Violence and aggression:

short-term management in
mental health, health and
community settings

NICE guideline
Published: 28 May 2015

[Link]/guidance/ng10

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Violence and aggression: short-term management in mental health, health and community
settings (NG10)

Your responsibility
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals
and practitioners are expected to take this guideline fully into account, alongside the
individual needs, preferences and values of their patients or the people using their service.
It is not mandatory to apply the recommendations, and the guideline does not override the
responsibility to make decisions appropriate to the circumstances of the individual, in
consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment
or in a procedure should be reported to the Medicines and Healthcare products Regulatory
Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the

guideline to be applied when individual professionals and people using services wish to
use it. They should do so in the context of local and national priorities for funding and
developing services, and in light of their duties to have due regard to the need to eliminate
unlawful discrimination, to advance equality of opportunity and to reduce health
inequalities. Nothing in this guideline should be interpreted in a way that would be
inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally

sustainable health and care system and should assess and reduce the environmental
impact of implementing NICE recommendations wherever possible.

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Contents
Overview ..................................................................................................................................... 5

Who is it for? .......................................................................................................................................... 5

Introduction ................................................................................................................................. 6

Safeguarding children ........................................................................................................................... 7

Medicines ............................................................................................................................................... 7

Person-centred care .................................................................................................................. 9

Key priorities for implementation .............................................................................................. 10

Anticipating and reducing the risk of violence and aggression........................................................ 11

Preventing violence and aggression ................................................................................................... 13

Using restrictive interventions in inpatient psychiatric settings....................................................... 14

Managing violence and aggression in emergency departments ...................................................... 16

Managing violence and aggression in community and primary care settings ................................ 16

Managing violence and aggression in children and young people .................................................. 17

1 Recommendations ................................................................................................................... 18

Terms used in this guideline................................................................................................................. 18

1.1 Principles for managing violence and aggression ......................................................................... 20

1.2 Anticipating and reducing the risk of violence and aggression .................................................. 23

1.3 Preventing violence and aggression.............................................................................................. 28

1.4 Using restrictive interventions in inpatient psychiatric settings ................................................. 33

1.5 Managing violence and aggression in emergency departments ................................................ 45

1.6 Managing violence and aggression in community and primary care settings .......................... 47

1.7 Managing violence and aggression in children and young people ............................................. 48

2 Research recommendations................................................................................................... 53

2.1 Medication for promoting de-escalation ....................................................................................... 53

2.2 Violence related to drug or alcohol misuse .................................................................................. 53

2.3 Advance statements and decisions .............................................................................................. 54

2.4 Content and nature of effective de-escalation ........................................................................... 54

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2.5 Long duration or very frequent manual restraint ......................................................................... 55

Implementation: getting started ............................................................................................... 57

Manual restraint..................................................................................................................................... 57

Rapid tranquillisation ............................................................................................................................ 58

Formal external post-incident reviews ................................................................................................ 60

Finding more information and committee details .................................................................... 62

Update information .................................................................................................................... 63

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This guideline replaces CG25 and ESUOM28.

This guideline is the basis of QS154.

Overview
This guideline covers the short-term management of violence and aggression in adults
(aged 18 and over), young people (aged 13 to 17) and children (aged 12 and under). It is
relevant for mental health, health and community settings. The guideline aims to safeguard
both staff and people who use services by helping to prevent violent situations and
providing guidance to manage them safely when they occur.

Who is it for?
• Healthcare professionals

• Adults, young people and children with a mental health problem who use services in
mental health, health and community settings, and their families and carers

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Introduction
Violence and aggression refer to a range of behaviours or actions that can result in harm,
hurt or injury to another person, regardless of whether the violence or aggression is
physically or verbally expressed, physical harm is sustained or the intention is clear.

Violence and aggression are relatively common and serious occurrences in health and
social care settings. Between 2013 and 2014 there were 68,683 assaults reported against
NHS staff in England: 69% in mental health or learning disability settings, 27% against
ambulance staff, 25% involving primary care staff and 26% involving acute hospital staff.
Violence and aggression in mental health settings occur most frequently in inpatient
psychiatric units and most acute hospital assaults take place in emergency departments.

The manifestation of violence and aggression depends on a combination of intrinsic

factors, such as personality characteristics and intense mental distress, and extrinsic
factors, such as the attitudes and behaviours of surrounding staff and service users, the
physical setting and any restrictions that limit the service user's freedom. The impact of
violence and aggression is significant and diverse, adversely affecting the health and
safety of the service user, other service users in the vicinity, carers and staff. Violence and
aggression can also affect public opinion about services and service users and result in a
strong negative impact on the overall experience of care. Although the guideline contains
recommendations on intervening before violence and aggression occur, it is not always
possible to avoid violence. Therefore a graded set of interventions is needed to prevent
minor violence from escalating into severe violence.

Since the publication of the previous guideline in 2005 (NICE guideline CG25) there have
been some important advances in our knowledge of the management of violence and
aggression, including service users' views on the use of physical intervention and
seclusion, and the effectiveness, acceptability and safety of drugs and their dosages for
rapid tranquillisation. The previous guideline was restricted to people aged 16 and over in
adult psychiatric settings and emergency departments; this update has been expanded to
include some of the previously excluded populations and settings. All areas of NICE
guideline CG25 have been updated and this guideline replaces it in full.

This guideline covers the short-term management of violence and physically threatening
behaviour in mental health, health and community settings. This includes inpatient
psychiatric care, emergency and urgent care, secondary mental health care (such as care

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provided by assertive community teams, community mental health teams, early

intervention teams and crisis resolution and home treatment teams), community
healthcare, primary care, social care and care provided in people's homes. The guideline
covers anticipating and reducing the risk of violence and aggression, prevention methods
(such as searching, de-escalation and pharmacological strategies, including p.r.n.
medication), restrictive interventions (for example, restraint, rapid tranquillisation and
seclusion), staff training, and post-incident debrief and review.

This guideline includes adults (aged 18 and over), children (aged 12 and under) and young
people (aged 13 to 17) with a mental health problem who are currently service users within
mental health, health and community settings. It also covers carers of service users with
mental health problems in these settings.

This guideline does not cover but may be relevant to practice regarding people who do not
have mental health problems, those who are not carers of people with mental health
problems, people in whom the primary behaviour is self-harm and people with a primary
diagnosis of learning disability.

Safeguarding children
Remember that child maltreatment:

• is common

• can present anywhere, such as emergency departments and primary care or on home
visits.

Be aware of or suspect abuse as a contributory factor to or cause of the symptoms or

signs of violence or aggression in children. Abuse may also coexist with violence or
aggression. See the NICE guideline on child maltreatment for clinical features that may be
associated with maltreatment.

This section has been agreed with the Royal College of Paediatrics and Child Health.

Medicines
The guideline assumes that prescribers will use a medicine's summary of product
characteristics to inform decisions made with individual service users.

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This guideline recommends some medicines for indications for which they do not have a
UK marketing authorisation at the date of consultation, if there is good evidence to
support that use. The prescriber should follow relevant professional guidance, taking full
responsibility for the decision. The service user (or those with authority to give consent on
their behalf) should provide informed consent, which should be documented. See the
General Medical Council's Prescribing guidance: prescribing unlicensed medicines for
further information. Where recommendations have been made for the use of medicines
outside their licensed indications ('off-label use'), these medicines are indicated in the
recommendations.

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Person-centred care
This guideline offers best practice advice on the care of service users with mental health
problems whose behaviour is violent or aggressive.

Service users and healthcare professionals have rights and responsibilities as set out in
the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment
and care should take into account individual needs and preferences. Service users should
have the opportunity to make informed decisions about their care and treatment, in
partnership with their healthcare professionals. If the service user is under 16, their family
or carers should also be given information and support to help the child or young person to
make decisions about their treatment. Healthcare professionals should follow the
Department of Health's advice on consent. If someone does not have capacity to make
decisions, healthcare professionals should follow the code of practice that accompanies
the Mental Capacity Act and the supplementary code of practice on deprivation of liberty
safeguards.

NICE has produced guidance on the components of good patient experience in adult NHS
services. All healthcare professionals should follow the recommendations in the NICE
guideline on patient experience in adult NHS services.

NICE has also produced guidance on the components of good service user experience. All
healthcare professionals and social care practitioners working with people using adult NHS
mental health services should follow the recommendations in the NICE guideline on
service user experience in adult mental health.

If a young person is moving between paediatric and adult services, care should be planned
and managed according to the best practice guidance described in the Department of
Health's Transition: getting it right for young people.

Adult and paediatric healthcare teams should work jointly to provide assessment and
services to young people with mental health problems whose behaviour is violent or
aggressive. Diagnosis and management should be reviewed throughout the transition
process, and there should be clarity about who is the lead clinician to ensure continuity of
care.

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Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The
full list of recommendations is in section 1.

See implementation: getting started for information about putting the recommendations on
manual restraint, rapid tranquillisation and formal external post-incident reviews into
practice.

