Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

Levels of evidence (I-IV) and grading of recommendations (A-D, [GPP]) are defined at the end of the "Major Recommendations" field.

Environment (In-Patient Psychiatric Settings)

The physical and therapeutic environment can have a strong, mitigating effect on the short-term management of disturbed/violent behaviour. The following recommendations are the minimum requirements that should be expected within inpatient psychiatric settings.

Safety and Security

D - When staff are engaged in the short-term management of disturbed/violent behaviour, every effort should be made to manage the service user in an open care setting.

D - All services should provide a designated area or room that staff may consider using, with the service user's agreement, specifically for the purpose of reducing arousal and/or agitation. In services where seclusion is practised, this area should be in addition to a seclusion room (see next recommendation).

D - In services in which seclusion is practiced, there should be a designated seclusion room fit for purpose. This room should allow clear observation, be well insulated and ventilated, have access to toilet/washing facilities, and be able to withstand attack/damage.

D (GPP) - Secure, lockable access to a service user's room, bathroom, and toilet area is required, with external staff override.

D - The internal design of the ward should be arranged to facilitate observation, and sight lines should be unimpeded (for example, not obstructed by the opening of doors). Measures should be taken to address blind spots within the facility, including consideration of the use of closed-circuit television (CCTV) and parabolic mirrors.

D - Facilities should ensure routes of safe entry and exit in the event of an emergency related to disturbed/violent behaviour.

D (GPP) - There should be a separate area to receive service users with police escorts.

Activities and External Areas

D - The environment should take into account the service user's needs.

• Services should be able to accommodate service users' needs for engaging 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.
• Service users should have single sex toilets, washing facilities, day areas, and sleeping accommodation.
• There should be a space set aside for prayer and quiet reflection.

D (GPP) - There should be daily opportunities for service users to engage in physical exercise, group interaction, therapy, and recreation.

D (GPP) - There should be access to the day room at night for service users who cannot sleep.

D (GPP) - Service users should be able to have easy access to fresh air and natural daylight.

D - Where practicable, access to an external area should be via the unit and where necessary, appropriate standards of fencing should be provided.

Service User Concerns

D - The environment should take into account service user needs for:

• Safety
• Privacy
• Dignity
• Gender- and cultural-sensitivity
• Sufficient physical space
• Social and spiritual expression

D - Where possible, service users should have privacy when making phone calls, receiving guests, and talking to a staff member.

D (GPP) - Facilities should have adequate means of controlling light, temperature, ventilation, and noise.

D (GPP) - Internal smoking areas/rooms should have powerful ventilation and be fitted with a smoke-stop door(s).

D (GPP) - All areas should look and smell clean.

D (GPP) - Suitable access facilities are needed for people who have problems with mobility, orientation, visual or hearing impairment, or other special needs.

Alarms

D - Each service should have a local policy on alarms and determine the need for alarms according to a comprehensive risk assessment of the clinical environment, service users, and staff. The policy should be disseminated, and staff made familiar with its contents.

D (GPP) - Comprehensive risk assessment of the clinical environment should be used to determine whether supplementary personal alarms should be issued to individual staff members and vulnerable service users.

D (GPP) - Collective responses to alarm calls should be agreed before incidents occur. These should be consistently applied and rehearsed.

D (GPP) - Furniture should be arranged so that alarms can be reached and doors are not obstructed.

D (GPP) - Alarms should be accessible in interview rooms, reception areas, and other areas where one service user and one staff member work together.

D (GPP) - All alarms (for example, panic buttons and personal alarms) should be well maintained and checked regularly.

Clinical Environment

D (GPP) - There should be a regular and comprehensive general risk assessment to ensure the safety of the clinical environment.

D (GPP) - Bed occupancy should be decided at a local level and this level should not be exceeded, because overcrowding leads to tension, frustration, and overstretched staff.

D (GPP) - There should be a stable and consistent in-patient team, as high staff turnover and overuse of short-term bank, locum, and agency healthcare staff may create an unsafe environment.

Interagency Working

D (GPP) - Local protocols should be developed to ensure that the police and staff are aware of the procedures and ascribed roles in an emergency, in order to prevent misunderstanding between different agencies. Such policies should set out what constitutes an emergency requiring police intervention.

Prediction

Disturbed/violent behaviour can never be predicted with 100% accuracy. However, this does not mean that risk assessment should not be carried out.

Policy

D - 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.

