FMH5 Minimise the risks to an individual and staff during clinical interventions and violent and aggressive episodes

Overview

This standard covers the steps that have to be taken when an individual may become or has become violent or aggressive or there is strong reason to believe that they will do so during a clinical intervention. The overwhelming preference is for de-escalation, but where verbal and locational de-escalation fail to work, additional interventions, such as physical intervention, rapid tranquillisation and seclusion may be needed to manage the incident. Such interventions should only be considered once de-escalation techniques have been tried and have not succeeded in calming the individual. All members of the multidisciplinary team need to know and support the care plan through the Care Programme Approach in order to achieve consistency of management. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 1

Knowledge and Understanding

You will need to know and understand:

1. The causes of aggression and violence in secure and community settings
2. Mental health disorders
3. Drug, alcohol or substance misuse
4. Offending behaviours with especial regards for violent behaviour not related to mental illness
5. Psychopathy and personality disorder
6. Self-harming behaviours, including ligation
7. De-escalation techniques
8. Methods of control and restraint
9. The principles and practice in the use of time-out
10. The link between physical conditions and the need for physical restraint
11. Rapid tranquillisation and local protocols for them
12. Current national guidelines (eg NICE, SIGN)
13. Protocols for seclusion
14. The range of treatments available at your own and other establishments
15. Inquiry reports on forensic mental health settings, including recommendations and analysis of practice in the management of violent and aggressive episodes
16. Resuscitation techniques
17. Local guidelines or policies on Advance Statements
18. Codes of professional conduct, local policies, protocols and guidelines
19. Negotiation
20. Theory and practice of managing aggression
21. Theory and practice of de-escalating aggression
22. Theory and practice of debriefing
23. How to re-establish relationships
24. How to display unconditional positive regard
25. Local policy and procedures on managing aggression
26. How to adapt communication styles in ways which are appropriate to different people (eg culture, language or special needs)
27. The religious beliefs of different cultures
28. The effects of culture and religious beliefs on individual communication styles
29. The different features services must have to meet people’s gender, culture, language or other needs
30. The effects of different cultures and religions on care management
31. The principle of confidentiality and what information may be given to whom
32. How information obtained from individuals should be recorded and stored
33. Analysis of specific antecedents of aggression by individual and unit

Performance Criteria

You must be able to do the following:

1. assess and make known to the team the individual’s history – reasons, stressors, vulnerabilities and destabilising conditions that have led to violence
2. identify when an individual and/or members of staff are at risk of harm from the individual’s actual or likely violence and aggression (eg identify known stressors)
3. adopt preventative measures through a team member who has a good rapport with the individual (e.g. expected behaviours and agreed effective alternative behaviours)
4. de-escalate in an environment known to be calming and not associated with seclusion
5. speak and behave in a way that avoids provocation (e.g. posture that the individual finds reassuring)
6. maintain verbal de-escalation and possibilities for engagement throughout the episode
7. use intensive support or restraint according to local protocols if de-escalation fails
8. resort to rapid tranquillisation or seclusion only if local protocols allow and only once de-escalation and other strategies have failed to calm the individual
9. select and conduct interventions proportionate to the risk posed by the individual, and consistent with the individual’s clinical needs and, where possible, Advance Statement
10. acknowledge which staff member is in charge when restraint, rapid tranquillisation or seclusion are required to support verbal de-escalation
11. ensure necessary emergency medical equipment is in place (e.g. resuscitation equipment)
12. conduct interventions consistent with best practice (e.g. NICE and SIGN, Codes of Practice), mental health legislation and local protocols (e.g. on rapid tranquillisation)
13. preserve the individual’s dignity and privacy as far as possible, consistent with the intervention
14. explain to the individual at the earliest opportunity the reasons for using rapid tranquillisation, restraint or seclusion
15. record the episode and re-evaluate the individual’s risk assessment, care plan and your risk management strategies
16. reintegrate the individual into normal daily routines as quickly as possible
17. debrief and support staff and the individual after the incident

Additional Information

This National Occupational Standard was developed by Skills for Health. This workforce competence links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB3 Protection of health and wellbeing