1. Prevention - Management of Violence and Aggression (PMVA) 5 day course 1

2. Legal Considerations 2 3. Legal Considerations General Services Physical Intervention Skills aim to fulfil as far as possible: The obligations to follow Health & Safety at work and the Employment Liability Act The obligation of staff to deal professionally and with minimal risk of injury with violent incidents The obligation of managers/staff to patients that in situations where they become involved in violent incidents these will be resolved safely, quietly and competently. 3 4. Legal Considerations The professional framework which staff should operate is spelt out by the UK Central Council for Nursing and requires each nurse to: Act at all times in such a manner as to justify public trust and confidence Act always in such a way as to promote and safeguard the wellbeing and interests of the patients Ensure that no action or omission on his/her part is detrimental to the condition or safety of patients Acknowledge any limitation of competence and refuse in such cases to accept delegated functions without first having received instruction and assessed as competent 4 5. Legal Considerations There are some basic principles which always govern the use of C&R (GSA) in every confrontation: It should only be used as a last resort, as little as possible and never as a matter of course [1] It should be used in an emergency when there seems a real possibility that significant harm would occur if intervention was withheld [1] In every situation where physical intervention by C&R (GSA) is used only the minimum force necessary should be deployed 5 6. Legal Considerations The use of Control and Restraint must always be a matter of judgment. No two threatening situations are ever identical. In general it is likely to be needed to prevent a patient from behaving violently or being a danger to him/herself or others Mental Health Act (1983) - Exclusions from consent to treatment 6 7. Legal Considerations More specifically, and in the context of the day-to-day life of the hospital, situations which may call for C&R include- 1. Likely self-injury by the patient 2. Possible injury to staff, other patients or visitors 3. Preventing escalation of an incident to a potentially more damaging situation leading to the active/passive involvement of other patients 4. An imminent threat to security (loss of keys, radio etc) 5. The possibility of a hostage situation 6. Seriously threatening behaviour which is likely to prejudice the normally equable regime of the unit 7. Failure to comply with the immediate need to evacuate the unit (Fire etc) 7 8. Legal Considerations The use of reasonable force Wherever practicable retreat/breakaway should be the first consideration. [14] Every member of staff must, where necessary, accept the responsibility to call for assistance. [2] However, where some more decisive action is needed, as in the situations listed above, then only reasonable force may be used to control or restrain patients. What constitutes reasonable must always be a matter of personal judgment. No two situations are ever similar in all respects. 8 9. Legal Considerations The use of reasonable force Nonetheless, there are one or two guidelines which may be useful: Where force is applied it should be done in a manner that attempts to reduce rather than provoke a further aggressive reaction The number of staff involved should be the minimum necessary to restrain the patient, while minimising injury to all parties The more serious the danger the more greater the degree of force which may be used to avoid such danger 9 10. Legal Considerations The use of reasonable force (cont.) The force used must be the minimum necessary to deal with the harm that needs to be prevented, i.e. it must be reasonable in the circumstances. [3] Where the justification for the use of force is self- defence, provocation, resisting violence etc, if a person has done only what he/she honestly and instinctively thought was necessary that would be the most potent evidence that only reasonable defensive action had been taken. [4] Violence must always be dealt with promptly and positively. No blame should be attached to a member of staff who has acted in good faith and consistently with the training he/she has received. [5] 10 11. Legal Considerations Negligence Negligence has three main elements: 1. The duty of care 2. A breach of duty 3. Any ensuing damage/injury The most important point to remember is that to take no action, where the outcome of the situation is that the patient injures himself or another, could be seen as negligent. [6] 11 12. Legal Considerations References 1. Mental Health