Management Imminent Violence



Background

The information contained here is based on the RCPsychiatrist Publication Management Imminent Violence - RCPsychiatry 2004 Quick Reference Guidance.


Risk assessment

All staff should be trained to recognise the warning signs of violence and to monitor their own verbal and non-verbal behaviour.

Possible antecedents of violence:

  • Increased restlessness, bodily tension, pacing, arousal
  • Refusal to communicate, withdrawal
  • Verbal threats or gestures
  • Increased volume of speech, erratic movements
  • Thought processes unclear, poor concentration
  • Self-reporting angry or violent feelings
  • Facial expression tense and angry, discontented
  • Delusions or hallucinations with violent content
  • Carers reporting users’ imminent violence

Tactics for de-escalation

  • Maintain adequate distance
  • Move towards safe place, avoid corners
  • Explain intentions to patient and others
  • Appear calm, self-controlled, confident
  • Ensure own non-verbal communication is non-threatening
  • Engage in conversation, acknowledge concerns and feelings
  • Ask for facts of problems, encourage reasoning
  • Ask for weapon to be put down (not handed over)
  • Consider methods (e.g. medication).

Restraint

Restraint should be used only after the failure of attempts to promote full participation in self care, e.g. by voluntary 'time out' and/or consent to take medication. It should not be used as a means of intimidation or punishment but only as a last resort, at the end of a hierarchy of interventions. If restraint is necessary, it should be used with thoughtful consideration for the self-respect, dignity, privacy, cultural values, and any special needs (e.g. physical illness or disability) that the patient may have. Mechanical restraints should not be used.

  • Staff must receive training in the use of restraint
  • The reasons for restraint should be explained to the patient
  • Team members should be allocated responsibilities
  • Miantain communication
  • Be appropriate to the age, size and gender of the patient (not be dependent on the height or weight of staff members or patient)
  • Not involve neck compression
  • Use secure grips, Minimise pain, Maintain dignity
  • Protect the patient's head during descent
  • Protect the patient's air supply and use controlled descents
  • Avoid unnecessary pressure on the patient's back or chest

Reasons for using restraint Serious degree of urgency and danger

  • Significant physical attacks
  • Significant threats or attempts at self-injury
  • Seriously destructive of property
  • Prolonged and serious verbal abuse, threats, disruption of ED
  • Risk of serious accident to self & others
  • Attempts to abscond (if detained under Section)
  • Protocol for rapid tranquillisation

Debriefing

All staff and patients, involved with the incident should be considered. Facilitate discussion about:

  • What happened and any trigger factors
  • Their role in the incident
  • How they feel now
  • How they might feel in the next few days
  • What can be done about it


Content by Dr Íomhar O' Sullivan based on Management Imminent Violence - RCPsychiatry 2004 Quick Reference Guidance 20/10/2005. Reviewed by Dr ÍOS 3/07/19.