ABMU HB Mental Health Directorate Caswell Clinic PROTOCOL FOR THE MANAGEMENT OF VIOLENCE Authors Task and Finish Group Date Approval Process 1. Completion/review 2. Caswell Risk Management group 3. Quality and Safety Group May 2010 May 2010 March 2014 1
PROTOCOL FOR THE MANAGEMENT OF VIOLENCE INTRODUCTION This protocol is intended to provide a philosophy of care and operational guidance on the management of violent behaviour from patients in Caswell Clinic. This protocol should be read in conjunction with the ABMU Health Board policy on Violence and Aggression Towards Staff. This protocol is additional to that policy and does not replace it. Where the Violence and Aggression Towards Staff policy is in conflict with this protocol, the policy takes precedence. Violent behaviour is a known risk amongst many patients detained in secure mental health settings. Violence risk assessment and risk management planning is a cornerstone of the work we undertake in rehabilitating offender patients. The risk of violence occurring within the inpatient setting is unlikely ever to be zero. However: Violence is not inevitable and it is never acceptable. It is a fact that patients admitted to Caswell Clinic are more likely than the general population, to have committed acts of violence from minor to serious, including homicide. In considering this it is perhaps surprising that assaults within the Clinic do not occur more often and with higher impact than they do. Despite this it is essential that we have an agreed service response to violence, from prevention through to resolution. This document sets out the service response to inpatient violence, with a particular emphasis on the needs of staff who have been or who may be at risk of being subjected to patient violence. Other policies and procedures exist to protect patients from abuse by other patients or from staff. All of these policies and procedures overlap and should be read and understood as a single overarching approach to risk and vulnerability that emphasise patient and staff safety and dignity. In all cases, Clinical Teams retain responsibility for the appropriate assessment and management of patients risks. 2
DEFINITION OF VIOLENCE The definition of interpersonal violence we use in this document is drawn from the HCR 20 v3 (2013), the main violence risk assessment tool used in Caswell Clinic: Violence is actual, attempted or threatened infliction of bodily harm to another person Bodily harm includes both physical and serious psychological harm, so long as it substantially interferes with the heatlh or well-being of an individual Psychological harm includes fear of physical injury, and other emotional, mental or cognitive consequences of the act in question. ABMU Health Board policy on Violence and Aggression Towards Staff sets out the range of circumstances in which an act of violence can be considered to fall within the remit of the policy: the term violence and aggression covers a wide range of incidents...not all of those incidents will result in physical injury. Violent incidents can occur in the delivery of everyday patient care, and can involve all staff who work within the [Health Board] 1. Violence can originate from relatives or members of the general public and may occur within and outside [Health Board] premises. (ABMU Health Board Policy) Aggression is generally considered to be synonymous with violence, the definition of aggression is sometimes given as behaviour intended to cause pain or harm. Aggression is also defined as a disposition to act aggressively. It may be considered to be predatory or combative behaviour that could be expressed directly as violence or indirectly as emotional or psychologically coercive or forceful behaviour. In distinguishing between violence and aggression, we might consider that aggression represents the psychological or emotional state of an individual who is poised to act violently, or in a predatory or combative way, or whose demeanour suggests violence proneness. Bullying or intimidation might be considered forms of aggression. 1 ABMU HEALTH BOARD, formerly ABM NHS Trust 3
This protocol refers to violence throughout. The management of bullying, predatory or intimidatory behaviour that does not involve direct physical harm or attempted harm can be dealt with using this protocol. The guiding principle for managing all incidents of violent or aggressive behaviour is the application of proportionate, timely and appropriate interventions that minimise the risk of harm, maximise the opportunities to engage the assailant in more effective social problem solving, and respect the needs of victims. MANAGEMENT OF VIOLENCE TOWARDS STAFF The Caswell Clinic approach to the management of violence risk can be considered under five headings: Prediction, Prevention, Preparation, Protection, and repair ( the five P s ). Prediction Caswell Clinic places emphasis on identifying factors leading to the accurate prediction of violence. To achieve this, the Clinic provides: 1. Training to Registered Nurses in pre-admission assessments so that the potential for violence is identified care planned for, in advance of admission. 2. Care and treatment planning under the Mental Health (Wales) Measure (2010) for all inpatients that includes violence risk assessment and violence risk management plans. 3. Training for multidisciplinary staff in the routine use of HCR20 and other evidence based violence risk assessments to accurately predict patients risk of future violence, identify risk scenarios and develop risk management plans. 4. Training for staff in the identification of relapse indicators and contingency planning so that a patient s relapse signature (and any increased risks to self or others) is flagged at an early stage and interventions made to manage the period of illness and return the patient to wellness. 5. Regular supervision and continuing professional development for staff. Prevention Caswell Clinic has an obligation to care for patients, protect the public and have respect for justice. Providing an environment that is 4
