Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

See implementation: getting started for information about putting the recommendations on manual restraint, rapid tranquillisation and formal external post-incident reviews into practice.

Anticipating and reducing the risk of violence and aggression

Reducing the use of restrictive interventions

Staff training
  • Health and social care provider organisations should train staff who work in services in which restrictive interventions may be used in psychosocial methods to avoid or minimise restrictive interventions. This training should enable staff to develop:

    • a person-centred, values-based approach to care, in which personal relationships, continuity of care and a positive approach to promoting health underpin the therapeutic relationship

    • an understanding of the relationship between mental health problems and the risk of violence and aggression

    • skills to assess why behaviour is likely to become violent or aggressive, including personal, constitutional, mental, physical, environmental, social, communicational, functional and behavioural factors

    • skills, methods and techniques to reduce or avert imminent violence and defuse aggression when it arises (for example, verbal de-escalation)

    • skills, methods and techniques to undertake restrictive interventions safely when these are required

    • skills to undertake an immediate post-incident debrief (see recommendations 1.4.55–1.4.61)

    • skills to undertake a formal external post-incident review in collaboration with experienced service users who are not currently using the service (see recommendations 1.4.62–1.4.63).

A framework for anticipating and reducing violence and aggression in inpatient psychiatric wards

  • Use the following framework to anticipate violence and aggression in inpatient psychiatric wards, exploring each domain to identify ways to reduce violence and aggression and the use of restrictive interventions.

    • Ensure that the staff work as a therapeutic team by using a positive and encouraging approach, maintaining staff emotional regulation and self‑management (see recommendation 1.3.19) and encouraging good leadership.

    • Ensure that service users are offered appropriate psychological therapies, physical activities, leisure pursuits such as film clubs and reading or writing groups, and support for communication difficulties.

    • Recognise possible teasing, bullying, unwanted physical or sexual contact or miscommunication between service users.

    • Recognise how each service user's mental health problem might affect their behaviour (for example, their diagnosis, severity of illness, current symptoms and past history of violence or aggression).

    • Anticipate the impact of the regulatory process on each service user (for example, being formally detained, having leave refused, having a failed detention appeal or being in a very restricted environment such as a low‑, medium- or high‑secure hospital).

    • Improve or optimise the physical environment (for example, use unlocked doors whenever possible, enhance the décor, simplify the ward layout and ensure easy access to outside spaces and privacy).

    • Anticipate that restricting a service user's liberty and freedom of movement (for example, not allowing service users to leave the building) can be a trigger for violence and aggression.

    • Anticipate and manage any personal factors occurring outside the hospital (for example, family disputes or financial difficulties) that may affect a service user's behaviour.

Preventing violence and aggression

Using p.r.n. medication

  • When prescribing p.r.n. medication as part of a strategy to de‑escalate or prevent situations that may lead to violence and aggression:

    • do not prescribe p.r.n. medication routinely or automatically on admission

    • tailor p.r.n. medication to individual need and include discussion with the service user if possible

    • ensure there is clarity about the rationale and circumstances in which p.r.n. medication may be used and that these are included in the care plan

    • ensure that the maximum daily dose is specified and does not inadvertently exceed the maximum daily dose stated in the British national formulary (BNF) when combined with the person's standard dose or their dose for rapid tranquillisation

    • only exceed the BNF maximum daily dose (including p.r.n. dose, the standard dose and dose for rapid tranquillisation) if this is planned to achieve an agreed therapeutic goal, documented and carried out under the direction of a senior doctor

    • ensure that the interval between p.r.n. doses is specified.

De‑escalation

Staff training
  • Health and social care provider organisations should give staff training in de‑escalation that enables them to:

    • recognise the early signs of agitation, irritation, anger and aggression

    • understand the likely causes of aggression or violence, both generally and for each service user

    • use techniques for distraction and calming, and ways to encourage relaxation

    • recognise the importance of personal space

    • respond to a service user's anger in an appropriate, measured and reasonable way and avoid provocation.

General principles
  • Establish a close working relationship with service users at the earliest opportunity and sensitively monitor changes in their mood or composure that may lead to aggression or violence.

Using restrictive interventions in inpatient psychiatric settings

Using restrictive interventions

  • Do not use restrictive interventions to punish, inflict pain, suffering or humiliation, or establish dominance.

Rapid tranquillisation

  • If there is evidence of cardiovascular disease, including a prolonged QT interval, or no electrocardiogram has been carried out, avoid intramuscular haloperidol combined with intramuscular promethazine and use intramuscular lorazepam instead.

Post‑incident debrief and review

Formal external post‑incident review
  • The service user experience monitoring unit or equivalent service user group should undertake a formal external post‑incident review as soon as possible and no later than 72 hours after the incident. The unit or group should ensure that the formal external post‑incident review:

    • is led by a service user and includes staff from outside the ward where the incident took place, all of whom are trained to undertake investigations that aim to help staff learn and improve rather than assign blame

    • uses the information recorded in the immediate post‑incident debrief and the service user's notes relating to the incident

    • includes interviews with staff, the service user involved and any witnesses if further information is needed

    • uses the framework in recommendation 1.2.7 to:

      • evaluate the physical and emotional impact on everyone involved, including witnesses

      • help service users and staff to identify what led to the incident and what could have been done differently

      • determine whether alternatives, including less restrictive interventions, were discussed

      • determine whether service barriers or constraints make it difficult to avoid the same course of actions in future

      • recommend changes to the service's philosophy, policies, care environment, treatment approaches, staff education and training, if appropriate

      • avoid a similar incident happening in future, if possible.

Managing violence and aggression in emergency departments

  • If a service user with a mental health problem becomes aggressive or violent, do not exclude them from the emergency department. Manage the violence or aggression in line with recommendations 1.4.1–1.4.45 and do not use seclusion. Regard the situation as a psychiatric emergency and refer the service user to mental health services urgently for a psychiatric assessment within 1 hour.

Managing violence and aggression in community and primary care settings

  • Health and social care provider organisations, including ambulance trusts, should consider training staff working in community and primary care settings in methods of avoiding violence, including anticipation, prevention, de‑escalation and breakaway techniques, depending on the frequency of violence and aggression in each setting and the extent to which staff move between settings.

Managing violence and aggression in children and young people

Staff training

  • Child and adolescent mental health services (CAMHS) should ensure that staff are trained in the management of violence and aggression using a training programme designed specifically for staff working with children and young people. Training programmes should include the use of psychosocial methods to avoid or minimise restrictive interventions whenever possible. Staff who might undertake restrictive interventions should be trained:

Managing violence and aggression

  • Manage violence and aggression in children and young people in line with the recommendations for adults in sections 1.1–1.6, taking into account:

    • the child or young person's level of physical, intellectual, emotional and psychological maturity

    • the recommendations for children and young people in this section

    • that the Mental Capacity Act 2005 applies to young people aged 16 and over.

Assessment and initial management

Identify any history of aggression or aggression trigger factors, including experience of abuse or trauma and previous response to management of violence or aggression.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

  • National Institute for Health and Care Excellence (NICE)