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Violence and aggression

About

What is covered

Violence and aggression refer to a range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear.
This interactive flowchart covers the short-term management of violence and physically threatening behaviour in mental health, health and community settings. This includes inpatient psychiatric care, emergency and urgent care, secondary mental health care (such as care provided by assertive community teams, community mental health teams, early intervention teams and crisis resolution and home treatment teams), community healthcare, primary care, social care and care provided in people's homes. The recommendations cover anticipating and reducing the risk of violence and aggression, prevention methods (including searching, de-escalation and pharmacological strategies, including 'pro re nata' medication), restrictive interventions (for example, restraint, rapid tranquillisation and seclusion), staff training and post-incident debrief and review.
This interactive flowchart covers adults (aged 18 and over), children (aged 12 and under) and young people (aged 13 to 17) with a mental health problem who are currently service users within mental health, health and community settings. It also covers carers of service users with mental health problems in these settings.

Updates

Updates to this interactive flowchart

28 June 2017 Violent and aggressive behaviours in people with mental health problems (NICE quality standard 154) added.
29 May 2015 Major update on publication of NICE's guideline on violence and aggression (NG10).

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on managing violence in mental health, health and community settings in an interactive flowchart

What is covered

Violence and aggression refer to a range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear.
This interactive flowchart covers the short-term management of violence and physically threatening behaviour in mental health, health and community settings. This includes inpatient psychiatric care, emergency and urgent care, secondary mental health care (such as care provided by assertive community teams, community mental health teams, early intervention teams and crisis resolution and home treatment teams), community healthcare, primary care, social care and care provided in people's homes. The recommendations cover anticipating and reducing the risk of violence and aggression, prevention methods (including searching, de-escalation and pharmacological strategies, including 'pro re nata' medication), restrictive interventions (for example, restraint, rapid tranquillisation and seclusion), staff training and post-incident debrief and review.
This interactive flowchart covers adults (aged 18 and over), children (aged 12 and under) and young people (aged 13 to 17) with a mental health problem who are currently service users within mental health, health and community settings. It also covers carers of service users with mental health problems in these settings.

Updates

Updates to this interactive flowchart

28 June 2017 Violent and aggressive behaviours in people with mental health problems (NICE quality standard 154) added.
29 May 2015 Major update on publication of NICE's guideline on violence and aggression (NG10).

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Violent and aggressive behaviours in people with mental health problems

These quality statements are taken from the violent and aggressive behaviours in people with mental health problems quality standard. The quality standard defines clinical best practice for violent and aggressive behaviours in people with mental health problems and should be read in full.

Quality statements

Identifying triggers and warning signs

This quality statement is taken from the violent and aggressive behaviours in people with mental health problems quality standard. The quality standard defines clinical best practice for violent and aggressive behaviours in people with mental health problems and should be read in full.

Quality statement

People in contact with mental health services who have been violent or aggressive are supported to identify triggers and early warning signs for these behaviours.

Rationale

Personal, social, institutional or environmental factors can trigger violent or aggressive behaviours in people with mental health problems who receive support in mental health, health or community settings. Identifying these triggers can help people using mental health services, care staff and carers to understand what prompts violent or aggressive behaviour when people are using these services. This knowledge can prevent violent or aggressive behaviours from escalating by alerting people to early warning signs of distress and enabling them to start immediate de escalation or remove the triggers causing the violent or aggressive behaviour. Identifying triggers and early warning signs can also help services to improve organisational practice.

Quality measures

Structure
Evidence of local arrangements to ensure that people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings have identified triggers and early warning signs for these behaviours included in their care plan.
Data source: Local data collection, for example, service protocols on managing violent or aggressive behaviours.
Process
Proportion of people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings whose care plan includes identified triggers and early warning signs for these behaviours.
Numerator – the number in the denominator with a care plan that includes any identified triggers and early warning signs.
Denominator – the number of people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings.
Data source: Local data collection.
Outcome
a) Service user experience of involvement in managing violent and aggressive behaviours.
Data source: Local data collection, for example, surveys capturing service user experience.
b) Number of incidents needing restrictive interventions including observation, seclusion, manual restraint, mechanical restraint and rapid tranquillisation.
Data source: Local data collection and restrictive interventions recorded in the mental health services data set.

