible (maintaining a safe distance to allow exit should

actual violence occur) , do not tower over the person


APPENDIX 3 – STAFF PARTICIPATION IN RESTRAINT

1. Introduction 2. Use of Restraint Techniques 3. Participation 4. Restraint Training 5. Temporary exemption 6. Permanent exemption 7. Action to be taken to decide whether an individual is exempt 8. Role of Occupational Health Dept in the Temporary or Permanent withdrawal of an

Employee from participation in Restraint 9. Action Regarding Permanent exemption 10. Action Regarding Temporary exemption 11. Ratio of Staff unable to participate in Restraint 12. Line mangers accountability

1. Introduction

This document outlines managers’ action in relation to maintaining available staff to carry out restraint.

NB the term Restraint in this document refers to a recognised set of physical intervention techniques, which are applied in order to restrain safely an individual. An approved Trainer who has successfully completed an approved Instructors course must teach restraint techniques.

2. Use of Restraint Techniques

The Education and Training Committee have indicated which staff should be trained in restraint techniques.

3. Participation

Staff can only be exempt from training and/or participation in applying restraint techniques if they have met conditions as outlined in sections 5 or 6 below.

4. Restraint Training

4.1 Training is available via trust training department

4.2 Staff completing the restraint course will be deemed ‘competent’ or ‘not yet competent’ by the Instructor.

4.3 Staff deemed ‘not competent’ at the end of the course will be temporarily exempt from practising Restraint (see section 5). These staff will be offered further opportunities to achieve competence and the Instructor will liase directly with the employee’s line manager in writing.

4.4 Staff who continue to be deemed ‘not yet competent’ after completing additional inputs as suggested by the Instructor will meet with their line manager to review whether the individual should be considered as ‘permanently exempt’ (see section 6).

5. Temporary Exemption

The following are a guide to reasons for temporary exemption:


• Staff awaiting to attend training (but must still contribute to the management of emergencies as required & competent to do)

• pregnancy • a medically diagnosed condition which would be aggravated by using Restraint

techniques • a medically diagnosed condition which prevents the individual from using Restraint

techniques

6. Permanent exemption

6.1 The following are a guide to reasons for permanent exemption:

• a medically diagnosed condition which would be aggravated by using restraint • A medically diagnosed condition which prevents the individual from using restraint.

7. Action to be taken to decide whether an individual is exempt

7.1 The individual must inform their Line Manager that they have a condition, which s/he

believes makes him/her exempt from using Restraint techniques either temporarily or permanently.

7.2 The Line Manager must ascertain whether the condition has been medically diagnosed and if not ask the employee to provide written confirmation of this within seven working days. The Line Manager can decide to make the employee exempt for this seven-day period.

7.3 Except for the case of pregnancy, which is automatic exemption, the Line Manager must

refer the employee to Occupational Health for confirmation that the condition is one, which exempts the employee for participation. The referral should request from Occupational Health an estimation of how long the employee may be unable to use Restraint techniques.

8. Role of Occupational Health Dept in the Temporary or Permanent withdrawal of an Employee from participation in Restraint

8.1 Occupational health doctors have been made aware of the physical requirements of restraint and will use this knowledge to decide whether the particular medical condition will be aggravated by the involvement of the individual in restraint activity.

9. Action Regarding Temporary exemption When the Line manager has confirmation that staff are temporarily unavailable to use Restraint techniques a decision regarding whether the individual can remain on the ward/unit is taken considering the following factors

• anticipated length of time the individual will be unavailable • number of staff currently unavailable • the contribution the individual can make to other aspects of managing emergencies

10. Action Regarding Permanent exemption

When the Line manager has confirmation that staff are permanently unavailable to use Restraint techniques a decision regarding whether the individual can remain on the ward/unit is taken considering the following factors:


• the contribution the individual can make to other aspects of managing emergencies • the long term impact on the team of a member of staff being unable to participate in

Restraint techniques • any plans within the team for retirement/leaving The Line manager must discuss the various alternatives with a senior manager and Human Resources manager. The alternatives are; • The individual remains on the ward/unit and the individual and other members of the

team are made aware of any change in role and when this will be reviewed. • The re-deployment process is triggered and the individual and other members of the

team are made aware of any change in role and when this will be reviewed.

11. Ratio of Staff unable to participate in Restraint techniques

11.1 Each ward / team should function at a minimum of 90% of staff available to use Restraint techniques. In a team of 25 this means only 3 can be unavailable to use the techniques either permanently or temporarily. This number can only rise if staff are awaiting training.

