Issue date: February 2005

Quick reference guide

Violence
The short-term management of
disturbed/violent behaviour in
psychiatric in-patient settings
and emergency departments
Clinical Guideline 25
Developed by the National Collaborating Centre for Nursing and
Supportive Care
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This guidance is written in the following context:
This guidance represents the view of the Institute, which was arrived at after careful consideration of the evidence
available. Health professionals are expected to take it fully into account when exercising their clinical judgement.
The guidance does not, however, override the individual responsibility of health professionals to make decisions
appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
National Institute for
Clinical Excellence
MidCity Place
71 High Holborn
London
WC1V 6NA
www.nice.org.uk
National Institute for Clinical Excellence, February 2005. All rights reserved. This material may be freely reproduced for educational and not-
for-profit purposes within the NHS. No reproduction by or for commercial organisations is allowed without the express written permission of
the National Institute for Clinical Excellence.
ISBN: 1-84257-896-0
Published by the National Institute for Clinical Excellence
February 2005
Artwork by LIMA Graphics Ltd, Frimley, Surrey
Printed by Abba Litho (Sales) Ltd
Contents
Key priorities for implementation 4
Overview algorithm for the short-term management of 5
disturbed/violent behaviour
Prediction 6
Risk factors 6
Antecedents and warning signs 7
Risk assessment 7
Searching 8
Prevention 9
De-escalation 9
Observation 10
Interventions for the management of disturbed/violent behaviour 14
Rapid tranquillisation algorithm 12
Rapid tranquillisation, physical intervention and seclusion: overarching recommendations 14
Rapid tranquillisation 15
Physical intervention 16
Seclusion 17
Post-incident review 18
Carrying out post-incident reviews 18
Emergency departments 19
Rapid tranquillisation in emergency departments 19
Working with service users 20
Service users with disabilities 20
Managing the risk of HIV or other infectious diseases 20
Pregnant women 20
Environment 20
Training 21
Implementation 23
Further information back cover
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This guideline makes recommendations on the short-term management of disturbed/violent behaviour in
adult in-patient psychiatric settings and emergency departments. This management takes place within a
multi-faceted legal framework, compliance with which is a core measure of quality and good practice.
Failure to act in accordance with the guideline may not only be a failure to act in accordance with best
practice, but in some circumstances may have legal consequences. For example, any intervention used
must be a reasonable and proportionate response to the risk it seeks to address.
All those involved in the short-term management of disturbed/violent behaviour should be familiar with,
in particular:
the relevant sections of the Mental Health Act 1983 and its Code of Practice
the principles underlying the Common Law doctrine of necessity, and
the requirements of the relevant articles of the European Convention on Human Rights, including
Articles 2, 3, 5, 8 and the principle of proportionality
the Health and Safety at Work Act 1974 and Management of Health and Safety at Work Regulations
1992.
For full details, please refer to the Legal preface in the NICE guideline.
Grading of the recommendations
The recommendations in this quick reference guide are based on the best available evidence.
Recommendations are graded , , , or good practice point depending on the type
of evidence they are based on.
For more information on the grading system, see the NICE guideline
(www.nice.org.uk/CG025NICEguideline)
About this quick reference guide
This quick reference guide summarises key practical recommendations to enable healthcare
professionals working within acute psychiatric settings and emergency departments to safely
and effectively manage actual or threatened violence. It also refers to the training necessary
to manage such situations. It does not include supportive recommendations made by the
Guideline Development Group, in such areas as organisational policies. To read the full set of
recommendations on the short-term management of disturbed/violent behaviour in these settings,
please refer to the NICE guideline, available at www.nice.org.uk/CG025NICEguideline
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Key priorities for implementation
The following recommendations have been identified as priorities for implementation. To read the
commentaries associated with these key priorities, please refer to the NICE guideline, available at
www.nice.org.uk/CG025NICEguideline
Prediction
Measures to reduce disturbed/violent behaviour need to be based on comprehensive risk
assessment and risk management. Therefore, mental health service providers should ensure that
there is a full risk management strategy for all their services.
Training
All service providers should have a policy for training employees and staff-in-training in relation
to the short-term management of disturbed/violent behaviour. This policy should specify who will
receive what level of training (based on risk assessment), how often they will be trained, and also
outline the techniques in which they will be trained.
