Quality statement 2: Preventing and managing violent or aggressive behaviour

Quality statement

People in contact with mental health services who have been violent or aggressive are supported to identify successful de-escalation techniques and make advance statements about the use of restrictive interventions.

Rationale

Identifying de-escalation techniques that have worked in the past increases the likelihood that de-escalation will be effective and restraint won't be necessary. De‑escalation should start when the first signs of agitation, irritation, anger or aggression are recognised. Should a situation escalate to a point at which restrictive intervention is needed, de-escalation should still be attempted. Making advance statements for circumstances when restrictive interventions need to be used allows the person to express their wishes about the most acceptable types of restrictive intervention and can minimise potential harm or discomfort.

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 any identified de‑escalation techniques that have been successful and advance statements about the use of restrictive interventions included in their care plan.

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

Process

a) 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 identifies de-escalation techniques that have been successful.

Numerator – the number in the denominator with a care plan that includes any identified de-escalation techniques that have been successful.

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, for example care plan reviews.

b) 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 advance statements about the use of restrictive interventions.

Numerator – the number in the denominator with a care plan that includes advance statements about the use of restrictive interventions.

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, for example care plan reviews.

Outcome

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

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

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

Data source: Local data collection. Information on restrictive interventions is 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 involve people with mental health problems who have been violent or aggressive while using the services in identifying de-escalation techniques that have been successful, and that the person's care plan includes advance statements about the use of restrictive interventions.

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 using the services to identify de-escalation techniques that have been successful and to make advance statements about the use of restrictive interventions, and record this information in the person's care plan.

Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that they commission services in which people with mental health problems who have been violent or aggressive while using the services are involved in identifying de-escalation techniques that have been successful and make advance statements about the use of restrictive interventions, and that this information is recorded in care plans.

People in contact with mental health services who have been violent or aggressive while using the services are encouraged to think about what made them feel calmer (such as talking with someone or taking a medication). They discuss this with their care team and explain what they would like their care team to do in the future if they become distressed. They may also make a written statement (called an advance statement) about their preferences if a 'restrictive intervention', such as physically holding them, or giving them an injection of medication, is needed. All of this information is 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]

De-escalation

The use of techniques (including verbal and non-verbal communication skills) aimed at defusing anger and averting aggression. 'When needed' (p.r.n.) medication can be used as part of a de-escalation strategy but 'when needed' medication used alone is not de-escalation.

[NICE's guideline on violence and aggression]

Advance statement

A written statement that conveys a person's preferences, wishes, beliefs and values about their future treatment and care. An advance statement is not legally binding.

[NICE's guideline on violence and aggression]

Restrictive interventions

Interventions that may infringe a person's human rights and freedom of movement, including observation, seclusion, manual restraint, mechanical restraint and rapid tranquillisation.

[NICE's guideline on violence and aggression]