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The Spinney Psychiatric Services

1 Day De-escalation Programme

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Introduction

• Facilitators• Facilities• Fire exits• Toilets• Refreshments• Breaks

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Ice Breaker

To start the course proper we will start with an exercise.

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Aims

• Management of aggression in health care settings

• Permissible forms of control• Organisational issues • Increase confidence

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Objectives

• Raise knowledge concerning aggressive/violent behaviours

• Examine own feelings and attitudes towards people who exhibit such behaviours

• Recognise triggers which cause aggression• Identify ways to reduce aggression• Learn strategies for dealing with

aggression and violence• Understand the main laws, policies and

guidelines in respect to work setting

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Violence

• Extreme end of spectrum• Causes damage, destruction or injury• Abuse, threats or assaults at work• Who is at risk?• Is it MY concern?

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Legal Requirement

• Section 2(1) of the Health and Safety at Work Act 1974

• Management of Health and Safety at Work Regulations 1999

• UKCC (1996)• The Spinney Policy Manual

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What the Law Requires

• The Management of Health and Safety at Work Regulations 1999

• The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR)

• Safety Representative and Safety Committees Regulations 1977

• Health and Safety (consultation with employees) Regulations 1996

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Violence to Staff in Health Care

• Health service advisory committee 1987 survey

1. Major injuries2. Minor injuries3. No physical injury due to threats4. Verbal abuse

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Mezey & Shepherd (1997)

• Primary health care and A & E increased assaults

• Increased injuries to nursing staff• Increased injuries to junior doctors,

support workers and student nurses

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Health Service Advisory Committee 1997

• Training• Causes of violence• Warning signs• Interpersonal skills• Incident reporting

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Violence in Mental Health Care UKCC 2001

• Violence directed towards anyone is unacceptable.

• Recognition, prevention and management of violence

• A need for appropriate training

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Break

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Reasonable Force (Definition)

“ Reasonableness means, firstly, that the force should be no more than is necessary to accomplish the object for which it is allowed (so retaliation and punishment are not permitted) secondly, the reaction must be in proportion to the harm that it is threatened… obviously, the greater the severity of the threatened anger, the more reasonable it is to take tougher action” Dimond (1995)

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Reasonable Force (Principles)

• Assessment• Assessing reasonable force• Rule of engagement• There must always be a resolution

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Use of Force

• Lord Griffiths ………• Section 3 criminal law act 1967

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Scenario 1

• Exercise on the use of force and what is reasonable

• Justification of actions• Correct documentation

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Review scenario 1

• Discussions on the scenario on the use of force.

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Body`s Autonomic Response

• Outward non-verbal cues• Indication of person aroused• Bodily responses to threat and

stress• These come in a variety of forms

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Responses

• Clenched fists, teeth and muscles• Wrinkled brow, frowning• Lack of eye contact• Invading personal space• Hands on hips, provocative

movements• Square on, confrontational

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Responses

• Flushed, pale or blotchy complexion

• Pacing, foot tapping, page flicking

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Group work

• Divide into three groups and brainstorm to find definitions of the following

1. Anger2. Aggression3. Violence

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Lunch Break

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Anger

• Emotional response• Disrupts thinking • Disrupts problem solving• Intense irritation• Motivation

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Aggression

• Outward act• Acceptable • Physical, verbal, mental and

passive• Difficult to define barrier

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Violence

• Extreme end• Great force• Damaging• Physical and mental• Two kinds

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Manifestations

• Thoughts• Feelings• Actions• Bodily functions

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Aggression in Healthcare

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Triggers

Personal factors• Genetic/constitutional/

physiological• Personality• Attitude

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Triggers

External factors• Frustration• Powerlessness• Threat• Fear• Provocation/abuse

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Assault Cycle

• Trigger• Escalation• Crisis• Plateau• Post crisis

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Assault Cycle Chart

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Baseline Behaviour

• Normal behaviour• Settled• Feeling in control• Different from person to person• Maslow`s(1970) hierarchy of needs

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Trigger

• A shift from baseline• Enforced socialisation• Lack of choice• Lack of privacy• Lack of autonomy• Trigger reduction

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Escalation

• Deviates more from baseline• Over focused• Early intervention• Non verbal cues

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Crisis

• Physically, emotionally and psychologically more aroused

• Direct assault likely• Focus on own safety• Intervention of physical restraint

(pre-emptive)

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Plateau

• High arousal slowly returns to baseline

• Adrenaline and glucose levels remain

• Possible further risk of assault• Interventions similar to escalation

phase

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Post Crisis

• Fall below the base line• Physically and mentally exhausted• Remorseful• Need support• Time to explore• Comprehensive documentation

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Role Plays

• There will be a series of role plays to be presented with your participation to illustrate the interventions at various stages of the cycle.

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Break

.

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Assault Cycle Chart

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Self positioning

• Clear exits• Angled sitting position• Ready for departure• Hand gestures• Distance• Not standing over person• Tone of voice• Peripheral vision

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Questions and Answers

• A little question and answer sheet for you to participate in

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Feedback and Evaluation

• Verbal• Written

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References

• Department of health and welsh office (1993). Code of practice: mental health act 1983. London HMSO

• Department of Health Guidelines HC(72)11 : Dealing with violence in the hospital setting

• Dimond, B. (1990). Legal aspects of nursing. London: prentice-hall.

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References

• Health and safety at work act (1974). London HMSO.

• Kaplan, S. G., & Wheeler, E. G. (1983). Survival skills for working with potentially violent clients. Social casework: the journal of contemporary social work.

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References

• Farrell,G.A. & Gray,C.(1992). Aggression, A Nurses guide to Therapeutic Management, London, Scutari Press

• Health and Safety at Work Act 1974 Section 2(1)

• Hogan, G (1995) Care and Responsibility the Legal Framework, Ashworth Hospital handout.

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References

• Maslow, A (1970) The farther reaches of human nature, New York: The Viking press.

• The Spinney Policy Manual 2002• UKCC (2001) The recognition,

prevention and therapeutic management of violence in mental health care.

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Home time

.

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Zero Tolerance

The NHS zero tolerance statement has two principal targets. They are:

• Public• Staff

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Zero Tolerance – Public

To get over to the public that violence against staff working for

the NHS is unacceptable. The government and the NHS are determined to stamp it out.

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Zero Tolerance - Staff

To get over to all staff that violence and intimidation is unacceptable

and is being tackled.

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Zero Tolerance – Survey 1998

• 3/1000 incidents every month in acute hospitals

• 7/1000 incidents every month in ambulance services

• 14/1000 incidents every month in community settings

• 24/1000 incidents every month in learning difficulties/mental health units

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Zero Tolerance Targets

• Record• Publish• Reduction• Police

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European Human Rights Act 1998

• Article 2 - A right to life1. Para 3.142. Para 3.153. Para 3.16• Article 3 - freedom form torture or

inhumane or degrading treatment1. Para 3.242. Para 3.25• Article 5 – personal freedom