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Type and Title of Submission


Title:

Prevention and management of violence and aggression - promoting safe and therapeutic services in older people's mental health

Description:

How a practice development nurse managed the introduction of a new programme of training in the prevention and management of violence and aggression for older people's mental health inpatient staff. We describe the process of implementation from pilot to rollout of an organisation/ county wide initiative and we describe the outcomes of clear patient and staff benefits.

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG42 - Dementia

Category(s) that most closely reflects the nature of the submission:

Practice development project - NICE recommendation

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

The aim of the programme was to improve the general wellbeing and overall experience of patients and staff in older people's mental health in-patient units by delivering a new and adapted in-house training programme for the safe and therapeutic management of violence and aggression. To incorporate known best practice in relation to the physical and psychological needs of older people and levels of frailty in line with national guidance on capacity and consent to treatment procedures to protect vulnerable adults - no secrets 2002, and guidance for restrictive physical interventions - how to provide safe services for people with learning disabilities, 2002. Also consulted was the RCN guidance, 2004 - Restraint revisited and the Commission for Social Care Inspectorate guidance Rights, Risk and restraint. To provide quantitative data on reduction/ change in incident reports relating to violence and aggression; monitor and improve staff sickness and absence and retention rates, reduce stress and to collect data related to the single equality scheme operating at the Trust in order to inform adaptations to the programme in an ongoing manner.

Objectives

Practice development nurse to undergo general services association (GSA) tutor training. Adapt the PMVA training programme for use in OPMHS. Pilot a five day course for senior staff (modern matrons, ward managers and charge nurses) within in-patient services to provide an opportunity for them to advise on the suitability and applicability of the course content. Pilot the training with staff in four inpatient units (two functional and two organic) in the East Locality of the Trust. Evaluate with pre and post training questionnaires based on the questions and standards used for the National Audit of Violence. Introduce paperwork to record and audit PMVA practice on each unit across OPMH. Identify need for training in floor restraint to be included. Identify commitment from senior management to provide an in-house specially adapted programme for the safe and therapeutic management of violence and aggression of older people with dementia and behaviour that challenges for all staff that work in the in-patient units for OPMHS that have responsibility working directly with in-patient service users (funding, tutor training) and scope for rollout across the Trust as mandatory training as part of the essential training review. To introduce psychology led reflective practice groups into all OPMHs inpatient units caring for people with dementia focussing on understanding the cognitive and emotional aspects of challenging behaviour in dementia. To identify practitioners working in OPMH inpatient units to train as PMVA tutors. Rollout the training with ongoing audit and monitoring to maintain specified improvements in outcome and develop practice in PMVA in OPMHs.

Context

Prevention and management of violence and aggression, PMVA training and particularly the use of 'control and restraint' training hasn't traditionally been deemed appropriate for use in OPMHS. The threat of physical assault is a real issue for staff working on in-patient units and they are often required to work with challenging situations without the necessary knowledge and skills to do so confidently and safely. Challenging behaviour is increasing on such units as older people are maintained in the community longer and are physically fitter than 20 years ago. People with dementia are at risk of serious injury from other people with dementia on in-patient units. The National Audit of Violence (2008) highlighted the difficulties experienced by this staff group. It found that nurses on wards for older people were significantly more likely to experience physical assault (64%) than those on wards for working age adults (46%), with some describing serious injury such as fractures, dislocations and black eyes. These numbers increase to 73% on those wards for people with organic disorders. 67% of staff had attended some PMVA training in the last 5 years and of those, 50% were dissatisfied with the training. Most reported they were unable to apply the training to real life situations. Local results reflected the overall national findings in this audit. The NHS security management services (SMS) and the National Institute for Mental Health in England (NIMHE) have developed a national syllabus of training in non-physical intervention that staff in mental health and learning disabilities must achieve. Local units were recording a high level of incidents related to violence and aggression from patients with behaviour that challenges and poor staff sickness absence and retention rates could be directly linked to stress and anxiety related to inappropriate knowledge and management in this area.