What the quality statement means for different audiences

Service providers (such as mental health trusts, mental health community services and primary care mental health services) ensure that systems are in place to identify the factors that prompt violent or aggressive behaviours in people with mental health problems. Service providers also ensure that people are supported to identify their own triggers and early warning signs and that these are recorded in the person’s care plan. Service providers share this information to inform care, organisational learning and practice.
Health and social care practitioners (such as mental health nurses, psychiatrists and social workers) encourage and support people with mental health problems who have been violent or aggressive while receiving support to identify triggers and early warning signs. They record identified triggers and early warning signs in the person’s care plan, and share this information to inform care, organisational learning and practice.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that they commission services that identify the factors that prompt violent or aggressive behaviours in people with mental health problems. They also ensure that people with mental health problems who have been violent or aggressive while receiving support in mental health, health or community settings are supported to identify their own triggers and early warning signs and that these are recorded in the person’s care plan.
People in contact with mental health services who have been violent or aggressive when they were using mental health, health or community services are encouraged to think about ‘triggers’ that might have caused the violent or aggressive behaviour (for example, something that happened to them, something they saw, or a feeling such as disappointment or anger). They are also encouraged to think about the early warning signs that they are about to feel violent or aggressive. They discuss their thoughts with their care team and any ‘triggers’ or possible warning signs they identify are recorded in their care plan.

Source guidance

Definitions of terms used in this quality statement

Violent or aggressive behaviours
A range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear.
[NICE’s guideline on violence and aggression]
Triggers
Factors that may instigate violent and aggressive behaviours. They may be:
  • personal
  • constitutional
  • mental
  • physical
  • environmental
  • social
  • communicational
  • functional
  • behavioural.
Triggers may be internal to the service user, based on their perception of the environment potentially shaped by delusions, hallucinations, confusion, disorientation and misperception, or they may be responding to the behaviour or actions of others.
Common triggers in inpatient psychiatric wards include the denial of a request, or a demand to either do something or cease an activity. The symptomatic behaviours of other service users can also trigger violence as they may be intrusive or hard to tolerate. A service user’s ability to handle frustration may be severely weakened by their mental health problem, making an aggressive response more likely than if they were well.
[NICE’s full guideline on violence and aggression]

Preventing and managing violent or aggressive behaviour

This quality statement is taken from the violent and aggressive behaviours in people with mental health problems quality standard. The quality standard defines clinical best practice for violent and aggressive behaviours in people with mental health problems and should be read in full.

Quality statement

People in contact with mental health services who have been violent or aggressive are supported to identify successful de-escalation techniques and make advance statements about the use of restrictive interventions.

Rationale

Identifying de-escalation techniques that have worked in the past increases the likelihood that de-escalation will be effective and restraint won’t be necessary. De escalation should start when the first signs of agitation, irritation, anger or aggression are recognised. Should a situation escalate to a point at which restrictive intervention is needed, de-escalation should still be attempted. Making advance statements for circumstances when restrictive interventions need to be used allows the person to express their wishes about the most acceptable types of restrictive intervention and can minimise potential harm or discomfort.

Quality measures

Structure
Evidence of local arrangements to ensure that people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings have any identified de escalation techniques that have been successful and advance statements about the use of restrictive interventions included in their care plan.
Data source: Local data collection, for example, service protocols on managing violent or aggressive behaviours.
Process
a) Proportion of people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings whose care plan identifies de-escalation techniques that have been successful.
Numerator – the number in the denominator with a care plan that includes any identified de-escalation techniques that have been successful.
Denominator – the number of people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings.
Data source: Local data collection, for example care plan reviews.
b) Proportion of people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings whose care plan includes advance statements about the use of restrictive interventions.
Numerator – the number in the denominator with a care plan that includes advance statements about the use of restrictive interventions.
Denominator – the number of people in contact with mental health services who have been violent or aggressive while receiving support in mental health, health or community settings.
Data source: Local data collection, for example care plan reviews.
Outcome
a) Service user experience of managing violent and aggressive behaviours.
Data source: Local data collection, for example surveys capturing service user experience.
b) Number of incidents requiring restrictive interventions including observation, seclusion, manual restraint, mechanical restraint and rapid tranquillisation.
Data source: Local data collection. Information on restrictive interventions is recorded in the mental health services data set.

