12 Aug A Guide to Restraining Violent Patients in Britain
Violence against nurses has always been and continues to be a concern. The Nursing Times says a national audit of violence in mental health units found that 73-86% of nurses have experienced violent and aggressive behaviour. Because of the nature of mental illness, patients may sometimes become a danger to themselves or others, warranting emergency intervention like mechanical or chemical restraints. They curtail patients’ freedom and should be used as a last resort– when you or another person is in harm’s way.
Acute care settings like psychiatric units and emergency departments have proven themselves dangerous for care staff time and time again. They have a high potential for chaos and can create or exacerbate violent and volatile behaviour. How are nurses to keep themselves and others safe?
Keep reading to discover the correct protocol and literature regarding safeguarding yourself and others in cases of violence.
Why People Become Violent
Patients can become violent because of unpleasant surroundings, unpleasant stimuli, like loud noises (people crying/screaming) and unpleasant smells (waste, cleaning products). They can also become violent as a result of overcrowding. Low frustration tolerance and exposure to violence may be additional driving factors.
For instance, in January, a man was taken to court from Kingston Hospital in London had spent the weekend in prison before his incident. The sights and smells in prison likely caused him distress, leading him to act out. Also, the hospital posted that their A&E was very busy that day on their X account. Perhaps the combination of overstimulation, exposure to violence, low frustration tolerance, and unpleasant stimuli drove him to act out.
On Restraint
The meaning of restraint is subjective. Hence, we’re going to use the term “restraint” as shorthand for:
- Physical restraint: Direct physical contact meant to restrict, prevent, or subdue movement of body parts. Also called holding or manual restraint.
- Mechanical restraint: Using a device to prevent, restrict or subdue movement of a person’s body, or part of the body, primarily to control behaviour.
- Chemical restraint: Using medication prescribed to control or subdue violent behaviour. Both NICE and The Code of Practice say oral medication should always be considered first to preserve a patient’s dignity.
- Seclusion: Confining and isolating a patient away from other patients where they are prevented from leaving to contain behavioural disturbance likely to harm others.
You’ll notice that we’ve mentioned the terms NICE and Code of Practice. These are guidelines written to protect care users from excessive psychological and physical harm.
NICE
NICE is the National Institute for Health and Care Excellence. They’ve published clinical guidelines on violence and aggression management in mental health care settings to balance care and containment.
Code of Practice
This is a legislative framework that outlines underlying principles for care, treatment and support under the Mental Health Act 1983 and good practice to advance equality and protect human rights. It aims to empower patients concerning their care and treatment.
You should read this in tandem with the Department of Health’s guidance:
Positive and Proactive Care: Reducing the Need for Restrictive Interventions (Positive and Safe)
A framework from the Department of Health published in 2014 serves to transform culture, leadership and professional practice to deliver care and support which keeps people safe and promotes recovery in collaboration with the Royal College of Nursing. It applies across health and social care in England.
Care Quality Commission Fundamental Standards
These are the standards below which care must never fall. The standards protect care users from abuse, including unnecessary restraint.
Deescalation Tactics
Prevention and management of violence and aggression in hospitals has long been a contentious matter. With the knowledge that using physical restraints curtails freedom and can lead to worse health outcomes, how do we protect others and ourselves?
In the past few years, new legislative frameworks have been put into place, such as the amendment of the Mental Health Act and the Royal Ascent of the 2018 Use of Force Act/Seni’s Law. Additionally, numerous pieces of literature have been newly published with evidence-based strategies clinicians can use to manage violent patients.
Let’s outline a few NHS-approved strategies as outlined by the legislature (Human Rights Act 1998, the Mental Capacity Act 2005, Seni’s Law and guidance (Care Quality Commission standards, Positive and Safe, the Act’s Code of Practice, NICE).
There are also training standards used like PMVA, Maybo, and MAPA. Note that the respective trusts may hold their staff to different standards than yours, like the Grimsby Model of Respect in Sheffield Health and Social Care NHS Foundation Trust or PRICE training in some care homes.
Let’s discuss training standards utilised in most NHS mental health services. These standards are known as breakaway training.
PMVA
PMVA stands for Prevention and Management of Violence and Aggression. It develops knowledge, attitudes and skills to effectively manage incidents in acute care environments, mostly in psychiatric units. Delegates learn conflict management and de-escalation techniques that promote non-restraint.
MAPA
MAPA stands for Management of Actual or Potential Aggression. It’s about responding to people in a non-judgemental way and treating them with respect and dignity whilst helping them stay safe in challenging situations. The interventions include talking and listening and, when necessary, holding someone to prevent harm to themselves or others.