Risk Assessment

D (GPP) - Risk assessment should include a structured and sensitive interview with the service user and, where appropriate, carers. Efforts should be made to ascertain the service user's own views about their trigger factors, early warning signs of disturbed/violent behaviour and other vulnerabilities, and the management of these. Sensitive and timely feedback should complete this process.

D (GPP) - Risk assessment should be used to establish whether a care plan should include specific interventions for the short-term management of disturbed/violent behaviour.

D (GPP) - When assessing for risk of disturbed/violent behaviour, care needs to be taken not to make negative assumptions based on ethnicity. Staff members should be aware that cultural mores may manifest as unfamiliar behaviour that could be misinterpreted as being aggressive. The assessment of risk should be objective, with consideration being given to the degree to which the perceived risk can be verified.

D (GPP) - All staff should be aware of the following factors that may provoke disturbed/violent behaviour:

• Attitudinal
• Situational
• Organisational
• Environmental

D - Actuarial tools and structured clinical judgement should be used in a consistent way to assist in risk assessment, although no "gold standard" tool can be recommended.

D - Since the components of risk are dynamic and may change according to circumstance, risk assessment (of the environment and the service user) should be ongoing and care plans based on an accurate and thorough risk assessment.

D - The approach to risk assessment should be multidisciplinary and reflective of the care setting in which it is undertaken. The findings of the risk assessment should be communicated across relevant agencies and care settings, in accordance with the law relating to patient confidentiality.

Antecedents and Warning Signs

D (GPP) - Certain features can serve as warning signs to indicate that a service user may be escalating towards physically violent behaviour. The following list is not intended to be exhaustive and these warning signs should be considered on an individual basis.

• Facial expressions tense and angry
• 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
• Thought processes unclear, 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

Risk Factors

Certain factors can indicate an increase 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.

D (GPP) - Demographic or personal history should be taken into account when assessing the risk of disturbed/violent behaviour, including the following features.

• History of disturbed/violent behaviour
• History of misuse of substances or alcohol
• Carers reporting service user's 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 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

D (GPP) - Clinical variables should be taken into account when assessing the risk of disturbed/violent behaviour, including the following features

• 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 violent theme)
  • Agitation, excitement, overt hostility, or suspiciousness
• Poor collaboration with suggested treatments
• Antisocial, explosive, or impulsive personality traits or disorder
• Organic dysfunction

D (GPP) - Situational variables should be taken into account when assessing the risk of disturbed/violent behaviour, including the following features.

• 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

Training

Staff need to have the appropriate skills to manage disturbed/violent behaviour in psychiatric inpatient settings. Training in the interventions used for the short-term management of disturbed/violent behaviour safeguards both staff and service users. Training that highlights awareness of racial, cultural, social, and religious/spiritual needs, and gender differences, along with other special concerns, also mitigates against disturbed/violent behaviour. Such training should be properly audited to ensure its effectiveness.

Policy

D - 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.

D - All service providers should specify who the training provider is and ensure consistency in terms of training and refresher courses.

D - Training relating to the management of disturbed/violent behaviour should be subject to approved national standards. (Note: The National Health Service [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.)

D - If participants on training courses demonstrate inappropriate attitudes then trainers should pass this information onto the relevant line manager for appropriate action

Specific Staff Training Needs

D - There should be an ongoing programme of training for all staff in racial, cultural, spiritual, social, and special needs issues to ensure that staff are aware of and know how to work with diverse populations and do not perpetuate stereotypes. Such courses should also cover any special populations, such as migrant populations and asylum seekers that are relevant to the locality.

D - 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.

D - 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.

D - 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, cardiopulmonary resuscitation [CPR], and use of defibrillators).

D - Staff who employ physical intervention or seclusion should as a minimum be trained to Basic Life Support (BLS - Resuscitation Council UK).

D - 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. (Note: 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.)

D - Service providers should ensure that staff's capability to undertake physical intervention and physical intervention training courses is assessed.

D - All staff whose level of need is determined by risk assessment should receive ongoing competency training in the use of seclusion. Training should include appropriate monitoring arrangements for service users placed in seclusion.

D - All staff involved in rapid tranquillisation should be trained in the use of pulse oximeters.

D - 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
• The risks associated with rapid tranquillisation, including cardio-respiratory effects of the acute administration of these drugs, particularly when the service user is highly aroused and may have been misusing drugs; is dehydrated or possibly physically ill
• The need to titrate doses to effect

D - All staff involved in undertaking of searches should receive appropriate instruction which is repeated and regularly updated.