What the quality statement means for different audiences

Service providers (such as mental health trusts, mental health community services and primary care mental health services) ensure that systems are in place to involve people with mental health problems who have been violent or aggressive while using the services in identifying de-escalation techniques that have been successful, and that the person's care plan includes advance statements about the use of restrictive interventions.
Health and social care practitioners (such as mental health nurses, psychiatrists and social workers) encourage and support people with mental health problems who have been violent or aggressive while using the services to identify de-escalation techniques that have been successful and to make advance statements about the use of restrictive interventions, and record this information in the person’s care plan.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that they commission services in which people with mental health problems who have been violent or aggressive while using the services are involved in identifying de-escalation techniques that have been successful and make advance statements about the use of restrictive interventions, and that this information is recorded in care plans.
People in contact with mental health services who have been violent or aggressive while using the services are encouraged to think about what made them feel calmer (such as talking with someone or taking a medication). They discuss this with their care team and explain what they would like their care team to do in the future if they become distressed. They may also make a written statement (called an advance statement) about their preferences if a ‘restrictive intervention’, such as physically holding them, or giving them an injection of medication, is needed. All of this information is recorded in their care plan.

Source guidance

Definitions of terms used in this quality statement

Violent or aggressive behaviours
A range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear.
[NICE’s guideline on violence and aggression]
De-escalation
The use of techniques (including verbal and non-verbal communication skills) aimed at defusing anger and averting aggression. ‘When needed’ (p.r.n.) medication can be used as part of a de-escalation strategy but ’when needed' medication used alone is not de-escalation.
[NICE’s guideline on violence and aggression]
Advance statement
A written statement that conveys a person's preferences, wishes, beliefs and values about their future treatment and care. An advance statement is not legally binding.
[NICE’s guideline on violence and aggression]
Restrictive interventions
Interventions that may infringe a person's human rights and freedom of movement, including observation, seclusion, manual restraint, mechanical restraint and rapid tranquillisation.
[NICE’s guideline on violence and aggression]

Physical health during and after manual restraint

This quality statement is taken from the violent and aggressive behaviours in people with mental health problems quality standard. The quality standard defines clinical best practice for violent and aggressive behaviours in people with mental health problems and should be read in full.

Quality statement

People with a mental health problem who are manually restrained have their physical health monitored during and after restraint.

Rationale

Restrictive interventions are most likely to be used in inpatient psychiatric settings and should only be used if other preventive strategies have failed. They should be used for no longer than necessary and de-escalation should continuously be attempted. Monitoring physical health during and after manual restraint is paramount for the person’s safety. There is a risk of death from obstructing airways during manual restraint, but harm can also occur after the event. People with mental health problems are at increased risk of coronary heart disease, cerebrovascular disease, diabetes, epilepsy and respiratory disease; all of which can be exacerbated by the effects of manual restraint.

Quality measures

Structure
Evidence of local arrangements to ensure that people with a mental health problem who are manually restrained have their physical health monitored during and after manual restraint.
Data source: Local data collection, for example, service protocol on physical restraint.
Process
a) Proportion of incidents involving manual restraint of a person with a mental health problem in which physical health was monitored during the restraint.
Numerator – the number in the denominator in which physical health was monitored during the restraint.
Denominator – the number of incidents involving manual restraint of a person with a mental health problem.
Data source: Local data collection, for example, patient safety incident reports.
b) Proportion of incidents involving manual restraint of a person with a mental health problem in which physical health was monitored after manual restraint.
Numerator – the number in the denominator in which physical health was monitored after manual restraint.
Denominator – the number of incidents involving manual restraint of a person with a mental health problem.
Data source: Local data collection, such as patient safety incident reports.
Outcome
Proportion of incidents involving manual restraint of a person with a mental health problem where harm to the person occurred.
Data source: Local data collection, such as organisation patient safety incident reports.