Maybo
Maybo aims to reduce and de-escalate conflict. It’s compliant with Restraint Reduction Network standards.
The Hierarchy of Holds
PMVA guidelines have a holding and intervention hierarchy that includes primary, secondary, and tertiary intervention guidelines and techniques. They’re used depending on the level of aggression present. The primary intervention uses non-physical responses like talking patients down. Secondary holds are precautionary and tertiary holds and use pain to ensure compliance if absolutely necessary. These should be used if they carry a lower level of risk to staff.
Primary Interventions
These are preventative de‐escalation strategies including distraction techniques, therapeutic engagement, co-production, guiding, advance directives and good communication. Defusing or talking down should be used as a first approach with any agitated patient, using verbal and non-verbal responses to defuse a situation. You should convey professional concern for the patient and assurance that no harm will come to them. Employ a calm and soothing voice, speaking non-provocatively and non-confrontationally. Use empathic statements such as, ‘‘I understand you’re not feeling well and that you’re having a hard time,’’ or ‘‘It sounds like you’re in pain and confused.’’
At the same time, the limits on patient behaviour and the consequences of present and future actions need to be verbalised. The patient should be told decisively and certainly that the staff will ensure and maintain control and that he or she will not be allowed to harm themself or others. Try using the Len Bowers model or DABS. You should also acquaint yourself with your trust’s particular deescalation models.
Secondary Interventions
Secondary interventions use precautionary and secure precautionary holds. You should use the hold that poses the least restriction on the patient, like seated holds.
Tertiary Interventions– Final Responses
Tertiary interventions like restraints and holds should be used as a final response to emergent and imminently dangerous behaviour. It’s crucial to maintain patient dignity, allowing participation in care decisions (like offering a tablet) and providing ongoing assessment and monitoring, provisioning physical care and comfort when the patient is in restraints and seclusion.
Physical (manual) restraint
Used in emergency holds on the floor and secures wrist. Try to avoid using the prone position insofar as you can.
Chemical restraint
Pharmacologic restraints involve using intramuscular or oral medication where possible, ideally voluntarily. Wherever possible, the patient should be given the choice of medication type or route. Oral medication can be used to address control issues.
Seclusion
Seclusion is a last resort and is only to be used on patients detained under the Mental Health Act unless it’s an emergency, in which case it should be used for the shortest time possible while the emergency is being managed and an assessment for detention is undertaken.
Mechanical Restraints
These must only be used as a final response to an emergency or exceptional circumstances and never punitively or as punishment. Mechanical restraints manage extreme violence directed at other people or limit self-harming behaviour of extremely high frequency or intensity. It must be planned (if possible), recorded, reviewed, and ended as soon as possible.
Some examples of mechanical restraints include soft (velcro) cuffs (ERB/SRB), handcuffs, and soft belts.
Be the Change
If you would like to get involved in bettering restraint standards, have a look at the following good practice initiatives:
4Pi National Involvement Standards
Led by The National Involvement Partnership project and NSUN in collaboration with mental health service users and carers. Their motto is “Nothing about us without us.” Get involved at http://www.nsun.org.uk/about-us/our-work/national-involvement-partnership/
No Force First
The No Force First initiative aims to change ward culture from restriction to rehabilitation and limit coercion. It’s been adopted by some mental health trusts that are part of ImROC Implementing Recovery through Organisational Change, partnered with the Centre for Mental Health and NHS Confederation.
Restraint Reduction Network
RRN brings together and supports organisations working towards restraint-free services.
RESPECT
Supervised by Lincolnshire social enterprise NAViGO Health and Social Care, based on supportive de-escalation.
REsTRAIN YOURSELF
Run by the Advancing Quality Alliance (AQuA), this initiative is based on the premise that seclusion and restraint can be prevented if issues like ward design, staff numbers, poor communication and negative behaviour by staff are addressed.
Safewards
Uses evidence-based tools that work towards making the wards safer for everyone.
Being Better
Now that you understand how to restrain violent patients safely, it’s time to get involved in transforming your ward’s culture. Get involved with any of the above good practice initiatives. Let’s limit restraint as much as we can and be kinder to everyone. Violent patients are not bad people–it isn’t their fault. Remember that if you must use restraints, it should be to keep everyone safe with dignity and freedom in mind.
If you would like to join a ward working to further better quality of care, get in touch with Proximity Healthcare. We’re an agency that works toward placing nurses in wards where they can make change, advance their careers, and get handsomely compensated for it on their schedules.
Get in touch with us today. We’re hiring acute care nurses throughout England and the UK.
References
Click on the publication titles in italics to access them.