All staff whose need is determined by risk assessment should receive ongoing competency
training to recognise anger, potential aggression, antecedents and risk factors of
disturbed/violent behaviour and to monitor their own verbal and non-verbal behaviour. Training
should include methods of anticipating, de-escalating or coping with disturbed/violent behaviour.
All staff involved in administering or prescribing rapid tranquillisation, or monitoring service
users to whom parenteral rapid tranquillisation has been administered, should receive ongoing
competency training to a minimum of Immediate Life Support (ILS Resuscitation Council UK)
(covers airway, cardio-pulmonary resuscitation [CPR] and use of defibrillators).
Staff who employ physical intervention or seclusion should as a minimum be trained to Basic Life
Support (BLS Resuscitation Council UK).
Working with service users
Service users should have access to information about the following in a suitable format:
which staff member has been assigned to them and how and when they can be contacted
why they have been admitted (and if detained, the reason for detention, the powers used
and their extent, and rights of appeal)
what their rights are with regard to consent to treatments, complaints procedures, and access
to independent help and advocacy
what may happen if they become disturbed/violent.
This information needs to be provided at each admission, repeated as necessary and recorded in
the notes.
Service users identified to be at risk of disturbed/violent behaviour should be given the
opportunity to have their needs and wishes recorded in the form of an advance directive. This
should fit within the context of their overall care and should clearly state what intervention(s)
they would and would not wish to receive. This document should be subject to periodic review.
Rapid tranquillisation, physical intervention and seclusion
Rapid tranquillisation, physical intervention and seclusion should only be considered once
de-escalation and other strategies have failed to calm the service user. These interventions
are management strategies and are not regarded as primary treatment techniques. When
determining which interventions to employ, clinical need, safety of service users and others
and, where possible, advance directives should be taken into account. The intervention selected
must be a reasonable and proportionate response to the risk posed by the service user.
INTERVENTIONS FOR CONTINUED MANAGEMENT
Consider, in addition to above, one or more of the following:
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Physical intervention
During physical intervention one team member should be responsible for protecting
and supporting the head and neck, where required. The team member who is responsible for
supporting the head and neck 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.
A number of physical skills may be used in the management of a disturbed/violent incident.
The level of force applied must be justifiable, appropriate, reasonable and proportionate to a
specific situation and should be applied for the minimum possible amount of time.
Every effort should be made to utilise skills and techniques that do not use the deliberate
application of pain.
The deliberate application of pain has no therapeutic value and could only be justified for the
immediate rescue of staff, service users and/or others.
PREDICTION
Risk assessment
Searching
PREVENTION
De-escalation techniques
Observation
Rapid tranquillisation
Used to avoid prolonged
physical intervention
Medication is required
to calm a psychotic
or non-psychotic
behaviourally disturbed
service user
Seclusion
Used to avoid prolonged
physical intervention
Physical intervention
Better if service user
responds quickly
Can be used to enable
rapid tranquillisation to
take effect
When service user
has taken previous
medication
(see pages 1213)
Should be terminated
when rapid
tranquillisation, if given,
has taken effect
When other interventions
not yet explored
Prolonged physical
intervention
CONTRA-INDICATED AS AN INTERVENTION
POST-INCIDENT REVIEW
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Overview algorithm for the short-term management of
disturbed/violent behaviour
EMERGENCY
DEPARTMENTS
Seek expert help
from a member of
the on-call mental
health team
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Prediction
Prediction
See also Training, pages 2122.
Risk factors
Certain factors can indicate an increased risk of physically violent behaviour. The following lists are not
intended to be exhaustive and these risk factors should be considered on an individual basis.