Act code of practice (1989) S. 18.9 2. DHSS Circular HC (76) 11 Par. 21 3. Mental Health Act code of practice (1989) S. 18.10 4. Stones Justices Manual (1987) S. 4.765 5. DHSS Circular HC (76) 11 Par. 18 6. Nursing times -19 Nov 1986 12 13. Cervical Spine instability in Downs Syndrome 13 Restraint and the condition 14. Cervical Spine instability in Downs Syndrome What is Cervical Spine Instability? Excessive movement of vertebrae in the neck How common is it? People with Down Syndrome have loose ligaments. This applies to all joints. How Common is it? It is estimated that 1% to 2% of people with Downs Syndrome suffer from cervical spine instability, although it may be under recognised. Can it be detected? There is no reliable test. Symptoms include deterioration in bowl or bladder control, headaches, loss of control of movement, Torticollis (muscle spasm causing head to turn to side). 14 15. Cervical Spine instability in Downs Syndrome Which activities can cause symptoms? Any sudden movement of the neck that causes forward flexing 15 16. Cervical Spine instability in Downs Syndrome Should restraint be used with people with Downs Syndrome? Little research has been done on this, and consequently little evidence that there is a risk of injury during restraint. Care staff should be aware of the symptoms and appropriate support given. Are there any other factors to consider? Higher the average incidence of cardiac problems (50%), hearing problems (80%), eyesight problems (70%), arthritis, communication difficulties and breathing through the mouth. 16 17. Cervical Spine instability in Downs Syndrome References: 1. Medical Problems in Downs Syndrome. Oxford Downs syndrome service 2. Cooley, W. and Graham, J. (1991). Downs Syndrome An update and review for the primary paediatrician. Clinical Paediatrics, pp 233-253. 3. Department of Health (1995). Cervical Spine Instability in people with Downs Syndrome. CMO Update 7, p 4. 17 18. Sickle Cell Disease 18 Restraint and the condition 19. Sickle Cell Disease What is Sickle Cell Disease (SCD)? SCD is a family of blood conditions which include sickle cell anaemia, sickle cell disease and sickle beta thalassaemia. Predominantly in people of Afro Caribbean or West African origin, though it also affects Mediterranean, Middle astern and Asian people. 19 The basic characteristics of these diseases is a alteration in haemoglobin. This is the substance in the blood which carries oxygen from the lungs to all parts of the body. In SCD these abnormally shaped cells become sticky and can clump together, blocking the flow of blood through small blood vessels. 20. Sickle Cell Disease Symptoms? SCD can lead to pain in different parts of the body, e.g. the bones and abdomen, and can cause extreme tiredness due to anaemia. The frequency and severity of pain and other problems varies from one individual to another and is dependant on the type of SCD. Physical conditions in people with SCD? Generally prone to various infections due to damage to the spleen. Adult chest syndrome, caused by sudden sickling in the lings, causing permanent chronic damage. Bleeding in the brain, such as strokes Ulcers on the lower limbs due to poor oxygen and blood flow Inflamed or infected weight baring joints Priapism (constant erection) often occurs, often leading to impotence 20 21. Sickle Cell Disease and Restraint With the above conditions in mind the following points should be considered if physical restraining anyone who potentially has SCD: A crisis or sickling may be brought on by: Dehydration Reduced oxygen in body tissues Infection Strenuous physical exertion Sudden changes in body temperature Emotional/physical stress pregnancy 21 22. Sickle Cell Disease and Restraint SCD sufferers will be: Prone to breathing difficulties due to reduced oxygen to tissues, and possible damage to the lungs Suffering possibly with inflammation, infection and permanent damage to any joint on the body At risk of abdominal pain, due to liver, spleen, and possible kidney damage Easily dehydrated due to possible renal failure Prone to leg ulcers on their limbs Prone to anaemia and exhaustion These points should be taken into account when physically restraining any SCD sufferer and appropriate techniques used 22 23. Neuroleptic malignant Syndrome 23 Restraint and the condition 24. Neuroleptic Malignant Syndrome What is Neuroleptic Malignant Syndrome (NMS)? NMS is a severe and potentially life threatening reaction to anti-psychotic medication. It is a little known syndrome that affects 0.5% of people using such medication. Men are thought to be more likely to be affected, possibly due to increased use and dosage. Mortality rates are approximately 10%. It commonly occurs within the first two weeks of a dosage increase or change in medication, but may appear months or years after such a change 24 25. Neuroleptic Malignant Syndrome Symptoms? Unresponsiveness Increased body temperature Agitation Exhaustion Dehydration Symptoms occur after therapeutic rather than toxic doses of anti-psychotic drugs. Often 24-72 hours after start of medication or dosage change. 