Should nurses restrain violent and aggressive patients?, Nursing Times.
Available at: https://www.nursingtimes.net/roles/mental-health-nurses/should-nurses-restrain-violent-and-aggressive-patients-07-03-2011/
(Accessed: 01 August 2024)
Percival, R. (2024) Dozens of officers swoop in on London Hospital after man started ‘acting aggressively’ before being hauled to court, Daily Mail Online.
Available at: https://www.dailymail.co.uk/news/article-13019225/Police-rush-London-hospital-violent-incident-sends-E-lockdown.html
(Accessed: 01 August 2024)
United Kingdom Government Mental Health Act 1983: Code of practice, Legislation.gov.uk
Available at: https://assets.publishing.service.gov.uk/media/5a80a774e5274a2e87dbb0f0/MHA_Code_of_Practice.PDF
(Accessed: 01 August 2024)
(1985) Reducing the Need for Restrictive Interventions (Positive and Safe)
Available at: https://assets.publishing.service.gov.uk/media/5a7ee560e5274a2e8ab48e2a/JRA_DoH_Guidance_on_RP_web_accessible.pdf
(Accessed: 01 August 2024)
The Fundamental Standards.
Available at: https://www.cqc.org.uk/about-us/fundamental-standards
(Accessed: 01 August 2024)
United Kingdom Government (1998) Human Rights Act 1998, Legislation.gov.uk.
Available at: https://www.legislation.gov.uk/ukpga/1998/42/contents
(Accessed: 01 August 2024)
United Kingdom Government Mental Capacity Act 2005, Legislation.gov.uk.
Available at:
https://www.legislation.gov.uk/ukpga/2005/9/contents
(Accessed: 01 August 2024)
United Kingdom Government Mental Health Units (Use of Force) Act 2018: Statutory guidance for NHS Organisations in England and Police Forces in England and Wales – draft for consultation, GOV.UK.
Available at: https://www.gov.uk/government/consultations/mental-health-units-use-of-force-act-2018-statutory-guidance/mental-health-units-use-of-force-act-2018-statutory-guidance-for-nhs-organisations-in-england-and-police-forces-in-england-and-wales-draft-for-co#:~:text=There%20are%20legal%20frameworks%20including,The%20Care%20Act%202014
(Accessed: 01 August 2024)
Ayhan, D. and Hiçdurmaz, D. (2020) De-escalation model in the simple form as aggression management in psychiatric services, Journal of Psychiatric Nursing.
Available at: https://www.researchgate.net/publication/344925457_De-escalation_model_in_the_simple_form_as_aggression_management_in_psychiatric_services
(Accessed: 01 August 2024)
Nau, J., Oud, N. and Walter, G. (2019) Measuring De-Escalation by Using the De- De-Escalating Aggressive Behaviour Scale (DABS), Violence in Clinical Psychiatry Proceedings of the 11th European Congress on Violence in Clinical Psychiatry (pp.263-266).
Available at: https://www.researchgate.net/publication/336836080_Measuring_de-escalation_by_using_the_De-_escalating_Aggressive_Behaviour_Scale_DABS
(Accessed: 01 August 2024)
NSUN Network for Mental Health, Mind, Restraint in Mental Health Services: What the Guidance Says, Mind.org.uk
Available at:
https://www.mind.org.uk/media-a/4429/restraintguidanceweb1.pdf
(Accessed 01 August 2024)
NHS Solent Trust Physical Intervention Policy.
Available at:
https://www.solent.nhs.uk/media/2376/mh02-physical-intervention-policy-v1.pdf
(Accessed: 01 August 2024).
Lacey, P. (2024) Training Standards, Restraint Reduction Network.
Available at:
https://restraintreductionnetwork.org/training-standards/
(Accessed: 01 August 2024)
Cumbria, Northumberland, Tyne and Wear NHS Foundation PMVA Practice Note.
Available at: https://www.cntw.nhs.uk/wp-content/uploads/2015/10/PMVA-PGN-01-SafeUseMechResEq-V04-Jun18.pdf
(Accessed: 01 August 2024)
Petit, J.R MD, Management of the Acutely Violent Patient, Psychiatric Clinic of North America
Available at:
http://www.antoniocasella.eu/archipsy/Petit_2005.pdf
(Accessed: 01 August 2024)
K, S. (2020) Using a Hierarchy of Interventions, The Mandt System.
Mustafa, Y. (2024) Safety Precautions in Psychiatric Units: Roar for Good, ROAR.
Available at: https://www.roarforgood.com/blog/safety-precautions-in-psychiatric-units/
(Accessed: 01 August 2024)