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					                        Policies and Procedures

    Document Title                     Recognition, Prevention and
                                      Management of Aggression and
                                                Violence

    Reference Number                                NTW(C)16
    Lead Officer                                Director of Nursing
    Author(s)                                      Robin Green
                                                Allison Armstrong
                                                   Chris Watson
                                                  Safety Domain
    Ratified by
    Date ratified                               30th January 2007
                                                  February 2007
    Date issued
    Implementation date                           February 2007
    Version Number                                     1.1
    Review Date                                   February 2008
                                     Date           Version         Reason
    Change Control                 March 2007         1.1     Appendix change
                                   March 2008         1.1     Roll over to Sept 08



                              Groups Consulted:
                     Domains
                     Clinical Risk Management Group
                     Management Structures
                     Staff Side


      This policy/procedure should be read in conjunction with:

•   Police Liaison Policy
•   Care Co-ordination & Clinical Risk Policy
•   Use of CCTV
•   Observation Policy
•   Rapid Tranquilisation Policy
•   Seclusion Policy
•   Resuscitation Policy
                         Recognition, Prevention and
                  Management of Aggression and Violence Policy

                                        CONTENTS                                    PAGE
1.            Introduction                                                              3
2.            Policy Statement                                                          3
3.            Aim of Policy                                                             4
4.            Scope of Policy                                                           4
5.            Responsibilities                                                          5
6.            Definitions                                                               6
7.            Expected standards of behaviour                                           7
8.            Training & Development                                                    8
9.            Preventing and Minimising Aggressive and Violent Behaviour               11
10.           Environment                                                              11
11.           Physical Environment                                                     12
12.           Safety and security                                                      12
13.           Alarms                                                                   13
14.           Activities and External Areas                                            13
15.           Clinical Risk                                                            13
16.           Support to Staff                                                         14
17.           Prediction                                                               14
18.           Use of Physical Interventions                                            18
19.           Physical Care and Observation During Restraint                           20
20.           Reporting                                                                21
21.           Compensations for injuries sustained in the course of duty               22
22.           Visitors (anyone who is not a service use or staff member)               23
23.           Liaison with local police                                                23
24.           Monitoring                                                               24
25.           Review                                                                   24
              References                                                               25

                                             APPENDICES

Appendix 1             Staff Training

Appendix 2a            Report on Incidents involving use of physical
                       Intervention (C&R)                                     Appendices
                                                                           Separate to policy
Appendix 2b            MVA – Record/Analysis Form

Appendix 3             Checklist

Appendix 4             MVA Poster
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1.         INTRODUCTION

1.1        Incidents of aggression and violence are a recognised risk when
           working in a healthcare environment, however such incidents should
           not be accepted.

1.2        All aggression and violence to staff and service users is unacceptable.

2.         POLICY STATEMENT

2.1        This policy sets out the process by which Northumberland, Tyne &
           Wear NHS Trust will seek to prevent such incidents occurring and
           support its staff in the management of aggression and violence should
           it arise relative to their work.

2.2        As part of this remit the Trust has nominated the Director of Nursing as
           responsible executive and trained Local Security Management
           Specialist(s) investigate, report and pursue legal recompense for such
           incidents as appropriate as set out by the Secretary of State Directions
           on NHS Security Management Measures.

2.3        The Trust will report violent incidents to the national Physical Assault
           Reporting System PARS.

2.4        The Health & Safety at Work Act 1974, Section 2(1) states that:

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

2.5        Northumberland, Tyne & Wear NHS Trust finds the actions of both
           verbal and non-verbal aggression and harassment totally
           unacceptable. Appropriate action may be taken which could lead to
           legal action against offenders.

2.6        The Trust accepts that minimizing aggression and violence towards
           staff and service users requires a high level of management
           commitment, professional competence and adequate resources.

2.6.1 Furthermore, it recognises that actual or threatened aggression and
      violence towards staff and service users can be very frightening and/or
      traumatic. The Trust believes that personal safety is of immense
      importance and that protection of the person is more important than the
      protection of possessions.

2.7        It is the intention of Northumberland, Tyne & Wear NHS Trust to
           minimise risks and to provide, or ensure that there is provision for,
           information, instruction, training, equipment and supervision as


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           is necessary to ensure, so far as is reasonably practicable, the health
           and safety at work of its employees.

3.         AIM OF THE POLICY

3.1        The aim of this policy is to contribute to a safer working
           environment by:

      •    Prevent and/or de-escalate potentially violent situations to reduce the
           need for physical interventions.

      •    Heighten awareness of staff and service user safety issues.

      •    Encourage a sensitive approach to work and relationships – to help
           minimise aggressive and violent incidents, and manage them safely
           and efficiently.

      •    Establish the basic training needs of all staff.

      •    Services will identify staff that need specific additional training.

      •    Ensure that all managers can give effective guidance on managing
           aggressive and violent behaviour.

      •    Provide staff and service users with responsive support systems when
           incidents do occur.
      •    Explain how to report aggressive and violent incidents.