safe for staff and patients is part that obligation. To achieve this, the organisation provides: 1. A staff to patient ratio that is higher than most general psychiatric services. 2. A suitable mix of male and female nursing staff. 3. Training of staff in the management of violence and aggression. 4. Training and Development of those staff (Health Care Assistants) statistically most likely to experience patient violence. 5. A purpose built environment designed to minimise the opportunity and likelihood of violence occurring. 6. Policies and procedures designed to enhance safety and dignity. 7. A culture that supports patients to positively influence their environment and their treatment without the use of violence or aggression, through advocacy, empowerment and joint working with staff. 8. Therapeutic interventions to help patients reduce their propensity for violence. 9. Violence risk management plans and victim safety plans included in the patients care and treatment plan. Victim safety planning can include plans for managing known or anticipated risks that a patient may pose to staff. Where a patient has made threats of violence against a particular member(s) of staff, the clinical team and ward manager will develop a plan for maintaining the safety of the member(s) of staff. This can include transferring the patient or the staff member(s) to a different location. Where possible, therapeutic interventions will be offered the patient to help them understand and manage their thoughts, feelings and behaviour in order to avoid violence risk. Staff will not be used to test the patient s risk, such exposure may be considered as provoking violence and not taking account of victim safety. However, good risk management entails the least restrictive and most therapeutically appropriate intervention necessary, and any decisions taken to manage risk must be in 5
proportion to the judged likelihood, immediacy and severity of any potential violent act. Preparation The Caswell Clinic will always endeavour to maintain a positive, therapeutic environment for the patient, and minimise the likelihood of causing harm and emotional distress to the patient through institutionalisation. Nevertheless, there are some necessary and unavoidable situations that may increase the risk of a patient becoming violent. These situations need to be anticipated and managed to minimise the risk of violence. Such situations could include the compulsory administration of medication, conveyance to or from court or prison, transfer between hospitals or wards, delivering bad news and so on. Where it could become necessary to manage these types of situations using physical restraint Caswell Clinic provides a tiered response: 1. Gather sufficient staff with sufficient skills and training in management of violence and aggression. 2. Plan in advance how controlled and proportionate force will be deployed to control the situation 3. Explain the intervention to the patient and seek their cooperation and concordance at all stages, speaking to the patient with a calm, reassuring tone and establishing their understanding of what is happening and any wishes they may have that will help them to cope with the situation. Where possible, take account of contingency plans that may be in the care and treatment plan, and other strategies that the patient has found helpful in the past. 4. If, after careful communication, the patient is not able to cooperate or physically resists the intervention, deploy staff using restrictive physical intervention strategies to enable the intervention to be carried out as quickly and effectively as possible. 5. Maintain the deployed staff until the restrictive physical intervention is complete and risk has reduced/returned to a manageable level. 6. Continue to offer support and reassurance to the patient for as long as they demonstrate a need for it. The patient may need further counselling or debriefing about the intervention, 6
and where possible, the patient should be encouraged to think about a contingency plan to manage similar situations in the future without need for restrictive physical intervention. Protection Caswell Clinic has a number of responses available for patients in crisis or when the likelihood of violence is thought to be increased which will protect patients and staff: 1. A Psychiatric Intensive Care Unit for treating those patients who may be at imminent risk of being violent. 2. Policies and procedures for the use of patient observations and lone working. 3. Policies and procedures for the management of specific situations that could increase the risk of a patient being violent such as the compulsory administration of medication without patient consent, and the transfer of patients into or out of the Clinic or between wards without their consent. 4. Policies and procedures for the management of patients acting violently such as the use of seclusion, restrictive physical intervention, and rapid tranquilisation. When a violent incident occurs, the Caswell Clinic provides a tiered response: 1. Break-away and stay away Whenever possible, a staff member who is subjected to violence should pull away from the assailant and keep a safe distance from the assailant. 2. Raise the alarm The victim or an observer can trigger a wall-mounted alarm. Staff in the PICU can activate the personal alarms that they routinely carry. 3. Responding to alarms There will be designated staff on every shift on each ward who are expected to respond immediately to an activated 7
