At what phase of the assault cycle are we most likely to successfully intervene?

For inpatient settings, based on evidence from studies of observation techniques used to pre-empt or prevent violent and aggressive behaviour, there is insufficient evidence to reach a conclusion about the impact that observation techniques have directly on violence and aggression. However, there was some evidence that levels of observation could in some circumstances be reduced without an increase in violence and aggression. Regarding service user and staff experience, it is perhaps not surprising that service users preferred to be observed by a nurse that they knew and that most staff found observation a stressful procedure.

For all settings, based on evidence from studies of modifications to the environment in the inpatient setting, there is insufficient evidence to reach a conclusion about the impact that modifications have directly on violence and aggression. However, environmental features are likely to impact on the need for seclusion and can have a positive impact on service user experience.

For all settings, based on evidence from studies of management strategies/training programmes in inpatient and emergency department settings, there is insufficient evidence to reach a conclusion about the impact that they have directly on violence and aggression. Nevertheless, such strategies may reduce the rates and duration of restrictive interventions without increasing the rate of violence and aggression. In addition, staff training is likely to improve staff confidence, knowledge and attitudes. The GDG agreed that although specific strategies and training programmes could not be recommended, a variety of principles would help improve practice by reducing the use of restrictive interventions. In addition, it was also felt that although there was a paucity of evidence, good practice necessitated recommendations about de-escalation and about using p.r.n. medication as part of a strategy to de-escalate or prevent situations that may lead to violence or aggression, and recommendations were developed by consensus. The GDG considered it important to separate recommendations for p.r.n. medication and rapid tranquilisation to distinguish between the use of pharmacological interventions used as part of strategies to de-escalate or prevent situations that may lead to violence and aggression (p.r.n.) and those used during an episode of violence or aggression (rapid tranquilisation). The GDG recognised that there may be occasions when the situation is changing rapidly and the point at which the intervention is administered (pre-event or during the event) is a subjective one. Bearing in mind general principles about the intervention being proportionate to the risk and using the least restrictive option, the GDG judged that the oral route should be used whenever this is appropriate and reasonable. When a decision is made to administer medication by the parenteral route in order to provide urgent sedation, this is considered to be rapid tranquilisation (see Chapter 6 for recommendations on rapid tranquillisation). The GDG agreed that recommendations should make it clear that any pharmacological strategy used to calm, relax, tranquillise or sedate service users in inpatient settings should be individualised and reviewed at least once a week, or more frequently if necessary. The GDG was concerned about possible risk of harm associated with use of p.r.n., for example, the maximum daily dose (including the standard dose, p.r.n. dose and dose used for rapid tranquillisation) being exceeded, and made recommendations accordingly.

For all settings, based on evidence from studies of advance decisions (formerly called ‘advance directives’) and advance statements in community settings, there is insufficient evidence to reach a conclusion about the direct impact that advance decisions and statements have on violence and aggression. Despite this, the GDG agreed that it was good practice to involve service users in all decisions about their care, and advance decisions or statements about the use of restrictive interventions should be encouraged.

No relevant evidence examining the benefits and harms associated with the use of personal and institutional alarms, CCTV and communication devices (including IT systems) met eligibility criteria; therefore, the GDG chose not to make recommendations concerning their use. In addition, there was no evidence to specifically address the question about the recognition and management of substance misuse in mental health service users with violent and aggressive behaviour in health and community care settings.

More generally, the GDG agreed that across all settings there were principles for managing violence and aggression that could be used to improve service user experience, participation in decision-making, and reduce discrimination. This includes respecting human rights and compliance with existing legislation. In particular, the GDG felt that barriers to a service user exercising their rights should be identified and reduced, and if this is not possible, the reason should be recorded in their notes. It was also agreed that carers should also be involved in decision-making wherever possible, if the service user agrees. In addition, prevention of violence and aggression would be assisted by health and social care provider organisations having policies on the searching of service users, carers and visitors.

In the inpatient setting, the GDG felt that it was important to make recommendations relevant to prevention based on good practice. It was felt that all staff working in inpatient settings should be trained and that they should understand the risks involved in using restrictive interventions. With regard to observation, it was agreed that health and social care provider organisations should have a policy on observation and positive engagement that adheres to definitions set out in this guideline. Based on expert opinion, the GDG agreed that when observation continues for 1 week or more, a multidisciplinary review should be conducted. In addition, based on their expert opinion, a review of the definitions in the previous guideline, and the views of stakeholders, the GDG developed what they considered to be more accurate definitions of the different levels of observation, namely low-level intermittent (every 30 to 60 minutes), high-level intermittent (every 15 to 30 minutes), continuous and multiprofessional continuous observation. Recommendations about the use of other restrictive interventions during an event are covered in Chapter 6.

In emergency department settings, the GDG agreed that healthcare provider organisations have an obligation to train staff in techniques to reduce the risk of violence and aggression, and also in mental health triage, and this should be used alongside physical health triage. In addition, it was important to ensure there were sufficient numbers of staff on duty who have had this training. Also regarding staffing, the GDG agreed that every emergency department should have a psychiatric liaison service that can provide immediate access to a psychiatric nurse or doctor. As a result of the stakeholder consultation the GDG added 5 recommendations: 2 on liaison mental health and 2 on having a designated room for mental health assessments, which were derived from the previous guideline, and 1 on training to differentiate between acute organic brain syndromes; acute brain injuries and mania or other psychoses.

In community settings, the GDG agreed it was good practice for healthcare provider organisations, including ambulance trusts, to ensure they have up-to-date policies for managing violence and aggression. These policies should cover lone working in community and primary care settings. As with other settings, the GDG agreed that it was important to make recommendations about staff training and management of violence and aggression, including risk assessment, but that training should be provided depending on the frequency of violence and aggression in each setting. In particular, based on GDG expert opinion, a recommendation was made about sharing risk assessments.

What are the 5 stages of the assault cycle?

What is the crisis phase in assault cycle?

What is the correct order of the assault cycle?

What is the first phase of the assault cycle?