History of disturbed/violent behaviour
History of misuse of substances or alcohol
Carers reporting service users previous anger
or violent feelings
Previous expression of intent to harm others
Evidence of rootlessness or social
restlessness
Previous use of weapons
Previous dangerous impulsive acts
Denial of previous established dangerous acts
Severity of previous acts
Known personal trigger factors
Verbal threat of violence
Evidence of recent severe stress, particularly a
loss event or the threat of loss
One or more of the above in combination
with any of the following:
cruelty to animals
reckless driving
history of bed-wetting
loss of a parent before the age of
8 years
Demographic or personal history
Misuse of substances and/or alcohol
Drug effects (disinhibition, akathisia)
Active symptoms of schizophrenia or mania,
in particular:
delusions or hallucinations focused on a
particular person
command hallucinations
preoccupation with violent fantasy
delusions of control (especially with a
violent theme)
agitation, excitement, overt hostility or
suspiciousness
Poor collaboration with suggested
treatments
Antisocial, explosive or impulsive personality
traits or disorder
Organic dysfunction
Clinical variables
Extent of social support
Immediate availability of a potential weapon
Relationship to potential victim (for example,
difficulties in relationship are known)
Access to potential victim
Limit setting (for example, staff members
setting parameters for activities, choices, etc)
Staff attitudes
Situational variables
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Prediction
Antecedents and warning signs
Certain features may serve as warning signs to indicate that a service user may be escalating towards
physically violent behaviour. The list is not intended to be exhaustive and these warning signs should be
considered on an individual basis.
Risk assessment
All staff should be aware of the following factors that may provoke disturbed/violent behaviour:
attitudinal
situational
organisational
environmental.
There should be a regular and comprehensive general risk assessment to ensure the safety of the
clinical environment.
Risk assessment (of the environment and the service user) should be ongoing, because risk may
change according to circumstance. Care plans should be based on an accurate and thorough risk
assessment.
Use risk assessment to establish whether specific interventions should be included in the
plan.
Risk assessment should include a structured and sensitive interview with the service user and, where
appropriate, carers.
Try to get the service users views about their trigger factors, early warning signs and other
vulnerabilities, and their management.
Complete the process with sensitive and timely feedback.
Take care not to make negative assumptions based on ethnicity. Be aware that cultural mores
may manifest as unfamiliar behaviour that could be misinterpreted as being aggressive. Risk
assessment should be objective, and should consider the degree to which the perceived risk can
be verified.
Take a multidisciplinary approach that reflects the care setting where risk assessment is taking place.
Communicate the findings across relevant agencies and care settings, in accordance with the law
relating to patient confidentiality.
Where a risk of disturbed/violent behaviour is discussed or identified as a possibility in the risk
assessment interview, record intervention and management strategies (and the service users
preferences regarding these) in the care plan and healthcare record. A copy of the care plan should
be given to the service user, and to their carer if the service user agrees.
Tense and angry facial expressions
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
Prolonged eye contact
Discontentment, refusal to communicate,
withdrawal, fear, irritation
Unclear thought processes, poor
concentration
Delusions or hallucinations with violent
content
Verbal threats or gestures
Replicating, or behaviour similar to that
which preceded earlier disturbed/violent
episodes
Reporting anger or violent feelings
Blocking escape routes D(GPP)
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Prediction
Searching
Based on an assessment of risk, it may be necessary to search some service users to ensure a safe and
therapeutic environment.
Policy
All facilities should have an operational policy on searching that includes the points below:
searching service users, their belongings and the environment in which they are accommodated
searching visitors
rub down or personal searching (ordinarily), together with procedures for their authorisation in
the absence of consent
the circumstances in which a service user physically resists being searched
the routine and random searching of detained service users.
Where necessary, it should refer to related policies, such as those for substance misuse and
police liaison.
Carrying out searches
The intrusiveness of a personal search must be a reasonable and proportionate response to the reason
for the search.
Undertake searches with due regard to the service users dignity and privacy. The search should be
done by member(s) of staff of the same sex as the service user.
If a service user physically resists, a multidisciplinary decision should be made as to the need to carry
out a search using physical intervention. If the decision is not to proceed, the searching policy should
set out the options available to deal with the situation.
If consent is withheld, a post-incident review should be undertaken that includes an advocacy service
or hospital managers visiting the service user who has been searched.
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Prevention
See also Training, pages 2122.
De-escalation
A service users anger needs to be treated with an appropriate, measured and reasonable
response.
Use de-escalation techniques before other interventions. Continue to use verbal de-escalation even if
other interventions are necessary.
In a crisis situation, staff are responsible for avoiding provocation. They should be aware of and
monitor their own verbal and non-verbal behaviour.
Staff should learn to recognise what generally and specifically upsets and calms the service user.
This should be noted in the care plan.
Where possible and appropriate, encourage the service user to understand their own triggers.
Note these in the care plan and give a copy to the service user.
Encourage the service user to discuss and negotiate their wishes should they become
agitated.