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Anticipating and reducing the risk of violence and

aggression

Reducing the use of restrictive interventions

Staff training

• Health and social care provider organisations should train staff who work in services in
which restrictive interventions may be used in psychosocial methods to avoid or
minimise restrictive interventions. This training should enable staff to develop:

－ a person-centred, values-based approach to care, in which personal relationships,

continuity of care and a positive approach to promoting health underpin the
therapeutic relationship

－ an understanding of the relationship between mental health problems and the risk
of violence and aggression

－ skills to assess why behaviour is likely to become violent or aggressive, including

personal, constitutional, mental, physical, environmental, social, communicational,
functional and behavioural factors

－ skills, methods and techniques to reduce or avert imminent violence and defuse
aggression when it arises (for example, verbal de-escalation)

－ skills, methods and techniques to undertake restrictive interventions safely when

these are required

－ skills to undertake an immediate post-incident debrief (see

recommendations 1.4.55 to 1.4.61)

－ skills to undertake a formal external post-incident review in collaboration with

experienced service users who are not currently using the service (see
recommendations 1.4.62 to 1.4.63).

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A framework for anticipating and reducing violence and

aggression in inpatient psychiatric wards
• Use the following framework to anticipate violence and aggression in inpatient
psychiatric wards, exploring each domain to identify ways to reduce violence and
aggression and the use of restrictive interventions.

－ Ensure that the staff work as a therapeutic team by using a positive and
encouraging approach, maintaining staff emotional regulation and
self-management (see recommendation 1.3.19) and encouraging good leadership.

－ Ensure that service users are offered appropriate psychological therapies,

physical activities, leisure pursuits such as film clubs and reading or writing
groups, and support for communication difficulties.

－ Recognise possible teasing, bullying, unwanted physical or sexual contact or

miscommunication between service users.

－ Recognise how each service user's mental health problem might affect their
behaviour (for example, their diagnosis, severity of illness, current symptoms and
past history of violence or aggression).

－ Anticipate the impact of the regulatory process on each service user (for example,
being formally detained, having leave refused, having a failed detention appeal or
being in a very restricted environment such as a low-, medium- or high-secure
hospital).

－ Improve or optimise the physical environment (for example, use unlocked doors
whenever possible, enhance the décor, simplify the ward layout and ensure easy
access to outside spaces and privacy).

－ Anticipate that restricting a service user's liberty and freedom of movement (for
example, not allowing service users to leave the building) can be a trigger for
violence and aggression.

－ Anticipate and manage any personal factors occurring outside the hospital (for
example, family disputes or financial difficulties) that may affect a service user's
behaviour.

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Preventing violence and aggression

Using p.r.n. medication

• When prescribing p.r.n. medication as part of a strategy to de-escalate or prevent
situations that may lead to violence and aggression:

－ do not prescribe p.r.n. medication routinely or automatically on admission

－ tailor p.r.n. medication to individual need and include discussion with the service
user if possible

－ ensure there is clarity about the rationale and circumstances in which p.r.n.
medication may be used and that these are included in the care plan

－ ensure that the maximum daily dose is specified and does not inadvertently
exceed the maximum daily dose stated in the British national formulary (BNF)
when combined with the person's standard dose or their dose for rapid
tranquillisation

－ only exceed the BNF maximum daily dose (including p.r.n. dose, the standard dose
and dose for rapid tranquillisation) if this is planned to achieve an agreed
therapeutic goal, documented and carried out under the direction of a senior
doctor

－ ensure that the interval between p.r.n. doses is specified.

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De-escalation

Staff training

• Health and social care provider organisations should give staff training in
de-escalation that enables them to:

－ recognise the early signs of agitation, irritation, anger and aggression

－ understand the likely causes of aggression or violence, both generally and for
each service user

－ use techniques for distraction and calming, and ways to encourage relaxation

－ recognise the importance of personal space

－ respond to a service user's anger in an appropriate, measured and reasonable way

and avoid provocation.

General principles

• Establish a close working relationship with service users at the earliest opportunity
and sensitively monitor changes in their mood or composure that may lead to
aggression or violence.

Using restrictive interventions in inpatient

psychiatric settings

Using restrictive interventions

• Do not use restrictive interventions to punish, inflict pain, suffering or humiliation, or
establish dominance.

Rapid tranquillisation
• If there is evidence of cardiovascular disease, including a prolonged QT interval, or no
electrocardiogram has been carried out, avoid intramuscular haloperidol combined
with intramuscular promethazine and use intramuscular lorazepam instead.

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Post-incident debrief and review

Formal external post-incident review

• The service user experience monitoring unit or equivalent service user group should
undertake a formal external post-incident review as soon as possible and no later than
72 hours after the incident. The unit or group should ensure that the formal external
post-incident review:

－ is led by a service user and includes staff from outside the ward where the
incident took place, all of whom are trained to undertake investigations that aim to
help staff learn and improve rather than assign blame

－ uses the information recorded in the immediate post-incident debrief and the
service user's notes relating to the incident

－ includes interviews with staff, the service user involved and any witnesses if
further information is needed

－ uses the framework in recommendation 1.2.7 to:

◇ evaluate the physical and emotional impact on everyone involved, including

witnesses

◇ help service users and staff to identify what led to the incident and what
could have been done differently

◇ determine whether alternatives, including less restrictive interventions, were

discussed

◇ determine whether service barriers or constraints make it difficult to avoid the

same course of actions in future

◇ recommend changes to the service's philosophy, policies, care environment,

treatment approaches, staff education and training, if appropriate

◇ avoid a similar incident happening in future, if possible.

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Managing violence and aggression in emergency

departments
• If a service user with a mental health problem becomes aggressive or violent, do not
exclude them from the emergency department. Manage the violence or aggression in
line with recommendations 1.4.1 to 1.4.45 and do not use seclusion. Regard the
situation as a psychiatric emergency and refer the service user to mental health
services urgently for a psychiatric assessment within 1 hour.

Managing violence and aggression in community

and primary care settings
• Health and social care provider organisations, including ambulance trusts, should
consider training staff working in community and primary care settings in methods of
avoiding violence, including anticipation, prevention, de-escalation and breakaway
techniques, depending on the frequency of violence and aggression in each setting
and the extent to which staff move between settings.

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Managing violence and aggression in children and

young people

Staff training
• Child and adolescent mental health services (CAMHS) should ensure that staff are
trained in the management of violence and aggression using a training programme
designed specifically for staff working with children and young people. Training
programmes should include the use of psychosocial methods to avoid or minimise
restrictive interventions whenever possible. Staff who might undertake restrictive
interventions should be trained:

－ in the use of these interventions in these age groups

－ to adapt the manual restraint techniques for adults in recommendations 1.4.23 to

1.4.33, adjusting them according to the child or young person's height, weight and
physical strength

－ in the use of resuscitation equipment (see recommendation 1.4.3) in children and

young people.

Managing violence and aggression

• Manage violence and aggression in children and young people in line with the
recommendations for adults in sections 1.1 to 1.6, taking into account:

－ the child or young person's level of physical, intellectual, emotional and

psychological maturity

－ the recommendations for children and young people in this section

－ that the Mental Capacity Act 2005 applies to young people aged 16 and over.

Assessment and initial management

Identify any history of aggression or aggression trigger factors, including experience of
abuse or trauma and previous response to management of violence or aggression.

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1 Recommendations
People have the right to be involved in discussions and make informed decisions
about their care, as described in NICE's information on making decisions about your
care.

Making decisions using NICE guidelines explains how we use words to show the
strength (or certainty) of our recommendations, and has information about
prescribing medicines (including off-label use), professional guidelines, standards
and laws (including on consent and mental capacity), and safeguarding.

Terms used in this guideline

Advance decision A written statement made by a person aged 18 or over that is legally
binding and conveys a person's decision to refuse specific treatments and interventions in
the future.

Advance statement A written statement that conveys a person's preferences, wishes,

beliefs and values about their future treatment and care. An advance statement is not
legally binding.

Advocate A person who represents someone's interests independently of any

organisation, and helps them to get the care and support they need.

Breakaway techniques A set of physical skills to help separate or break away from an
aggressor in a safe manner. They do not involve the use of restraint.

Carer A person who provides unpaid support to a partner, family member, friend or
neighbour who is ill, struggling or disabled.

Children People aged 12 years or under.

De-escalation The use of techniques (including verbal and non-verbal communication

skills) aimed at defusing anger and averting aggression. P.r.n. medication can be used as
part of a de-escalation strategy but p.r.n. medication used alone is not de-escalation.

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Incident Any event that involves the use of a restrictive intervention – restraint, rapid
tranquillisation or seclusion (but not observation) – to manage violence or aggression.

Manual restraint A skilled, hands-on method of physical restraint used by trained

healthcare professionals to prevent service users from harming themselves, endangering
others or compromising the therapeutic environment. Its purpose is to safely immobilise
the service user.

Mechanical restraint A method of physical intervention involving the use of authorised

equipment, for example handcuffs or restraining belts, applied in a skilled manner by
designated healthcare professionals. Its purpose is to safely immobilise or restrict
movement of part(s) of the body of the service user.