What the quality statement means for different audiences

Service providers (such as mental health trusts, secondary care services, forensic mental healthcare services) ensure that systems are in place for people with a mental health problem who are manually restrained to have their physical health monitored during and after manual restraint until there are no further concerns. They should also ensure that the healthcare practitioners who may be required to physically restrain service users are trained in the safe application of physical interventions and monitoring the physical health of people during and after restraint.
Healthcare practitioners (such as mental health nurses and staff working in forensic mental healthcare services) use manual restraint only when de-escalation techniques have not worked for people with a mental health problem who are being violent or aggressive. Healthcare practitioners who may be required to physically restrain service users are trained in the safe application of physical interventions and monitoring of the physical health of people during and after restraint. If they do manually restrain a person, they monitor the person’s physical health during and after restraint until there are no further concerns.
Commissioners (clinical commissioning groups and NHS England) ensure that the services they commission keep the person safe by monitoring their physical health during and after manual restraint until there are no further concerns. They also ensure that they commission services in which manual restraint is used only when de-escalation techniques have not worked for people with a mental health problem who are being violent or aggressive.
People with a mental health problem who are being violent or aggressive are only manually restrained (physically held so that they can’t hurt themselves or others) if all other attempts to stop the violence or aggression have failed. If manual restraint is used, the person has checks during and after the restraint to make sure that they stay safe and well.

Source guidance

Definitions of terms used in this quality statement

Manually restrained
Use of a skilled, hands-on method of physical restraint by trained healthcare professionals to prevent service users from harming themselves, endangering others or compromising the therapeutic environment. Its purpose is to safely immobilise the service user.
[NICE’s guideline on violence and aggression]
Physical health monitored during manual restraint
Monitoring of vital signs such as pulse (rate), respiration (respiratory rate), complexion (with special attention to pallor or discolouration) and level of consciousness.
[Expert consensus]
Physical health monitored after manual restraint
Monitoring physiological parameters could, as a minimum, be in line with the Royal College of Physicians’ National Early Warning Score (NEWS), which measures:
  • respiratory rate
  • oxygen saturations
  • temperature
  • systolic blood pressure
  • pulse rate
  • level of consciousness.
[Expert consensus] 

Physical health after rapid tranquillisation

This quality statement is taken from the violent and aggressive behaviours in people with mental health problems quality standard. The quality standard defines clinical best practice for violent and aggressive behaviours in people with mental health problems and should be read in full.

Quality statement

People with a mental health problem who are given rapid tranquillisation have side effects, vital signs, hydration level and consciousness monitored after the intervention.

Rationale

Restrictive interventions are most likely to be used in inpatient psychiatric settings and should only be used if de-escalation and other preventive strategies have failed, and there is potential for harm to the person or other people if no action is taken. Rapid tranquillisation is a potentially high-risk intervention that can result in a range of side effects linked to the medication and dose. People given rapid tranquillisation need to be monitored at least every hour until there are no further concerns about their physical status. If rapid tranquilisation is used while the person is in seclusion, additional measures may be needed to ensure safety. People with mental health problems are at increased risk of coronary heart disease, cerebrovascular disease, diabetes, epilepsy and respiratory disease; all of which can be exacerbated by the effects of rapid tranquillisation.

Quality measures

Structure
Evidence of local arrangements to ensure that people with a mental health problem who are given rapid tranquillisation have side effects, vital signs, hydration level and consciousness monitored.
Data source: Local data collection, for example, service protocol on physical restraint.
Process
Proportion of incidents involving rapid tranquillisation of people with a mental health problem in which side effects, vital signs, hydration level and consciousness were monitored after the intervention.
Numerator – the number in the denominator in which side effects, vital signs, hydration level and consciousness were monitored after the intervention.
Denominator – the number of incidents involving rapid tranquillisation of people with a mental health problem.
Data source: Local data collection, for example, patient safety incident reports.
Outcome
Proportion of incidents involving rapid tranquillisation of a person with a mental health problem where harm to the person occurred.
Data source: Local data collection, such as organisation patient safety incident reports.

