SEPT
Prevention and Management of Violence and Aggression
2 Day Team Work update
Course Journal
Name ………………………………….
Reviewed: January 2013
1 Contents
Introduction and user guide Page 3 Standards for course Page 4 Learning outcomes for course Page 5-6 Section 1 The role of NHS Protect / Definitions of Violence Page 7-12 The Public Health Model Section 2 Causes of Violence and Aggression Page 13-14 Section 3 Relationship between mental disorders and Violence Page 15 Section 4 De-escalation Page 16-20 Section 5 Restraint Safety and Legal aspects Page 21-34 Section 6 Managing Clinical Risk Page 35-36 Section 7 Post incident procedures / closing the loop Page 37-39 Section 8 Documentation and incident reporting Page 40-43 Section 9 Rapid Tranquilisation Page 44-47 PLEASE NOTE SECTION 9 IS COVERED IN MEDICINE MANAGEMENT Section 10 Gender Page 48-52 Section 11 Equality and Diversity Page 53-54 Section 12 Culture, Race and Ethnicity Page 55-56 Section 13 Key messages and Action Planning Page 57-59
Ground Rules Page 63
At the end of the training journal are some appendixes, which may be of use to clinicians when dealing with clients, in the Prevention & Management of Violence & Aggression.
Appendix Number 1 Translating & Interpreting Services…….. Page 60 Appendix Number 2 Safe Client Escorts…………………………Page 61-62
2 Introduction and User Guide
The outcome of this 2-day course and learning journal is to achieve and update on the ten learning outcomes of the Security Management Services (SMS) Conflict Resolution Training that will be taught within the course.
The course will also update you on the essential key elements of the theory relevant to the Prevention and Management of Violence and Aggression as well as the all-practical elements.
The practical elements include breakaway techniques and recommended restraint procedures.
During this course…
The instructing team will use continuous assessment of your performance as an on-going process by:
1) Linking theory to the practical components
2) Giving and receiving verbal feedback.
3) Observing participation during group activities (You will receive guidance from the instructors for each learning activity that you undertake)
The instructing team have a strong commitment toward offering a high standard of teaching practice at ALL times, and will utilise a range of teaching resources and learning strategies in order to help you complete the course successfully.
Workforce responsibilities.
All staff must have completed the 5 day Team Work course before embarking on this two day update, within the last year
3 Standards for 2 Day Team Work update
1. All individuals attending the 2 day team work update course, to have a working understanding of local policy on managing violence and aggression, as well as basic knowledge of, and skills in basic CPR.
2. Support for participants on the course, will be provided by qualified trainers, on both a group and individual basis, dependant upon individual need.
3. The course is monitored through continuous assessment.
4. Participants will be expected at all times to adhere to safety protocols as laid down by instructional team.
5. All participants, by course completion, will be able to demonstrate the safety issues pertaining to the physical restraint.
6. In order to successfully complete the course all participants will be expected to display physical techniques to a safe standard which will be monitored by the instructional team.
7. All participants will be expected to:
Work within the guidelines and boundaries set out within the course, Display an understanding of, and effectively use communication, both within the team, as well as with other individuals in the immediate area, Display a positive attitude toward the other participants, as well as a positive attitude to the subject matter, Work as part of a team, Appreciate the role of physical interventions as a last resort in the Prevention and Management of Violence and Aggression.
8. Where an individual is unsuccessful in attaining the required standards, reasons for this will be given to the participant and their manager both verbally and in writing, and wherever possible the participant placed on a further training course in order to successfully meet the course’s criteria.
9. In order for the individual to safely carry on utilising the techniques taught staff are required to attend the yearly update.
4 Learning Outcomes for 2 day team work update
1. Describe the role of the Security Management Director (SMD) and Local Security Management (LSMS) in relation managing violence in mental health or learning disability settings. These are set out in Department of Health (DH) in directions issued to all health bodies (DH 2003)
2. Describe theoretical, pathological and environmental explanations for aggression in mental health or learning disability settings.