Observation A minimally restrictive intervention of varying intensity in which a member of

the healthcare staff observes and maintains contact with a service user to ensure the
service user's safety and the safety of others. There are different levels of observation, as
defined in recommendation 1.4.11.

Positive engagement An intervention that aims to empower service users to actively

participate in their care. Rather than 'having things done to' them, service users negotiate
the level of engagement that will be most therapeutic.

p.r.n. (pro re nata) When needed. In this guideline, p.r.n. refers to the use of medication as
part of a strategy to de-escalate or prevent situations that may lead to violence or
aggression; it does not refer to p.r.n. medication used on its own for rapid tranquillisation
during an episode of violence of aggression

Rapid tranquillisation Use of medication by the parenteral route (usually intramuscular or,
exceptionally, intravenous) if oral medication is not possible or appropriate and urgent
sedation with medication is needed.

Restrictive interventions Interventions that may infringe a person's human rights and
freedom of movement, including observation, seclusion, manual restraint, mechanical
restraint and rapid tranquillisation.

Seclusion Defined in accordance with the Mental Health Act 1983 Code of Practice: 'the
supervised confinement of a patient in a room, which may be locked. Its sole aim is to
contain severely disturbed behaviour that is likely to cause harm to others'.

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Violence and aggression A range of behaviours or actions that can result in harm, hurt or
injury to another person, regardless of whether the violence or aggression is physically or
verbally expressed, physical harm is sustained or the intention is clear.

Young people People aged between 13 and 17 years.

1.1 Principles for managing violence and

aggression

Improving service user experience

1.1.1 Use this guideline in conjunction with NICE's guideline on service user
experience in adult mental health and:

• work in partnership with service users and their carers

• adopt approaches to care that respect service users' independence, choice

and human rights

• increase social inclusion by decreasing exclusionary practices, such as the use

of seclusion and the Mental Health Act 1983.

1.1.2 Ensure that the safety and dignity of service users and the safety of staff
are priorities when anticipating or managing violence and aggression.

1.1.3 Use of restrictive interventions must be undertaken in a manner that

complies with the Human Rights Act 1998 and the relevant rights in the
European Convention on Human Rights.

1.1.4 Unless a service user is detained under the Mental Health Act 1983 or
subject to a deprivation of liberty authorisation or order under the Mental
Capacity Act 2005, health and social care provider organisations must
ensure that the use of restrictive interventions does not impose
restrictions that amount to a deprivation of liberty.

Staff training
1.1.5 In any setting in which restrictive interventions could be used, health and

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social care provider organisations should train staff to understand and

apply the Human Rights Act 1998, the Mental Capacity Act 2005 and the
Mental Health Act 1983.

Involving service users in decision-making

1.1.6 Involve service users in all decisions about their care and treatment, and
develop care and risk management plans jointly with them. If a service
user is unable or unwilling to participate, offer them the opportunity to
review and revise the plans as soon as they are able or willing and, if
they agree, involve their carer.

1.1.7 Check whether service users have made advance decisions or advance
statements about the use of restrictive interventions, and whether a
decision-maker has been appointed for them, as soon as possible (for
example, during admission to an inpatient psychiatric unit) and take this
information into account when making decisions about care.

1.1.8 If a service user has not made any advance decisions or statements
about the use of restrictive interventions, encourage them to do so as
soon as possible (for example, during admission to an inpatient
psychiatric unit). Ensure that service users understand the main
side-effect profiles of the medications recommended in this guideline for
rapid tranquillisation (see recommendation 1.4.37) so that they can make
an informed choice.

1.1.9 Ensure that service users understand that during any restrictive
intervention their human rights will be respected and the least restrictive
intervention will be used to enable them to exercise their rights (for
example, their right to follow religious or cultural practices during
restrictive interventions) as much as possible. Identify and reduce any
barriers to a service user exercising their rights and, if this is not
possible, record the reasons in their notes.

1.1.10 Ensure that carers are involved in decision-making whenever possible, if

the service user agrees, and that carers are involved in decision-making
for all service users who lack mental capacity, in accordance with the
Mental Capacity Act 2005.

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Preventing violations of service users' rights

1.1.11 Evaluate, together with the service user, whether adjustments to
services are needed to ensure that their rights and those of their carers
(including rights related to protected characteristics as defined by the
Equality Act 2010) are respected, and make any adjustments that are
needed. Adjustments might include providing a particular type of
support, modifying the way services are delivered or the approach to
interaction with the service user, or making changes to facilities. Record
this in the service user's care plan.

1.1.12 Health and social care provider organisations should train staff in cultural
awareness and in the organisation's duties under the Equality Act 2010.

Working with the police

1.1.13 Health and social care provider organisations should work with the
police, and local service user groups if possible, to develop policies for
joint working and locally agreed operating protocols that cover:

• when and how police enter health or social care settings (including psychiatric
and forensic inpatients, emergency departments, general health inpatients, GP
surgeries, social care and community settings and 136 place-of-safety suites)

• when and how health and social care professionals enter police cells

• transferring service users between settings.

Review the operating protocols regularly to ensure compliance with the policies
and update the policies in light of operational experience.

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1.2 Anticipating and reducing the risk of violence

and aggression

Reducing the use of restrictive interventions

Staff training

1.2.1 Health and social care provider organisations should train staff who work
in services in which restrictive interventions may be used in psychosocial
methods to avoid or minimise restrictive interventions. This training
should enable staff to develop:

• a person-centred, values-based approach to care, in which personal

relationships, continuity of care and a positive approach to promoting health
underpin the therapeutic relationship

• an understanding of the relationship between mental health problems and the

risk of violence and aggression

• skills to assess why behaviour is likely to become violent or aggressive,

including personal, constitutional, mental, physical, environmental, social,
communicational, functional and behavioural factors

• skills, methods and techniques to reduce or avert imminent violence and

defuse aggression when it arises (for example, verbal de-escalation)

• skills, methods and techniques to undertake restrictive interventions safely

when these are required

• skills to undertake an immediate post-incident debrief (see

recommendations 1.4.55 to 1.4.61)

• skills to undertake a formal external post-incident review in collaboration with

experienced service users who are not currently using the service (see
recommendations 1.4.62 and 1.4.63).

Restrictive intervention reduction programme

1.2.2 Health and social care provider organisations should ensure that all

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services that use restrictive interventions have a restrictive intervention

reduction programme (see recommendation 1.2.3) to reduce the
incidence of violence and aggression and the use of restrictive
interventions.

1.2.3 Restrictive intervention reduction programmes should:

• ensure effective service leadership

• address environmental factors likely to increase or decrease the need for

restrictive interventions (see recommendation 1.2.7)

• involve and empower service users and their carers

• include leisure activities that are personally meaningful and physical exercise
for service users

• use clear and simple care pathways

• use de-escalation

• use crisis and risk management plans and strategies to reduce the need for
restrictive interventions

• include post-incident debrief and review (see recommendations 1.4.55 to

1.4.61)

• explore the current and potential use of technology in reporting, monitoring

and improving the use of restrictive interventions

• have routine outcome monitoring, including quality of life and service user
experience

• be based on outcome measures (safety, effectiveness and service user

experience) to support quality improvement programmes

• include regular staff training in line with recommendation 1.2.1.

1.2.4 Health and social care provider organisations should collate, analyse and
synthesise all data about violent events and the use of restrictive
interventions, and involve service users in the process. The information
should:

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• be shared with the teams and services involved

• be shared with the trust board or equivalent organisational governing body

• be linked to the standards set in safeguarding procedures.

1.2.5 Health and social care provider organisations should develop a service
user experience monitoring unit, or equivalent service user group, led by
service users and including staff, to report and analyse data on violence
and aggression and the use of restrictive interventions.

1.2.6 Health and social care provider organisations should publish board
reports on their public websites that include data about incidents of
violence and aggression and use of restrictive interventions within each
team, ward and service, and include reasons for the similarities and
differences between services.

A framework for anticipating and reducing violence and

aggression in inpatient psychiatric wards
1.2.7 Use the following framework to anticipate violence and aggression in
inpatient psychiatric wards, exploring each domain to identify ways to
reduce violence and aggression and the use of restrictive interventions.

• Ensure that the staff work as a therapeutic team by using a positive and
encouraging approach, maintaining staff emotional regulation and
self-management (see recommendation 1.3.19) and encouraging good
leadership.

• Ensure that service users are offered appropriate psychological therapies,

physical activities, leisure pursuits such as film clubs and reading or writing
groups, and support for communication difficulties.

• Recognise possible teasing, bullying, unwanted physical or sexual contact, or

miscommunication between service users.

• Recognise how each service user's mental health problem might affect their
behaviour (for example, their diagnosis, severity of illness, current symptoms
and past history of violence or aggression).

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• Anticipate the impact of the regulatory process on each service user, for
example, being formally detained, having leave refused, having a failed
detention appeal or being in a very restricted environment such as a low-,
medium- or high-secure hospital.

