NICE clinical guidelines
Issued: February 2005
CG25

Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg25

Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

Prediction

  • Measures to reduce disturbed/violent behaviour need to be based on comprehensive risk assessment and risk management. Therefore, mental health service providers should ensure that there is a full risk management strategy for all their services.

Training

  • All service providers should have a policy for training employees and staff-in-training in relation to the short-term management of disturbed/violent behaviour. This policy should specify who will receive what level of training (based on risk assessment), how often they will be trained, and also outline the techniques in which they will be trained.

  • All staff whose need is determined by risk assessment should receive ongoing competency training to recognise anger, potential aggression, antecedents and risk factors of disturbed/violent behaviour, and to monitor their own verbal and non-verbal behaviour. Training should include methods of anticipating, de-escalating or coping with disturbed/violent behaviour.

  • All staff involved in administering or prescribing rapid tranquillisation, or monitoring service users to whom parenteral rapid tranquillisation has been administered, should receive ongoing competency training to a minimum of Immediate Life Support (ILS – Resuscitation Council UK) (covers airway, cardio-pulmonary resuscitation [CPR] and use of defibrillators).

  • Staff who employ physical intervention or seclusion should as a minimum be trained to Basic Life Support (BLS – Resuscitation Council UK).

Commentary

No studies were identified that specifically addressed the issues described in the five key priorities above (the extent to which risk assessment and risk management reduce the risk of disturbed/violent behaviour; the effectiveness of policies on training or training itself in relation to the management of disturbed/violent behaviour; or training in relation to resuscitation in psychiatric settings). The Guideline Development Group carefully considered the available evidence and used formal consensus techniques to extrapolate and develop these recommendations. In the opinion of the Group the fulfilment of the last two recommendations above constitutes a duty of care. (See also the Legal preface .)

Working with service users

  • Service users should have access to information about the following in a suitable format:

    • which staff member has been assigned to them and how and when they can be contacted

    • why they have been admitted (and if detained, the reason for detention, the powers used and their extent, and rights of appeal)

    • what their rights are with regard to consent to treatments, complaints procedures, and access to independent help and advocacy

    • what may happen if they become disturbed/violent.

This information needs to be provided at each admission, repeated as necessary and recorded in the notes.

Commentary

Although no studies were identified that specifically addressed the issue of information provision for service users, the Guideline Development Group viewed this as an important issue requiring guidance. The Group maintain it is a legal right that detained service users are given this information and that this information should be viewed as a right for all service users. (See also the Legal preface .)

  • Service users identified to be at risk of disturbed/violent behaviour should be given the opportunity to have their needs and wishes recorded in the form of an advance directive. This should fit within the context of their overall care and should clearly state what intervention(s) they would and would not wish to receive. This document should be subject to periodic review.

Commentary

Although no studies were identified that specifically addressed the issue of advance directives, the Guideline Development Group (in particular those with personal experience of the issue) felt that it was important for service users to be able to have input into their care. The Group did not consider that discussing these issues with appropriate service users would cause unnecessary anxiety. The Group used formal consensus techniques to develop this recommendation.

Rapid tranquillisation, physical intervention and seclusion

  • Rapid tranquillisation, physical intervention and seclusion should only be considered once de-escalation and other strategies have failed to calm the service user. These interventions are management strategies and are not regarded as primary treatment techniques. When determining which interventions to employ, clinical need, safety of service users and others, and, where possible, advance directives should be taken into account. The intervention selected must be a reasonable and proportionate response to the risk posed by the service user.

Commentary

There is a lack of evidence relating to the effectiveness of these three interventions, particularly for physical intervention and seclusion. The Guideline Development Group therefore felt the need to stress caution when implementing these interventions, and used formal consensus techniques to derive this recommendation. (See also the Legal preface .)

Physical intervention

  • During physical intervention one team member should be responsible for protecting and supporting the head and neck, where required. The team member who is responsible for supporting the head and neck 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.

Commentary

There is limited evidence in this area. However, a number of high profile inquiries, most recently, the inquiry into the death of David Bennett, have stressed the need for staff to protect a service user's head and airway during the physical intervention process. The inquest suggests that failure to do so, and the application of pressure to certain parts of the body, may endanger the life of the service user. The focus groups conducted for this guideline also heard reports from participants who described finding it difficult to breathe during physical intervention due to their head not being sufficiently supported. After consultation with experts, including trainers, the Guideline Development Group used formal consensus techniques to develop recommendations in this area. The Group consider the protection of the head when appropriate to constitute a duty of care. (See also the Legal preface .)

  • A number of physical skills may be used in the management of a disturbed/violent incident.

    • The level of force applied must be justifiable, appropriate, reasonable and proportionate to a specific situation and should be applied for the minimum possible amount of time.

    • Every effort should be made to utilise skills and techniques that do not use the deliberate application of pain.

    • The deliberate application of pain has no therapeutic value and could only be justified for the immediate rescue of staff, service users and/or others.

Commentary

There is limited evidence in this area. A great deal of discussion took place in the course of the development of the guideline concerning this issue. To ensure a balanced representation at guideline development meetings, experts holding differing perspectives were invited to give presentations. Using formal consensus techniques the Guideline Development Group derived a recommendation which restricts the use of pain to the immediate rescue of staff, service users or others.