4.         SCOPE OF POLICY

4.1        The policy is concerned with the following people:

      •    All staff (including bank staff and students).
      •    Lone workers.
      •    Community staff.
      •    Agency staff.
      •    Service Users
      •    Visitors, including contractors.
      •    Volunteers.

4.2        The Trust provides services for people who may suffer from:

      •    Mental health problems
      •    Neurological disorder
      •    Cognitive impairment
      •    Sensory impairment
      •    Learning Disabilities
      •    Dementia
      •    Autistic Spectrum Disorders

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      •    Personality Disorder

5.         RESPONSIBILITIES

5.1        The Chief Executive will have overall responsibility for health and
           safety within Northumberland, Tyne & Wear NHS Trust and is
           responsible for.

      •    Identification of risks and ensuring appropriate action is taken thereby
           reducing risks.

      •    Arranging training and information to an appropriate level for all staff in
           the recognition, prevention and management of aggression and
           violence.

      •    Identification of specialised training needs.

      •    Ensuring the reporting, recording and investigation of all incidents of
           aggression and violence.

      •    Ensuring a culture is adopted in which staff are supported in terms of
           desired outcomes following any incident (e.g. Staff Side representation,
           post incident support, prosecutions or temporary re-deployment).

      •    Ensuring bank and agency staff have been adequately trained before
           commencing duties within the Trust.

      •    Arranging where it is felt acceptable, the display of signs within their
           services stating their intentions towards aggressive or violent behaviour
           (see Appendix 4).

      •    Identifying any prosecution or action necessary against offenders and
           taking forward any action deemed necessary (see Section 19).

      •    Continuous monitoring of all aspects of the above safety system.

5.2        Senior Management/Service Managers will have:

      •    Lead responsibility to ensure safe practices within their service area
           e.g. effective management of complaints, staff attendance at
           appropriate training as identified in personal development plan.

5.3        Ward Manager will have responsibility to ensure:

      •    Staff are made aware of factors, which predispose violent or
           aggressive behaviour.

      •    Each service user has a care plan which addresses violent and
           aggressive behaviour where necessary/appropriate.

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      •    Promote a stable safe environment                                      to     reduce            environmental
           contribution to violence and aggression.

      •    Clinical and non-clinical risk assessment are carried out and reviewed
           on an annual basis.

      •    Inform service managers regarding any changes, which may affect
           service delivery, e.g. skill mix, staffing levels, environmental issues or
           individual patient need.

5.4        Individual Staff have a responsibility to:

      •    Understand importance of observation in preventing acts of violence.

      •    Reporting any untoward occurrences/regarding any interventions.

      •    Be familiar with and adhere to agreed individual anger management
           plans.

      •    Participate in post incident support, clinical supervision to reflect on
           own practice as regards Management of Violence and Aggression
           (MVA).

      •    Maintain an adequate level of fitness to enable them to respond
           accordingly to violence and aggression situations and highlight any
           issues with Line Manager.

      •    Attend training relating to MVA as identified by their place of
           work/Personal Development Plan (PDP)/Manager.

6.         DEFINITIONS

6.1        De-escalation

           De-escalation involves the use of techniques that calm down an
           escalating situation or service user; action plans should stress that de-
           escalation should be employed early on in any escalating situation.
           (NICE Clinical Guideline 25, February 2005)

6.2        Physical Assault

           The intentional application of force to the person of another, without
           lawful justification, resulting in physical injury or personal discomfort.

6.3        Non-physical Assault

           The use of inappropriate words or behaviour causing distress and/or
           constituting harassment.
           (Promoting safer & therapeutic services NHS SMS, October 2005)
Northumberland, Tyne & Wear NHS Trust                                                                                  6
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7.         EXPECTED STANDARDS OF BEHAVIOUR

7.1        The following are examples of behaviour’s not acceptable on Trust
           premises or shown towards staff, service users or visitors of the Trust
           in any location:

      •    Excessive noise, e.g. loud or intrusive conversation or shouting.
      •    Threatening or abusive language involving excessive swearing or
           offensive remarks.
      •    Derogatory racial or sexual remarks.
      •    Malicious allegations relating to members of staff, other service users
           or visitors.
      •    Offensive sexual gestures or behaviours.
      •    Abusing alcohol or drugs in hospital (however, all medically identifiable
           substance abuse problems will be treated appropriately).
      •    Drug dealing.
      •    Wilful damage to Trust property.
      •    Theft.
      •    Threats or threatening behaviour.
      •    Violence.
      •    Stalking.


7.2        Prosecution/Sanctions Against Service Users
           (Prosecution / Sanctions Policy to be developed)

           7.2.1 Following consideration of the circumstances, a decision may be
                 made by the Trust to report an assault or crime to the police.
                 This does not preclude an individual employee initiating a
                 personal prosecution against an assailant.

7.3        Action to Be Taken After Each Incident

           7.3.1 Each incident needs to be considered by the person in charge of
                 the ward in which the incident occurred, or the manager if the
                 incident occurred in a non service user setting.