• Improve or optimise the physical environment (for example, use unlocked doors
whenever possible, enhance the décor, simplify the ward layout and ensure
easy access to outside spaces and privacy).

• Anticipate that restricting a service user's liberty and freedom of movement

(for example, not allowing service users to leave the building) can be a trigger
for violence and aggression.

• Anticipate and manage any personal factors occurring outside the hospital (for
example, family disputes or financial difficulties) that may affect a service
user's behaviour.

Assessing and managing the risk of violence and aggression

1.2.8 When assessing and managing the risk of violence and aggression use a
multidisciplinary approach that reflects the care setting.

1.2.9 Before assessing the risk of violence or aggression:

• Take into account previous violent or aggressive episodes because these are
associated with an increased risk of future violence and aggression.

• Do not make negative assumptions based on culture, religion or ethnicity.

• Recognise that unfamiliar cultural practices and customs could be

misinterpreted as being aggressive.

• Ensure that the risk assessment will be objective and take into account the
degree to which the perceived risk can be verified.

1.2.10 Carry out the risk assessment with the service user and, if they agree,
their carer. If this finds that the service user could become violent or
aggressive, set out approaches that address:

• service user-related domains in the framework (see recommendation 1.2.7)

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• contexts in which violence and aggression tend to occur

• usual manifestations and factors likely to be associated with the development

of violence and aggression

• primary prevention strategies that focus on improving quality of life and

meeting the service user's needs

• symptoms or feelings that may lead to violence and aggression, such as

anxiety, agitation, disappointment, jealousy and anger, and secondary
prevention strategies focusing on these symptoms or feelings

• de-escalation techniques that have worked effectively in the past

• restrictive interventions that have worked effectively in the past, when they are
most likely to be necessary and how potential harm or discomfort can be
minimised.

1.2.11 Consider using an actuarial prediction instrument such as the BVC

(Brøset Violence Checklist) or the DASA-IV (Dynamic Appraisal of
Situational Aggression – Inpatient Version), rather than unstructured
clinical judgement alone, to monitor and reduce incidents of violence and
aggression and to help develop a risk management plan in inpatient
psychiatric settings.

1.2.12 Consider offering service users with a history of violence or aggression

psychological help to develop greater self-control and techniques for
self-soothing.

1.2.13 Regularly review risk assessments and risk management plans,

addressing the service user and environmental domains listed in
recommendation 1.2.7 and following recommendations 1.2.9 and 1.2.10.
The regularity of the review should depend on the assessment of the
level of risk. Base the care plan on accurate and thorough risk
assessments.

1.2.14 If service users are transferring to another agency or care setting, or

being discharged, share the content of the risk assessment with staff in
the relevant agencies or care settings, and with carers.

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An individualised pharmacological strategy to reduce the risk of

violence and aggression
1.2.15 A multidisciplinary team that includes a psychiatrist and a specialist
pharmacist should develop and document an individualised
pharmacological strategy for using routine and p.r.n. medication to calm,
relax, tranquillise or sedate service users who are at risk of violence and
aggression as soon as possible after admission to an inpatient
psychiatric unit.

1.2.16 The multidisciplinary team should review the pharmacological strategy

and the use of medication at least once a week and more frequently if
events are escalating and restrictive interventions are being planned or
used. The review should be recorded and include:

• clarification of target symptoms

• the likely timescale for response to medication

• the total daily dose of medication, prescribed and administered, including p.r.n.
medication

• the number of and reason for any missed doses

• therapeutic response

• the emergence of unwanted effects.

If rapid tranquillisation is being used, a senior doctor should review all

medication at least once a day.

1.3 Preventing violence and aggression

Searching

Developing a policy on searching

1.3.1 Health and social care provider organisations should have an operational
policy on the searching of service users, their belongings and the

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environment in which they are accommodated, and the searching of

carers and visitors. The policy should address:

• the reasons for carrying out a search, ensuring that the decision to search is
proportionate to the risks

• the searching of service users detained under the Mental Health Act 1983 who
lack mental capacity

• the rationale for repeated searching of service users, carers or visitors, for
example those who misuse drugs or alcohol

• the legal grounds for, and the methods used when, undertaking a search
without consent, including when the person physically resists searching

• which staff members are allowed to undertake searching and in which contexts

• who and what can be searched, including persons, clothing, possessions and
environments

• the storage, return and disposal of drugs or alcohol

• how to manage any firearms or other weapons carried by service users,

including when to call the police

• links to other related policies such as those on drugs and alcohol, and on police
liaison.

1.3.2 Develop and share a clear and easily understandable summary of the
policy on searching, for use across the organisation for all service users,
carers or visitors who may be searched.

Carrying out searches

1.3.3 Health and social care provider organisations should ensure that
searches are undertaken by 2 members of staff, at least 1 of whom
should be the same sex as the person being searched.

1.3.4 When a decision has been made to undertake a search:

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• provide the person who is to be searched with the summary of the

organisation's policy on searching

• seek consent to undertake the search

• explain what is being done and why throughout the search

• ensure the person's dignity and privacy are respected during the search

• record what was searched, why and how it was searched, and the disposal of
any items found.

1.3.5 If a service user refuses to be searched, carry out a multidisciplinary

review of the need to perform a search using physical force and explore
any consequences in advance. Use physical force only as a last resort.

1.3.6 If consent for a search has not been given, a multidisciplinary review has
been conducted and physical force has been used, conduct an
immediate post-incident debrief (see recommendations 1.4.55 to 1.4.61)
and a formal external post-incident review (see recommendations 1.4.62
and 1.4.63) with the service user that includes a visit from an advocacy
service or hospital manager.

1.3.7 If a service user is carrying a weapon, ask them to place it in a neutral

location rather than handing it over.

1.3.8 If a service user who is at risk of becoming violent or aggressive is in a

room or area where there are objects that could be used as weapons,
remove the objects or relocate the service user.

1.3.9 Audit the exercise of powers of search and report the outcomes to the
trust board or equivalent governing body at least twice a year.

Using p.r.n. medication

1.3.10 When prescribing p.r.n. medication as part of a strategy to de-escalate or
prevent situations that may lead to violence and aggression:

• do not prescribe p.r.n. medication routinely or automatically on admission

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• tailor p.r.n. medication to individual need and include discussion with the
service user if possible

• ensure there is clarity about the rationale and circumstances in which p.r.n.
medication may be used and that these are included in the care plan

• ensure that the maximum daily dose is specified and does not inadvertently
exceed the maximum daily dose stated in the British national formulary (BNF)
when combined with the person's standard dose or their dose for rapid
tranquillisation

• only exceed the BNF maximum daily dose (including p.r.n. dose, the standard
dose and dose for rapid tranquillisation) if this is planned to achieve an agreed
therapeutic goal, documented, and carried out under the direction of a senior
doctor

• ensure that the interval between p.r.n. doses is specified.

1.3.11 The multidisciplinary team should review p.r.n. medication at least once a
week and, if p.r.n. medication is to be continued, the rationale for its
continuation should be included in the review. If p.r.n. medication has not
been used since the last review, consider stopping it.

De-escalation

Staff training

1.3.12 Health and social care provider organisations should give staff training in
de-escalation that enables them to:

• recognise the early signs of agitation, irritation, anger and aggression

• understand the likely causes of aggression or violence, both generally and for
each service user

• use techniques for distraction and calming, and ways to encourage relaxation

• recognise the importance of personal space

• respond to a service user's anger in an appropriate, measured and reasonable

way and avoid provocation.

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General principles

1.3.13 Establish a close working relationship with service users at the earliest
opportunity and sensitively monitor changes in their mood or composure
that may lead to aggression or violence.

1.3.14 Separate agitated service users from others (using quiet areas of the
ward, bedrooms, comfort rooms, gardens or other available spaces) to
aid de-escalation, ensuring that staff do not become isolated.

1.3.15 Use a wide range of verbal and non-verbal skills and interactional
techniques to avoid or manage known 'flashpoint' situations (such as
refusing a service user's request, asking them to stop doing something
they wish to do or asking that they do something they don't wish to do)
without provoking aggression.

1.3.16 Encourage service users to recognise their own triggers and early
warning signs of violence and aggression and other vulnerabilities, and
to discuss and negotiate their wishes should they become agitated.
Include this information in care plans and advance statements and give a
copy to the service user.

1.3.17 Communicate respect for and empathy with the service user at all stages
of de-escalation.

De-escalation techniques

1.3.18 If a service user becomes agitated or angry, 1 staff member should take
the primary role in communicating with them. That staff member should
assess the situation for safety, seek clarification with the service user
and negotiate to resolve the situation in a non-confrontational manner.

1.3.19 Use emotional regulation and self-management techniques to control

verbal and non-verbal expressions of anxiety or frustration (for example,
body posture and eye contact) when carrying out de-escalation.

1.3.20 Use a designated area or room to reduce emotional arousal or agitation

and support the service user to become calm. In services where
seclusion is practised, do not routinely use the seclusion room for this

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purpose because the service user may perceive this as threatening.

