Mental health staff should understand how their behaviour can increase or decrease risks of violence, guidance urges

February 28, 2005
by Adam James

Mental 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 have urged.

Training for staff should also include how to recognise anger, potential aggression, antecedents, and risk factors of disturbed and violent behaviour.

The recommendations were published last week in guidelines by the National Institute for Clinical Excellence (NICE).

The guidelines are for staff working in NHS in-patient psychiatric wards and accident and emergency departments in England and Wales.

Another recommendation is that all mental health service providers should ensure their services have a full risk management strategy for assessing risk and preventing violence.

This should include drawing up measures to calm down a potentially violent situation and intervene safely when violence occurs.

The guidelines state that rapid tranquillisation, physical restraint, and seclusion should be considered only after such measures have failed to calm a patient.

The 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."

The guidelines 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 user groups.

Some mental health groups are alarmed, however, that no three-minute time limit for the face-down restraint of mental health patients, has been set.

This is despite recommendations by an inquiry commissioned by the NHS.

Instead, 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".

The inquiry into the death of David "Rocky" Bennett in the Norvic clinic in Norwich in 1998 called for the three-minute limit.

He died after being held face down on the floor for about 25 minutes, most of the time by four nurses.

The 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.

However, consultant psychiatrist Sue Johnston, and a member of the NICE development group said it was dangerous to assume that three minutes was "magically safe".

"There is no safe time. Any intervention is potentially hazardous," she told societyguardian.co.uk.

But Richard Brook, chief executive of mental health charity Mind was "dismayed" that the guidelines did not specify a maximum time limit for restraint.

"Failure 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.

Mr Brook did, nevertheless, welcome other aspects of the guidelines.

"It's been clear for years that these guidelines are desperately needed, and their introduction is welcome," he said.

"Positive steps have been taken to include more training for staff on anticipating and de-escalating situations in which violence may occur."

The 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 required.

This 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.

To 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.

Donna-Maria 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."

Professor Kevin Gournay, of the health services research department at the Institute of Psychiatry, London, is chairman of the development group.

He 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."

Mental 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 wards.

"While 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.

Read for yourself:
NICE guidelines on the short-term management of disturbed/violent behaviour in inpatient psychiatric settings and emergency departments.

See also:
Mental health comment
Feb 7, 2005: Compassion not compulsion - psychiatric treatment by force amounts to state-sponsored violence, says Rufus May

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
April 24, 2004: Restraint training to go ahead for all mental health nurses

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