NICE’s updated guideline aims to help safeguard NHS staff and patients by preventing violent situations and offering clear guidance on managing them safely if needed. Physical restraint should only be used as a last resort, once all other methods of preventing or calming the situation have failed. However, if restraint is the only course of action available, the guideline includes clear recommendations on how it should be done to ensure the safety of both staff and the individual.

Commenting on the newly updated guideline, Professor Mark Baker, NICE Centre for Clinical Practice director, said: “This newly updated guideline is designed to help prevent violent situations and to manage them safely when they do occur. New information on anticipating and reducing risk, as well as ways to calm people down has been incorporated and we have also listened to the views of service users on physical restraint and isolation. The guideline focuses on how to assess risk and prevent violence, including how to recognise warning signs, to calm potentially violent patients and manage difficult situations (de-escalation), as well as to intervene safely when violence happens.”

Between 2013 and 2014 there were 68,683 assaults reported against NHS staff in England. The majority of these - 69% - occurred in mental health or learning disability settings and include incidents involving the families or carers of service users as well as service users themselves ¹. The updated guideline covers the short-term management of violence and physically threatening behaviour in psychiatric settings, emergency and urgent care services, assertive community teams, community mental health teams and primary care.

Professor Peter Tyrer, professor of community psychiatry, Centre for Mental Health, Imperial College London and chair of the group that developed the NICE guideline, said: “What became abundantly clear during the discussions of the guideline development group was that violence prevented is NHS money saved. We have many programmes in the country that concentrate on dealing with actual violence but not enough on preventing and de-escalating violence when it is beginning to emerge. Greater understanding of the suffering that leads to violence is an essential part of management.”

Professor Tim Kendall, director of the National Collaborating Centre for Mental Health and facilitator of the group that developed the guideline, said: “As a medical director and consultant psychiatrist I welcome this updated guideline which will make a very important contribution to helping reduce violence and aggression throughout the NHS, especially but not solely in mental health. We now want to see a culture of tolerance towards people with mental health problems, helping health and social care professionals to de-escalate difficult situations and help service users get the support they need when circumstances in the health service can make things worse.

“We want to reduce the times when we restrict people who are wound up by mental health problems and placed in restrictive environments. We are recommending that every trust has a restrictive interventions reduction programme. We also want to develop a culture of learning, such that service users and professionals together can review every time we restrain or restrict a person’s freedom; and give as much attention to human rights as we do to safety. This guidance represents a major step forward for people with mental health problems, especially in institutional settings, but also in the community and across health and social care.”

Dr Peter Staves, service user, informatician and healthcare scientist, Public Health England, and member of the group that developed the guideline, said: “Patient recovery rate and service user experience and wellbeing are directly affected by the management of challenging behaviour. Acute wards, where patients can be at their most challenging yet at the same time most vulnerable, is a prime example of this.

“In my experience the adoption of best practice guidance on the management of patients with difficult symptoms on acute wards can lead to happy ward life. When service users are treated not for their diagnosis but rather as a person, and involved fully in their treatment, ward life turns from two combative fronts; patient and staff, to one team all with the same goal; health. This in turn leads to a reduction in the level of violence and aggression and a reduction in cost to mental health services.

“Getting to this stage involves changes of ethos and approach from both NHS staff and the service users they treat. This can be difficult to achieve if both parties are set in their ways due to bitter past experience. Recently however, my experience has been that happy mental health services can be fostered with a strong yet caring, focused leadership pushing for true patient involvement.

“This updated guidance has many suggestions on how to engage with the patient, even when the use of restraint or rapid tranquilisation is required, that if adopted with global aims of compassion, caring and positive enthusiasm can make mental health services more tolerant environments in which to be a patient, carer or NHS employee.”  

Key recommendations in the guideline include:

Anticipating and reducing the risk of violence and aggression, 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:

• 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

De-escalation: 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 and use techniques for distraction and calming, and ways to encourage relaxation.

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. 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, to help separate them from an aggressor in a safe manner without the use of restraint.

Managing violence and aggression in children and young people: 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.

Physical restraint: Physical restraint should only be used as a last resort, once all other methods of preventing or calming the situation have failed. When using physical restraint the person’s head and neck should be supported and nothing should interfere with their breathing, circulation or ability to communicate – physical restraint should not be used for more than 10 minutes. The recommendations are clear that restraining a person on the floor should be avoided. If it becomes necessary, it should be with their back to the ground. If prone or ‘face down’ restraint is unavoidable, it should be for as short a time as possible.

The updated guideline on the short-term management of violent and physically threatening behaviour in mental health, health and community settings will be available at http://www.nice.org.uk/guidance/NG10 from 29 May 2015.

Ends

For more information call the NICE press office on 0300 323 0142 or out of hours on 07775 583 813.

Notes to Editors

About the guidance

1. Between 2011 and 2012 there were 60,000 assaults reported against NHS staff in England: 69% in mental health or learning disability settings; 3% against ambulance staff; 3% involving primary care staff and 26% involving acute hospital staff. Most violent or aggressive incidents in mental health settings occur in inpatient units and most acute hospital assaults occur in emergency departments.
2. Embargoed copies of the guidance are available from the NICE press office on request.
3. 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.