De-escalation techniques
One staff member should assume control of a potentially disturbed/violent situation. This staff
member should:
consider which de-escalation techniques are appropriate for the situation
manage others in the environment (for example, removing other service users from the area,
getting colleagues to help and creating space) and move towards a safe place
explain to the service user and others nearby what they intend to do, giving clear, brief, assertive
instructions
ask for facts about the problem and encourage reasoning (attempt to establish a rapport; offer
and negotiate realistic options; avoid threats; ask open questions and ask about the reason for the
service users anger; show concern and attentiveness through non-verbal and verbal responses;
listen carefully; do not patronise and do not minimise the service users concerns)
ensure that their own non-verbal communication is non-threatening and not provocative.
Where there are potential weapons, the service user should be relocated to a safer environment,
where possible.
If a weapon is involved, ask for it to be put in a neutral location rather than handed over.
Consider asking the service user to make use of the designated area or room to help them calm
down. The seclusion room (in services where seclusion is practised) should not routinely be used for
this purpose.
All services should provide a designated area or room that staff may consider using, with the service
users agreement, specifically for the purpose of reducing arousal and/or agitation. In services in
which seclusion is practised, this area should be in addition to the seclusion room. D
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Observation
Policy
Each service should have a policy on observation and engagement, adhering to the terminology and
definitions used in this guideline (see Levels of observation, below) that includes:
who can instigate observation above the general level and who can change the level of observation
who should review the level of observation and when reviews should take place (at least every
shift)
how the service users perspectives will be taken into account
a process through which a review by a full clinical team will take place if observation above the
general level continues for more than 1 week.
Levels of observation
The terminology adopted in this guideline should be adopted across England and Wales.
General observation
This is the minimum acceptable level for all
service users
The location of the service user should be
known to staff at all times but they are not
necessarily within sight
Positive engagement with the service user
should take place at least once a shift
Evaluate the service users moods and
behaviours associated with disturbed/
violent behaviour, and record these in
the notes
Intermittent observation
This level is appropriate for service users
potentially at risk of disturbed/violent
behaviour, including those who have
previously been at risk but are in the process
of recovery
The service users location should be checked
every 1530 minutes (specify exact times in
the notes)
Intrusion should be minimised and positive
engagement with the service user should
take place
Within eyesight observation
Service users who could, at any time, make
an attempt to harm themselves or others
should be observed at this level
The service user should be within eyesight
and accessible at all times, day and night
Any possible tools or instruments that could
be used should be removed, if deemed
necessary
Searching of the service user and their
belongings may be necessary, which should
be conducted sensitively and with due
regard to legal rights
Positive engagement with the service user is
essential
Within arms length observation
Service users at the highest levels of risk of
harming themselves or others may need to
be observed at this level
The service user should be supervised in
close proximity
More than one staff member may be
necessary on specified occasions
Issues of privacy and dignity, consideration
of gender issues, and environmental dangers
should be discussed and incorporated into
the care plan
Positive engagement with the service user
is essential
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Prevention
Warning signs for observation
In addition to the warning signs shown on page 7 (Prediction), the following may indicate that
observation above the general level should be considered.
Carrying out observation
Carry out designated levels of observation only if the risk of disturbed/violent behaviour has not been
reduced by positive engagement with the service user.
Ensure that the least intrusive level of observation that is appropriate is adopted.
Explain the aims and level of the observation to the service users nearest relative, friend or carer
(if appropriate and with the service users agreement).
Record decisions about observation levels in the service users notes (both medical and nursing
entries), clearly specifying the reasons for using observation.
When making decisions about the specific level of observation, take into account the following:
the service users current mental state
any prescribed medications and their effects
the current assessment of risk
the views of the service user, as far as possible.
Clear directions should be recorded that specify the name/title of the persons who will be responsible
for carrying out the review and its timing.
Use observation skills to recognise, prevent and therapeutically manage disturbed/violent behaviour.
Specific observation tasks should be carried out by registered nurses who may delegate to competent
persons.
Nurses and other staff who carry out observation should:
engage positively with the service user
be appropriately briefed about the service users history, background, risk factors and needs
be familiar with the ward, ward policy for emergency procedures and potential environmental risks
be able to increase or decrease the level of engagement according to the level of observation
be approachable, listen to the service user, understand how to use self-disclosure and silence, and
be able to convey to the service user that they are valued.