alarm. The numbers and skill mix of designated staff will be sufficient to contain most violent incidents. 4. De-escalation Where appropriate, the first response to a violent incident will be an attempt to deescalate the situation using support and reassurance. Where a patient does not respond to deescalation techniques, a designated team of specially trained staff will be deployed to use restrictive physical interventions to re-assume control and contain risk. Restrictive physical intervention must not be applied in the absence of a trained RPI team, except in the most extreme and life threatening circumstances. The use of controlled and proportionate physical force to contain and impede violence necessarily involves staff being in close physical contact with the patient, and in these situations staff injury can occur either accidentally due to the patient struggling, or due to patient making a deliberate assault. To minimise the risk of injury to staff and the patient during restrictive physical intervention, the policy for the use of restrictive physical intervention must always be adhered to. Repair When a patient commits an act of violence, and in particular where a patient assaults a member of staff or another patient, the victim and the clinical team have a number of options available to them. 1. Pursuing a complaint to the police The Violence and Aggression Towards Staff Policy will be followed in all instances, including reporting incidents to the police. Staff will be made aware of the Violence and Aggression Towards Staff Policy through the Clinic induction course and violence and aggression training. Staff will also be directed to the policy if they have been a victim of violence within the Clinic. However, we must recognise that court diversion schemes exist to divert mentally disordered offenders away from courts and into care and treatment from the health and social care sectors. It is therefore expected that the same considerations will apply to patients who are violent and staff victims as would apply to 8
mentally disordered offenders and their victims in the community. In some instances, therefore, it may not be realistic to expect a prosecution to occur. 2. Victim impact discussion Caswell Clinic will ensure that staff who are victims of violence or near miss situations are offered the opportunity to discuss the personal and professional impact on them of the incident by their line manager who will record the discussion in the staff members personal file. As complete an account of the incident as possible should be made available to Clinical Teams and this should inform future risk management planning. Reports to clinical teams should refer to the victim using initials only, and care should be taken to preserve the privacy and dignity of the victim and not include information about them that should remain confidential. The Health Board provides an occupational health service that includes access to counsellors who staff can contact independently should the need arise. A decision about who should conduct the victim impact discussion will be made in collaboration with the victim, but the ward manager / line manager will ensure that the offer is made. 3. Review of placement A patient who commits an act of violence will have the suitability of their placement within the clinic reviewed and if necessary they will be transferred to a more suitable location. 4. Treatment review Risk assessments, risk management, and victim safety plans will be reviewed and updated to take account of lessons learnt from any violent incidents. Current treatment plans will be reviewed to consider changes that might reduce the risk of violence in future. 9
5. Restoration and reparation Where appropriate, the patient will be supported by the clinical team to take steps to make reparation for harm or damage caused and / or to repair relationships with staff and other patients. This may involve an apology to the victim(s), or payment towards the cost of repairs to damaged property. MANAGING THE CONSEQUENCES OF VIOLENCE Violence carries consequences for both victim and assailant. Violence can cause physical and psychological harm to both parties. The management of violence must therefore take into account the physical and psychological consequences for both victims and assailants. Possible consequences for a violent assailant The actions necessary to reduce the risk of violence and its consequences can be experienced by the patient as punishing, frightening or traumatic. This is particularly true for restrictive physical interventions, but can also be caused by other restrictions to the patients liberty. To minimise the risk of causing additional distress to the patient, all interventions to contain and manage violence will be the least restrictive possible and will involve the most appropriate balance of physical, procedural and relational security. The experience of being violent can, in itself, be experienced as frightening and traumatic by the assailant. There are complex psychological and emotional factors involved in violence, and there is often a close link between violence and negative feelings about the self, anxiety, fearfulness and memories of past trauma and abuse. At the same time, successful rehabilitation requires individuals to be responsible for their own actions and choices. Patients who exhibit violent behaviour will always be treated respectfully and with compassion. The clinical team will take steps to help the patient understand and manage their risk of violence, including the causes and meaning of violent behaviour and will help the patient to develop skills to manage their behaviour and feelings and understand the impact of their actions on other people. 10