Incident Recording

D - Training should be given to all appropriate staff to ensure that they are aware of how to correctly record any incident using the appropriate local templates.

Refresher Courses

D - Services should review their training strategy annually to identify those staff groups that require ongoing professional training in the recognition, prevention, and de-escalation of disturbed/violent behaviour and in physical intervention to manage disturbed/violent behaviour.

Evaluating Training

D - All training should be evaluated, including training in racial, cultural, religious/spiritual, and gender issues, along with training that focuses on other special service user concerns.

D - Independent bodies/service user groups should, if possible, be involved in evaluating the effectiveness of training.

Service User Training/Involvement in Training

D - Service users and/or service user groups should have the opportunity to become actively involved in training and setting the training agenda, for example groups with potential vulnerabilities such as:

• Service users with a sensory impairment
• Black and minority ethnic service users
• Service users with a physical impairment
• Service users with a cognitive impairment
• Female service users
• Service users with communication difficulties

Working with Service Users

There is a growing acceptance that service users in adult psychiatric in-patient settings ought to be involved in their care, as far as possible. This extends to the short-term management of disturbed/violent behaviour where service user input can be made through measures such as advance directives. Listening to service users' views and taking them seriously is now also regarded as an important factor in the short-term management of disturbed/violent behaviour. Service users may also have physical needs that need to be taken into account when using the interventions discussed in this guideline. The recommendations and good practice points that follow also address the needs that arise from diversity (cultural, social, religious/spiritual, and gender-related needs) and physical needs in the context of the short-term management of disturbed/violent behaviour. It is important that service users should not be treated less favourably on the basis of their culture, gender, diagnosis, sexual orientation, disability, ethnicity, or religious/spiritual beliefs.

Creating a Feeling of Safety and Understanding

Preventing disturbed/violent behaviour is a priority. Providing relevant information so that service users feel safe and understand what may happen to them in the event that they become disturbed/violent will help prevent unnecessary aggravation.

D - All service users, regardless of culture, gender, diagnosis, sexual orientation, disability, ethnicity, or religious/spiritual beliefs should be treated with dignity and respect.

D - 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.

D (GPP) - An effective and fair complaints procedure should be put in place.

D (GPP) - Where at all possible, service users should have a choice of key worker.

D - 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.

D (GPP) - During the staff/service user risk assessment interview, where a risk of disturbed/violent behaviour is discussed or identified as a possibility, intervention and management strategies (and the service user's preferences regarding these) should be recorded in the service user's care plan and healthcare record. Efforts should be made to ascertain the service user's own views about their trigger factors, early warning signs of disturbed/violent behaviour, and other vulnerabilities, and the management of these. The service user should be given a copy of the care plan and, subject to their agreement, a copy should be given to their carer.

D (GPP) - The physical needs of the service user should be assessed on admission or as soon as possible thereafter and then regularly reassessed. The care plan should reflect the service user's physical needs.

D - Following any intervention for the short-term management of disturbed/violent behaviour, every opportunity should be taken to establish whether the service user understands why this has happened. Where possible, this should be carried out by a staff member not directly involved in the intervention. This should be documented in the service user's notes.

D (GPP) - Staff should take time to listen to service users, including those from diverse backgrounds (taking into account that this may take longer when using interpreters), so that therapeutic relationships can be established.

D - All services should have a policy for preventing and dealing with all forms of harassment and abuse. Notification of this policy should be disseminated to all staff and displayed prominently in all clinical and public areas.

D (GPP) - In the event of any form of alleged abuse, the matter should be dealt with by staff as soon as is practicable in accordance with relevant policies of the service.

D (GPP) - During the administration or supply of medicines to service users, confidentiality should be ensured.

D (GPP) - Prescribers should be available for and responsive to requests from the service user for medication review.

D - Staff should be encouraged to talk to service users from diverse backgrounds, including those with special needs, about their experiences and to offer them support and understanding, especially if their experience has been negative.

Pregnant Women

D (GPP) - Special provision should be made for pregnant women in the event that interventions for the short-term management of disturbed/violent behaviour are needed. These should be recorded in the service user's care plan.

Black and Minority Ethnic Service Users

See also recommendation under "Risk Assessment."

D - Services must identify a board member to take specific responsibility for all matters relating to equality and diversity. Responsibilities must include the nature and adequacy of service provision in relation to the short-term management of disturbed/violent behaviour, training on all matters relating to equality and diversity, monitoring service usage by ethnicity, and consultation with local Black and minority ethnic groups.