12. Line Manager’s accountability Line manager’s have responsibility to maintain a safe environment; if line managers are concerned about the ratio of staff unavailable to carry out Restraint techniques this must be raised with senior managers as soon as possible. The training department has responsibility for the provision of courses; any difficulties encountered regarding access to training must be directed promptly to the training manager. Overall responsibility for the content and availability of training rests with the Director of Nursing and Education.


APPENDIX 4

A GUIDE TO THE INITIAL RESPONSE FOR HOSTAGE, SIEGE, BARRICADE OR SUICIDE INTERVENTION INCIDENTS

These incidents ARE DANGEROUS – it is about SAFETY your SAFETY – you cannot help anyone if you become a victim, or are seriously injured. *INFORM THE POLICE -999 – PROVIDE CLEAR INFORMATION REGARDING THE LOCATION AND THE EVENTS OCCURRING. It is about ensuring that staff with you are thinking about SAFETY, and that you can prevent people getting hurt. The GOLDEN RULE of all incidents is to CONTAIN the incident, ISOLATE the place where it is happening (police call it the stronghold) EVACUATE persons at risk – Then NEGOTIATE. This will prevent the situation escalating or moving to somewhere else where you have less control. You cannot do this on your own; it needs to be a TEAM response. The Must or Do Points to consider: - � Talk to the subject, ignoring communication from them until you get help will only inflame the

situation. � Always be available to the person. � Work with a partner who can help you with prompts, and make notes, keep the speaking

role to one person. � Take any threat from the person very seriously. Don’t make your own assessment of the

risk just because you know them in their normal behaviour. Always challenge the threat e.g. “please take the knife away from your throat!”

� Do not deliver anything into the area unless someone else who is now in charge of the incident has made that decision. Deliveries are extremely dangerous situations in a siege.

� Do consider using a telephone rather than shouting through a closed door. It is safer and conducive to building a worthwhile rapport.

� What can you do to prevent a breakout, or if he/she surrenders do you have enough or your team to deal with that?

� Active listening – its not what they are saying but how they are saying it. Is there a clue in their emotions, which is not in line with the content of their words?

� Do use open-ended questions, e.g. what has happened, who is with you? Where, When and Why.

� Let the person know you are there and that you are listening, encourage them to talk / keep talking.

� Find the focus of the problem/key issues – don’t solve it yourself. � Always make sure you understand, but do not invite demands, paraphrase and repeat back

“are you saying…” � Take your time, find things out. � Be polite, remain as calm as possible, controlled, concise. � Personalise yourself; consider using your first name (if person sees you are part of the

problem you should not be there). � Seek to personalise all the other people who may be with him/her.


� Always ask to speak to those being held. Show them you are working for them; NEVER refer to them as “hostages”.

� Never miss an opportunity to press for an early release of anyone being held. � Do be prepared for hostility, anger and confrontation by the subject. � Always challenge any threat to injure any of the persons inside –e.g. “you are responsible

for any harm that you do – don’t do it”. � Do thank the subject for even the smallest concession. � Try and be consistent with your message and seek to get them to confront reality. � If it is unclear whether the person is suicidal or not, ask them! Do not be afraid to use the

words “suicide or death”. � Do keep a record of what is being said and the key points so that others can be briefed. � Be prepared to tell the police all the things you have learned so that the incident can be

handed over. DO NOT � Negotiate if you are the person in the Unit who will be making the decisions. Negotiators

must defer decisions to someone else. � If demands or deadlines are given, listen and note them very carefully, however do not

accept them or make promises. “The things you have asked for may be hard to get, I’ll see what I can do for you”.

� Do not get close or expose yourself to danger. Face to Face is the most dangerous form of Negotiation!

� Do not offer an exchange of people, we only get people out. � Do not use intermediaries or friends into the negotiations – there are complex decisions that

will probably be relevant by the time police arrive. Police will never use them impromptu and unprepared.

DO NOT lie, if there is a repeat situation it will make it extremely difficult to resolve because you have lied to them just to get them to come out. DO NOT be afraid to talk about your feelings after the incident has been resolved – use your own support networks. *ALWAYS ENSURE A FULL POST INCIDENT REVIEW AND DE-BRIEF FOR ALL INVOLVED.


APPENDIX 5:

EQUALITY IMPACT ASSESSMENT

PART 1 – INITIAL SCREENING

1. Name of the policy / function / service development being assessed? Promoting Safe and Therapeutic Services Preventing and Managing Violence and Aggression Policy 2. Name of person responsible for carrying out the assessment? Cliff Bean/ Natalie Hammond

3. Describe the main aim, objective and intended outcomes of the policy / function / service development?

Aim: To provide a policy framework for staff to manage the risks associated with violence and aggression in Trust services. Intended Outcomes: To prevent incidents of violence and aggression, and to manage safety incidents and challenging behaviour when it does occur. 4. Is there reason to believe that the policy / function / service development could have a negative impact on a group or groups? No 5. What evidence do you have and how has this been collected?