1.4 Using restrictive interventions in inpatient

psychiatric settings
Restrictive interventions are most likely to be used in inpatient psychiatric settings, but
may be used in emergency departments, outpatient services and child and adolescent
mental health services (CAMHS).

See implementation: getting started for information about putting the recommendations on
manual restraint, rapid tranquillisation and formal external post-incident reviews into
practice.

Staff training
1.4.1 Health and social care provider organisations should train staff working
in inpatient psychiatric settings to undertake restrictive interventions and
understand the risks involved in their use, including the side-effect
profiles of the medication recommended for rapid tranquillisation in this
guideline, and to communicate these risks to service users.

Staffing and equipment

1.4.2 Health and social care provider organisations should:

• define staff:patient ratios for each inpatient psychiatric ward and the numbers
of staff required to undertake restrictive interventions

• ensure that restrictive interventions are used only if there are sufficient
numbers of trained staff available

• ensure the safety of staff during the use of restrictive interventions, including
techniques to avoid injuries from needles during rapid tranquillisation.

1.4.3 Health and social care provider organisations should ensure that
resuscitation equipment is immediately available if restrictive
interventions might be used and:

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• include an automatic external defibrillator, a bag valve mask, oxygen, cannulas,

intravenous fluids, suction and first-line resuscitation medications

• maintain equipment and check it every week.

1.4.4 Staff trained in immediate life support and a doctor trained to use
resuscitation equipment should be immediately available to attend an
emergency if restrictive interventions might be used.

Using restrictive interventions

1.4.5 Use a restrictive intervention only if de-escalation and other preventive
strategies, including p.r.n. medication, have failed and there is potential
for harm to the service user or other people if no action is taken.
Continue to attempt de-escalation throughout a restrictive intervention.

1.4.6 Do not use restrictive interventions to punish, inflict pain, suffering or

humiliation, or establish dominance.

1.4.7 Ensure that the techniques and methods used to restrict a service user:

• are proportionate to the risk and potential seriousness of harm

• are the least restrictive option to meet the need

• are used for no longer than necessary

• take account of the service user's preferences, if known and it is possible to do

so

• take account of the service user's physical health, degree of frailty and
developmental age.

Observation

General principles

1.4.8 Staff should be aware of the location of all service users for whom they
are responsible, but not all service users need to be kept within sight.

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1.4.9 At least once during each shift a nurse should set aside dedicated time
to assess the mental state of, and engage positively with, the service
user. As part of the assessment, the nurse should evaluate the impact of
the service user's mental state on the risk of violence and aggression,
and record any risk in the notes.

Developing a policy on observation

1.4.10 Health and social care provider organisations should have a policy on
observation and positive engagement that includes:

• definitions of levels of observation in line with recommendation 1.4.11

• who can instigate, increase, decrease and review observation

• when an observer should be male or female

• how often reviews should take place

• how service users' experience of observation will be taken into account

• how to ensure that observation is underpinned by continuous attempts to

engage therapeutically

• the levels of observation necessary during the use of other restrictive

interventions (for example, seclusion)

• the need for multidisciplinary review when observation continues for 1 week or
more.

Levels of observation

1.4.11 Staff in inpatient psychiatric wards (including general adult wards, older
adult wards, psychiatric intensive care units and forensic wards) should
use the following definitions for levels of observation, unless a locally
agreed policy states otherwise.

• Low-level intermittent observation: the baseline level of observation in a

specified psychiatric setting. The frequency of observation is once every 30 to
60 minutes.

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• High-level intermittent observation: usually used if a service user is at risk of

becoming violent or aggressive but does not represent an immediate risk. The
frequency of observation is once every 15 to 30 minutes.

• Continuous observation: usually used when a service user presents an

immediate threat and needs to be kept within eyesight or at arm's length of a
designated one-to-one nurse, with immediate access to other members of
staff if needed.

• Multiprofessional continuous observation: usually used when a service user is

at the highest risk of harming themselves or others and needs to be kept within
eyesight of 2 or 3 staff members and at arm's length of at least 1 staff member.

Using observation

1.4.12 Use observation only after positive engagement with the service user
has failed to dissipate the risk of violence and aggression.

1.4.13 Recognise that service users sometimes find observation provocative,

and that it can lead to feelings of isolation and dehumanisation.

1.4.14 Use the least intrusive level of observation necessary, balancing the
service user's safety, dignity and privacy with the need to maintain the
safety of those around them.

1.4.15 Give the service user information about why they are under observation,
the aims of observation, how long it is likely to last and what needs to be
achieved for it to be stopped. If the service user agrees, tell their carer
about the aims and level of observation.

1.4.16 Record decisions about observation levels in the service user's notes and
clearly specify the reasons for the observation.

1.4.17 When deciding on levels of observation take into account:

• the service user's current mental state

• any prescribed and non-prescribed medications and their effects

• the current assessment of risk

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• the views of the service user, as far as possible.

1.4.18 Record clearly the names and titles of the staff responsible for carrying
out a review of observation levels (see recommendation 1.4.11) and when
the review should take place.

1.4.19 Staff undertaking observation should:

• take an active role in engaging positively with the service user

• be appropriately briefed about the service user's history, background, specific

risk factors and particular needs

• be familiar with the ward, the ward policy for emergency procedures and
potential risks in the environment

• be approachable, listen to the service user and be able to convey to the

service user that they are valued.

1.4.20 Ensure that an individual staff member does not undertake a continuous
period of observation above the general level for longer than 2 hours. If
observation is needed for longer than 2 hours, ensure the staff member
has regular breaks.

1.4.21 When handing over to another staff member during a period of

observation, include the service user in any discussions during the
handover if possible.

1.4.22 Tell the service user's psychiatrist or on-call doctor as soon as possible if
observation above the general level is carried out (see
recommendation 1.4.11).

Manual restraint
1.4.23 Health and social care provider organisations should ensure that manual
restraint is undertaken by staff who work closely together as a team,
understand each other's roles and have a clearly defined lead.

1.4.24 When using manual restraint, avoid taking the service user to the floor,
but if this becomes necessary:

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• use the supine (face up) position if possible or

• if the prone (face down) position is necessary, use it for as short a time as
possible.

1.4.25 Do not use manual restraint in a way that interferes with the service
user's airway, breathing or circulation, for example by applying pressure
to the rib cage, neck or abdomen, or obstructing the mouth or nose.

1.4.26 Do not use manual restraint in a way that interferes with the service
user's ability to communicate, for example by obstructing the eyes, ears
or mouth.

1.4.27 Undertake manual restraint with extra care if the service user is
physically unwell, disabled, pregnant or obese.

1.4.28 Aim to preserve the service user's dignity and safety as far as possible
during manual restraint.

1.4.29 Do not routinely use manual restraint for more than 10 minutes.

1.4.30 Consider rapid tranquillisation or seclusion as alternatives to prolonged

manual restraint (longer than 10 minutes).

1.4.31 Ensure that the level of force applied during manual restraint is
justifiable, appropriate, reasonable, proportionate to the situation and
applied for the shortest time possible.

1.4.32 One staff member should lead throughout the use of manual restraint.
This person should ensure that other staff members are:

• able to protect and support the service user's head and neck, if needed

• able to check that the service user's airway and breathing are not
compromised

• able to monitor vital signs

• supported throughout the process.

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1.4.33 Monitor the service user's physical and psychological health for as long
as clinically necessary after using manual restraint.

Mechanical restraint
1.4.34 Health and social care provider organisations should ensure that
mechanical restraint in adults is used only in high-secure settings (except
when transferring service users between medium- and high-secure
settings as in recommendation 1.4.36) and its use is reported to the trust
board.

1.4.35 Use mechanical restraint only as a last resort and for the purpose of:

• managing extreme violence directed at other people or

• limiting self-injurious behaviour of extremely high frequency or intensity.

1.4.36 Consider mechanical restraint, such as handcuffs, when transferring

service users who are at high risk of violence and aggression between
medium- and high-secure settings. In this context, restraint should be
clearly planned as part of overall risk management.

Rapid tranquillisation
Rapid tranquillisation in this guideline refers to the use of medication by the parenteral
route (usually intramuscular or, exceptionally, intravenous) if oral medication is not
possible or appropriate and urgent sedation with medication is needed.

1.4.37 Use either intramuscular lorazepam on its own or intramuscular

haloperidol combined with intramuscular promethazine for rapid
tranquillisation in adults. When deciding which medication to use, take
into account:

• the service user's preferences or advance statements and decisions

• pre-existing physical health problems or pregnancy

• possible intoxication

• previous response to these medications, including adverse effects

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• potential for interactions with other medications

• the total daily dose of medications prescribed and administered.

1.4.38 If there is insufficient information to guide the choice of medication for

rapid tranquillisation, or the service user has not taken antipsychotic
medication before, use intramuscular lorazepam.

1.4.39 If there is evidence of cardiovascular disease, including a prolonged QT

interval, or no electrocardiogram has been carried out, avoid
intramuscular haloperidol combined with intramuscular promethazine
and use intramuscular lorazepam instead.

