THE STATE HOSPITALS BOARD FOR SCOTLAND

THE PREVENTION AND MANAGEMENT OF VIOLENCE AND AGGRESSION POLICY

(PMVA)

Policy Reference Number / CP02 / Issue: 2
Lead Author / Nursing Director
Contributing Authors / Training and Professional Development Manager
Nurse Consultant – FN
Risk Management Team Leader
PMVA Senior Trainer/Advisor
Clinical Effectiveness Team Leader
Advisory Group / PMVA working group
Approval Group / Senior Management Team
Implementation Date / 01/08/2011
Review Date / 31/07/2013
Responsible Officer (SMT) / Nursing Director

Contents

No /
Index
/
Page
1 / Purpose / 3
2 / Scope / 3
3 / Guiding Principles / 3
4 /

Legislative Framework

/

4

5 / Good Practice Guidance / 6
6 / Definitions / 7
7 / Risk Assessment Procedures
  • Appendix 1 – Initial Admission Risk Assessment
/ 10
(16-18)
8 / Risk Management Procedures / 11
9 / Incident Reviews / 14
10 / Performance Indicators / 14
11 / Format / 15
12 / Review / 15
13 / Policies
  • Forensic Psychiatric Observations Policy
  • Appendix 1 – Observation plan
  • Appendix 2a – Observation flow chart 1
  • Appendix 2b – Observation flow chart 2
/ 19-28
  • Disassociation Policy
/ 29-33
  • Physical Intervention Policy
  • Appendix 1 – Physical Intervention Flow chart
  • Appendix 2 – Post Physical Intervention Nursing Assessment
/ 34-47
  • Medication in the Management of Violence Policy
  • Appendix 1 – Emergency Prescribing Algorithm
  • Appendix 2 – Physical Observation Chart for Acute Psychiatric Emergency Treatment
/ 48-54
  • Seclusion Policy
  • Appendix 1 – Instigation Form
  • Appendix 2 – Primary Review Form
  • Appendix 3a – Emergency Care Plan Guidance
  • Appendix 3b – Emergency Care Plan
  • Appendix 4 – Nursing Review Form
  • Appendix 5a – Junior Medical Staff Review Form
  • Appendix 5b – Junior Medical Staff Review Form (Night)
  • Appendix 6a – Senior Medical Staff Review Form
  • Appendix 6b – Senior Medical Staff Review Form (Night)
  • Appendix 7 – Clinical Team Care Plan
  • Appendix 8 – Daily Report Template
  • Appendix 9 – Notification of Seclusion Ending
  • Appendix 10 – Seclusion Recording Sheet
  • Appendix 11a – Seclusion Flow chart 1
  • Appendix 11b – Seclusion Flow chart 2
/ 55-80
  • Pinel Restraint System Policy
  • Appendix 1 – Flowchart of process
/ 81-87
  • Use of Extra-ordinary Personal Protective Equipment Policy
  • Appendix 1 – Personal Protective Equipment Request Form
  • Appendix 2 – Personal Protective Equipment Weekly Check
  • Appendix 3 – Personal Protective Equipment Return Form
/ 88-93
14 / PMVA Clinical Group Protocol / 94
15 / References / 95-97
16 / Bibliography / 98-100
  1. PURPOSE

The safe and effective treatment of patients who may present as violent, aggressive or dangerous is a key function of The State Hospital. The prevention and management of violent and aggressive behaviour requires a cohesive, multi-faceted organisational approach.

The purpose of this group of policies is to:

  • assess and reduce the risk of externally directed violence towards our staff, other patients and members of the public;
  • establish safe, appropriate management of patients who may present a potential or actual risk of behaving in a violent or aggressive way;
  • describe graded interventions ranging from, the recognition of potential violence and its prevention, de-escalation, physical intervention techniques, seclusion, and in exceptional cases the use of personal protective equipment by staff;
  • ensure adequate training and refresher courses for staff in the prevention and management of violence and aggression;
  • establish audit mechanisms for the regular review of episodes of violence and aggression and
  • ensure that all patients, regardless of culture, gender, diagnosis, sexual orientation, disability, and ethnicity or religious/spiritual beliefs should be treated with dignity and respect.
  1. SCOPE

2.1This policy applies to all situations where violence or aggression occurs, or may occur, within the context of The State Hospital, including incidents out with the hospital when patients are under the supervision of staff.