           7.3.2 Dependent on the seriousness of the incident, and whether it is
                 an isolated incident or a consistent pattern of unacceptable
                 behaviour, one of the following actions will be taken:

                                 A verbal explanation by a member of staff of what is
                                 unacceptable behaviour and the possible consequences
                                 of any further repetition of unacceptable behaviour, and
                                 an entry made in the service user’s notes of the
                                 explanation given.




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                                 If further action is considered necessary the victim of the
                                 incident should not be part of the decision making
                                 process. This is to ensure that any actions taken against
                                 a service user or visitor are objective and can be clearly
                                 seen to protect staff, victims, other users, and the
                                 ‘offender’.

                                 The incident to be discussed in MDT to consider options
                                 and future plans of care.

           7.3.3 Service users will be given the opportunity to write up their
                 account of the intervention wherever possible, this will be
                 managed at the service       user’s communication level, for
                 example documentation of a verbal account or facilitated using
                 talking mats/symbols etc and may be part of a post incident
                 support scenario. This may necessitate the assistance of
                 advocates and relatives. The written account will be filed in the
                 service users nursing notes. Service users will be engaged in
                 discussion with staff to learn and share lessons.

8.         TRAINING AND DEVELOPMENT

8.1        All staff whose need is determined by risk assessment will receive
           ongoing mandatory training to recognise anger, potential aggression,
           antecedents and factors of violence, monitor their own verbal and non-
           verbal behaviour, anticipating, de-escalating and coping with /
           managing violent behaviour (see training matrix - Appendix 1).

8.2        Training will follow the principals described by the NHS Security
           Management Service - Promoting Safer and Therapeutic Services and
           will include the following:

           8.2.1 The role of the Security Management Service in relation to the
                 management of violence in mental health and learning disability
                 settings

           8.2.2 Theoretical, pathological and environmental explanations for
                 aggression within mental health or learning disability settings.

           8.2.3 Aspects of non-verbal de-escalation, verbal strategies and
                 conflict resolution styles

           8.2.4 The effect of functional and dysfunctional coping strategies on
                 people’s behaviour in mental health & learning disability settings

           8.2.5 The positive contributions that service users can make to
                 prevention strategies, including awareness of how issues
                 relating to culture, race, disability, sexuality and gender can
                 enhance the process


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           8.2.6 Organisational and individual responsibilities with regard to
                 legal, ethical and moral frameworks relating to the use of force

           8.2.7 The application of risk management interventions and the
                 requirements for the effective assessment of dangerousness
                 with reference to  prevention planning

           8.2.8 Restraint related risks as outlined in the Bennett Inquiry and
                 NICE guidelines with a view to incorporating risk reduction
                 strategies into practice

           8.2.9 The need and scope of post-incident review procedures and of
                 how to identify strategies and interventions for future prevention

           8.2.10 Spheres of influence in relation to the individual, team and
                  organisational change required to achieve a reduction in
                  aggression and violence

8.3        Training will be delivered at four levels:

      •   Level/module 1     - Management Of Violence & Aggression –
          Promoting Safer & Therapeutic Services (non-physical)
      •   Level/module 2 - Management Of Violence & Aggression –
          Breakaway Skills
      •   Level/Module 3 - Management Of Violence & Aggression – Physical
          Intervention
      •    Level/Module 4 - Management Of Violence & Aggression – Service /
           client specific interventions

8.4        All non–physical courses for prevention and management of violence
           and aggression will be service specific depending upon speciality and
           will be refreshed / updated every 2 years.

8.5        All physical intervention courses (including breakaway skills) will be
           service specific depending upon speciality and will include Promoting
           Safer & Therapeutic Services. These courses will be refreshed /
           updated every 12 months.

8.6        All restrictive physical intervention courses will be service specific
           depending upon speciality, will include the above and:

           8.6.1      Information on positional asphyxia.

           8.6.2      Immediate Life Support (ILS – Resuscitation Council UK)
                      (covers airway, Cardio-Pulmonary Resuscitation (CPR) and use
                      of automated defibrillators).

           8.6.3      Use of pulse oximetry.


Northumberland, Tyne & Wear NHS Trust                                                                             9
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           8.6.4      Physical techniques to hold & restraint a person using a graded
                      approach in teams.

           8.6.5      Post incident support.

           8.6.6      Individual training programmes will be tailored to match
                      variations in staff/ service user need. These may be delivered
                      with the workplace or classroom.

           8.6.7      Training environments will be suitable for purpose, large well-
                      ventilated room, matted floor and separate seating area.

           8.6.8      Physical intervention tutors will advise managers of additional
                      training/development required for staff as a result of; working
                      environment, characteristics of service users, physical
                      limitations, competence, conduct and attitude.

           8.6.9      Participants will complete a health questionnaire as evidence
                      that they can undertake training.

           8.6.10     Information about physical intervention courses will be
                      distributed annually in the Trust training manual or sooner if
                      there are any major changes.

           8.6.11     Participants will be continually assessed during physical
                      intervention courses in relation to attitudes, knowledge and
                      competence. Those not      reaching the required standard will
                      be referred, given advice and      support, be encouraged to
                      undertake training at a future date and be deemed not suitable
                      to use physical interventions in the workplace. The physical
                      intervention manager will write to inform the participant’s
                      manager of details, a copy will also be sent to the participant.