An individual staff member should not carry out observation above the general level for more than
2 hours.
Ensure that the service users psychiatrist/on-call doctor is informed of any decisions concerning
observation above the general level as soon as possible.
A nominated hospital manager should be made aware when observation above the general level
is implemented, so that adequate numbers and grades of staff can be made available for future
shifts.
History of previous suicide attempts,
self-harm or attacks on others
Hallucinations, particularly voices suggesting
harm to self or others
Paranoid ideas where the service user
believes that other people pose a threat
Thoughts or ideas that the service user has
about harming themselves or others
Threat control override symptoms
Past or current problems with drugs or alcohol
Recent loss
Poor adherence to, or non-compliance with,
medication programmes
Marked changes in behaviour or medication
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13
NICE Guideline: quick reference guide Violence
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14
NICE Guideline: quick reference guide Violence
I
n
t
e
r
v
e
n
t
i
o
n
s
f
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t
h
e
m
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b
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a
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r
c
o
n
t
i
n
u
e
d
Interventions for the management of
disturbed/violent behaviour
Interventions for the management of disturbed/violent
behaviour
Alarms
Agree collective responses to alarm calls before incidents occur. These should be consistently applied
and rehearsed.
Rapid tranquillisation, physical intervention and seclusion:
overarching recommendations
See also Training, pages 2122, and Post-incident review, page 18.
Rapid tranquillisation, physical intervention and seclusion are management strategies and are not
regarded as primary treatment techniques. If employed:
they should only be considered once de-escalation and other strategies have failed
clinical need, the safety of service users and others and, where possible, advance directives should
be taken into account when making decisions on which interventions to use
the intervention selected must be a reasonable and proportionate response to the risk posed by
the service user.
Equipment
A crash bag should be available within 3 minutes in healthcare settings where these interventions
might be used. This equipment should:
include an automatic external defibrillator, a bag valve mask, oxygen, cannulas, fluids, suction and
first-line resuscitation medications
be maintained and checked weekly.
Personnel
At all times, a doctor should be available to quickly attend an alert by staff members when these
interventions are implemented
1
.
Legal concerns
All staff need to be aware of the legal framework that authorises the use of these interventions.
The guidance of the Mental Health Act Code of Practice (chapter 19) should be followed
(www.dh.gov.uk/assetRoot/04/07/49/61/04074961.pdf).
Any departures from that guidance should be clearly recorded and justified as being in the service
users best interest.
1
The Bennett report recommended that a doctor should be available within 20 minutes. The Guideline Development Group
considers quick attendance to mean within 30 minutes of an alert.
D(GPP)
D(GPP)
D
D
D
Service user concerns
If using these interventions:
try to ensure that the service user does not feel humiliated (for example, respecting their need for
dignity and privacy commensurate with the needs of administering the intervention)
explain the reasons for using the interventions to the service user at the earliest
opportunity
reassess the service users care plan and help them to reintegrate into the ward milieu at the
earliest safe opportunity following the intervention.
Service users should be given the opportunity to document their account of the intervention in their
notes.
15
NICE Guideline: quick reference guide Violence
I
n
t
e
r
v
e
n
t
i
o
n
s
f
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r
t
h
e
m
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u
e
d
Interventions for the management of
disturbed/violent behaviour
D(GPP)
D(GPP)
Rapid tranquillisation
See also the Rapid tranquillisation algorithm, pages 1213.
The aim of rapid tranquillisation is to achieve a state of calm sufficient to minimise the risk posed
to the service user or to others.
Doses
It is recognised that clinicians may decide that the use of medication outside of the Summary of
Product Characteristics (SPC) is occasionally justified, bearing in mind the overall risks. However,
where the regulatory authorities or manufacturer issues a specific warning that this may result in an
increased risk of fatality, the medication should only be used strictly in accordance with the current
marketing authorisation.
In certain circumstances, current British National Formulary (BNF) uses and limits and the
manufacturers SPC may be knowingly exceeded (for example, for lorazepam).
This decision should not be taken lightly or the risks underestimated.
Record a riskbenefit analysis in the case notes and a rationale in the care plan. Where the
riskbenefit is unclear, advice may be sought from clinicians not directly involved in the service
users care.
If current BNF doses or SPC are exceeded:
it is particularly important to undertake frequent and intensive monitoring of a calmed
service user
pay particular attention to regular checks of airway, level of consciousness, pulse, blood
pressure, respiratory effort, temperature and hydration.