What the quality statement means for different audiences

Service providers (such as mental health trusts, secondary care services, forensic mental healthcare services) ensure that systems are in place for people with a mental health problem who are given rapid tranquillisation to have their side effects, vital signs, hydration level and consciousness monitored until there are no further concerns about their physical health.
Healthcare practitioners (such as mental health nurses and staff working in forensic mental healthcare services) who use rapid tranquillisation only when de-escalation techniques have not worked for people with a mental health problem who are being violent or aggressive. If they give rapid tranquillisation, they monitor the side effects, vital signs, hydration level and consciousness at least every hour until there are no further concerns about the person’s physical health.
Commissioners (clinical commissioning groups and NHS England) ensure that the services they commission keep people safe after rapid tranquillisation by monitoring side effects, vital signs, hydration level and consciousness until there are no further concerns about the person’s physical health. They also ensure that they commission services in which rapid tranquillisation is used only when de-escalation techniques have not worked for people with a mental health problem who are being violent or aggressive.
People with a mental health problem who are being violent or aggressive and are given rapid tranquillisation by an injection of medicine have frequent checks after the injection for any side effects and to make sure that they stay safe and well. Rapid tranquillisation is given to calm people down quickly if all other attempts to stop violence or aggression haven’t worked.

Source guidance

Definitions of terms used in this quality statement

Rapid tranquillisation
Use of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral medication is not possible or appropriate and urgent sedation with medication is needed.
[NICE’s guideline on violence and aggression]

Immediate post-incident debrief

This quality statement is taken from the violent and aggressive behaviours in people with mental health problems quality standard. The quality standard defines clinical best practice for violent and aggressive behaviours in people with mental health problems and should be read in full.

Quality statement

People with a mental health problem who experience restraint, rapid tranquillisation or seclusion are involved in an immediate post-incident debrief.

Rationale

Restrictive interventions are most likely to be used in inpatient psychiatric settings. Conducting a post-incident debrief helps the organisation to identify and address any physical harm to service users or staff, ongoing risks, and the emotional impact on service users and staff. The person with a mental health problem who was involved in the incident should be offered the opportunity to contribute to the immediate debrief and discuss the incident with a member or staff, an advocate or a carer. This debrief should take place as soon as possible after the person has recovered their composure. This gives them the opportunity to give their perspective of the event and understand what happened.

Quality measures

Structure
a) Evidence of local arrangements to ensure that the service carries out an immediate post-incident debrief after each incident when restraint, rapid tranquillisation or seclusion was used.
Data source: Local data collection, for example, service protocol on physical restraint.
b) Evidence of local arrangements to ensure that people with a mental health problem who experience restraint, rapid tranquillisation or seclusion are involved in an immediate post-incident debrief.
Data source: Local data collection, for example, service protocol on physical restraint.
Process
Proportion of incidents involving a person with a mental health problem where the person was involved in the immediate post-incident debrief.
Numerator – the number in the denominator where the person was involved in the immediate post-incident debrief.
Denominator – the number of incidents involving a person with a mental health problem.
Data source: Local data collection, for example, patient safety incident reports.
Outcome
a) Service user experience of post-incident debriefs.
Data source: Local data collection, for example, local surveys capturing service user experience.
b) Reduced number of incidents.
Data source: Local data collection and restrictive interventions recorded in the mental health services data set.

What the quality statement means for different audiences

Service providers (such as providers of mental health services and secondary care services) ensure that they conduct an immediate post-incident debrief after the use of restraint, rapid tranquillisation or seclusion to address physical harm, ongoing risks and the emotional impact of the incident. They should ensure that they provide an opportunity for people with a mental health problem involved in the incident to be involved in the debrief as soon as they feel ready.
Healthcare practitioners (such as mental health nurses and staff working in forensic mental healthcare services) use restraint, rapid tranquillisation or seclusion only when de-escalation techniques have not worked. Immediately after an incident, they conduct a post-incident debrief that includes addressing physical harm, ongoing risks and the emotional impact of the incident. They provide an opportunity for people with a mental health problem involved in the incident to be involved in the debrief as soon as they feel ready.
Commissioners (clinical commissioning groups and NHS England) ensure the services they commission carry out an immediate post-incident debrief that includes addressing physical harm, ongoing risks and the emotional impact of the incident to service users. They also ensure that they commission services in which restraint, rapid tranquillisation and seclusion are used only when de-escalation techniques have not worked.
People with a mental health problem who become violent or aggressive and have manual restraint, rapid tranquillisation or seclusion are given a chance to talk about what happened, why the restraint was used and how they feel about it. This should happen only after they have recovered their composure. Manual restraint, rapid tranquillisation (giving an injection of medication) and seclusion (taking the person to a room away from everyone else) are used to stop violent or aggressive behaviour when all other methods of stopping it haven’t worked.