1.4.40 If there is a partial response to intramuscular lorazepam, consider a

further dose.

1.4.41 If there is no response to intramuscular lorazepam, consider

intramuscular haloperidol combined with intramuscular promethazine.

1.4.42 If there is a partial response to intramuscular haloperidol combined with

intramuscular promethazine, consider a further dose.

1.4.43 If there is no response to intramuscular haloperidol combined with

intramuscular promethazine, consider intramuscular lorazepam if this
hasn't been used already during this episode. If intramuscular lorazepam
has already been used, arrange an urgent team meeting to carry out a
review and seek a second opinion if needed.

1.4.44 When prescribing medication for use in rapid tranquillisation, write the
initial prescription as a single dose, and do not repeat it until the effect of
the initial dose has been reviewed.

1.4.45 After rapid tranquillisation, monitor side effects and the service user's
pulse, blood pressure, respiratory rate, temperature, level of hydration
and level of consciousness at least every hour until there are no further
concerns about their physical health status. Monitor every 15 minutes if
the BNF maximum dose has been exceeded or the service user:

• appears to be asleep or sedated

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• has taken illicit drugs or alcohol

• has a pre-existing physical health problem

• has experienced any harm as a result of any restrictive intervention.

Seclusion
1.4.46 Use seclusion in adults only if the service user is detained in accordance
with the Mental Health Act 1983. If a service user not detained under the
Mental Health Act 1983 is secluded in an emergency, arrange a mental
health assessment under the Mental Health Act 1983 immediately.

1.4.47 Services that use seclusion should have a designated seclusion room
that:

• allows staff to clearly observe and communicate with the service user

• is well insulated and ventilated, with temperature controls outside the room

• has access to toilet and washing facilities

• has furniture, windows and doors that can withstand damage.

Carrying out seclusion

1.4.48 Record the use of seclusion in accordance with the Mental Health
Act 1983 Code of Practice.

1.4.49 Ensure that seclusion lasts for the shortest time possible. Review the
need for seclusion at least every 2 hours and tell the service user that
these reviews will take place.

1.4.50 Set out an observation schedule for service users in seclusion. Allocate a
suitably trained member of staff to carry out the observation, which
should be within eyesight as a minimum.

1.4.51 Ensure that a service user in seclusion keeps their clothing and, if they
wish, any personal items, including those of personal, religious or cultural
significance, unless doing so compromises their safety or the safety of

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others.

Rapid tranquillisation during seclusion

1.4.52 If rapid tranquillisation is needed while a service user is secluded,
undertake with caution following recommendations 1.4.37 to 1.4.45 and:

• be aware of and prepared to address any complications associated with rapid

tranquillisation

• ensure the service user is observed within eyesight by a trained staff member

• undertake a risk assessment and consider ending the seclusion when rapid
tranquillisation has taken effect.

Post-incident debrief and formal review

In this guideline an incident is defined as any event that involves the use of a restrictive
intervention – restraint, rapid tranquillisation or seclusion (but not observation) – to
manage violence or aggression.

1.4.53 Health and social care provider organisations should ensure that wards
have sufficient staff with a mix of skills and seniority levels that enable
them to:

• conduct an immediate post-incident debrief (see recommendations 1.4.55 to

1.4.61)

• monitor and respond to ongoing risks, and contribute to formal external

post-incident reviews (see recommendations 1.4.62 to 1.4.63).

1.4.54 The trust board or equivalent governing body should ensure that it
receives regular reports from each ward about violent incidents, the use
of restrictive interventions, service users' experience of those
interventions and the learning gained.

Immediate post-incident debrief

1.4.55 After using a restrictive intervention, and when the risks of harm have

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been contained, conduct an immediate post-incident debrief, including a

nurse and a doctor, to identify and address physical harm to service
users or staff, ongoing risks and the emotional impact on service users
and staff, including witnesses.

1.4.56 Use the framework outlined in recommendation 1.2.7 to determine the

factors that contributed to an incident that led to a restrictive
intervention, identify any factors that can be addressed quickly to reduce
the likelihood of a further incident and amend risk and care plans
accordingly.

1.4.57 Advise the service user experience monitoring unit, or equivalent service
user group, to start a formal external post-incident review.

1.4.58 Ensure that the service user involved has the opportunity to discuss the
incident in a supportive environment with a member of staff or an
advocate or carer. Offer the service user the opportunity to write their
perspective of the event in the notes.

1.4.59 Ensure that any other service users who may have seen or heard the
incident are given the opportunity to discuss it so that they can
understand what has happened.

1.4.60 Ensure that all staff involved in the incident have the opportunity to
discuss their experience with staff who were not involved.

1.4.61 Discuss the incident with service users, witnesses and staff involved only
after they have recovered their composure and aim to:

• acknowledge the emotional responses to the incident and assess whether

there is a need for emotional support for any trauma experienced

• promote relaxation and feelings of safety

• support a return to normal patterns of activity

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• ensure that everyone involved in the service user's care, including their carers,
has been informed of the event, if the service user agrees.

Ensure that the necessary documentation has been completed.

Formal external post-incident review

1.4.62 The service user experience monitoring unit or equivalent service user
group should undertake a formal external post-incident review as soon
as possible and no later than 72 hours after the incident. The unit or
group should ensure that the formal external post-incident review:

• is led by a service user and includes staff from outside the ward where the
incident took place, all of whom are trained to undertake investigations that
aim to help staff learn and improve rather than assign blame

• uses the information recorded in the immediate post-incident debrief and the
service user's notes relating to the incident

• includes interviews with staff, the service user involved and any witnesses if
further information is needed

• uses the framework in recommendation 1.2.7 to:

－ evaluate the physical and emotional impact on everyone involved, including

witnesses

－ help service users and staff to identify what led to the incident and what
could have been done differently

－ determine whether alternatives, including less restrictive interventions,

were discussed

－ determine whether service barriers or constraints make it difficult to avoid

the same course of actions in future

－ recommend changes to the service's philosophy, policies, care

environment, treatment approaches, staff education and training, if
appropriate

－ avoid a similar incident happening in future, if possible.

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1.4.63 The service user experience monitoring unit or equivalent service user
group should give a report to the ward that is based on the formal
external post-incident review.

1.5Managing violence and aggression in

emergency departments
For guidance on manual restraint and rapid tranquillisation, which may be used in
emergency departments, see recommendations 1.4.23 to 1.4.33 and
recommendations 1.4.37 to 1.4.45 respectively. Emergency department staff may also be
involved in immediate post-incident debriefs (see recommendations 1.4.55 to 1.4.61).

Liaison mental health

1.5.1 Healthcare provider organisations and commissioners should ensure that
every emergency department has routine and urgent access to a
multidisciplinary liaison team that includes consultant psychiatrists and
registered psychiatric nurses who are able to work with children, young
people, adults and older adults.

1.5.2 Healthcare provider organisations should ensure that a full mental health
assessment is available within 1 hour of alert from the emergency
department at all times.

Staff training
1.5.3 Healthcare provider organisations should train staff in emergency
departments in methods and techniques to reduce the risk of violence
and aggression, including anticipation, prevention and de-escalation.

1.5.4 Healthcare provider organisations should train staff in emergency

departments in mental health triage.

1.5.5 Healthcare provider organisations should train staff in emergency

departments to distinguish between excited delirium states (acute
organic brain syndrome), acute brain injury and excited psychiatric states
(such as mania and other psychoses).

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Staffing
1.5.6 Healthcare provider organisations should ensure that, at all times, there
are sufficient numbers of staff on duty in emergency departments who
have training in the management of violence and aggression in line with
this guideline.

Preventing violence and aggression

1.5.7 Undertake mental health triage for all service users on entry to
emergency departments, alongside physical health triage.

1.5.8 Healthcare provider organisations should ensure that emergency

departments have at least 1 designated interview room for mental health
assessment that:

• is close to or part of the main emergency department receiving area

• is made available for mental health assessments as a priority

• can comfortably seat 6 people

• is fitted with an emergency call system, an outward opening door and a

window for observation

• contains soft furnishings and is well ventilated

• contains no potential weapons.

1.5.9 Staff interviewing a person in the designated interview room should:

• inform a senior member of the emergency nursing staff before starting the
interview

• make sure another staff member is present.

Managing violence and aggression

1.5.10 If a service user with a mental health problem becomes aggressive or
violent, do not exclude them from the emergency department. Manage

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the violence or aggression in line with recommendations 1.4.1 to 1.4.45

and do not use seclusion. Regard the situation as a psychiatric
emergency and refer the service user to mental health services urgently
for a psychiatric assessment within 1 hour.

1.6 Managing violence and aggression in

community and primary care settings
For guidance on manual restraint, which may be used by ambulance staff, see
recommendations 1.4.23 to 1.4.33. Ambulance staff may also be involved in immediate
post-incident debriefs (see recommendations 1.4.55 to 1.4.61).

Developing policies
1.6.1 Health and social care provider organisations, including ambulance
trusts, should ensure that they have up-to-date policies on the
management of violence and aggression in people with mental health
problems, and on lone working, in community and primary care settings,
in line with this guideline.