Individualise the dose of antipsychotic medication for each service user. This will be dependent
on several factors including the service users age (older service users generally require lower
doses); concomitant physical disorders (such as renal, hepatic, cardiovascular or neurological);
and concomitant medication.
D
D
D
D(GPP)
16
NICE Guideline: quick reference guide Violence
I
n
t
e
r
v
e
n
t
i
o
n
s
f
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t
h
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m
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d
Interventions for the management of
disturbed/violent behaviour
Physical intervention
There are real dangers with physical intervention in any position.
Physical intervention should be avoided if at all possible.
Physical intervention should not be used for prolonged periods, and should be brought to an end
as soon as possible.
Remember the level of force applied must be justifiable, appropriate, reasonable and
proportionate to a specific situation, and applied for the shortest possible time.
Carrying out physical intervention
Continue to employ de-escalation techniques throughout.
One staff member should assume control throughout the process. He or she should be responsible
for:
protecting and supporting the service users head and neck, where required
ensuring their airway and breathing are not compromised
ensuring vital signs are monitored
leading the team through the process.
Monitor the services users overall physical and psychological well-being throughout.
Under no circumstances should direct pressure be applied to the neck, thorax, abdomen, back or
pelvic area.
To avoid prolonged physical intervention, consider rapid tranquillisation or seclusion (where
available) as alternatives.
Every effort should be made to use skills and techniques that do not use the deliberate
application of pain.
The application of pain has no therapeutic value and could only be justified for the immediate
rescue of staff, other service users or others.
D
D
D
D
D
D
D
D
D
D
17
NICE Guideline: quick reference guide Violence
I
n
t
e
r
v
e
n
t
i
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n
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d
Interventions for the management of
disturbed/violent behaviour
Seclusion
Carrying out seclusion
The use of seclusion should be recorded in accordance with the guidance in the Mental Health
Act Code of Practice.
Seclusion should be for the shortest time possible.
It should be reviewed at least every 2 hours in accordance with the guidance in the Mental
Health Act Code of Practice.
Staff should explain to the service user that a review will take place at least every 2 hours.
An observation schedule should be specified.
A service user in seclusion should keep their clothing and any personal items, including those of
religious or cultural significance (such as some items of jewellery), provided this does not
compromise their safety or the safety of others.
Rapid tranquillisation and seclusion
This is not absolutely contraindicated, providing that the points below are followed.
If the service user is secluded, take the potential complications of rapid tranquillisation
particularly seriously (see Rapid tranquillisation, pages 1213 and 15).
Monitor the service user by within eyesight observation (see Observation, page 10).
End the seclusion when rapid tranquillisation has taken effect.
In services where seclusion is practised, there should be a designated room fit for purpose.
This seclusion room should:
allow clear observation
be well insulated and ventilated
have access to toilet/washing facilities
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Post-incident review
Post-incident review
Record any incident requiring rapid tranquillisation, physical intervention or seclusion
contemporaneously, using a local template.
Carrying out post-incident reviews
A post-incident review should take place as soon as possible and at least within 72 hours of an
incident ending.
If possible, a person not directly involved in the incident should lead the review. The review should
address:
what happened during the incident
any trigger factors
each persons role in the incident
their feelings at the time of the incident, at the review and how they may feel in the near future
what can be done to address their concerns.
The aim of a post-incident review should be to seek to learn lessons, support staff and service
users, and encourage the therapeutic relationship between staff, service users and their
carers.
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Emergency departments
Emergency departments
See also Training, pages 2122.
Emergency department staff should seek specialist advice from the relevant mental health
professional if an initial assessment suggests a patient requires a mental health assessment.
Rapid tranquillisation in emergency departments
See also Rapid tranquillisation, pages 1213 and 15.
In an emergency setting, a senior medical staff member should take the decision to use rapid
tranquillisation, where at all possible.
If rapid tranquillisation is thought necessary, consider lorazepam as the first-line drug of choice:
when prior to formal diagnosis
where there is any uncertainty about previous medical history (including history of cardiovascular
disease, uncertainty regarding current medication, or the possibility of current illicit drug/alcohol
intoxication).
If there is a confirmed history of previous significant antipsychotic exposure, and response,
haloperidol in combination with lorazepam is sometimes used.