           8.6.12     Detailed records of attendance, individual’s performance, course
                      evaluation and will be kept at all times by the central training
                      department.

           8.6.13     Physical intervention skills will not be shared informally and only
                      delivered by staff, which have received the appropriate training.

           8.6.14 All      staff involved in administering or prescribing rapid
                      tranquillisation, or monitoring service users to whom parenteral
                      rapid tranquillisation has been administered, will receive Rapid
                      Tranquillisation training every    three years. This will be
                      provided by the Trust and will include: -

                      •    The properties of benzodiazepines; their antagonist,
                           flumazenil;    antipsychotics; antimuscarinics; and
                           antihistamines



Northumberland, Tyne & Wear NHS Trust                                                                            10
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                      •    The risks associated with rapid tranquillisation, including
                           cardio-respiratory effects of the acute administration of these
                           drugs, particularly when the service user is highly aroused
                           and may have been misusing drugs; is dehydrated or
                           possibly physically ill

           8.6.15     All Multi-disciplinary team members must receive clinical risk
                      assessment/management, including ethnic and cultural
                      awareness, education and training as part of an organisational
                      induction      programme.

9.         PREVENTING AND MINIMISING AGGRESSIVE AND VIOLENT
           BEHAVIOUR

9.1        Accounts of injuries (both psychological and physical) to staff and
           service users following exposure to aggression, violence and the
           process of restraining, are well documented. In the most serious cases,
           death has occurred. It is only through a multi-dimensional approach
           that mental health service providers can address the problem of
           aggression and violence in its inpatient services. This approach should
           be aimed at minimising its occurrence and promoting a safe and
           therapeutic environment for people to live in, work in and visit (NIMHE,
           2004).

9.2        Approaches to minimising aggression and violence are multi faceted in
           nature. The primary focus when dealing with aggressive behaviour
           should be that of recognition, prevention and de-escalation in a culture
           that seeks to minimise the risk of its occurrence through effective
           systems of organisational, environmental and clinical risk assessment
           and management.

10.        ENVIRONMENT

10.1       The physical and therapeutic environment can have a strong,
           mitigating effect on the management of disturbed (violent) behaviour.
           The following are good practice recommendations for psychiatric
           facilities:

           10.1.1     A safe designated area or room specifically for the purpose of
                      reducing arousal and/or agitation must be provided in addition to
                      a seclusion room.

           10.1.2     The internal design of the ward must be arranged to facilitate
                      observation and sight lines must be unimpeded (e.g. not
                      obstructed by opening of doors). Measures must be taken to
                      address ‘blind spots’ within the facility.

           10.1.3     Each ward / department must have a local policy/protocol on
                      alarms and determine the need for alarms according to a
                      comprehensive risk assessment of the clinical environment,

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                      service users and staff. The policy /protocol must be based on
                      the information contained in this policy and disseminated to
                      ensure staff are familiar with its contents.

           10.1.4     The environment must take into account service user needs for
                      safety, privacy, dignity, gender and cultural-sensitivity, sufficient
                      physical space, social and spiritual expression.

           10.1.5    Wards and departments should be able to accommodate service
                     users needs for engaging in activities and individual choice -
                     there should be an activity room and a dayroom with a
                     television, as boredom can lead to violent behaviour.

           10.1.6     Service users must have single sex toilets,                                           sleeping
                      accommodation, day areas and washing facilities.

           10.1.7     There should also be a space set aside for prayer and quiet
                      reflection.

11.        PHYSICAL ENVIRONMENT

11.1       Service users should have privacy when making phone calls, receiving
           guests, and talking to a staff member.

11.2       Facilities must have adequate means of controlling temperature,
           ventilation and noise.

11.3       All internal smoking areas/rooms must have powerful ventilation and be
           fitted with a smoke-stop door(s).

11.4       All areas should look and smell clean.

11.5       Bed occupancy and patient mix should be decided at a local level by
           the multidisciplinary team and this level should not be exceeded, since
           over-crowding leads to tension, frustration and over-stretched staff.

11.6       Suitable access facilities are needed for people who have problems
           with mobility, orientation, visual or hearing impairment or other special
           needs.

11.7       There should be access to the day room at night for those who cannot
           sleep.

11.8       Ideally there should be separate areas to receive service users with
           police escorts.

12.        SAFETY AND SECURITY

12.1       Secure lockable access to a service user's room, bathroom and toilet
           area is required with external staff override.

Northumberland, Tyne & Wear NHS Trust                                                                             12
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12.2       Facilities must ensure routes of safe entry and exit in the event of a
           violence-related emergency.

12.3       All exits and entrances should be within the sight of staff.

12.4       Consideration should be given to the use of CCTV and parabolic
           mirrors (e.g. corridor areas, staircases, reception, etc.)

           (Royal College of Psychiatrists – recommendations for the safe
           design of interview rooms).