3. Identify and demonstrate aspects of non-verbal de-escalation, verbal strategies and conflict resolution styles.
4. Identify and reflect on the effect of functional and dysfunctional coping strategies on people’s lives and behaviour and be able to relate this to mental health or learning disability settings.
5. Demonstrate an understanding of the positive contributions service users can make to prevention strategies. You will also have an awareness of how issues relating to culture, race, disability, sexuality and gender can enhance this process.
6. Describe individual and organisational responsibilities in relation to legal, ethical and moral frameworks relating to the use of force.
7. Demonstrate an understanding of the application of risk management interventions and the need for effective assessments of dangerousness with references to prevention planning.
8. Demonstrate an understanding of restraint-related risks, as outlined in the Bennett inquiry report (Blofeld 2003) and National Institute for Clinical Excellence (NICE) guidelines (NICE 2005) with a view incorporating risk reduction strategies into practice.
9. Demonstrate an understanding of the need for and scope of post-incident review procedures and how to identify strategies and interventions for future prevention.
10.Identify ‘spheres of influence’ in relation to how individuals, teams and organisations must change in order to prevent incidents of aggression and violence.
5 11.To display an appreciation of physical techniques as a last resort in the interventions which can be utilised in dealing with a violent or aggressive individual.
12. All participants to show an appropriate level understanding of guidelines as set out in local policy, the law, and the M.H.A. Code of Practice regarding the management of violence & aggression and physical restraint.
13.All participants will be expected to display all included physical techniques to a standard deemed appropriate by the instructional team.
14.Participants must display a clear understanding of the anatomical risks of unsafe restraint techniques, as well as a working knowledge of the safety aspects of the physical techniques taught.
15. Additionally all participants will have basic knowledge and skills in CPR techniques.
6 Section 1 The Role of NHS Protect
Background
In April 2003, the NHS Security Management Service (SMS) was established, with a remit of encompassing policy and operation responsibility, for the management of security within the NHS; this included the protection of people, property and assets.
In November 2003, the Secretary of State issued new national guidelines, regarding tackling violence against NHS staff. The aim of which was to deliver an environment that is safe and secure for staff, ensuring the highest standards of clinical care, are made available to patients.
The Role of NHS Protect
NHS Protect is a special health authority which has overall responsibility for all policy and operational matters, related to the management of Security within the NHS.
NHS Protect leads on work to identify and tackle crime across the health service. The aim is to protect NHS staff and resources from activities that would otherwise undermine their effectiveness and their ability to meet the needs of patients and professionals. Ultimately, this helps to ensure the proper use of valuable NHS resources and a safer, more secure environment in which to deliver and receive care.
Security Management Appointments
It is a statutory requirement for NHS Trusts to have: A nominated Security Management Director (SMD) A nominated and accredited Local Security Management Specialist (LSMS) A Non-Executive Director (NED) with responsibility for the security management agenda.
The Director nominated as the 'Security Management Director' (SMD) is Peter Wadum- Buhl, Executive Director of Strategy & Business Development, who has overall responsibility for security management work with particular responsibilities for tackling violence within SEPT.Our Non-Executive Director, (NED) Steve Currell, ensures and monitors necessary requirements are in place within the Trust and guidelines adhered too.
SEPT has two Accredited Local Security Management Specialist’s (LSMS), whose role is to implement the national security management strategy and guidance at SEPT.
7 The LSMS leads, assists in and co-ordinates the prevention strategies, investigation and resultant actions following incidents of violence. The LSMS is the central contact point for NHS Protect, and will facilitate information sharing and gathering between SEPT and NHS Protect, including Safety Alerts and annual statistics, relating to assaults within the organisation.
The LSMS is the central contact point for the police and staff within SEPT when dealing with assaults and other criminal acts under investigation
Violence Strategy
NHS Protect is committed to tackling violence towards NHS staff. It strives to ensure strategies are developed and put in place to promote safer work environments. NHS Protect also recognises that staff working in certain settings have specific and complex needs. An example is mental health or learning disabilities settings, where there are higher levels of violence. Violence within these settings can (not always) be attributed to a range of factors, including environmental and cultural ones.