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Working with service users
Working with service users
Treat all service users with dignity and respect, regardless of culture, gender, diagnosis, sexual
orientation, disability, ethnicity or religious/spiritual beliefs.
Ensure that service users have access to the information below, in a suitable format. This should be
provided at each admission, repeated as necessary and recorded in the notes.
The staff member assigned to them, and how and when they can be contacted.
The reason for admission (and if detained, the reason for detention, the powers used and their
extent, and rights of appeal).
Their rights with regard to consent to treatments, complaints procedures, and access to
independent help and advocacy.
What may happen if they become disturbed/violent.
Ensure that service users identified as being at risk of disturbed/violent behaviour have the
opportunity to record their needs and wishes in an advance directive. This should:
fit within the context of their overall care
clearly state what intervention(s) they would and would not wish to receive
be subject to periodic review.
Ensure that the service users physical needs are assessed on admission (or as soon as possible after
admission) and are regularly reassessed. These should be reflected in the care plan.
Help to establish therapeutic relationships by taking time to listen to service users, including those
from diverse backgrounds (be aware that this may take longer when using interpreters).
Ensure confidentiality when administering or supplying medicines to service users. Prescribers should
be available for and responsive to requests from the service user for medication review.
Service users with disabilities
Staff responsibilities (for de-escalation, rapid tranquillisation, physical intervention and seclusion)
should be detailed in the individual care plans of service users with disabilities (this includes service
users with physical or sensory impairment and/or other communication difficulties).
Managing the risk of HIV or other infectious diseases
If staff are aware that a service user has HIV, hepatitis or other infectious or contagious diseases, they
should seek the advice of the Trust infection control officer or relevant officer in the service.
Follow the local infection control policy if any service user or staff member is injured during the
management of disturbed/violent behaviour where blood is spilt or the skin is broken, or there
has been direct contact with bodily fluids (all bodily fluids should be treated as potentially
infectious).
Pregnant women
Special provision should be made for pregnant women in the event that interventions are needed.
These should be recorded in the service users care plan.
Environment
The environment should take into account the service users needs.
Ensure that service users can engage in activities and individual choice. There should be an activity
room and a dayroom with a television, as boredom can lead to disturbed/violent behaviour.
There should be single sex toilets, washing facilities, sleeping accommodation and day areas.
There should be a space set aside for prayer and quiet reflection.
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Training
Training
Specific staff training needs
Diversity issues
There should be an ongoing programme for all staff in racial, cultural, spiritual, social and special
needs issues, to ensure staff are aware of and know how to work with diverse populations and do
not perpetuate stereotypes. The courses should also cover any relevant local special populations,
such as migrant populations and asylum seekers.
Antecedents and risk factors
All staff whose need is determined by risk assessment should receive ongoing competency training to
recognise anger, potential aggression, antecedents and risk factors of disturbed/violent behaviour and
to monitor their own verbal and non-verbal behaviour. This should include methods of anticipating,
de-escalating or coping with disturbed/violent behaviour.
Observation
Staff members responsible for carrying out observation and engagement should receive ongoing
competency training in observation so that they are equipped with the skills and confidence to
engage with service users.
Life support
All staff involved in administering or prescribing rapid tranquillisation, or monitoring service users to
whom parenteral rapid tranquillisation has been administered, should receive ongoing competency
training to a minimum of Immediate Life Support (ILS Resuscitation Council UK) (covers airway,
cardio-pulmonary resuscitation [CPR] and use of defibrillators).
Staff who employ physical intervention or seclusion should as a minimum be trained to Basic Life
Support (BLS Resuscitation Council UK).
Physical intervention
All staff whose level of need is determined by risk assessment should receive training to ensure
current competency in the use of physical intervention which should adhere to approved national
standards
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Seclusion
All staff whose level of need is determined by risk assessment should receive ongoing competency
training in the use of seclusion. This should include appropriate monitoring arrangements for service
users placed in seclusion.
2
The NHS Security Management Service (SMS) is developing a training curriculum for the management of violence. The
National Institute for Mental Health in England (NIMHE) is drawing up an accreditation scheme for trainers. The work is due
for completion in 2005.
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Training
Rapid tranquillisation
All staff involved in rapid tranquillisation should be trained in the use of pulse oximeters.