13.        ALARMS

13.1       Collective protocols and responses to alarm calls should be agreed
           before incidents occur, consistently applied and rehearsed.

13.2       Local protocols must be developed to ensure that the police and staff
           are aware of the procedures and ascribed roles in an emergency, in
           order to prevent misunderstanding between different agencies.

13.3       Furniture must be arranged so that alarms can be reached and doors
           are not obstructed.

13.4       Alarms must be installed in interview rooms and in reception areas and
           any other areas where one service user and one clinician work
           together.

13.5       All alarms (panic buttons, personal alarms etc.) must be well
           maintained and checked regularly and detailed in local protocol.

13.6       Comprehensive risk assessment of the clinical environment must be
           used to determine whether supplementary personal alarms should be
           issued to individual staff members and vulnerable service users.

14.        ACTIVITIES AND EXTERNAL AREAS

14.1       Service users must be given access to fresh air and natural daylight.

14.2       Where practicable, access to an external area should be via the unit
           and appropriate standards of fencing should be provided.

14.3       There must be regular opportunities for service users to engage in
           physical exercise, group interaction, therapy and recreation.

15.        CLINICAL RISK

15.1       These assessments should be made and recorded in line with the
           clinical risk assessment procedures.


Northumberland, Tyne & Wear NHS Trust                                                                            13
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15.2       When planning care for service users with aggressive or potentially
           aggressive behaviour, a full individual assessment of service user need
           should be made by the practitioner in discussion with the
           multidisciplinary team providing the care.

15.3       Assessment and the management of risk is an essential part of the
           care and treatment provided for service users and is an integral part of
           the Care Programme Approach (CPA), Care Co-ordination, and the
           Single Assessment Process for Older People. It is essential that on
           admission a clinical risk assessment of all individuals is carried out and
           a risk management plan is put in place. This should be conducted in
           collaboration with the service user and their carer wherever possible.

15.4       Risk assessments and risk management plans should be regularly
           reviewed with the service user and their carer wherever possible. Plans
           should record known triggers to aggressive/violent behaviour based on
           previous history and discussion with service users and their
           carers/families. Changes in levels of risk should be recorded,
           communicated and risk management plans changed accordingly.

16.        SUPPORT TO STAFF

16.1       It is recognised that the Trust has a key role in ensuring that
           appropriate support is provided to staff following an actual or potential
           aggressive or violent incident. It is important that support is offered
           post-incident to staff (Checklist Appendix 3).

16.2       Confidential advice and support is available to all staff through the
           Occupational Health Department. Managers and staff should be fully
           aware of the Trust counselling and support services, as well as
           immediate support offered at ward/department level.

16.3       Northumberland, Tyne & Wear NHS Trust will support and advise staff
           who find themselves the subject of complaint or legal action, if they
           have followed and acted within the scope of the Trust’s policies and
           procedures relating to the recognition, prevention and management of
           aggression and violence, provided that the action taken was in good
           faith for the benefit and safety of themselves, service users, colleagues
           or other members of the public.

17.        PREDICTION

17.1       Violence can never be predicted with 100% accuracy. However, this
           does not mean that risk assessment of service users should not be
           carried out.

17.2       Since the components of risk are dynamic and may change according
           to circumstance, risk assessment (environment and service user) must
           be ongoing and care plans must be based on an accurate and
           thorough risk assessment.

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17.3       The approach to risk assessment must be multidisciplinary and
           reflective of the care setting in which it is undertaken. The risk factors
           must be communicated across care settings.

17.4       Risk assessment should include an interview with the service user and
           where appropriate carers. Efforts should be made to ascertain the
           service user’s own views about their antecedents, warning signs and
           management of these feelings.

17.5       All staff must be aware of any of the following factors, which may
           provoke violent behaviour:

           •    attitudinal
           •    situational
           •    organisational
           •    environmental

17.6       Certain features can serve as warning signs to indicate that a service
           user may be escalating towards physically violent behaviour. The
           following list is not intended to be exhaustive and these warning signs
           must be weighed on an individual basis:

           Antecedents / Warning Signs

           •    Increased or prolonged restlessness; body tension; pacing
           •    General over-arousal of body systems (increased breathing and
                heart rate, muscle twitching, dilating pupils)
           •    Increased volume of speech, erratic movements
           •    Facial expressions tense and angry
           •    Prolonged eye contact
           •    Discontented, refusal to communicate, withdrawn, fear, irritation
           •    Thought processes unclear, poor concentration
           •    Delusions or hallucinations with violent content
           •    Verbal threats or gestures
           •    Replicating behaviour similar to that, which preceded earlier violent
                episodes
           •    Reporting anger or violent feelings
           •    Blocking escape routes
           •    Carers reporting service user’s previous anger or violent feelings



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           Risk Factors

           •    Certain factors can indicate an increase risk of physically violent
                behaviour. The following list is not intended to be exhaustive and
                these risk factors must be weighed on an individual basis.