SEPT is highly committed to ensuring that staff work in a safe and secure environment and has robust policies, procedures, guidance and training programmes in place to reduce the risk of violence.
The Trust LSMS investigates every assault at SEPT and the provides support to staff victims of assault. The LSMS is available to all staff who need advice or support in relation to violence, workplace risk assessments for violence and aggression, managing violence strategies and post incident follow up and support.
Assaults and violence are managed via the Datix system (as with all incidents at SEPT). The LSMS is alerted immediately an incident related to violence against staff or trust property or other security incident but if you do not report an incident on Datix the LSMS will not be aware it happened.
SEPT Prevention & Management of Violence & Aggression Policy (RM09) and procedural guidelines can be found here: http://tchw2kent02/documents.php?doc_id=9821
8 Property & Assets
NHS Protect works to protect and secure NHS property and assets.
In the document ‘A Professional Approach to Managing Security in the NHS’, property is defined as ‘the physical buildings in which NHS staff and professionals work, where patients are treated and from where the business of the NHS is delivered’.
In the same document, assets are defined as ‘the materials and equipment used to deliver NHS healthcare. In respect of staff, professionals and patients it can also mean the personal possessions they retain whilst working in, using or providing services to the NHS’.
These definitions also cover assets donated to or acquired by the health bodies, as these allow NHS staff and professionals to deliver healthcare to patients. SEPT Security Policy (RM09) and procedural guidelines can be found here: http://tchw2kent02/documents.php?doc_id=9821
Counter Terrorism
In response to the terrorist threat, NHS Protect is committed to working with national, regional and local stakeholders to ensure that all trusts identify vulnerability and adopt risk-assessed proportionate protective security measures.
In the development of major incident plans, NHS Protect is also working with stakeholders to ensure that security issues are fully considered.
Lockdown is part of the counter terrorism strategy and is led by the LSMS at SEPT.
Legal Services
NHS Protects Legal Protection Unit (LPU) was formed in December 2003 as an integral part of the NHS Security Management Service. It works with health bodies, the police and the Crown Prosecution Service to increase the rate of prosecutions.
The unit also provides cost-effective advice on a wide range of sanctions against individuals who are violent towards staff and professionals working in or providing services to the NHS.
9 NHS Protect Operations
The NHS Security Management Service operations team includes Area Security Management Specialists who provide operational support to the network of Local Security Management Specialists.
The team’s initial priority was to meet with Security Management Directors, Non- Executive Directors, and nominated and accredited Local Security Management Specialists for the health bodies in their areas. It helped them meet the requirements of the national frameworks for tackling violence against NHS staff and general security management arrangements.
Area Security Management Specialists
Area Security Management Specialists (ASMS's) provide the link between the network of Local Security Management Specialists and NHS Protect, ensuring that operational work informs and drives revision of national policy, systems and procedures.
The ASMS’s manage the regional Local Security Management Specialist networks, ensuring that best practice is highlighted and that updated legal and procedural information is made available.
Local Security Management Specialists
Trained and accredited Local Security Management Specialists (LSMS’s) have taken the lead in security management work in all health bodies since April 2004.
LSMS work takes place within a clear legal framework, set out in Directions issued by the Department of Health to relevant health bodies and the strategic framework outlined in the National Strategy document.
In addition to being their health body’s expert resource in matters of security management, the LSMS liaises with their Area Security Management Specialist, networks with their peers and attends LSMS-focused events to ensure the ongoing development of their role.