2.2It does not extend to the general assessment and management of all risks posed by State Hospital patients, who may require to stay in a secure environment as a result of a perceived risk to the general public, but who do not necessarily pose an immediate threat of violence.

2.3Observation is a key part of the prevention and management of violence and aggression. Its use for other areas of clinical risk such as self-harm or suicide is not addressed in these policies.

  1. GUIDING PRINCIPLES

3.1All patients should be treated under conditions of no greater security than is justified by the degree of danger they present to themselves or others, and in such a way as to maximise rehabilitation and their chances of sustaining an independent life.

3.2The State Hospital policies and procedures in respect of patient care are guided by and compliant with theUniversal Declaration of Human Rights (Human Rights Act 1998).

3.3Although the knowledge and skills of hospital staff enable them to carry out the primary purpose of the hospital, (the management and treatment of people with mental disorder who manifest dangerous, violent, and criminal propensities) nevertheless, in common with the rest of the NHS, The State Hospital operates a policy of violence reduction and will ensure that systems and procedures reflect this stance.

3.4The Policy on Staff Personal Safety (Human Resource 08) and Incident Response/Staff Support (Quality Policy 12) should be read in conjunction with this group of Clinical Policies.

3.5TheState Hospital policy states that the management of violence and aggression should begin with prevention, wherever possible.

3.6This group of policies seeks to guide staff in the procedures to be used. Staff involved in the prevention and management of violent and aggressive behaviour should be familiar with these policies, particularly the legislative background as outlined below.

4.LEGISLATIVE FRAMEWORK

4.1The Mental Health (Care & Treatment) (Scotland) Act 2003 came in to force in October 2005.

  • This defines the duties and responsibilities of mental health professionals in respect of patients detained under the Act. These provisions apply to all State Hospital patients, whether admitted under the Mental Health (Care &Treatment) (Scotland) Act 2003 or under sections of the Criminal Procedure (Scotland) Act 1995.
  • In the Act, one of the criteria to be satisfied for any compulsory care is that if the patient were not provided with medical treatment there would be a significant risk to their health, safety or welfare or; to the safety of any other person.
  • Section 24.3 (3) (d) of the Act defines the circumstances in which urgent medical treatment can be given and includes; “Preventing the patient from – Behaving violently, Being a danger to the patient or others”.
  • Emphasises the rights of patients and its statement of principles (10 guiding principles) highlights the importance of staff taking in to account the views and wishes of patients and carers when carrying out any functions under the Act.
  • May include Advance Statements by patients of their preferences in respect of the management of episodes of violence and aggression. Staff must have regard to these wishes and, if over-riding them, must be able to justify this.

4.2The Human Rights Act (1998) incorporates the European Convention of Human Rights (ECHR) into UK legislation. The ECHR provides a framework within which the individual’s rights are balanced against the public interest. It is unlawful for public authorities to act, or fail to act in a way which compromises a convention right, unless there is an adequate reason, and that the reasons for the decision are transparent and not arbitrary.

4.2.1The State Hospital, as a public authority, is required to ensure that respect for human rights is at the core of our day to day work.

4.2.2In order to assess whether any actions under this group of policies are compatible with the ECHR or not, three key aspects must be addressed.

The actions taken must:

  • be lawful and inaccordance within the statutory powers of the hospital staff e.g. Mental Health (Care & Treatment) (Scotland) Act 2003 and other laws and regulations;
  • have a legitimate aim, with justification for any breach that may occur;
  • deemed necessary in a democratic society and
  • beproportionate.

In the case of procedures for the prevention and management of violence and aggression, especially those that potentially may involve greater infringement of patients’ rights, the staff response must be justified, appropriate and proportionate to the assessed actual or potential risk.

4.2.3Absolute rights: the absolute rights contained in Articles 2 and 3 must not be compromised. Article 3 of the ECHR states that “no one shall be subjected to torture or to inhuman or degrading treatment or punishment”. The State Hospital will teach and practice techniques for the prevention and management of violence and aggression that are humane, proportionate to the threat posed, and not punitive.

4.2.4Limited rights: these include the rights under Articles 5: the right to liberty and security of person, and Article 6, the right to a fair and public hearing. These are interfered with by legitimate means such as the detention of a mentally disordered person in accordance with the law.