Service Users with Disabilities

D (GPP) - Each service should have a policy that outlines the procedures for dealing with service users who have disabilities, including those with physical or sensory impairment and/or other communication difficulties.

D (GPP) - Individual care plans should detail staff responsibilities for de-escalation, rapid tranquillisation, physical intervention, and seclusion of service users who have disabilities, including those with physical or sensory impairment and/or other communication difficulties.

Managing the Risk of Human Immunodeficiency Virus (HIV) or Other Infectious Diseases

Policy

D (GPP) - Services should have policies in place, developed in conjunction with the Trust infection control officer or relevant officer in the service, that outline the reasonable steps that can be taken to safeguard staff and other service users if a service user who has HIV, hepatitis, or other infectious or contagious diseases is acting in a manner that may endanger others.

D (GPP) - If staff are aware that a service user has HIV, hepatitis, or other infectious or contagious diseases, the advice of the Trust infection control officer or relevant officer in the service should be sought.

Confidentiality Issues

D (GPP) - Service users are owed important obligations of confidentiality but these are not absolute. In certain circumstances they may be breached to safeguard others. This is particularly relevant where a service user has HIV, hepatitis, or other infectious or contagious diseases, and is acting in a manner that puts others at risk. Legal and ethical advice should be sought in these circumstances.

D (GPP) - If any service user or staff member has sustained any injury during the management of disturbed/violent behaviour where blood has been spilt or the skin has been broken, or there has been direct contact with bodily fluids (all bodily fluids should be treated as potentially infectious), the local infection control policy should be followed.

Searching

The undertaking of necessary and lawful searches of both service users and visitors can make an important contribution to the effective management of disturbed/violent behaviour in psychiatric in-patient settings. Unlawful, insensitive and unnecessary searches can also exacerbate disturbed/violent behaviour. Searches should be undertaken by appropriately trained staff. See also recommendations under "Training."

Policy

D - All facilities should have an operational policy on the searching of service users, their belongings and the environment in which they are accommodated, and also the searching of visitors. Where necessary the policy should refer to related policies such as those for substance misuse and police liaison. The searching policy should be in place in order to ensure the creation and maintenance of a safe and therapeutic environment for service users, staff, and visitors.

D - The searching policy should address all aspects of personal through to environmental searching, from the decision to initiate a search through to the storage, return, or other disposal (including the lawful disposal of any items such as firearms and illicit drugs) of items found.

D - Post-search support for all those involved should be provided.

D - The searching policy should set out, in terms that can easily be understood by all those with responsibilities under the policy, the legal grounds for undertaking searches in the absence of consent.

D - The searching policy should specifically address the searching of service users detained under the Mental Health Act; informal service users without capacity to consent at the time of the search; informal service users with capacity to do so; and staff and visitors.

D - The searching policy should also extend to the routine and random searching of detained service users, where it is proposed to do so because there is a pressing social need to do so (for example, there is a chronic substance abuse problem on the ward) and undertaking such searches is a proportionate response to that need.

Carrying Out Searches

D - The level of intrusiveness of any personal search undertaken must be a reasonable and proportionate response to the reason for the search. Ordinarily, rub down or personal searching should be provided for in the policy together with procedures for their authorisation in the absence of consent.

D - All searches should be undertaken with due regard to the service user's dignity and privacy and by a member(s) of staff of the same sex.

D - The searching policy should provide for the circumstances in which a service user physically resists being searched. In this event a multidisciplinary decision should be made as to the need to carry out a search using physical intervention. If a decision is made not to proceed, then the searching policy should set out the options available to deal with the situation.

D - The searching policy should make provision for the following:

• Service users, staff, and visitors should be informed that there is a policy on searching.
• The consent of the person it is proposed to search should always be sought.
• The person being searched should be kept informed of what is happening and why.
• A comprehensive record of every search should be made, including its justification.
• Any consequent risk assessment and risk management should be placed in the appropriate records.

D - Following every search undertaken where consent has been withheld there should be a post-incident review that includes an advocacy service or hospital managers visiting the service user who has been searched.

D - The exercise of powers of search should be audited regularly and the outcomes reported regularly to the Trust Board or appropriate body.

De-escalation Techniques

De-escalation involves the use of techniques that calm down an escalating situation or service user; therefore, action plans should stress that de-escalation should be employed early on in any escalating situation. Action plans should be developed at a local level that detail how to call for help in an emergency.

See also recommendations under "Environment" and "Training."