Methods

The Practice development nurse successfully completed the GSA tutor certificate and reviewed the content of the physical skills training to ensure it was applicable for use in OPMHs. A pilot week of PMVA training was launched for senior nursing staff within in-patient services giving them an opportunity to consult and advise on course content. In addition to standard PMVA the course contains a session on understanding challenging behaviours from the point of view of patient and staff and the inter-relationship between these. It proposes a model of reflective practice to use in groups on all OPMHs inpatient units. Physical skills training in break-away techniques is included for all staff and physical intervention skills training up to seated restraint and de-escalation is included for all frontline clinical staff working on in-patient units. Training in floor restraint has been offered to teams where there is a particular need. All interventions are assessed for risk and care-planned for individual service users. 68 staff have been trained in the pilot out of the 214 OPMHS inpatient staff working across the Trust, approximately 31% . All staff who attended the training completed the pre and post training questionnaires. Audit data on number and type of incidents related to violence and aggression before and after training have been analysed and levels of sickness and retention both before and after training are included. As a result of the successful pilot a commitment to rollout the training as part of a Trust wide essential training review was secured. In addition to standard PMVA training two mandated training programmes are available for people working in OPMH; the 5 day qualifying physical intervention/ breakaway course and 2 day physical intervention refresher and breakaway course. Reflective practice groups have been planned in all OPMHS organic inpatient units.

Results and evaluation

68 staff were trained in PMVA during December 2008 and March 2009. This represents 74% of staff working on inpatient units in one locality. 68 questionnaires were sent out: pre course - 52 returned. Post course - 23 returned - 96% of staff had been attacked, threatened or made to feel unsafe prior to the training compared with 52% post training. - 75% staff felt they dealt well with violence from service users pre training (2% made no comment, 12% felt they didn't deal well with violence from service users) this rose to only 78% post training (but 26% made no comment, no one felt they didn't do this well). - 25% agreed staff would use the threat of medication to control service users pre course, 65% staff felt this was less likely to happen post training, (4% felt they were more likely, 30% made no comment). - 48% of staff reported that they would be less likely to use physical interventions post training, (30% thought they were more likely, 26% made no comment). Incident reports on violence and aggression 65 violent incidents in the 6 months preceding training (39 service user assaults on staff, 16 between service users), against 10 incidents in the 5 months post training (7 assaults on staff, 3 between service users, this period includes the closure of 14 organic assessment beds in September 2008, leaving 60 inpatient beds in OPMHs, East Sussex). Sickness data 547 days were lost to sickness across inpatient staff in East Sussex during the 4 month period (August to November 2008), this increased to 716 days during April to July 2009. (This may well be a seasonal variation and will need comparison against the same period for this year 2009).

Key learning points

The programme was rolled out to staff teams, unit by unit this worked particularly well in supporting teams to develop a shared approach to managing challenging behaviour. The training has raised the moral and confidence of staff. They feel it has recognised the difficulties and anxiety they were experiencing. The training also draws on and values their experience in managing and de escalating aggressive and violent behaviour exhibited by some people with dementia. Audit questions could have included the use of risk assessment and care plans related to the use of PMVA and the use of language to describe incidents of aggression within nursing records. Future audit will also include prescribing practice. Anecdotally staff have reported increasing confidence in their skills of verbally defusing situations because of their increased confidence in their own ability and their knowledge of physical interventions. Need to include a 'burn out' questionnaire as part of the pre-course information. This can raise practitioner awareness of their emotional health and the impact it has on their patient care. It has been very difficult being the only OPMH practitioner trained in PMVA deliver such large training programme when this has been only part of my job responsibilities. In retrospect it would have been better to have trained with someone else who worked in OPMHs as a practitioner to help deliver the training. Incorporating a reflective practice element to the training worked well in helping staff understand challenging behaviour in context. There is a requirement to teach rapid tranquillisation now as a part of PMVA training which needs to be given on the floor to safeguard the patient the author is also aware that this needs serious consideration in the light of recent research on the impact of anti psychotic medication on people with Dementia.

Contact Details

Name:Wendy Harlow
Job Title:NICE & SCIE Implementation facilitator
Organisation:Sussex Partnership NHS Foundation Trust
Address:Aldrington House
Town:Brighton
County:East Sussex
Postcode:BN3 4AG
Phone:07917592984
Email:wendy.harlow@sussexpartnership.nhs.uk

 

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This page was last updated: 28 September 2009

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.