Action 5.34

Predicting, preventing and managing aggression and violence

Action 5.34 states

The health service organisation has processes to support collaboration with patients, carers and families to:

  1. Identify patients at risk of becoming aggressive or violent
  2. Implement de-escalation strategies
  3. Safely manage aggression, and minimise harm to patients, carers, families and the workforce

Intent

Collaborative processes are used to minimise the risk of aggression and violence, and incidents are managed safely when they occur.

Reflective questions

What processes are in place to ensure that the workforce can work collaboratively to identify patients at risk of becoming aggressive or violent?

What strategies are used to support patients at risk of becoming aggressive or violent to control their behaviour?

How does the health service organisation minimise harm to patients, carers, families and the workforce from patients who are aggressive or violent?

Key tasks

  • Train the workforce to effectively screen for specific risks.

  • Implement processes that support members of the workforce to use strategies to reduce the risk of violence.

  • Implement processes to respond to aggression and violence when they occur, to minimise the risk of harm to people.

Strategies for improvement

Hospitals

Screening for risk of aggression and violence is an important and complex undertaking for members of the healthcare workforce. Because it is predictable that violence will occur in healthcare settings, ensure that the health service organisation has effective risk assessment and risk management processes in place. The National Institute for Health and Care Excellence guidelines recommend the use of standardised tools to augment clinical judgement.1

Predictive factors for risk of aggression include:

  • Previous history of aggression or violence
  • Intoxication or withdrawal from licit or illicit substances
  • Acute brain injury
  • Cognitive impairment.

Ensure that the use of screening tools and risk management processes does not lead to stigmatising practices, which have been associated with suboptimal healthcare delivery. In particular, ensure that people with mental illness are not automatically assessed as presenting high risk for aggression, and, conversely, that people without mental illness are categorised as low risk. Risk assessment needs to be a dynamic process, based on evidence, rather than assigning a person to a category and proceeding.

There will be times when a person who has not been screened as presenting a risk of violence becomes aggressive. Be alert to changes in a person’s behaviour, cognitive function, perception, physical function or emotional state that may indicate deterioration in their mental state and lead to aggression. This action aligns with the Recognising and Responding to Acute Deterioration Standard. The National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state outlines the processes to effectively manage these situations.

Train the workforce in the use of de-escalation strategies, which are demonstrated to reduce the likelihood of verbal aggression progressing to physical violence.1 De-escalation strategies are appropriate for patients with severe behavioural disturbance relating to delirium or dementia, when sedation should be avoided unless they are at risk of harm to themselves or others. Ensure that policies relating to preventing and responding to aggression include specific guidance on sedation that is age appropriate.

Principles for Safe Management of Disturbed and/or Aggressive Behaviour and the Use of Restraint contains valuable information about aggressive patient behaviour.

Day Procedure Services

There is low prevalence of violence in day procedure services. Day procedure services should use screening processes to identify patients at risk of becoming aggressive or violent.

Pre-admission screening can identify if there is a potential risk for someone to become confused or agitated when admitted for a brief procedure (for example, someone with dementia). Mitigating strategies begin with collecting clear and comprehensive information about triggers for the individual, and optimal management strategies. If a risk is identified, a management strategy can be formulated before admission. This typically consists of arranging for a family member or carer known to the person to accompany them.

Members of the workforce can communicate in a specific way to assist the person. Appropriate and safe use of medicine can help when conducting procedures on people who may become agitated.

Refer to the hospitals tab for detailed implementation strategies and examples of evidence for this action.

MPS & Small Hospitals

Screening for risk of aggression and violence is an important and complex task for members of the healthcare workforce. Because it is predictable that violence will occur in healthcare settings, ensure that the health service organisation has effective risk assessment and risk management processes in place. The National Institute for Health and Care Excellence guidelines recommend the use of standardised tools to augment clinical judgement.1

Predictive factors for risk of aggression include:

  • Previous history of aggression or violence
  • Intoxication or withdrawal from licit or illicit substances
  • Acute brain injury
  • Cognitive impairment.

Ensure that the use of screening tools and risk management processes do not lead to stigmatising practices, which have been associated with suboptimal healthcare delivery. In particular, ensure that people with mental illness are not automatically assessed as presenting high risk for aggression, and, conversely, that people without mental illness are categorised as low risk. Risk assessment needs to be a dynamic process, based on evidence, rather than assigning a person to a category and proceeding.

There will be times when a person who has not been screened as presenting a risk of violence becomes aggressive. Be alert to changes in a person’s behaviour, cognitive function, perception, physical function or emotional state that may indicate deterioration in their mental state and lead to aggression. This action aligns with the Recognising and Responding to Acute Deterioration Standard. The National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state outlines the processes to effectively manage these situations.

Train the workforce in the use of de-escalation strategies, which are demonstrated to reduce the likelihood of verbal aggression progressing to physical violence.1 De-escalation strategies are appropriate for patients with severe behavioural disturbance relating to delirium or dementia, when sedation should be avoided unless they are at risk of harm to themselves or others. Ensure that policies relating to preventing and responding to aggression include specific guidance on sedation that is age appropriate.