25 26. Neuroleptic Malignant Syndrome Relationship of NMS with restraint? There has been little research done on the relationship between NMS and restraint, but it is none to increase risk of Positional Asphyxia. As with all episodes of restraint, care should be taken to observe the persons physical condition at all times to reduce risks and maximise the persons safety. 26 27. Neuroleptic Malignant Syndrome References 1. Benzer, T. (1999). Neuroleptic Malignant Syndrome. Harvard medical School. 2. Sachdev, P., Mason, C., and Hadxi-Pavlovic, D. (1997). Case control study of Neuroleptic Malignant Syndrome. American Journal of Psychiatry. pp.1156- 1158. 3. Cries of Anguish. (1999) National Alliance for the Mentally Ill. 27 28. Prediction 28 29. Prediction Risk Factors Certain factors can indicate an increased risk of physically violent behaviour. 29 Personal History History of violent behaviour History of misuse of substance/alcohol Report of recent anger feelings Expression of intent to harm others Previous use of weapons Denial of previous dangerous act Severity of previous act Known personal triggers Verbal threat of violence Evidence of severe stress One or more of the above in combination with: Cruelty to animals History of bed wetting Loss or parent before 8 30. Prediction Risk Factors Certain factors can indicate an increased risk of physically violent behaviour. 30 Clinical Variables Drug effects Active symptoms of schizophrenia: - Delusions or hallucinations focused on a particular person - Command hallucinations - Preoccupation with violent fantasy - Delusions of control - Agitation, excitement, overt hostility or suspiciousness Poor collaboration with suggested treatment Antisocial, explosive or impulsive personality traits or disorder 31. Prediction Risk Factors Certain factors can indicate an increased risk of physically violent behaviour. 31 Situational Variables Extent of social support Immediate availability of a potential weapon Relationship with potential victim (e.g. if difficulties in relationship are known) Access to potential victim Limit setting (e.g. staff setting parameters for activities, choices) Staff attitudes 32. Prediction Antecedent and warning signs Certain features may serve as warning signs to indicate that a service user may be escalating towards physically violent behaviour. 32 Tense and angry facial expression Increased or prolonged restlessness, body tension, pacing General over-arousal of body system (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 33. Caplin and wheeler Assault Cycle 33 Note: Phase 3 shows several peaks. A patient often has more then one incident before recovery phase begins. Phase 4 is critical. Staff should increase observations for the following 90 minute. This is the cool down period. 34. De-escalation 34 35. De-escalation It is rare that violent behaviour is simply attention seeking, more often it is seen as a response to provocation, boredom, frustration, anxiety or physical discomfort. To reduce the probability of violence, preventative measures may include: Promotion or calm, relaxed atmosphere Provision of activities Avoidance of criticism Teaching stress management Keeping clients fully informed on what is happening and why! 35 36. De-escalation When considering the management of violence, staff are required to take any reasonable action to reduce the risk of harm to the client or others, including themselves. You must use your professional judgment to decide which intervention will be most effective Intervention may include calming in which staff recognise a client becoming disturbed, but not yet displaying any serious violence 36 37. De-escalation Guidelines: avoiding an incident Try to anticipate the mood of the client Try to find out why the client feels as he/she does and make every effort to remove the cause of anxiety Show the client you are trying to help and where possible draw up a plan of action Never show that you are disinterested or dont understand Never show hostility or threaten the client Be aware of body language i.e. restless, confronting body posture, stood still with full angry eye contact. 