           Demographic or personal history

           •    History of violence
           •    Previous expression of intent to harm others
           •    Evidence of ruthlessness or ‘social restlessness’
           •    Previous use of weapons
           •    Previous dangerous impulsive acts
           •    Denial of previous dangerous acts
           •    Severity of previous acts.
           •    Known personal trigger factors
           •    Verbal threat of violence.
           •    Evidence of recent severe stress, particularly loss event or the
                threat of loss
           •    History of bed-wetting, cruelty to animals, reckless driving or loss of
                a parent before the age of eight
           •    Member of a sub-culture prone to violence

           Clinical variables
           •    Misuse of substances and/or alcohol
           •    Active symptoms of schizophrenia or mania, in particular if:
                      -    Delusions or hallucinations are focused on a particular
                           person
                      -     Preoccupation with violent fantasy
                      -     Delusions of control (especially with violent theme)
                      -     Agitation, excitement, overt hostility or suspiciousness
           •    Poor collaboration with suggested treatments
           •    Anti-social, explosive or impulsive personality traits or disorder
           •    Organic dysfunction

           Situational variables
           •    Extent of social support
           •    Immediate availability of a potential weapon

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           •    Relationship to potential victim
           •    Access to potential victim.

17.7       This approach should also promote therapeutic engagement,
           collaboration with service users and the use of advanced directives.
           Services and staff should encourage mutual respect, and recognise the
           need for privacy, dignity and, racial and cultural diversity as essential
           values that must be engendered and asserted in all policy, education,
           training and practice initiatives.

17.8       Staff, service users and carers groups identified, during focus groups
           held as part of the National Audit (Royal College of Psychiatrists 2000),
           a number of issues which influenced the development of violent
           incidents. These included:

           •    Lack of access to privacy
           •    Lack of access to open space and fresh air
           •    Boredom
           •    Inadequacy of staffing levels and skill mix
           •    Lack of opportunity to participate in therapy and social activities
           •    Poor staff attitudes

17.9       All staff must receive recognition, prevention and de-escalation skills
           awareness training as part of an organisational induction programme.
           The content of which should be based upon an organisational risk
           assessment relating to incidence of work place aggression and
           violence.

17.10 The Trust will ensure that all policies, procedures, education and
      training programmes promote recognition, prevention and de-
      escalation as the first line approach when responding to aggressive
      behaviour. Physical interventions should be viewed as a final option in
      a hierarchy of therapeutic interventions.

17.11 Services should ensure that systems are in place to regularly review
      multi-disciplinary team staffing levels and skill mix on inpatient
      wards/units. This is to ensure that they provide sufficient capacity to
      provide a safe and therapeutic environment for all, as well as providing
      dedicated time for staff to spend with service users, their carers and
      families to engage in therapeutic and social activities.

17.12 Multi-disciplinary teams should work in collaboration with service users
      and, where appropriate, their carer(s) to develop individualised
      advance statements so that future interventions, wherever possible,
      meet the specific needs and wishes of service users as part of their
      overall package of care.


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17.13 Clear and effective communication is an integral part of prevention and
      de-escalation of aggression and violence, but is of greater importance
      for people who have hearing or visual impairment, cognitive impairment
      or whose first language is not English.

17.14 The Trust will ensure that education, training, policies and procedures
      emphasise the need for clear and effective communication with all
      service users. Where necessary this will involve access to interpreters
      and staff with specific communication skills e.g. signing.

18.        USE OF PHYSICAL INTERVENTIONS

18.1       The use of any form of physical restraint methods will be considered to
           be the last resort. It should not be used until all other approaches have
           failed and/or violence is imminent. Any restraint must be reasonable in
           the circumstances and the force used must be the minimum required to
           deal with the harm that needs to be prevented.

18.2       The purpose of physical restraint is firstly to take control of a
           dangerous situation and secondly to limit the service user’s freedom for
           no longer than is necessary to end or reduce significantly the threat to
           self or others.

18.3       It is generally considered to be unsafe for anybody to try to restrain
           another person on their own. If you are alone in a difficult situation you
           should try to escape from the situation and summon assistance
           verbally or by using the alarm system (if available). Where single
           person restraint is appropriate this will be detailed in the service users
           care plan.

18.4       Methods of Physical Restraint

           18.4.1                Any form of physical restraint requires that the duty of
                                 care afforded to our service users is never compromised
                                 and that it takes into account the safety and well being of
                                 everyone involved.

           18.4.2                Physical restraint requires the safe immobilisation of a
                                 person in an effort to avoid potential harm.

           18.4.3                It is not possible or desirable to outline specific restraint
                                 skills in this document.

           18.4.4                Staff not trained in physical intervention techniques still
                                 have a duty of care for their service users and should act
                                 in a manner reasonable to the situation and in good faith,
                                 bearing in mind guidelines on physical restraint.




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18.5       Physical Intervention Techniques

           18.5.1                When using physical restraint methods, the following
                                 guidelines must be borne in mind:

                      •    One person should co-ordinate the whole situation and utilise
                           resources to meet all of the needs of the incident, e.g.
                           looking after the needs of other service users, staff, etc.

                      •    Make a visual check for weapons.

                      •    Nominate staff members to assist and allocate each a
                           specific task.

