staff should understand how their behaviour can increase or decrease
risks of violence, guidance urges
health nurses, psychiatrists and other staff responsible for potentially
violent patients should all undergo training to understand how their
own behaviour can increase or decrease risks of violence, new guidelines
for staff should also include how to recognise anger, potential
aggression, antecedents, and risk factors of disturbed and violent
recommendations were published last week in guidelines by the National
Institute for Clinical Excellence (NICE).
guidelines are for staff working in NHS in-patient psychiatric wards
and accident and emergency departments in England and Wales.
recommendation is that all mental health service providers should
ensure their services have a full risk management strategy for assessing
risk and preventing violence.
should include drawing up measures to calm down a potentially violent
situation and intervene safely when violence occurs.
guidelines state that rapid tranquillisation, physical restraint,
and seclusion should be considered only after such measures have
failed to calm a patient.
guidelines warn that failure to act in accordance with its recommendations
would "not only be a failure to act in accordance with best
practice, but in some circumstances may have legal consequences."
were devised specifically for NICE by the National Collaborating
Centre for Nursing and Supportive Care, a development group based
at the Royal College of Nursing. They included input from service
mental health groups are alarmed, however, that no three-minute
time limit for the face-down restraint of mental health patients,
has been set.
is despite recommendations by an inquiry commissioned by the NHS.
the guidelines say the level of force used in managing violent patients
must be "justifiable, appropriate, reasonable and proportionate"
and applied for "the minimum possible amount of time".
inquiry into the death of David "Rocky" Bennett in the
Norvic clinic in Norwich in 1998 called for the three-minute limit.
died after being held face down on the floor for about 25 minutes,
most of the time by four nurses.
inquiry recognised the three-minute figure was "arbitrary".
But it said there was "conclusive" evidence that the shorter
the period a person was held down, the less the risk incurred.
consultant psychiatrist Sue Johnston, and a member of the NICE development
group said it was dangerous to assume that three minutes was "magically
is no safe time. Any intervention is potentially hazardous,"
she told societyguardian.co.uk.
Richard Brook, chief executive of mental health charity Mind was
"dismayed" that the guidelines did not specify a maximum
time limit for restraint.
to introduce a maximum time limit for restraint seriously threatens
the wellbeing of some of the most vulnerable people in the mental
health system," he said.
did, nevertheless, welcome other aspects of the guidelines.
been clear for years that these guidelines are desperately needed,
and their introduction is welcome," he said.
steps have been taken to include more training for staff on anticipating
and de-escalating situations in which violence may occur."
guidelines also specify that during physical restraint, one team
member - likely to be a mental health nurse - should be responsible
for protecting and supporting the patient's head and neck, where
team member should take responsibility for leading the team through
the physical intervention process, and for ensuring that the airway
and breathing are not compromised and that vital signs are monitored.
try to work more effectively with service users, the guidelines
suggest that those identified to be at risk of disturbed or violent
behaviour should be given the opportunity to have their needs and
wishes recorded in the form of an advance directive.
Fraher, who represented service users on the development group,
said: "This guideline is good news for service users because
it emphasises the importance of actively involving service users
in the decision making process...The focus on relationships and
on alternatives to drugs and restraint in this guideline are important
indicators of a shift to a more humane and respectful service."
Kevin Gournay, of the health services research department at the
Institute of Psychiatry, London, is chairman of the development
said: "This guidance has taken into account all the available
evidence and has been compiled taking into account the views of
staff, patients, service users, patient's families, and all who
are involved in the area of mental health."
health charity Sane's chief executive, Marjorie Wallace commented
that training to identify and deal with violence without resorting
to drugs or restraint will only work if there is a major increase
in the number of nurses and improvement in the state of psychiatric
these shortages and conditions remain, it will be difficult for
nurses to sustain relationships and respond to early signs of disturbed
or violent behaviour," she warned.
NICE guidelines on the short-term
management of disturbed/violent behaviour in inpatient psychiatric
settings and emergency departments.
Mental health comment
Feb 7, 2005:
Compassion not compulsion - psychiatric treatment by force amounts
to state-sponsored violence, says Rufus May
3, 2004: All mental health staff to receive anti-racist training
- ministers accept recommendation of inquiry into the death of David
"Rocky" Bennett in 1999
24, 2004: Restraint training to go ahead for all mental health nurses
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