37 38. De-escalation Take the client out of the situation or somewhere quiet: remove external stimuli/redirect aggression. Dont touch the client unless you are confident of the response. Inform and warn colleagues of the possible incident. When interviewing potentially aggressive clients, ensure all staff know where you are and can discretely observe, Use of personal alarm Dont promise what you cant deliver Always approach client with hands on front of you, palms down. 38 39. De-escalation Guidelines: avoiding an incident Stay calm Do not handle a client alone unless essential A client may be restrained before a victim is struck Ensure the nurse in charge is aware and there is sufficient staff to deal with the incident At all times think SAFETY first 39 40. De-escalation Guidelines: avoiding an incident When intervention is necessary staff should reflect on their training procedures. Only trained staff should be deployed into an aggressive or violent client episode. During physical intervention staff should use de-escalation strategies, offering the client options throughout. No pressure should be applied to the neck, throat, chest or abdomen. If appropriate give proscribed medication Talk to the client throughout, reassuring and explaining what is happening and why. 40 41. De-escalation Guidance: Verbal Behaviour Initial contact: Listen carefully to what client is saying Show understanding- paraphrasing and reflecting During exchange: Using open questions (how, what, when, where) Put difficult issues back to client Use words designed to calm what we may nee to do Capitalise on interests and characteristics in common Break the cycle of escalation- change subject 41 42. De-escalation Guidance: Verbal Behaviour Try to avoid being reactive Monitor effects of intervention, prepare to adapt Do not use phrases which may antagonise Towards resolution Attempt to get the client to take, or co-operate in positive action Follow up Review action taken and its effects. Work towards longer- term contract of action Dont use the clients label as a reason for not giving full 42 43. De-escalation Para-verbal communication: Para-verbal communication is how we say what we say. the tone, volume and rate of speech. Ensure the tone is supportive or alternatively more directive if necessary. Personal Safety Stance: By maintaining two or three feet of distance between yourself and the anxious person, you communicate a certain degree of respect. Standing off to the side presents a non-threatening, non-challenging posture and a smaller target area. By standing side on, open posture, relaxed muscle tone you provide a margin of at least on length of distance. 43 44. De-escalation Notes: Early response: an early response in the de-escalation process and responding in a supportive manner is the best way to defuse potentially explosive situations. Non-verbal: as much as 80/90 per cent of our communication is estimated to be non-verbal Personal space: When approaching a person with anxious behaviour, keep in mind they may not ne comfortable with the situation. Body language: by tuning in to peoples body language we can get some important cues about their level of anxiety (pacing, fidgeting, wringing hands) Be aware of your body language you are using: contrasting supportive words with negative body language can send mixed signals. 44 45. De-escalation Summary: Anxiety is generally the first stage of crisis Behaviour changes manifest in non-verbal behaviour Recognise and respond in a supportive manor Recommended use of personal safety stance respect personal space avoid presenting a challenge Try to be aware of Para-verbal communication 45 46. Searches 46 47. Searches D25 Based on an assessment of risk, it may be necessary to search some service users to ensure a safe and therapeutic environment: Code of Practice In all cases the consent of the patient should be sought before a search is attempted. If consent is refused, the RC for the patient should first be contacted so that any clinical objection to a search by force may be raised. If no such objection is raised the search should proceed. While this is being resolved the patient should be isolated from other patients and kept under observation. Staff should explain why in terms appropriate to his/her understanding. All searches should be carried out with due regard for the dignity of the individual and the need to ensure privacy. 