Staff training
1.6.2 Health and social care provider organisations, including ambulance
trusts, should consider training staff working in community and primary
care settings in methods of avoiding violence, including anticipation,
prevention, de-escalation and breakaway techniques, depending on the
frequency of violence and aggression in each setting and the extent to
which staff move between settings.

1.6.3 Health and social care provider organisations, including ambulance

trusts, should ensure that staff working in community and primary care
settings are able to undertake a risk assessment for violence and
aggression in collaboration with service users known to be at risk and
their carers if possible. The risk assessment should be available for case
supervision and in community teams it should be subject to
multidisciplinary review.

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Managing violence and aggression

1.6.4 After a risk assessment has been carried out, staff working in community
and primary care settings should:

• share the risk assessment with other health and social care services and
partner agencies (including the police and probation service) who may be
involved in the person's care and treatment, and with carers if there are risks to
them

• be aware of professional responsibilities in relation to limits of confidentiality

and the need to share information about risks.

1.6.5 In community settings, carry out Mental Health Act 1983 assessments
with a minimum of 2 people, for example a doctor and a social worker.

1.6.6 Community mental health teams should not use manual restraint in
community settings. In situations of medium risk, staff should consider
using breakaway techniques and de-escalation. In situations of high risk,
staff should remove themselves from the situation and, if there is
immediate risk to life, contact the police.

1.7 Managing violence and aggression in children

and young people

Staff training
1.7.1 Child and adolescent mental health services (CAMHS) should ensure that
staff are trained in the management of violence and aggression using a
training programme designed specifically for staff working with children
and young people. Training programmes should include the use of
psychosocial methods to avoid or minimise restrictive interventions
whenever possible. Staff who might undertake restrictive interventions
should be trained:

• in the use of these interventions in these age groups

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• to adapt the manual restraint techniques for adults in recommendations 1.4.23

to 1.4.33, adjusting them according to the child or young person's height,
weight and physical strength

• in the use of resuscitation equipment (see recommendation 1.4.3) in children

and young people.

1.7.2 CAMHS should have a clear and consistently enforced policy about
managing antisocial behaviour and ensure that staff are trained in
psychosocial and behavioural techniques for managing the behaviour.

1.7.3 CAMHS staff should be familiar with the Children Act 1989 and 2004 and
the Mental Health Act 1983, as well as the Mental Capacity Act 2005 and
the Human Rights Act 1998. They should also be aware of the United
Nations Convention on the Rights of the Child.

Managing violence and aggression

1.7.4 Manage violence and aggression in children and young people in line
with the recommendations for adults in sections 1.1 to 1.6, taking into
account:

• the child or young person's level of physical, intellectual, emotional and

psychological maturity

• the recommendations for children and young people in this section

• that the Mental Capacity Act 2005 applies to young people aged 16 and over.

1.7.5 Collaborate with those who have parental responsibility when managing
violence and aggression in children and young people.

1.7.6 Use safeguarding procedures to ensure the child or young person's

safety.

1.7.7 Involve the child or young person in making decisions about their care
whenever possible.

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Assessment and initial management

1.7.8 Assess and treat any underlying mental health problems in line with
relevant NICE guidelines, including the NICE guidelines on antisocial
behaviour and conduct disorders in children and young people, attention
deficit hyperactivity disorder, psychosis and schizophrenia in children
and young people, autism diagnosis in children and young people and
autism.

1.7.9 Identify any history of aggression or aggression trigger factors, including

experience of abuse or trauma and previous response to management of
violence or aggression.

1.7.10 Identify cognitive, language, communication and cultural factors that may
increase the risk of violence or aggression in a child or young person.

1.7.11 Consider offering children and young people with a history of violence or
aggression psychological help to develop greater self-control and
techniques for self-soothing.

1.7.12 Offer support and age-appropriate interventions (including parent

training programmes) in line with the NICE guideline on antisocial
behaviour and conduct disorders in children and young people to parents
of children and young people whose behaviour is violent or aggressive.

De-escalation

1.7.13 Use de-escalation in line with recommendations 1.3.12 to 1.3.20 for

adults, modified for children and young people, and:

• use calming techniques and distraction

• offer the child or young person the opportunity to move away from the
situation in which the violence or aggression is occurring, for example to a
quiet room or area

• aim to build emotional bridges and maintain a therapeutic relationship.

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Restrictive interventions

1.7.14 Use restrictive interventions only if all attempts to defuse the situation
have failed and the child or young person becomes aggressive or violent.

1.7.15 When restrictive interventions are used, monitor the child or young
person's wellbeing closely and continuously, and ensure their physical
and emotional comfort.

1.7.16 Do not use punishments, such as removing contact with parents or

carers or access to social interaction, withholding nutrition or fluids, or
corporal punishment, to force compliance.

Manual restraint

1.7.17 If possible, allocate a staff member who is the same sex as the child or
young person to carry out manual restraint.

Mechanical restraint

1.7.18 Do not use mechanical restraint in children.

1.7.19 Healthcare provider organisations should ensure that, except when

transferring young people between medium- and high-secure settings
(as in recommendation 1.7.20), mechanical restraint in young people is
used only in high-secure settings (on those occasions when young
people are being treated in adult high-secure settings), in accordance
with the Mental Health Act 1983 and with support and agreement from a
multidisciplinary team that includes a consultant psychiatrist in CAMHS.

1.7.20 Consider using mechanical restraint, such as handcuffs, when

transferring young people who are at high risk of violence or aggression
between medium- and high-secure settings, and remove the restraint at
the earliest opportunity.

Rapid tranquillisation

1.7.21 Use intramuscular lorazepam for rapid tranquillisation in a child or young

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person and adjust the dose according to their age and weight.

In May 2015, lorazepam was off label in children and young people for
this indication.

1.7.22 If there is only a partial response to intramuscular lorazepam, check the

dose again according to the child or young person's age and weight and
consider a further dose.

1.7.23 Monitor physical health and emotional impact continuously when

undertaking rapid tranquillisation in a child or young person.

Seclusion

1.7.24 Decisions about whether to seclude a child or young person should be

approved by a senior doctor and reviewed by a multidisciplinary team at
the earliest opportunity.

1.7.25 Report all uses of seclusion to the trust board or equivalent governing
body.

1.7.26 Do not seclude a child in a locked room, including their own bedroom.

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2 Research recommendations
The Guideline Development Group has made the following recommendations for research,
based on its review of evidence, to improve NICE guidance and patient care in the future.
The Guideline Development Group's full set of research recommendations is detailed in the
full guideline.

2.1 Medication for promoting de-escalation

Which medication is effective in promoting de-escalation in people who are identified as
likely to demonstrate significant violence?

Why this is important

Although there are studies that demonstrate the value of medication in the management
of violence and aggression, there is little information on management before violence
becomes overt. Often p.r.n. medication is given at this point but there is little evidence of
efficacy. It is clearly preferable to avoid violence whenever possible.

This question should be addressed by a randomised controlled trial in which people at risk
of becoming violent are randomised, with their consent, to 1 or more of the medications
commonly used to effect rapid tranquillisation or other medication not normally used for
this purpose. Outcomes should include measures of violence, degree of sedation,
acceptability of the medication and adverse effects, all recorded over a suitable timescale
to match the pharmacokinetic properties of the drugs.

2.2 Violence related to drug or alcohol misuse

What is the best environment in which to contain violence in people who have misused
drugs or alcohol?

Why this is important

There are major problems in managing drug- and alcohol-related violence. The risk of
severe violence can last for many hours in people who have misused drugs and alcohol

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and most settings in which violence takes place (such as emergency departments) do not
have the facilities needed to contain people for several hours with an adequate level of
supervision. As a consequence many people are taken, often inappropriately, to police
cells. It is likely that there are less expensive and more effective environments available for
this purpose.

Data about the size of this problem and an epidemiological survey of its frequency and
duration, as well as current methods of managing drug- and alcohol-related violence, are
needed to start answering this question.

2.3 Advance statements and decisions

What forms of management of violence and aggression do service users prefer and do
advance statements and decisions have an important role in management and prevention?

Why this is important

There are widely differing opinions among service users about the best way of managing
violence and decisions are often made according to personal preference. Advance
statements and decisions are not widely used, although they might have an important role
in management and prevention.

The question could be answered by randomising people who are at risk of becoming
violent or who have demonstrated repeated violence into 2 groups: a control group with no
advance statements and decisions, and a group who make advance statements and
decisions indicating the forms of management they prefer and those they do not want.
The subsequent frequency of violent episodes and their outcomes could then be
compared.

2.4 Content and nature of effective de-escalation

What is the content and nature of effective de-escalatory actions, interactions and
activities used by mental health nurses, including the most effective and efficient means
of training nurses to use them in a timely and appropriate way?

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Why this is important

Although it is regularly recommended, there has been little research on the nature and
efficacy of verbal and non-verbal de-escalation for adults with mental health problems
who become agitated. Research is needed to systematically describe current techniques
for de-escalation and develop and test these techniques with adults who have cognitive
impairment or psychosis. In addition, research should be carried out to develop methods
of training staff and test the outcomes of these methods.