Source guidance

Definitions of terms used in this quality statement

Incident
Any event that involves the use of a restrictive intervention – restraint, rapid tranquillisation or seclusion (but not observation) – to manage violence or aggression.
[NICE’s guideline on violence and aggression]
Immediate post incident debrief
The debrief should include a nurse and a doctor and identify and address physical harm to service users or staff, ongoing risks and the emotional impact on service users and staff, including witnesses. The incident should only be discussed with service users, witnesses and staff involved after they have recovered their composure.
The debrief should use a framework for anticipating and reducing violence and aggression to determine the factors that contributed to an incident that led to a restrictive intervention, identify any factors that can be addressed quickly to reduce the likelihood of a further incident and amend risk and care plans accordingly.
[Adapted from NICE’s guideline on violence and aggression]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

a written statement made by a person aged 18 or over that is legally binding and conveys a person's decision to refuse specific treatments and interventions in the future
a written statement made by a person aged 18 or over that is legally binding and conveys a person's decision to refuse specific treatments and interventions in the future
a written statement that conveys a person's preferences, wishes, beliefs and values about their future treatment and care – an advance statement is not legally binding
a written statement that conveys a person's preferences, wishes, beliefs and values about their future treatment and care – an advance statement is not legally binding
a person who represents someone's interests independently of any organisation, and helps them to get the care and support they need
a set of physical skills to help separate or break away from an aggressor in a safe manner; these techniques do not involve the use of restraint
a person who provides unpaid support to a partner, family member, friend or neighbour who is ill, struggling or disabled
a person who provides unpaid support to a partner, family member, friend or neighbour who is ill, struggling or disabled
the use of techniques (including verbal and non-verbal communication skills) aimed at defusing anger and averting aggression. p.r.n medication can be used as part of a de-escalation strategy but p.r.n medication used alone is not de-escalation
any event that involves the use of a restrictive intervention – restraint, rapid tranquillisation or seclusion (but not observation) – to manage violence or aggression
any event that involves the use of a restrictive intervention – restraint, rapid tranquillisation or seclusion (but not observation) – to manage violence or aggression
a skilled, hands-on method of physical restraint used by trained healthcare professionals to prevent service users from harming themselves, endangering others or compromising the therapeutic environment; its purpose is to safely immobilise the service user
a method of physical intervention involving the use of authorised equipment, for example handcuffs or restraining belts, applied in a skilled manner by designated healthcare professionals; its purpose is to safely immobilise or restrict movement of part(s) of the body of the service user
a minimally restrictive intervention of varying intensity in which a member of the healthcare staff observes and maintains contact with a service user to ensure the service user's safety and the safety of others
an intervention that aims to empower service users to actively participate in their care – rather than 'having things done to' them, service users negotiate the level of engagement that will be most therapeutic
refers to the use of medication as part of a strategy to de-escalate or prevent situations that may lead to violence or aggression; it does not refer to p.r.n. medication used on its own for rapid tranquillisation during an episode of violence of aggression
use of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral medication is not possible or appropriate and urgent sedation with medication is needed
interventions that may infringe a person's human rights and freedom of movement, including observation, seclusion, manual restraint, mechanical restraint and rapid tranquillisation
defined in accordance with the Mental Health Act 1983 Code of Practice: 'the supervised confinement of a patient in a room, which may be locked. Its sole aim is to contain severely disturbed behaviour that is likely to cause harm to others'

Paths in this pathway

Pathway created: March 2014 Last updated: June 2017

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