The patient will always be offered support, empathy and reassurance in the aftermath of a violent incident whilst also being helped to take responsibility for their actions. Possible consequences for the victim of violence Victims of violence may experience a wide array of emotional and psychological responses that can be short lived or longer lasting. The Caswell Clinic has policies and procedures that aim to promote resilience, reflective practice and mutual support amongst staff. Managerial support for victims of violence will be in line with ABMU Health Board policies. In addition, line managers will endeavour to make reasonable adjustments to staffs working arrangements in order to minimise risk of future victimisation and to promote the resolution of any adverse consequences. Where necessary, the assistance and advice of the Human Resources department and Occupational Health department will be sought. Line managers will assist staff who are subjected to violence or abuse from patients to be aware of their rights and responsibilities. The Caswell Clinic will maintain a no blame culture, but will endeavour to learn lessons and improve practice in the aftermath of violent incidents. Reporting violent incidents All violent incidents will be recorded in the patients health care records accurately and as close to the time of the incident as possible. Incident reports will also be completed as per ABMU Health Board policy. Violent incidents will be accurately recorded in reports prepared for Mental Health Review Tribunals Violent incidents will be recorded in reports to the Ministry of Justice in a timely fashion. These reports are used by the Ministry of Justice to inform their decisions about Community Leave, transfer and discharge for patients subject to restrictions under the Mental Health Act (1983, as amended 2007). The Ministry of Justice must be in possession of all relevant facts related to the patients progress and risk in order to make appropriate and informed decisions. 11
Violent incidents will be accurately recorded in Clinical Team Meeting minutes and care and treatment plan review nursing reports. Other disciplines may also need to describe and comment on violent incidents as appropriate. Victim Disclosure Staff and patients who are subjected to violence are entitled to information about what has been or will be done as a result of their experience, including organisational responses. This does not extend to confidential information about patients and their care where such information is not relevant to the actions taken and lessons learned as a result of the incident. Legal Advice and Compensation Victims of violence may, in some circumstances, be entitled to seek compensation or may wish to commission the services of a solicitor to advise them. The ABMU Health Board policy on Violence and Aggression Towards Staff contains some advice on rights and entitlements. It should be noted that the Criminal Injuries Compensation Authority can make awards in cases where mentally disordered offenders are not prosecuted: It is not necessary for the assailant to have been convicted of a criminal offence in connection with the injury. Moreover, even where the injury is attributable to conduct within paragraph 8 in respect of which the assailant cannot be convicted of an offence by reason of age, insanity or diplomatic immunity, the conduct may nevertheless be treated as constituting a criminal act. (Paragraph 10, THE CRIMINAL INJURIES COMPENSATION SCHEME (2008)) ABMU Health Board cannot advise staff on when or how to seek legal advice, but, in line with ABMU Health Board policies, the Caswell Clinic will fully cooperate with any formal complaints or Freedom of Information Act requests. Making a Complaint to the Police The Caswell Clinic will follow ABMU Health Board policy in regards to making complaints to the police and assisting the police in their inquiries into violent incidents. Staff who are subjected to violence may decide to make a complaint to the police independently, or the patients clinical team may decide to report an incident to the police. 12
Where a staff member wishes to report a violent incident to the police on their own behalf, the clinical team will support the member of staff and provide appropriate assistance to the police. Where a clinical team wish to make a complaint to the police they will as far as possible take into account the views of the victim. However, if a serious violent incident has occurred and the victim does not wish to have a complaint to the police made, the clinical team will make a decision that takes account of the balance between public protection, respect for justice, duty of care to the patient and duty of care to the victim. If a complaint is made to the police in opposition to the wishes of the victim, the victims line manager will ensure the victim is offered support as appropriate. A complaint to the police and subsequent investigations or criminal charges may increase the risk of further violence or aggression towards a victim. There may be other less obvious risks such as querulous allegations between the parties concerned, or a compromised therapeutic relationship. Where the situation cannot be resolved through other management strategies, consideration should be given to relocating one or other of the parties by transferring them to different care environments. Similar action should be considered if the police offer an opinion that maintaining both parties in the same environment could contaminate a criminal investigation. These considerations apply as much in the case of staff victims as they do to patient victims FINAL REMARKS Human violence is complex, ambiguous and ultimately, tragic. It is essentially interpersonal and relational. It involves legal, social, psychiatric and moral dimensions. Violence can never be understood from a single vantage point, and is seldom an entirely individual affair. Violence that occurs in an institution occurs against a background of unequal distributions of power and authority. The overall culture of the Caswell Clinic will therefore be a factor in the level of violence generally in the Clinic, and may affect the individual violence risk of many of our patients. It is therefore vital that we maintain a positive therapeutic culture for patients, and a supportive and conducive working environment for staff. Reflective practice, supervision and healthcare governance are the cornerstones of the Clinics culture and all disciplines are expected to contribute to these activities. 13
Violence can inhibit the capacity for thoughtful endeavour and can provoke the desire to punish. In managing patients risk of violence whilst paying due regard to the safety of victims and potential victims, Caswell Clinic will always strive to maintain compassionate, respectful and supportive relationships with assailants and victims, and will always try to understand as well as manage violence risk. 14