                      •    Fewer well-briefed staff are likely to be more effective than
                           large numbers of staff grabbing in an unorganised fashion.

                      •    The service user should not automatically be taken to the
                           floor, however if this is deemed necessary arms and legs
                           should be immobilised swiftly and safely.

                      •    Protect the head from harm and maintain airway.

                      •    Do not use neck holds or place any weight on thoracic area,
                           especially chest and stomach.

                      •    Continually explain the reason for the action to the service
                           user and encourage co-operation and voluntary control as
                           soon as possible. Where possible staff should remove items
                           of jewellery, name badges and ties prior to restraint. This will
                           help to reduce the risk of damage and injury occurring.

                      •    Any form of restraint should not be punitive.

18.6       Weapons

           18.6.1                Where possible, if faced with an armed person, staff
                                 should try to reduce the risk of harm they could present. If
                                 weapons are involved the advice of senior staff should be
                                 sought, and the decision of whether or not to call the
                                 police considered.

18.7       Organisation and Implementation – Physical Restraint

           18.7.1                Where there is an identifiable team of people involved in
                                 the physical restraint of a person, one member of staff
                                 should assume the role of team co-ordinator. All other
                                 persons in the team should take instructions from the
                                 team co-ordinator who, wherever possible, should be the
                                 staff who has the best rapport with the service user.
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           18.7.2                Co-operation should be sought and encouraged at all
                                 times from the person who is being restrained.

           18.7.3                Keep the service user informed about what is happening
                                 and the consequences of any actions.

           18.7.4                Communication between the team co-ordinator and the
                                 service user should be continuous in an effort to establish
                                 when it is appropriate to end the restraint procedure or
                                 reduce the degree of physical restraint required.

           18.7.5                Ask all other people who are not involved in the situation
                                 to leave the immediate vicinity in order to maintain the
                                 privacy and dignity of the service user.

           18.7.6                A full detailed account of the incident must be recorded in
                                 the service user’s notes and incident forms.

19.        PHYSICAL CARE AND OBSERVATION DURING RESTRAINT

19.1       Any physical condition, which may increase the risk to the service user
           of collapse or injury during restraint should be clearly documented in
           the service user’s records and communicated to all multidisciplinary
           team members.

19.2       Where there is a foreseeable risk a care plan should clearly identify the
           physical condition and the strategies to minimise the risk to the service
           user. This care plan should be communicated to all multidisciplinary
           team members and regularly reviewed and evaluated with the service
           user and, where appropriate, their carer/advocate.

19.3       If seclusion is considered as an alternative strategy to physical
           restraint, when managing actual violence, the Trust Observation Policy,
           Rapid Tranquilisation Policy and Seclusion Policy must be followed.

19.4       Where physical restraint methods have been employed, the care team
           should review their intervention strategy and discuss the treatment
           regime as soon as it is practicable with the rest of the multi-disciplinary
           team.

19.5       In all wards/units where the use of restraint is foreseeable there should
           be immediate access to basic life support equipment which is regularly
           checked (i.e. weekly) and maintained in working condition.

19.4       In all wards/units where the use of restraint is foreseeable and where
           urgent medical assistance may be required, there should be systems in
           place to ensure ‘immediate’ life support access to medical / Para-
           medical assistance via on-call duty doctor, cardio-pulmonary


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           resuscitation teams, or paramedical services, equipment which is
           regularly checked as detailed in the resuscitation policy.

19.5       Any person subject to restraint should be physically monitored
           continuously during restraint and at least every 2 hours post restraint
           for a period of up to 24 hours. This physical check should include:

           •    Care in the recovery position where appropriate
           •    Pulse
           •    Blood pressure
           •    Respiration
           •    Temperature.
           •    Fluid and food intake and output

19.6       Based on this monitoring, it is the clinical responsibility of the nurse in
           charge of the ward to seek medical assessment at the earliest
           opportunity should it be necessary.

19.7       If consent and co-operation for these observations is not forthcoming
           from the person subject to this process, then it should be clearly
           documented in their records why certain checks could not be
           performed and what alternative actions have been taken.

19.8       Physical monitoring is especially important:

           •    Following a prolonged or violent struggle
           •    If the service user has been subject to enforced medication or rapid
                tranquillisation
           •    If the service user is suspected to be under the influence of
                alcohol or illicit substances
           •    If the service user has a known physical condition, which may
                inhibit cardio-pulmonary function e.g. asthma, obesity (when lying
                face down)

19.9       Wherever possible, restraining service users on the floor should be
           avoided. If, however, the floor is used then this should be for the
           shortest period of time and for the central reason of gaining control of
           the situation. In situations where the service user needs to be placed in
           the prone position (face down) this should be for the shortest possible
           period of time to bring the situation under control.

20.        REPORTING

20.1       All potential, or actual, aggressive and violent incidents should be
           reported by staff to their line manager and centrally using the Trust’s

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           incident reporting systems. It is the responsibility of the immediate
           service manager to ensure that these incidents are investigated and
           that appropriate action is taken to reduce the possibility of
           reoccurrence.