47 48. Searches D25 Personal Search Must be carried out in an appropriate area away from main unit All members of search team to wear gloves One member of team will conduct search, 1 or 2 members of the team will observe (all same gender as patient) In the interest of protecting staff from any allegations of inappropriate action all search teams must consist of at lease one qualified Nurse 48 49. Searches D25 How to conduct a Personal Search Patient should be asked to remove all jewellery, belts, shoes, socks, and turn out all pockets. These should be individually examined. Patients should be searches in a systematic way from head to toe: Ask patient to run fingers through hair Check ears, nostrils and mouth Check collars and clothes labels Rub down front and side of chest and stomach, under arms, inner and outer arms and ask patient to spread fingers Check waistband of trousers/skirt Run hands up the inner thigh to the groin area avoiding genitalia. Rub down front legs and ask patient to spread toes Ask patient to turn around, check behind ears, neck and rub down back and shoulders and lower back Check rear of waistband and rub down back of legs 49 50. Searches D25 How to conduct a Personal Search Inform the patient of property that is to be removed and where it will be stored, return property that has been checked. All property to be recorded and checked by two people. Record in search form and patients clinical notes. The RC of the patient should be informed as soon as possible. Staff should be available to offer support should the patient require this following the search The procedure is the same for detained and informal patients 50 51. Searches D25 Intimate searches A search that consists of the physical examination of a persons body orifices, other that the mouth does not fall within our remit or responsibility (S. 65 of the Police and Criminal Evidence Act 1984). If it is felt necessary to conduct an intimate search, staff should seek advice via the Director of Operations Services so that legal advice can be obtained. 51 52. Searches D25 Searching of patient areas Part of the responsibility of nursing staff is to ensure the safety of patients and staff. To further enhance this safety room searches will be carried out in each patient's room and in other patient areas to ensure that dangerous or prohibited items are not present. Staff carrying them out should remain sensitive to the individuality and dignity of patients. The operation of searches should not be of an oppressive nature. Outside regular searches, the following would be reason for instigating immediate room/area searches: Dangerous items e.g. knife is reported as unaccounted for in the immediate area. (Senior Nurse will determine how many areas of the unit are to be searched other the immediate area.) If it is discovered that contraband items have been brought onto the unit. If there is reasonable suspicion that a patient is harbouring something in their room, which could be dangerous to themselves or others. 52 53. Searches D25 Searching of patient areas Room to be locked and patients in area escorted to day room Explanation should be given to patient by the nurse in charge Patient should be invited to be present which room is searched Two staff (one a qualified nurse) will be present at all times Work together to search in a systematic way. Searches should include: Letters, electrical equipment Bed stripped and bedding examined for damage/tampering Mattress should be examined for damage/tampering Physical structure of bed should be examined for damage/tampering Curtains and curtain rail examined for damage/tampering Wardrobe and cupboards should be examined and emptied Draws should be removed and physical structure checked Door tops and ledges checked Washbasin and taps examined Ceiling lights should be checked for damage/tampering 53 54. Positional Asphyxia 54 55. Positional Asphyxia What is it? Position Asphyxia occurs when the position of the human body interferes with respiration resulting in asphyxiation. What are the risk factors? Position during restrain (particularly face down and hyperflexion) Prolonged struggle Drug and alcohol intoxication Mania Obesity Respiratory syndrome Cardio vascular disorder Prescribed drugs (OHalloran and Learman, 1993) 55 56. Positional Asphyxia Why? Breathing involves a mechanical process in which the chest wall, the rib cage, the diaphragm and the muscles of the abdomen are all involved. If movement of any or all of these is impaired for a period then death may result as a result of hypoxia , which may disturb heart rhythm. 56 Gaseous Exchange Airways Bellows 57. Positional Asphyxia General signs and symptoms Noisy, laboured breathing Gray-blue skin (cyanosis) Flaring of nostrils Reversed movement of the chest while breathing Drawing in of the chest wall between the ribs and the soft spaces above the collarbones and breastbone. First aid Remove any obstruction to breathing, check for movement or anything over the mouth or nose. If needed move patient into fresh air. Dial 999 for an ambulance. Place patient in recovery position. If conscious reassure patient. Even if patient seems to recover inform a doctor. 