4.2.5Qualified rights: the most important for these policies include rights under Article 8, the right to privacy, and Article 11, the right to freedom of peaceful assembly and to freedom of association with others.

4.2.6There may be circumstances in which qualified rights have to be curtailed for a period of time in the context of these policies in order to prevent greater harm to the security and safety of others.

4.2.7.The grounds for any action interfering with a qualified right must be established and the response must be proportionate. This means that the interference must be the minimum consistent with the actual risk of violence or aggression and subject to review as circumstances change.

4.2.8.The interpretation of these rights is changing as new case law is established and this must be taken into account in policy.

4.2.9The State Hospital upholds the limited and qualified rights of patients to liberty and security, privacy, and freedom of expression.

4.2.10The Human Rights Act (1998) places a responsibility on the hospital to give a reasonable explanation to patients of actions by staff that may infringe their rights. These policies will be made accessible to patients for their information, with the exception of security aspects that will remain within The State Hospital Security Manual.

4.3The Health and Safety at Work Act (1974) (section 2) states:

“It shall be the duty of every employer to ensure, so far as reasonably practicable, the health, safety and welfare at work of all its employees”.

4.4The Management of Health and Safety at Work Regulations (1999)Regulation 3 (1) states:

“Every employer shall make a suitable and sufficient assessment of the risks to the health and safety of his employees to which they are exposed whilst they are at work”.

4.5The PPE at Work Regulations 1992 (as amended) requires personal protective equipment be supplied and used at work wherever there are risks to health and safety that cannot be adequately controlled in other ways.

4.6Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) (RIDDOR)places a duty on employers to record and report assaults against their staff. The State Hospital therefore has a responsibility to monitor episodes of violence and aggression in which staff may be injured, to understand the causes, investigate serious incidents and do all it can as an employer to reduce the risk of harm to staff.

  1. GOOD PRACTICE GUIDANCE

In addition to the legislative framework, these policies have been created using good practice guidance as follows:

American Nurses Association (2000) Position Statement on the Use of Seclusion and Restraint: USA: ANA.

Blofeld, J.(chair) (2003) An Independent Inquiry Set Up Under HSG(94)27 into the Death of David ‘Rocky’ Bennett. Norfolk, Suffolk and Cambridgeshire Strategic Health Authority: Cambridge.

British Institute of Learning Disabilities (1996) Physical Interventions: A Policy Framework. Glasgow: BILD.

Department of Health (2000) Report of the Review of Security at High Security Hospitals.London: HMSO.

National Institute for Mental Health in England (2004) Developing Positive Practice to Support the Safe and Therapeutic Management of Aggression and Violence in Mental Health Inpatient Settings: Mental Health Policy Implementation Guide.

Ndegwa, D. (2000) Social Division and Difference: Black and Ethnic Minorities. London: NHS National Programme on Forensic Mental Health Research and Development.

Nursing and Midwifery Advisory Committee (1999) Practice Guidance: Safe and Supportive Observation of Patients at Risk: Mental Health Nursing Addressing Acute Concern. London: NMAC.

RoyalCollege of Nursing (1998) Dealing with Violence Against Nursing Staff: An RCN Guide for Nurses and Managers. London: RCN.

RoyalCollege of Psychiatrists (1998) The Management of Imminent Violence:A Quick Reference Guide. London.

The Mental Welfare Commission for Scotland (2002) Rights, Risks and Limits to Freedom: Guidance for the Use of Restraint. Edinburgh.

The National Institute for Clinical Excellence (2005) Violence: The Short-term Management of Disturbed/Violent Behaviour in Psychiatric Inpatient Settings and Emergency Departments:A Clinical PracticeGuideline. London: NICE.

The United Kingdom Central Council (2002) The Recognition, Prevention, and Therapeutic Management of Violence in Mental Health Care. London:UKCC.

The United Kingdom Central Council (2002) Nursing in Secure Environments. London: UKCC.

6. DEFINITIONS

Acute Psychiatric Emergency Treatment is treatment defined by local protocol for the management of acute psychiatric emergencies, also know as rapid tranquillisation. This usually involves the administration of medication over a period of 30-60 minutes in order to produce a state of calm/light sedation. The aim is to achieve an optimal reduction in agitation and aggression, thereby allowing continued interaction including response to speech. Deep sedation or sleep is not considered a desirable outcome of Acute Psychiatric Emergency Treatment (NICE 2005).