Dealing with aggression and violence has specific workplace health and safety implications for MPSs and small hospitals because of the reduced workforce available to deal with incidents compared with large organisations. Small hospitals can work with local police services to respond to incidents of aggression.

Principles for Safe Management of Disturbed and/or Aggressive Behaviour and the Use of Restraint contains valuable information about aggressive patient behaviour.

Hospitals

Screening for risk of aggression and violence is an important and complex undertaking for members of the healthcare workforce. Because it is predictable that violence will occur in healthcare settings, ensure that the health service organisation has effective risk assessment and risk management processes in place. The National Institute for Health and Care Excellence guidelines recommend the use of standardised tools to augment clinical judgement.1

Predictive factors for risk of aggression include:

  • Previous history of aggression or violence
  • Intoxication or withdrawal from licit or illicit substances
  • Acute brain injury
  • Cognitive impairment.

Ensure that the use of screening tools and risk management processes does not lead to stigmatising practices, which have been associated with suboptimal healthcare delivery. In particular, ensure that people with mental illness are not automatically assessed as presenting high risk for aggression, and, conversely, that people without mental illness are categorised as low risk. Risk assessment needs to be a dynamic process, based on evidence, rather than assigning a person to a category and proceeding.

There will be times when a person who has not been screened as presenting a risk of violence becomes aggressive. Be alert to changes in a person’s behaviour, cognitive function, perception, physical function or emotional state that may indicate deterioration in their mental state and lead to aggression. This action aligns with the Recognising and Responding to Acute Deterioration Standard. The National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state outlines the processes to effectively manage these situations.

Train the workforce in the use of de-escalation strategies, which are demonstrated to reduce the likelihood of verbal aggression progressing to physical violence.1 De-escalation strategies are appropriate for patients with severe behavioural disturbance relating to delirium or dementia, when sedation should be avoided unless they are at risk of harm to themselves or others. Ensure that policies relating to preventing and responding to aggression include specific guidance on sedation that is age appropriate.

Principles for Safe Management of Disturbed and/or Aggressive Behaviour and the Use of Restraint contains valuable information about aggressive patient behaviour.

Day Procedure Services

There is low prevalence of violence in day procedure services. Day procedure services should use screening processes to identify patients at risk of becoming aggressive or violent.

Pre-admission screening can identify if there is a potential risk for someone to become confused or agitated when admitted for a brief procedure (for example, someone with dementia). Mitigating strategies begin with collecting clear and comprehensive information about triggers for the individual, and optimal management strategies. If a risk is identified, a management strategy can be formulated before admission. This typically consists of arranging for a family member or carer known to the person to accompany them.

Members of the workforce can communicate in a specific way to assist the person. Appropriate and safe use of medicine can help when conducting procedures on people who may become agitated.

Refer to the hospitals tab for detailed implementation strategies and examples of evidence for this action.

MPS & Small Hospitals

Screening for risk of aggression and violence is an important and complex task for members of the healthcare workforce. Because it is predictable that violence will occur in healthcare settings, ensure that the health service organisation has effective risk assessment and risk management processes in place. The National Institute for Health and Care Excellence guidelines recommend the use of standardised tools to augment clinical judgement.1

Predictive factors for risk of aggression include:

  • Previous history of aggression or violence
  • Intoxication or withdrawal from licit or illicit substances
  • Acute brain injury
  • Cognitive impairment.

Ensure that the use of screening tools and risk management processes do not lead to stigmatising practices, which have been associated with suboptimal healthcare delivery. In particular, ensure that people with mental illness are not automatically assessed as presenting high risk for aggression, and, conversely, that people without mental illness are categorised as low risk. Risk assessment needs to be a dynamic process, based on evidence, rather than assigning a person to a category and proceeding.

There will be times when a person who has not been screened as presenting a risk of violence becomes aggressive. Be alert to changes in a person’s behaviour, cognitive function, perception, physical function or emotional state that may indicate deterioration in their mental state and lead to aggression. This action aligns with the Recognising and Responding to Acute Deterioration Standard. The National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state outlines the processes to effectively manage these situations.

Train the workforce in the use of de-escalation strategies, which are demonstrated to reduce the likelihood of verbal aggression progressing to physical violence.1 De-escalation strategies are appropriate for patients with severe behavioural disturbance relating to delirium or dementia, when sedation should be avoided unless they are at risk of harm to themselves or others. Ensure that policies relating to preventing and responding to aggression include specific guidance on sedation that is age appropriate.

Dealing with aggression and violence has specific workplace health and safety implications for MPSs and small hospitals because of the reduced workforce available to deal with incidents compared with large organisations. Small hospitals can work with local police services to respond to incidents of aggression.

Principles for Safe Management of Disturbed and/or Aggressive Behaviour and the Use of Restraint contains valuable information about aggressive patient behaviour.

Reference

  1. Price O, Baker J. Key components of de-escalation techniques: a thematic synthesis. Int J Ment Health Nurs 2012;21(4):310–9.
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