Prescribers and those who administer medicines should be familiar with and have received training
in rapid tranquillisation, including:
the properties of benzodiazepines; their antagonist, flumazenil; antipsychotics; antimuscarinics
and antihistamines
associated risks, including cardio-respiratory effects of the acute administration of the drugs,
particularly when the service user is highly aroused and may have been misusing drugs; is
dehydrated or is possibly physically ill
the need to titrate doses to effect.
Searching
All staff involved in undertaking searches should receive appropriate instruction which is repeated
and regularly updated.
Incident recording
All appropriate staff should be trained to ensure that they are aware of how to correctly record any
incident using the appropriate local templates.
Emergency department staff
In addition to ongoing competency training in the management of disturbed/violent behaviour,
appropriate staff groups in emergency departments should receive training in the recognition of
acute mental illness and awareness of organic differential diagnoses. Service user involvement should
be encouraged.
Service user training/involvement in training
There should be opportunity for service users and/or service user groups to become actively involved
in training and setting the training agenda, for example groups with potential vulnerabilities such as:
service users with a sensory, physical or cognitive impairment
Black and minority ethnic service users
female service users
service users with communication difficulties.
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Implementation
Local health communities should review their existing practice for the short-term management of
disturbed/violent behaviour in psychiatric in-patient settings and emergency departments against this
guideline. The review should consider the resources required to implement the recommendations set out
in Section 1 of the NICE guideline, the people and processes involved and the timeline over which full
implementation is envisaged. It is in the interests of service users that the implementation is as rapid as
possible.
Relevant local clinical guidelines, care pathways and protocols should be reviewed in the light of this
guidance and revised accordingly.
Information on the cost impact of this guideline in England is available on the NICE website and includes
a template that local communities can use (www.nice.org.uk/CG025costtemplate).
This guideline should be used in conjunction with the NICE guideline on schizophrenia (see Section 6 of
the NICE guideline) and the Commission for Health Improvement audit material created by the Royal
College of Psychiatrists (2004).
National Institute for
Clinical Excellence
MidCity Place
71 High Holborn
London
WC1V 6NA
www.nice.org.uk
Ordering information
Copies of this quick reference guide can be obtained from the NICE website
at www.nice.org.uk/CG025quickrefguide or from the Department of Health
Publications Order Line by telephoning 0870 1555 455 and quoting reference
number N0828. Information for the public is also available from the NICE website or
from the Department of Health Publications Order Line (quote reference number
N0829 for the English version, and N0830 for the version in English and Welsh).
N0828 1P 80k Feb 05 (ABA)
Further information
Distribution
This quick reference guide to the Institutes
guideline on the short-term management of
disturbed/violent behaviour contains the key
priorities for implementation, summaries of
selected recommendations from the guidance,
and notes on implementation. The distribution
list for this quick reference guide is available
from www.nice.org.uk/CG025distributionlist.
NICE guideline
The NICE guideline, Violence: the short-term
management of disturbed/violent behaviour in
psychiatric in-patient settings and emergency
departments is available on the NICE website
(www.nice.org.uk/CG025NICEguideline).
The NICE guideline contains the following
sections: Key priorities for implementation;
Introduction; Legal preface; 1 Guidance; 2 Notes
on the scope of the guidance; 3 Implementation
in the NHS; 4 Research recommendations; 5 Full
guideline; 6 Review date. It also gives details of the
scheme used for grading the recommendations,
membership of the Guideline Development Group
and the Guideline Review Panel, and technical
details on criteria for audit.
Full guideline
The full guideline includes the evidence on which
the recommendations are based, in addition to the
information in the NICE guideline published by the
National Collaborating Centre for Nursing and
Supportive Care; it is available from its website
(www.rcn.org.uk/resources/guidelines.php), the
NICE website (www.nice.org.uk) and the website
of the National Library for Health (www.nlh.nhs.uk).
Information for the public
A version of this guideline for service users,
their advocates and carers, and for the public is
available, in English and Welsh, from the NICE
website (www.nice.org.uk/CG025publicinfo).
Printed versions are also available see below
for ordering information.
Review date
The process of reviewing the evidence is expected
to begin 4 years after the date of issue of this
guideline. Reviewing may begin earlier than 4 years
if significant evidence that affects the guideline
recommendations is identified sooner. The updated
guideline will be available within 2 years of the
start of the review process.