Standard 5: Comprehensive Care

Predicting, preventing and managing aggression and violence

Action 5.33

The health service organisation has processes to identify and mitigate situations that may precipitate aggression

Intent

The risk of aggression and violence is minimised by reducing environmental or procedural triggers for aggression.

Reflective questions

What processes are in place to ensure that the workforce can identify situations that may precipitate aggression?

What processes are used to mitigate these situations?

What features of the environment are used to minimise sources of potential conflict?

Key tasks

  • Identify factors in the environment that could trigger aggression or complicate management of aggression when it occurs.

  • Identify elements of the organisation’s procedures that could contribute to stress, which may lead to aggression.

  • Implement strategies to lessen stresses caused by environmental or procedural factors.

Strategies for improvement

Hospitals

Aggression and violence are predictable in healthcare settings, and health service organisations need to implement strategies to reduce the risk of aggression occurring, and reduce the risk of harm when it does occur. This action relates to steps that an organisation can take to modify environmental or procedural factors that can contribute to the risk of aggression.

It links to Action 1.29, which addresses designing healthcare environments to maximise safety. It also links to Action 5.34, which addresses strategies to reduce the risk of aggression in individual patients.

Healthcare environments can be stressful places. People are dealing with uncomfortable experiences, including pain and uncertainty, in environments that are both unfamiliar and high stimulus. People also experience frustration with processes that may be routine for members of the healthcare workforce, but are new and not always comprehensible from the perspective of the patient or carer. For some people, these contextual factors can lead to feelings of aggression.

Although the design of healthcare environments can contribute to reducing aggression, it is not always possible to change the ‘bricks and mortar’ in the short term.

Use the given environment in ways that reduce the risk of aggression, such as:

  • Allowing people to move around, preferably with access to outside areas
  • Reducing stimulus such as bright lights or loud noises
  • Providing privacy using curtains or side lounges.

Sensory modulation spaces and resources help people to manage their own distressing feelings and regain control without restrictive interventions or aggressive outcomes.

The Safewards intervention is a specialist concept, designed for use in mental health inpatient units. The model acknowledges the settings and processes through which mental health inpatient services are inherently stressful. It guides members of the workforce to recognise potential sources of conflict or ‘flashpoints’, and implement a range of strategies to contain risks.

Day Procedure Services

Many of the factors that can precipitate aggression within health services are not relevant in day procedure services, because people are typically admitted for only a few hours, and may be sedated for much of this time. Admission is also typically voluntary, and interactions with others are minimal.

Some people experience a period of confusion after anaesthesia. In rare instances, they may behave aggressively while in this agitated state. Members of the workforce should be trained in recognising the signs of postoperative delirium, and implement environmental and supportive measures to prevent the onset of delirium and shorten its duration (see Action 5.29).

Refer to the hospital tab for detailed implementation strategies and examples of evidence for this action.

MPS & Small Hospitals

Aggression and violence are predictable in healthcare settings, and health service organisations need to implement strategies to reduce the risk of aggression occurring, and reduce the risk of harm when it does occur. This action relates to steps that an organisation can take to modify environmental or procedural factors that can contribute to the risk of aggression. It links to Action 1.29 which addresses designing healthcare environments to maximise safety. It also links to Action 5.34, which addresses strategies to reduce the risk of aggression in individual patients.

Healthcare environments can be stressful places. People are dealing with uncomfortable experiences, including pain and uncertainty, in environments that are both unfamiliar and high stimulus. People also experience frustration with processes that may be routine for members of the healthcare workforce, but are new and not always comprehensible from the perspective of the patient or carer. For some people, these contextual factors can lead to feelings of aggression.

Although the design of healthcare environments can contribute to reducing aggression, it is not always possible to change the ‘bricks and mortar’ in the short term. Use the given environment in ways that reduce the risk of aggression, such as:

  • Allowing people to move around, preferably with access to outside areas
  • Reducing stimulus such as bright lights or loud noises
  • Providing privacy using curtains or side lounges
  • Implementing sensory modulation strategies.

Action 5.34

The health service organisation has processes to support collaboration with patients, carers and families to:

a. Identify patients at risk of becoming aggressive or violent

b. Implement de-escalation strategies

c. Safely manage aggression, and minimise harm to patients, carers, families and the workforce

Intent

Collaborative processes are used to minimise the risk of aggression and violence, and incidents are managed safely when they occur.

Reflective questions

What processes are in place to ensure that the workforce can work collaboratively to identify patients at risk of becoming aggressive or violent?

What strategies are used to support patients at risk of becoming aggressive or violent to control their behaviour?

How does the health service organisation minimise harm to patients, carers, families and the workforce from patients who are aggressive or violent?

Key tasks

  • Train the workforce to effectively screen for specific risks.

  • Implement processes that support members of the workforce to use strategies to reduce the risk of violence.

  • Implement processes to respond to aggression and violence when they occur, to minimise the risk of harm to people.

