Introduction

Violence and aggression refer to a range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear.

Violence and aggression are relatively common and serious occurrences in health and social care settings. Between 2013 and 2014 there were 68,683 assaults reported against NHS staff in England: 69% in mental health or learning disability settings, 27% against ambulance staff, 25% involving primary care staff and 26% involving acute hospital staff. Violence and aggression in mental health settings occur most frequently in inpatient psychiatric units and most acute hospital assaults take place in emergency departments.

The manifestation of violence and aggression depends on a combination of intrinsic factors, such as personality characteristics and intense mental distress, and extrinsic factors, such as the attitudes and behaviours of surrounding staff and service users, the physical setting and any restrictions that limit the service user's freedom. The impact of violence and aggression is significant and diverse, adversely affecting the health and safety of the service user, other service users in the vicinity, carers and staff. Violence and aggression can also affect public opinion about services and service users and result in a strong negative impact on the overall experience of care. Although the guideline contains recommendations on intervening before violence and aggression occur, it is not always possible to avoid violence. Therefore a graded set of interventions is needed to prevent minor violence from escalating into severe violence.

Since the publication of the previous guideline in 2005 (NICE guideline CG25) there have been some important advances in our knowledge of the management of violence and aggression, including service users' views on the use of physical intervention and seclusion, and the effectiveness, acceptability and safety of drugs and their dosages for rapid tranquillisation. The previous guideline was restricted to people aged 16 and over in adult psychiatric settings and emergency departments; this update has been expanded to include some of the previously excluded populations and settings. All areas of NICE guideline CG25 have been updated and this guideline replaces it in full.

This guideline covers the short-term management of violence and physically threatening behaviour in mental health, health and community settings. This includes inpatient psychiatric care, emergency and urgent care, secondary mental health care (such as care provided by assertive community teams, community mental health teams, early intervention teams and crisis resolution and home treatment teams), community healthcare, primary care, social care and care provided in people's homes. The guideline covers anticipating and reducing the risk of violence and aggression, prevention methods (such as searching, de‑escalation and pharmacological strategies, including p.r.n. medication), restrictive interventions (for example, restraint, rapid tranquillisation and seclusion), staff training, and post‑incident debrief and review.

This guideline includes adults (aged 18 and over), children (aged 12 and under) and young people (aged 13 to 17) with a mental health problem who are currently service users within mental health, health and community settings. It also covers carers of service users with mental health problems in these settings.

This guideline does not cover but may be relevant to practice regarding people who do not have mental health problems, those who are not carers of people with mental health problems, people in whom the primary behaviour is self‑harm and people with a primary diagnosis of learning disability.

Safeguarding children

Remember that child maltreatment:

  • is common

  • can present anywhere, such as emergency departments and primary care or on home visits.

Be aware of or suspect abuse as a contributory factor to or cause of the symptoms or signs of violence or aggression in children. Abuse may also coexist with violence or aggression. See the NICE guideline on child maltreatment for clinical features that may be associated with maltreatment.

This section has been agreed with the Royal College of Paediatrics and Child Health.

Medicines

The guideline assumes that prescribers will use a medicine's summary of product characteristics to inform decisions made with individual service users.

This guideline recommends some medicines for indications for which they do not have a UK marketing authorisation at the date of consultation, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The service user (or those with authority to give consent on their behalf) should provide informed consent, which should be documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Where recommendations have been made for the use of medicines outside their licensed indications ('off‑label use'), these medicines are marked with a footnote in the recommendations.

  • National Institute for Health and Care Excellence (NICE)