There is a similar lack of research on the nature and efficacy of verbal and non-verbal
de-escalation of seriously agitated children and young people with mental health
problems. These techniques need to take account of and be adapted to the specific
background, developmental/cognitive and psychiatric characteristics of this age group.
Additional research should therefore be commissioned on the lines recommended for
adults. The research should systematically describe expert practice in adults, develop and
test those techniques in aroused children and young people with mental health problems,
and develop and test different methods of training staff working with children and young
people with mental health problems.

2.5 Long duration or very frequent manual

restraint
In what circumstances and how often are long-duration or repeated manual restraint used,
and what alternatives are there that are safer and more effective?

Why this is important

Adults who are agitated and violent sometimes continue to struggle and fight during
manual restraint and rapid tranquillisation may fail. This results in long periods of restraint
and further doses of medication. These occurrences are used as justifications for
seclusion and, very rarely, for the use of mechanical restraint if repeat episodes occur. Yet
there is no information about the frequency of such events or the demography and
symptomatology of the adults who are subject to such measures. Exploratory survey work
should be commissioned as a matter of urgency to assess the scope of this problem and
potential measures for prevention or alternative management that minimise excessive,
severe and risky containment methods.

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The reasons why children and young people with mental health problems need
long-duration or very frequent manual restraint may be expected to vary from those in
adults but have similarly been little investigated. Exploratory survey work should therefore
specifically address the scope of this problem as it affects children and young people and
assess potential measures for prevention or alternative management that minimise any
existing excessive, severe or risky containment methods.

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Implementation: getting started

While developing this guideline, the Guideline Development Group identified 13
recommendations in 6 areas as key priorities for implementation. With input from
stakeholders, experts and health professionals, 3 areas were identified as having a big
impact on practice and being challenging to implement. This section highlights some
important changes to practice that may result from implementing the guideline. However,
other changes to practice may be needed to fully implement the guideline.

Staff working in inpatient mental health and emergency care settings may be particularly
affected by these changes.

Manual restraint
Recommendations 1.4.4 to 1.4.6 and recommendations 1.4.24 and 1.4.29.

Potential impact of implementation

This guideline recommends that taking service users to the floor during manual restraint
should be avoided, but that if it is necessary, the supine (face up) position should be used
in preference to the prone (face down) position. The Winterbourne View Hospital:
Department of Health review and response reported that restraint was being used to
abuse service users. Mind's Mental health crisis care: physical restraint in crisis found that
restrictive interventions were being used for too long, often not as a last resort, and
sometimes purposely to inflict pain, humiliate or punish. Mind also reported that in 2011/12
the prone position was being used, in some trusts as many as 2 to 3 times a day. This
position can, and has, caused death after as little as 10 minutes, by causing a cardiac
event. Consistent implementation of these recommendations will save lives, improve
safety and minimise distress for all involved.

Challenges for implementation

• Higher staffing levels will be needed in some settings to successfully implement these
recommendations, particularly ensuring that a doctor trained to use emergency
equipment is immediately available if manual restraint might be used.

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• Training will be needed in psychosocial interventions to avoid or minimise the use of

restrictive interventions, and about why manual restraint, when used, should last no
longer than 10 minutes.

Support for implementation

• Section 1.2 of this guideline outlines how to reduce the use of restrictive interventions,
including manual restraint, and other methods that can be used to reduce the risk of
violence and aggression. It includes a framework for anticipating and reducing
violence and aggression in inpatient psychiatric wards.

• The Department of Health's Positive and safe programme promotes a reduction in the
use of restrictive interventions. Department of Health's Positive and proactive care:
reducing the need for restrictive interventions and Department of Health, Skills for
Care and Skills for Health's A positive and proactive workforce provide a framework to
help staff working in health and social care settings to change their culture, leadership
and professional practice to deliver care and support that keeps people safe and
promotes recovery.

• The Mental Health Act 1983 Code of Practice provides guidance for professionals as
well as guidance about for service users, their families and carers about their rights.

Return to recommendations

Rapid tranquillisation
Recommendations 1.4.37 to 1.4.45

Potential impact of implementation

Rapid tranquillisation is defined in this guideline as the administration of sedative
medication by injection, and although a number of effective agents are available for
sedation, there is no evidence showing clear superiority for any one agent. Therefore
individualised treatment needs to be emphasised, taking into account the service user's
view, pre-existing physical health problems, previous response to medications including
adverse effects, the potential for interactions with other medications, and the total daily
dose of medications prescribed and administered. Intramuscular lorazepam is
recommended for service users who have not taken antipsychotic medication before

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because it is an effective intervention that is likely to be acceptable to the majority of

service users. Prescribing the initial dose of rapid tranquillisation as a single dose will
ensure that any subsequent treatment options can be individualised, taking account of
both response and any emergent adverse effects of the initial treatment choice.

Challenges for implementation

• During development of the guideline it became known that the manufacturer of
intramuscular olanzapine had decided to withdraw the product from the UK market,
and so the Guideline Development Group would not be able to make recommendations
for its use. However, it remains a licensed product in the European Union (EU) and
some organisations import the product from elsewhere in the EU.

• Local rapid tranquillisation policies and protocols will need revision and healthcare
professionals will need educating in how these differ from previous versions. It may
also be necessary to emphasise the need to tailor the choice of medication for rapid
tranquillisation to the individual. Where rapid tranquillisation is used, adequate
numbers of skilled staff should be available to monitor the outcome of the intervention
in order to make an individualised decision about subsequent choice of medication
and dose frequency.

Support for implementation

• The rationale for the recommendations is described in section 6.5.1 of the full
guideline.

• The cost difference between medication options is not large and the most
cost-effective strategy is likely to be one that tailors treatment to the individual, taking
into account their preferences, current medication and medication history.

• The use of intramuscular lorazepam for service users who have not taken
antipsychotic medication before is supported because of its favourable benefit:harm
profile.

• Although it is possible to import intramuscular olanzapine into the UK as an

EU-licensed product, the Guideline Development Group was unable to comment on
the use of this preparation because the manufacturer had withdrawn it from the UK
market.

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• These recommendations do not preclude the use of alternative treatment options.

However, their use should be tailored to the individual in line with the
recommendations for rapid tranquillisation.

• The summary of product characteristics for haloperidol recommends a baseline

electrocardiogram (ECG). If an ECG is not available the prescriber should consider the
risks and benefits of using this treatment and be able to justify their prescribing
decision, because it may be considered an off-label use.

Return to recommendations

Formal external post-incident reviews

Recommendations 1.4.53 to 1.4.63

Potential impact of implementation

Formal external post-incident reviews are an important aid in identifying the causes and
effects of violence if restraint is needed to contain a situation, and the impact of this on all
involved. Full recording of incidents of violence and aggression is currently variable and
therefore it is difficult to get a clear picture nationally. Mind's Mental health crisis care:
physical restraint in crisis reported responses from freedom of information requests made
to all 54 mental health trusts in England in 2013 about the use of prone restraint. Of these,
27 trusts did not record this information.

The information gathered during a review can inform future service delivery and, on an
individual level, any further work with the service user involved to make it less likely that a
similar event will happen again. Use of formal external post-incident reviews could lead to
safety improvements for staff and service users, and save costs to the service long-term
if, as a result of the review, positive changes are made to avoid such situations in the
future.

Challenges for implementation

• In organisations where formal external post-incident reviews are not carried out
routinely, new policies and processes will need to be developed; staff will need to be
trained to carry out the reviews and service users will need to be supported to take
part in this process.

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• Additional training and guidance will be needed about when and how to approach
service users to include them in the process in ways that meet their needs.

• Getting all of the necessary staff, including a doctor, in addition to volunteers and
service users to participate in the review process may have an impact on current
workload and service capacity.

• In some settings there can be many incidents in a short time. In such circumstances
implementing the 72-hour follow-up may be more challenging.

Support for implementation

• The framework outlined in recommendation 1.2.7 can be used to determine the factors
that contributed to an incident that involved using a restrictive intervention.

• No economic evidence was found on post-incident management strategies. Clear

costs are incurred when considering the staff time needed to deliver comprehensive
post-incident reviews. These costs may be recouped by the potential for improved
relationships and better understanding of events, allowing safer and more adaptive
practice in the future.

Return to recommendations

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Finding more information and committee

details
You can see everything NICE says on this topic in the NICE Pathway on violence and
aggression.

To find NICE guidance on related topics, including guidance in development, see the NICE
webpage on mental health services.

For full details of the evidence and the guideline committee's discussions, see the full
guideline. You can also find information about how the guideline was developed, including
details of the committee.

NICE has produced tools and resources to help you put this guideline into practice. For
general help and advice on putting our guidelines into practice, see resources to help you
put NICE guidance into practice.

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Update information
This guideline updates and replaces NICE guideline CG25 (published February 2005).

ISBN: 978-1-4731-1234-6

Accreditation

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