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NICE updates guidance on managing violence in NHS settings

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Latest NHS guidance on dealing with aggression in mental health patients has placed emphasis on training staff to defuse potentially violent situations and to avoid using physical restraint, where possible.

The guidelines, published today by the National Institute for Health and Care Excellence, are intended to help nurses and other staff manage violent and aggressive behaviour in people with mental health problems when they are being treated in the NHS.

They apply to all types of provider organisations and patient age groups. Previous NICE guidance, from 2005, only applied to people aged 16 and over in either inpatient psychiatric settings or emergency departments.

“The guideline focuses on how to assess risk and prevent violence, including how to recognise warning signs”

Mark Baker

The new guidelines place a greater emphasis on training staff about how to anticipate aggression and reduce restrictive interventions such as physical restraint.

They also clearly state restraining a person on the floor should be avoided, but when deemed necessary should be for as short a time as possible and that “face down” restraint should be the last resort.

A framework included in the guidelines emphasises staff should be trained in a values-based approach to care, understanding why violence may occur, and skills to defuse aggression when it arises. Staff should also be trained in how to use restrictive interventions safely.

The new guidelines also explicitly state seclusion should not be used in emergency departments and that if mental health patients become aggressive in this setting, staff should view it as psychiatric emergency and urgently refer them for assessment within one hour.

In addition, NICE now recommends that following a restrictive intervention an immediate post-incident debrief should take place – including a nurse and a doctor – to discuss the incident. This is in addition to a previous requirement for a formal external review within 72 hours.

“It is crucial that employers take all the steps they can to safeguard their staff”

Peter Carter

Staffing levels are also addressed in the guidance, calling on employers to define staff to patient ratios for each inpatient psychiatric ward and the numbers of staff required to carry out restrictive interventions.

“Higher staffing levels will be needed in some settings to successfully implement these recommendations,” stated the guidance.

Professor Mark Baker, director of NICE’s centre for clinical practice, said: “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.

“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,” he added.

The Royal College of Nursing welcomed the guidance”, noting that nurses often experienced long-term affects after violent incidents.

“[This guideline] will be useful for many staff who may be at risk to have clear, specific guidance to help them manage in what can be a stressful and intense environment,” said RCN chief executive and general secretary Peter Carter.

“It is also crucial that employers take all the steps they can to safeguard their staff. This means having safe staffing levels, proper training and systems in place to call help quickly if it is needed,” he said.

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Readers' comments (3)

  • As a generalisation most NHS staff cannot tell the difference between someone frightened and someone being aggressive thus making the person more frightened and trying to escape.

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  • want there a judge who said it was in the job decription to be assaulted by patients and their relatives?

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  • Ah, now we are mind readers, body language experts, psychics! Busy ward, lots to do, yes I've got time to notice that patient A. is going to attack me! Sarcastic? Me? never!

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