Quality statement 1: Identifying triggers and warning signs

Quality statement

People in contact with mental health services who have been violent or aggressive are supported to identify triggers and early warning signs for these behaviours.

Rationale

Personal, social, institutional or environmental factors can trigger violent or aggressive behaviours in people with mental health problems who receive support in mental health, health or community settings. Identifying these triggers can help people using mental health services, care staff and carers to understand what prompts violent or aggressive behaviour when people are using these services. This knowledge can prevent violent or aggressive behaviours from escalating by alerting people to early warning signs of distress and enabling them to start immediate de‑escalation or remove the triggers causing the violent or aggressive behaviour. Identifying triggers and early warning signs can also help services to improve organisational practice.

Quality measures

Structure

Evidence of local arrangements to ensure that people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings have identified triggers and early warning signs for these behaviours included in their care plan.

Data source: Local data collection, for example, service protocols on managing violent or aggressive behaviours.

Process

Proportion of people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings whose care plan includes identified triggers and early warning signs for these behaviours.

Numerator – the number in the denominator with a care plan that includes any identified triggers and early warning signs.

Denominator – the number of people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings.

Data source: Local data collection.

Outcome

a) Service user experience of involvement in managing violent and aggressive behaviours.

Data source: Local data collection, for example, surveys capturing service user experience.

b) Number of incidents needing restrictive interventions including observation, seclusion, manual restraint, mechanical restraint and rapid tranquillisation.

Data source: Local data collection and restrictive interventions recorded in the mental health services data set.

What the quality statement means for different audiences

Service providers (such as mental health trusts, mental health community services and primary care mental health services) ensure that systems are in place to identify the factors that prompt violent or aggressive behaviours in people with mental health problems. Service providers also ensure that people are supported to identify their own triggers and early warning signs and that these are recorded in the person's care plan. Service providers share this information to inform care, organisational learning and practice.

Health and social care practitioners (such as mental health nurses, psychiatrists and social workers) encourage and support people with mental health problems who have been violent or aggressive while receiving support to identify triggers and early warning signs. They record identified triggers and early warning signs in the person's care plan, and share this information to inform care, organisational learning and practice.

Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that they commission services that identify the factors that prompt violent or aggressive behaviours in people with mental health problems. They also ensure that people with mental health problems who have been violent or aggressive while receiving support in mental health, health or community settings are supported to identify their own triggers and early warning signs and that these are recorded in the person's care plan.

People in contact with mental health services who have been violent or aggressive when they were using mental health, health or community services are encouraged to think about 'triggers' that might have caused the violent or aggressive behaviour (for example, something that happened to them, something they saw, or a feeling such as disappointment or anger). They are also encouraged to think about the early warning signs that they are about to feel violent or aggressive. They discuss their thoughts with their care team and any 'triggers' or possible warning signs they identify are recorded in their care plan.

Source guidance

Violence and aggression: short-term management in mental health, health and community settings (2015) NICE guideline NG10, recommendation 1.3.16

Definitions of terms used in this quality statement

Violent or aggressive behaviours

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.

[NICE's guideline on violence and aggression]

Triggers

Factors that may instigate violent and aggressive behaviours. They may be:

  • personal

  • constitutional

  • mental

  • physical

  • environmental

  • social

  • communicational

  • functional

  • behavioural.

Triggers may be internal to the service user, based on their perception of the environment potentially shaped by delusions, hallucinations, confusion, disorientation and misperception, or they may be responding to the behaviour or actions of others.

Common triggers in inpatient psychiatric wards include the denial of a request, or a demand to either do something or cease an activity. The symptomatic behaviours of other service users can also trigger violence as they may be intrusive or hard to tolerate. A service user's ability to handle frustration may be severely weakened by their mental health problem, making an aggressive response more likely than if they were well.

[NICE's full guideline on violence and aggression]