General

D (GPP) - A service user's anger needs to be treated with an appropriate, measured, and reasonable response. De-escalation techniques should be employed prior to other interventions being used.

D (GPP) - Staff should accept that in a crisis situation they are responsible for avoiding provocation. It is not realistic to expect the person exhibiting disturbed/violent behaviour to simply calm down.

D (GPP) - Staff should learn to recognise what generally and specifically upsets and calms people. This will involve listening to individual service users' and carers' reports of what upsets the service user, and this should be reflected in the service user's care plan.

D (GPP) - Staff should be aware of, and learn to monitor and control, their own verbal and nonverbal behaviour, such as body posture and eye contact.

D (GPP) - Where possible and appropriate, service users should be encouraged to recognise their own trigger factors, early warning signs of disturbed/violent behaviour, and other vulnerabilities. This information should be included in care plans and a copy given to the service user. Service users should also be encouraged to discuss and negotiate their wishes should they become agitated.

D (GPP) - Where de-escalation techniques fail to sufficiently calm a situation or service user, staff should remember that verbal de-escalation is an ongoing element of the management of an escalating individual. Verbal de-escalation is supported but not replaced by appropriate physical intervention.

De-escalation Techniques

D (GPP) - One staff member should assume control of a potentially disturbed/violent situation.

D (GPP) - The staff member who has taken control 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, enlisting the help of colleagues, and creating space
• Explain to the service user and others in the immediate vicinity what they intend to do
• Give clear, brief, assertive instructions
• Move towards a safe place and avoid being trapped in a corner

D (GPP) - The staff member who has taken control should ask for facts about the problem and encourage reasoning. This will involve:

• Attempting to establish a rapport and emphasising cooperation
• Offering and negotiating realistic options and avoiding threats
• Asking open questions and inquiring about the reason for the service user's anger, for example "What has caused you to feel upset/angry?"
• Showing concern and attentiveness through non-verbal and verbal responses
• Listening carefully and showing empathy, acknowledging any grievances, concerns, or frustrations, and not being patronising or minimising service user concerns

D (GPP) - The staff member who has taken control should ensure that their own nonverbal communication is non-threatening and not provocative. This will involve:

• Paying attention to nonverbal cues, such as eye contact and allowing greater body space than normal
• Adopting a non-threatening but safe posture
• Appearing calm, self-controlled, and confident without being dismissive or over-bearing

D (GPP) - Where there are potential weapons the disturbed/violent person should be relocated to a safer environment, where at all possible.

D (GPP) - Where weapons are involved a staff member should ask for the weapon to be placed in a neutral location rather than handed over.

D (GPP) - Staff should consider asking the service user to make use of the designated area or room specifically for the purpose of reducing arousal and/or agitation to help them calm down. In services where seclusion is practised, the seclusion room should not routinely be used for this purpose. See also recommendations under "Safety and Security."

Observation and Engagement

The primary aim of observation should be to engage positively with the service user. This involves a two-way relationship, established between a service user and a staff member, which is meaningful, grounded in trust, and therapeutic for the service user. Observation is an intervention that is used both for the short-term management of disturbed/violent behaviour and to prevent self-harm. The recommendations and good practice points below are specifically directed towards the use of observation as an intervention for the short-term management of disturbed/violent behaviour. However, many are also applicable where observation is used to prevent self-harm. The terminology covers both uses of observation.

See also recommendations under "Training."

Policy

D - Each service should have a policy on observation and engagement that adheres to contemporary NICE terminology and definitions. This policy should include:

• Who can instigate observation above a general level
• Who can increase or decrease the level of observation
• Who should review the level of observation
• When reviews should take place (at least every shift)
• How 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 a general level continues for more than 1 week

Definitions of Levels of Observation

D - The observation terminology used in this guideline should be adopted across England and Wales to ensure consistency of use.

D - General observation is the minimum acceptable level of observation for all in-patients. The location of all service users should be known to staff, but not all service users need to be kept within sight. At least once a shift a nurse should set aside dedicated time to assess the mental state of the service user and engage positively with the service user. The aim of this should be to develop a positive, caring, and therapeutic relationship with the service user. This assessment should always include an evaluation of the service user's moods and behaviours associated with risks of disturbed/violent behaviour, and these should be recorded in the notes.

D - Intermittent observation means that the service user's location should be checked every 15 to 30 minutes (exact times to be specified in the notes). Checks need to be carried out sensitively in order to cause as little intrusion as possible. However, this check should also be seen in terms of positive engagement with the service user. This level is appropriate when service users are potentially, but not immediately, at risk of disturbed/violent behaviour. Service users who have previously been at risk of harming themselves or others, but who are in a process of recovery, require intermittent observation.