N/A

6. Have you explained your policy / function / service development to people who might be affected by it? Service users and their representatives have been involved in working groups and meetings where this policy have been discussed/developed.


7. If the policy / function / service development positively promotes equality please explain how? Not applicable

8. From the screening process do you consider the policy / function / service development will have a positive or negative impact on equality groups? Please rate the level of impact and summarise the reason for your decision.

Positive : Medium

(moderately likely to promote equality of opportunity and good relations)

Negative: Low probably will not have a negative impact)

Neutral: High (highly likely)

Reason for your decision: Special groups have been considered under section 14. Special situations and considerations.

Date completed: …29th August 2011…………………………………. Signed ……Cliff Bean/Natalie Hammond…………….. If the screening process has shown potential for a high negative impact you will need to carry out a full equality impact assessment


APPENDIX 6 – HUMAN RIGHTS ACT ASSESSMENT

To be completed and attached to any procedural document when submitted to an appropriate committee for consideration and approval. If any potential infringements of Human Rights are identified, i.e. by answering Yes to any of the sections below, note them in the Comments box and then refer the documents to SLaM Legal Services for further review.

For advice in completing the Assessment please contact Paul Bellerby, Legal Services [[email protected]]

HRA Act 1998 Impact Assessment Yes/No If Yes, add relevant comments

The Human Rights Act allows for the following relevant rights listed below. Does the policy/guidance NEGATIVELY affect any of these rights?

• Article 2 - Right to Life [Resuscitation /experimental treatments, care of at risk patients]

No

• Article 3 - Freedom from torture, inhumane or degrading treatment or punishment [physical & mental wellbeing - potentially this could apply to some forms of treatment or patient management]

No

• Article 5 – Right to Liberty and security of persons i.e. freedom from detention unless justified in law e.g. detained under the Mental Health Act [Safeguarding issues]

No

• Article 6 – Right to a Fair Trial, public hearing before an independent and impartial tribunal within a reasonable time [complaints/grievances]

No

• Article 8 – Respect for Private and Family Life, home and correspondence / all other communications [right to choose, right to bodily integrity i.e. consent to treatment, Restrictions on visitors, Disclosure issues]

No

• Article 9 - Freedom of thought, conscience and religion [Drugging patients, Religious and language issues]

No

• Article 10 - Freedom of expression and to receive and impart information and ideas without interference. [withholding information]

No

• Article 11 - Freedom of assembly and association

No


HRA Act 1998 Impact Assessment Yes/No If Yes, add relevant comments

• Article 14 - Freedom from all discrimination No

Name of person completing the Initial HRA Assessment:

Cliff Bean

Date: 29/10/2011

Person in Legal Services completing the further HRA Assessment (if required):

N/A

Date:


APPENDIX 7 – CHECKLIST FOR THE REVIEW AND APPROVAL OF A POLICY

This checklist must be used for self-assessment at the policy writing stage by policy leads and be completed prior to submission to an appropriate Executive Committee/Group for ratification.

Title of document being reviewed: Yes/No/ Unsure Comments

1. Style and Format

Does the document follow The South London and Maudsley NHS Foundation Trust Style Guidelines? i.e.:

• The Trust logo is in the top left corner of the front page only and in a standard size and position as described on the Intranet

• Front page footer contains the statement about Trust copyright in Arial 10pt

• Document is written in Arial font, size 11pt (or 12pt)

• Headings are all numbered

• Headings for policy sections are in bold and not underlined

• Pages are numbered in the format Page X of Y

Yes

2. Title

Is the title clear and unambiguous? Yes

3. Document History

Is the document history completed? Yes

4. Definitions

Are all terms which could be unclear defined? Yes

5. Policy specific content

Does the policy address, as a minimum, the NHSLA Risk management Standards at Level 1 where appropriate

Yes

6. Consultation and Approval

Has the document been consulted upon? Yes

Where required has the joint Human Resources/staff side committee (or equivalent) approved the document?

Not Required

7. Dissemination


Title of document being reviewed: Yes/No/ Unsure

Comments

Does the document include a plan for dissemination of the policy?

Yes

8. Process for Monitoring Compliance

Is it explicit how compliance with the policy will be monitored?

Yes

9. Review Date

Is the review date identified on the cover of the document?

Yes

10. References

Are supporting references cited? Yes

11. Associated documents

Are associated SLaM documents cited? Yes

12. Impact Assessments

Is an Equality Impact Assessment included as the appendix of the document?

Yes