Strategies for improvement

Hospitals

Screening for risk of aggression and violence is an important and complex undertaking for members of the healthcare workforce. Because it is predictable that violence will occur in healthcare settings, ensure that the health service organisation has effective risk assessment and risk management processes in place. The National Institute for Clinical Excellence guidelines recommend the use of standardised tools to augment clinical judgement.1

Predictive factors for risk of aggression include:

  • Previous history of aggression or violence
  • Intoxication or withdrawal from licit or illicit substances
  • Acute brain injury
  • Cognitive impairment.

Ensure that the use of screening tools and risk management processes does not lead to stigmatising practices, which have been associated with suboptimal healthcare delivery. In particular, ensure that people with mental illness are not automatically assessed as presenting high risk for aggression, and, conversely, that people without mental illness are categorised as low risk. Risk assessment needs to be a dynamic process, based on evidence, rather than assigning a person to a category and proceeding.

There will be times when a person who has not been screened as presenting a risk of violence becomes aggressive. Be alert to changes in a person’s behaviour, cognitive function, perception, physical function or emotional state that may indicate deterioration in their mental state and lead to aggression. This action aligns with the Recognising and Responding to Acute Deterioration Standard. The National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state2 outlines the processes to effectively manage these situations.

Train the workforce in the use of de-escalation strategies, which are demonstrated to reduce the likelihood of verbal aggression progressing to physical violence.3 De-escalation strategies are appropriate for patients with severe behavioural disturbance relating to delirium or dementia, when sedation should be avoided unless they are at risk of harm to themselves or others. Ensure that policies relating to preventing and responding to aggression include specific guidance on sedation that is age appropriate.

Principles for Safe Management of Disturbed and/or Aggressive Behaviour and the Use of Restraint4 contains valuable information about aggressive patient behaviour.

Day Procedure Services

There is low prevalence of violence in day procedure services. Day procedure services should use screening processes to identify patients at risk of becoming aggressive or violent.

Pre-admission screening can identify if there is a potential risk for someone to become confused or agitated when admitted for a brief procedure (for example, someone with dementia). Mitigating strategies begin with collecting clear and comprehensive information about triggers for the individual, and optimal management strategies. If a risk is identified, a management strategy can be formulated before admission. This typically consists of arranging for a family member or carer known to the person to accompany them.

Members of the workforce can communicate in a specific way to assist the person. Appropriate and safe use of medicine can help when conducting procedures on people who may become agitated.

Refer to the hospitals tab for detailed implementation strategies and examples of evidence for this action.

MPS & Small Hospitals

Screening for risk of aggression and violence is an important and complex task for members of the healthcare workforce. Because it is predictable that violence will occur in healthcare settings, ensure that the health service organisation has effective risk assessment and risk management processes in place. The National Institute for Health and Care Excellence guidelines recommend the use of standardised tools to augment clinical judgement.1

Predictive factors for risk of aggression include:

  • Previous history of aggression or violence
  • Intoxication or withdrawal from licit or illicit substances
  • Acute brain injury
  • Cognitive impairment.

Ensure that the use of screening tools and risk management processes do not lead to stigmatising practices, which have been associated with suboptimal healthcare delivery. In particular, ensure that people with mental illness are not automatically assessed as presenting high risk for aggression, and, conversely, that people without mental illness are categorised as low risk. Risk assessment needs to be a dynamic process, based on evidence, rather than assigning a person to a category and proceeding.

There will be times when a person who has not been screened as presenting a risk of violence becomes aggressive. Be alert to changes in a person’s behaviour, cognitive function, perception, physical function or emotional state that may indicate deterioration in their mental state and lead to aggression. This action aligns with the Recognising and Responding to Acute Deterioration Standard. The National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state2 outlines the processes to effectively manage these situations.

Train the workforce in the use of de-escalation strategies, which are demonstrated to reduce the likelihood of verbal aggression progressing to physical violence.3 De-escalation strategies are appropriate for patients with severe behavioural disturbance relating to delirium or dementia, when sedation should be avoided unless they are at risk of harm to themselves or others. Ensure that policies relating to preventing and responding to aggression include specific guidance on sedation that is age appropriate.

Dealing with aggression and violence has specific workplace health and safety implications for MPSs and small hospitals because of the reduced workforce available to deal with incidents compared with large organisations. Small hospitals can work with local police services to respond to incidents of aggression.

Principles for Safe Management of Disturbed and/or Aggressive Behaviour and the Use of Restraint4 contains valuable information about aggressive patient behaviour.

Last updated 5th July, 2018 at 11:28pm
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References

National Institute for Clinical Excellence (UK). Violence and aggression: short-term management in mental health. London: NICE; 2015.

Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to deterioration in a person’s mental state. Sydney: ACSQHC; 2017.

Price O, Baker J. Key components of de-escalation techniques: a thematic synthesis. Int J Ment Health Nurs 2012;21(4):310–9.

NSW Ministry of Health. Principles for safe management of disturbed and/or aggressive behaviour and the use of restraint. Policy directive PD2015_004. Sydney: NSW Ministry of Health; 2015.