D - Within eyesight means the service user should be kept within eyesight and accessible at all times, by day and by night and, if deemed necessary, any tools or instruments that could be used to harm themselves or others should be removed. It is required when the service user could, at any time, make an attempt to harm themselves or others. It may be necessary to search the service user and their belongings, while having due regard for the service user's legal rights and conducting the search in a sensitive way. Positive engagement with the service user is an essential aspect of this level of observation.

D - Within arms length is needed for service users at the highest levels of risk of harming themselves or others, who may need to be supervised in close proximity. On specified occasions more than one member of staff may be necessary. Issues of privacy, dignity, and the consideration of gender in allocating staff, and the environmental dangers need to be discussed and incorporated into the care plan. Positive engagement with the service user is an essential aspect of this level of observation.

Possible Antecedents or Warning Signs that Observation is Required

D (GPP) - In addition to the antecedents that indicate disturbed/violent behaviour (See recommendations under "Antecedents and Warning Signs" in the "Prediction" section), observation above a general level should be considered if any of the following are present:

• 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 medication programmes or non-compliance with medication programmes
• Marked changes in behaviour or medication
• Known risk indicators

Carrying Out Observation

D (GPP) - Designated levels of observation should only be implemented after positive engagement with the service user has failed to dissipate the potential for disturbed/violent behaviour.

D (GPP) - The least intrusive level of observation that is appropriate to the situation should always be adopted so that due sensitivity is given to a service user's dignity and privacy whilst maintaining the safety of those around them.

D (GPP) - Decisions about observation levels should be recorded by both medical and nursing entries in the service user's notes. The reasons for using observation should be clearly specified.

D (GPP) - All decisions about the specific level of observation should take into account:

• The service user's current mental state
• Any prescribed medications and their effects
• The current assessment of risk
• The views of the service user as far as possible

D (GPP) - When making decisions about observation levels, clear directions should be recorded that specify:

• The name/title of the persons who will be responsible for carrying out the review
• The timing of the review

D - Observation skills should be used to recognise, prevent, and therapeutically manage disturbed/violent behaviour. Specific observation tasks should be undertaken by registered nurses, who may delegate to competent persons.

D (GPP) - Nurses and other staff undertaking observation:

• Should take an active role in engaging positively with the service user
• Should be appropriately briefed about the service user's history, background, specific risk factors, and particular needs
• Should be familiar with the ward, the ward policy for emergency procedures, and potential risks in the environment
• Should be able to increase or decrease the level of engagement with the service user as the level of observation changes
• Should be approachable, listen to the service user, know when self-disclosure and the therapeutic use of silence are appropriate, and be able to convey to the service user that they are valued

D - An individual staff member should not undertake a continuous period of observation above the general level for longer than 2 hours.

D (GPP) - The service user's psychiatrist/on-call doctor should be informed of any decisions concerning observation above the general level as soon as possible.

D (GPP) - 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.

D (GPP) - Staff members should be aware that service users sometimes find observation provocative, and that it can lead to feelings of isolation and even dehumanisation.

Service User Needs

D (GPP) - The service user should be provided with information about why they are under observation, the aims of observation, and how long it is likely to be maintained.

D (GPP) - The aims and level of observation should, where appropriate, be communicated with the service user's approval to the nearest relative, friend, or carer.

D (GPP) - Although difficult, where possible, the handover from one nurse or staff member to another should involve the service user so that they are aware of what is being said about them.

Other Interventions

Where de-escalation techniques have failed to calm a service user, it may be necessary to make use of additional interventions, such as physical intervention, rapid tranquillisation, and seclusion to manage the incident. All such interventions should only be considered once de-escalation techniques have been tried and have not succeeded in calming the service user. The choice of intervention(s) will depend on a number of factors, but should be guided primarily by:

• Service user preference (if known)
• The clinical needs of, and risks to, the service user
• Obligations to other service users affected by the disturbed/violent behaviour
• The protection of staff, service users, and visitors
• The facilities available within the particular setting

Audit Criteria/Indicators
Clinical Algorithm
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides

The following is available:

The following is available:

• Violence: managing disturbed/violent behaviour.  Understanding NICE guidance - information for service users, their advocates, families and carers, and the public. National Institute for Health and Clinical Excellence (NICE), 2005 Feb. 68 p.

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