57 58. Excited Delirium 58 59. Excited Delirium The risk of positional asphyxia affecting a person who is in an excited delirium state is far greater than for a normal violent person. Excited delirium may manifest itself as a bizarre and manic violent behaviour. Causes: Drug/alcohol intoxication or psychiatric illness Warning signs: Skin hot to touch Hallucinations Suddenly become subdued May collapse 59 Abnormal strength Gurgling gasping sound Verbal complaint of not being able to breath Blue coloration in skin 60. Excited Delirium Circumstances in which this occurs are when: An individual is laid face down on their stomach and pressure is applied to their thorax, back or spine area or to any part of the body that respiration is inhibited. Confined spaces An individuals arms and legs are held behind the back whilst lying on their stomach for any length or time. Increased risk if: Individual is intoxicated with alcohol or drugs History of mental disorder Individual has through violent activity expanded much physical energy (restraint/fighting) and is suffering respiratory fatigue. Individual is overweight or has large abdomen. Significant risk because forces content of abdomen upwards within the abdominal cavity. When in prone position restricts movement of diaphragm. 60 61. Excited Delirium Reducing the risk: Avoid putting direct pressure on the back or spinal area Achieve a kneeling, sitting or standing position as soon as practical Monitor the individuals vital signs Get medical assistance immediately if you have any concerns Note recent history and medical history- establish any hear complaints, breathing problems etc. Vigilant monitoring of the subject must be stressed 61 62. Compartment Syndrome 62 Restraint and the condition 63. Compartment Syndrome 63 What is it? Muscles are surrounded by facia that hold things in place Bones and fascia combine to form well defined compartments They dont allow a lot of give, so swelling in the compartment can lead to increased pressure It is more common in the lower leg 64. Compartment Syndrome Causes The build up of pressure will compress the artery and nerves e.g. bandages too tight or other external compression Repetitive movement e.g. during exercise repeated movement of the foot up and down. Trauma: crash injury or haematoma Symptoms; 5 Ps Pain Parasthesias (loss of feeling in limb) Passive stretch (extreme pain when stretching muscles) Pressure Pulslelssness 64 65. Compartment Syndrome 65 A Fasciotomy will be needed to treat the swelling What to do? See a doctor or attend hospital as soon as possible If allowed to deteriorate, nerve endings and muscle tissues will begin to die and an operation or amputation may be needed 66. The Facts 66 67. Breakdown of incident category Oct 08 Sep 09 67 Absconding 6 Damage to property 44 Drug Error/Missing Medication 3 Dangerous Incident 3 Major Injury 2 Minor Injury 18 Missing Person 3 Risk to self or others 221 Unexplained Behaviour 12 Abusive Incident 14 Other 7 68. Accident and incident Per Month 68 0 5 10 15 20 25 30 35 40 45 69. Breakdown of incidents/accidents per category 69 Green = 217 Amber = 115 Red = 1 70. 70 C & R Used 12 PRN Used 49 Breakdown of Use of C & R and PRN 0 1 2 3 4 5 6 7 8 9 10 No of PRN Used Per Month 71. Some examples: Green incident- damage to property: Client A visited her mums shop and started taken down products off the shelves, then see a store room door opened and went in there and started ripping the cartons and throwing them on the floor. Staff tried to restrain her and client A bite one of the hair stylists. Green incident- abusive incident: Client B tried to grab the mug filled with tea from another patient in the corridor, and was becoming aggressive. Client C tried to protect his mug and swung a fist on client Bs mouth, client B followed fellow client to his bedroom and staff tried to calm him. Green incident- Risk to self and others: Client D was very afraid of client E as he showed aggressive behavior in front of him, later client D tried to attack client E. Amber incident- Dangerous occurrence Client F came out of the lounge and ran directly towards staff member and hit her in the head without any provocation, and when staff tried to intervene client F resisted. Amber incident- Risk to self and others Client G was attacked for an unknown cause by client H. Client G retaliated and staff had to intervene to stop him he tried to attack them. Red incident- Major injury Client J was met in her bathroom sitting on the toilet and cutting her right arm with a blade 71