BreakawayTechniques are defined as specific physical intervention techniques that are used by staff to protect themselves from (actual or potential) injury and / or to escape from a patient who is holding them by their clothing or a body part (Southcott et al 2002).

Close Proximity is a distance close to, though not within arms length of a patient.

Competent Member of Staff is a person designated by a registered nurse who has specific observation tasks. This member of staff should:

  • take an active role in engaging positively with the patient;
  • be appropriately briefed about the patient’s history, background, specific risk factors and particular needs;
  • be familiar with the ward, the ward policy for emergency procedures and potential risks in the environment;
  • be able to increase or decrease the level of engagement with the patient as the level of observation changes and
  • be approachable, listen to the patient, know when self disclosure and the therapeutic use of silence are appropriate and be able to convey to the patient that they are valued.

(NICE, Guidelines 2005)

Constant eyesight is when the patient should be observed visually at all times.

DATIX is a risk management software programme which is used at department level to record all reportable incidents within the hospital. The Risk Management Team utilise this information to identify whether any further investigation is required and to record all claims, complaints, issues and the hospital corporate risk register.

Deep sedation is a reduction of consciousness and motor and sensory activity, where verbal contact is progressively lost (NICE 2005).

De-escalation refers to the process of using verbal and non-verbal communication skills to manage aggressive behaviour by lowering levels of arousal during the assault cycle. De-escalation techniques may be used to avert an aggressive incident during the escalation phase of thecycle, or to assist in reducing arousal during the crisis and recovery phase of an incident. The use of de-escalation strategies may be planned or may occur spontaneously in response to an imminent crisis (NHS Education for Scotland 2005).

Disassociation is a risk management procedure put in place when a patient is considered to pose a significant threat of serious harm to other named patients, or particular members of staff. The individual concerned may be prevented from meeting those persons when attending any off-ward therapy, Health Centre, on grounds access or on suspension of detention e.g. court appearances.

Excited Delirium is a state of mental and physiological arousal, agitation, hyper pyrexia with euphoria, and hostility. Observers typically emphasise extreme sweating, bizarre behaviour and speech, and the patient’s extraordinary strength and endurance when struggling, apparently without fatigue. It is usually the result of alcohol and or drug use, mostly cocaine. This state however can also be produced by severe manic depression, schizophrenia or excited post ictal (post seizure) states(Farnham and Kennedy 1997).

Incident Supervisor is usually the first person arriving at the incident after a PAA call for assistance. This person would initially take charge of an incident and be responsible for the deployment of a team/s to assist in the management of a patient/s. One person should assume this role, and must be trained in Level two Physical Intervention skills. The Incident Supervisor is usually the person in charge of that area, but if they are involved in the fray this role would pass onto either the first available staff at the location or the first available staff arriving from another department (Prevention & Management of Violence and Aggression, (PMVA Manual 2006).

Lead Person is the person leading a team of staff intervening with a violent/potentially violent patient. The lead person can be anyone who has successfully completed Level two Physical Interventions training. The role of the lead person is to:

  • take charge of all decisions with regards to the patient;
  • take charge of all decisions with regards to the staff in the team;
  • safely protect and minimise injury to the patient’s head and neck;
  • ensure the patient’s vital signs ( respirations, responsiveness and colour) are monitored;
  • communicate with the patient;
  • communicate with staff and;
  • ensure the necessary documentation is completed (PMVA Manual 2006).

Level One Trained is the successful completion of training in personal safety and breakaway techniques.

Level Two Trained is the successful completion of training relating to the prevention of management and violence and aggression including the use of physical interventions.

Level 1 – General Observation: General Observation is designed to meet the needs of most patients for most of the time. The Nurse in Charge of the ward, or an allocated member of any other department where the patient may be for the time being (for example Health Centre, PARS departments, Resource Centre or Psychological Therapies) should know where all patients are at all times. Specific checks should be carried out at mealtimes and shift changeovers or at other appropriate intervals as agreed by theMulti Disciplinary Team. When patients are in their bedrooms they must be observed a minimum of twice in every hour.