Dealing with violence in healthcare settings is about more than drugs and restraint, claims the National Institute for Clinical Excellence. But what is it about?
Dealing with violence in healthcare settings such as accident and emergency (A&E) departments can be trickier than in other places where security and other staff may face aggressive behaviour – shopping malls, say, or stadia. The violent person could be psychotic, delusional, and on medication. They could want to harm themselves.
Yes, A&E and mental health staff can use options not available to security patrollers in art galleries or nightclubs – ‘rapid tranquillisation’. Yet wrong moves could – as a National Institute for Clinical Excellence (NICE) quick reference guide points out at the start – have ‘legal consequences’. NICE mention high profile cases where patients have died during staff ‘intervention’. Any intervention, NICE adds, must be a reasonable and proportionate response to the risk it seeks to address. Safety of others (the Health and Safety at Work Act) must be taken into account, and the violent person’s dignity and rights.
Violence at work
As with any walk of life, facts about violence at work are thin on the ground (see the February 2004 Professional Security for The Corps manager Ian Hall’s own research). NICE quote a 1998-99 NHS Executive survey that there were about 65,000 violent incidents a year against staff across the NHS. The average number of incidents in mental health trusts was more than three times the average for all trusts. NICE’s guidelines for the NHS on handling disturbed and violent behaviour in psychiatric inpatient settings and A&E talk in terms of risk assessment and risk management. The guide says: “Rapid tranquillisation, physical intervention and seclusion should only be considered once de-escalation and other strategies have failed to calm the service user.”
Avoid physical intervention
What the guide calls ‘physical intervention’ should be avoided: “Under no circumstances should direct pressure be applied to the neck, thorax, abdomen, back or pelvic area … Every effort should be made to use skills and techniques that do not use deliberate application of pain.” Earlier the guide says: “The level of force applied must be justifiable, appropriate, reasonable and proportionate to a specific situation and should be applied for the minimum possible amount of time.” For instance: “Based on an assessment of risk, it may be necessary to search some service users to ensure a safe and therapeutic environment.” A search should be a ‘reasonable and proportionate response’ to the reason for a search.
De-escalation
Staff should be aware of their verbal, and non-verbal behaviour, according to the guide. De-escalation techniques include attempting to establish a rapport; offering and negotiating realistic options; avoiding threats; asking open questions and asking about the reason for the service user’s anger; showing concern and attentiveness through non-verbal and verbal responses; listening carefully; not patronising and not minimising the service user’s concerns. “If a weapon is involved, ask for it to be put in a neutral location rather than handed over.” The document suggests possible warning signs ‘to indicate that a service user may be escalating towards physically violent behaviour’; such as tense and angry facial expressions, pacing, refusal to communicate, and verbal threats.
Need for training
The document stresses the need for training: “All staff whose need is determined by risk assessment should receive ongoing competency training to recognise anger, potential aggression, antecedents and risk factors of disturbed/violent behaviour and to monitor their own verbal and non-verbal behaviour. This should include methods of anticipating, de-escalating or coping with disturbed/violent behaviour.”
For the full 83-page NICE guide ‘Violence: the short-term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments’ visit www.nice.org.uk/CG025NICEguideline
NHS security service view
Maria Nyberg-Coles, Senior Policy Manager at the NHS Security Management Service (NHS SMS) said: “The NHS SMS is pleased to have supported the development of this essential piece of work. Experts from many fields have collaborated in drawing up this important guidance, which I expect to make real improvements to the lives of staff and service users. The NHS SMS, with NIMHE [National Institute for Mental Health in England], have developed a training syllabus on non-physical intervention techniques for staff working in this environment. Following trials in the summer, it will be implemented throughout the NHS and includes de-escalation techniques and cultural awareness sessions.”
Lack of provision
All very well, but so what? Well, because of ‘care in the community’, it may be that security staff like police come into contact with the mentally ill.
Equally, if private security contract staff are doing former police tasks, such as in custody units, they may have to deal with some mentally ill. A conference organised by the Independent Police Complaints Commission in January heard that half of those who die in police custody have some form of mental illness. Sgt Jon Dowd of Northumbria Police, pictured, has studied how police deal with the mentally distressed. Last year he won a Queen’s Award for Innovation for delivering training to Northumbria firearms officers and negotiators, so that they can better assess a situation with people with mental health difficulties. Despite the need for mental health training for police officers being mentioned in official reports and inquiries over the years, Sgt Dowd added there is no UK police provision for mental health training. He claimed that such training would increase officer confidence.