           Consideration to the level of investigation dependant on the severity of
           incident and will be determined by the clinical team.

20.2       Staff must clearly record the incident, intervention and outcomes in the
           service user’s notes. Care plans should be reviewed after each incident
           to ensure interventions are still relevant.


20.3       All incidents of physical restraint must be reported via:

           •          Trust’s incident reporting systems
           •          Use of physical intervention reporting (App 2a in previous 3Ns
                      areas, Appendix 2b in previous STW areas, previous N&P areas
                      use on-line reporting system where available)

21.        COMPENSATION FOR INJURIES SUSTAINED IN THE COURSE OF
           DUTY

21.1       In the event of injury sustained by an individual whilst undertaking their
           official duties, employees are entitled to report the assault to the police
           and to submit an application form for compensation under the Criminal
           Injuries Compensation Act, 1968. To support an application for criminal
           injuries compensation, form B195, available from the Department for
           Social Security must be completed by the member of staff and by
           obtaining a registered crime incident number from the police. Payment
           is in accordance with Department of Health guidance.

21.2       Any member of staff may be entitled to temporary, and subsequently
           permanent, injury benefit if an absence is attributable to an injury
           sustained during the course of their official duties.

21.3       In order to claim such benefits, it is the responsibility of the staff
           member involved to complete the Trust IR1 Form at the time of the
           accident or incident (or at least within 24 hours of the occurrence).
           Wherever this is not possible the individual’s manager should complete
           the form on their behalf. The Human Resources Department must also
           be notified by the member of staff in writing that they wish to claim the
           benefit.

21.4       Delays in completing the appropriate reporting documentation may
           prejudice compensation claims.

21.5       The Trust will ensure that employees who are the victims of assault, or
           who sustain any injury as a result of an accident during the course of

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           their official duties are made aware of the above and given every
           assistance in pursuing such claims.

21.6       The Trust recognises its responsibility as a good employer and in
           accordance with the Disability Discrimination Act 1995 to seek, if
           practicable, reasonable adjustments to existing roles and / or attempt
           to secure alternative employment within the Trust if a member of staff
           is prevented from returning to their present post as a result of
           incapacity.

22.        VISITORS (ANYONE WHO IS NOT A SERVICE USER OR STAFF
           MEMBER)

22.1       The following are examples of behaviours not acceptable on Trust
           premises or shown towards staff and service users of the Trust in any
           location (Appendix 4):

           •          Visitors who display any of the behaviours stated in point 6 will
                      be asked to desist and offered the opportunity to explain their
                      actions.

           •          Continued failure to comply with the required standard of
                      behaviour will result in site security or the police being
                      called and the removal of the offending individual from
                      Trust property. The excluded individual may request an
                      immediate review of the exclusion and should be informed
                      of this.

           •          Any visitor behaving in an unlawful manner will be reported to
                      the police and the Trust will seek the application of the
                      maximum penalties available in law. The Trust will prosecute all
                      perpetrators of crime on or against Trust property, assets, staff,
                      and service users.

           •          The relevant Service Manager may decide to continue to
                      exclude any individual removed from the premises or restrict
                      their visiting only to specific times and, if necessary, under
                      escort, making reference to MHA Code of Practice (paragraph
                      26.2).

23.        LIAISON WITH LOCAL POLICE (refer to police liaison policy)

           23.1       Managers should make contact with the local police to discuss
                      particular areas of concern and take advice on basic site
                      security issues from crime reduction officers.

           23.2       Summoning police assistance generally means that the police
                      will assume responsibility for the control of a violent or
                      potentially violent incident. Nursing staff should meet the police
                      on their arrival to the unit, brief them on the situation and

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                      ascertain what assistance the police require. It is essential,
                      therefore, that the circumstances when assistance will be sought
                      should be discussed with the police service in advance by the
                      relevant service manager, including types of intervention that
                      may be employed.

24.        MONITORING

24.1       The Local Security Management Specialist will prepare quarterly
           reports to Services to identify trends in violent incidents. Services will
           produce action plans to minimize reoccurrence. Trends will be
           discussed at each meeting of the Trust Health & Safety Committee and
           the Trust Security Management Group.

24.2       Local monitoring of all incidents will be carried out by members of the
           Trust Management Team.

25.        REVIEW

25.1       This policy will be reviewed on a 12 monthly basis.

25.2       This policy supplements the Northumberland, Tyne & Wear NHS Trust
           Health and Safety arrangements, which are an obligation under the
           Health and Safety at Work Act 1974.




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References


Code of Practice Mental Health Act 1983. Department of Health, 1999.

Developing Positive Practice to Support the Safe and Therapeutic
Management of Aggression and Violence in Mental Health Inpatient Settings.
National Institute for Mental Health in England, 2004.

Guidelines for the Prevention and Management of Violence at Work. British
Psychological Society, 1992.

Health & Safety at Work Act (1974). London, HMSO

National Audit of the Management of Violence in Mental Health Settings Final
Report: Year1, June 2000. Royal College of Psychiatrists, London, 2000




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