Only the LSMS may perform the duties and functions described in Directions, subsequent guidance and requirements specified in the NHS Security Management Manual (only an accredited LSMS has access to the NHS Security Manual on behalf of the Trust). The LSMS team are responsible for the following Trust Policies and related work streams:
10 Trust Security PMVA Lone Working Zero Tolerance CCTV Lockdown (Lockdown Plan is Part of the Major Incident Policy)
The SEPT LSMS team is based in the Trust Risk Management Team at The Lodge in Essex:
Suzanne Deighton, Accredited LSMS for Mental Health, Learning Disability & Corporate Services ~ 01268 739728/07961223381 Jo Englefield, Accredited LSMS for Community Health Services (CHS) ~ 01268 739724/07950486561
Peter Howlett, LSMS ~ 01268 739734
Listed below are the historic national policies
• Zero Tolerance (1999) (2000) • National Audit Office Report (2003) • Blofeld inquiry into the death of David Bennet (2004) • National Institute of Mental Health England (2004) • NHS Security Management Service measures (2003) • National Institute of Clinical Excellence (2005) • BILD (1996 onwards) • Dept of Health Guidance on Restrictive Physical Interventions (2002) • National Audit Office Report (2003)
Definitions of violence
The HSE (1997) describe physical assault and non-physical assault as
Physical assault ‘The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort’
Non-physical assault - The use of inappropriate words or behaviour causing distress and/or constituting harassment
11 The Public Health Model This model is advocated by the World Health Organisation as the cornerstone of attempts to address workplace violence views prevention as having three dimensions. Each dimension is important but the emphasis is on primary prevention.
The model is shown below: -
The Public Health Model
Physical interventions, Tertiary post incident reviews Prevention & debriefs Secondary Reactive responses; Prevention De- Escalation techniques Primary Prevention
Addressing the root causes
• Primary prevention: preventing violence before it happened by addressing root causes • Secondary prevention: reactive responses de-escalation • Tertiary prevention: physical interventions post incident reviews and debriefs
Prevention at every level of the model requires: -
Action at the level of the organisation The staff team The individual worker
12 The service user
Section 2 Causes of Violence & Aggression.
A TRIGGER A WEAPON
VIOLENCE
A TARGET A HIGH LEVEL OF AROUSAL
Bailey (1997) felt that for violence to take place, all 4 of the elements mentioned above must be present. The removal of any one of the above will result in a reduction in the risk of violence in the same way as fire, heat, fuel & oxygen are all necessary for a fire, and removal or absence of any of the four will end a fire.
Adapted from Bailey 1977 in Paterson B, Leadbetter D, & McComish A. "De-escalation in the management of aggression and violence." Nursing Times September 3, Volume 93, No 36, (1997).
Triggers
Verbal - phrases which evoke anger / frustration Physical - causing pain / discomfort, touch, invading personal space, poor use of body language. Environmental – noisy surroundings, lack of privacy, peer pressure toward anti-social behaviors. The above may sometimes involve causing offence to an individual on the grounds of their sexuality, culture or spiritual beliefs, or just unluckily pressing the wrong buttons.
Weapon
Some body parts may be used as a weapon, where inanimate objects are concerned however, are these essential in the area / or may they be removed where staff are concerned?
13 Target The recipient of the assailant’s aggression.
What could make you the target? What do you represent? E.g. Male / Female. Status / what you represent. Lack of experience. Your communication skills. Student or agency. Remember cultural issues.
Arousal Stimulus Interpretation Behaviors Emotions
“Anger as a form of arousal is a consequence of an interpretation of a event or incident as being provocative.” Novoco (1976) "Aggression can be broken down into two categories - 'hostile' and 'instrumental'. Hostile aggression is that associated with high arousal and anger. Paterson B, Leadbetter D, & McComish A.(1997).
In instrumental aggression, anger and arousal may be absent and the aggression displayed in order to achieve a specific goal." E.g. If I ‘kick Off’, I’ll get Lorazepam, I like Lorazepam, I’ll ‘kick off’ then so that I can get it, or the child who shouts and cries in the shopping queue, as they know that mum or dad will buy sweets just to keep them quiet.
14 Section 3 Relationship Between Mental Disorders & Violence?
Mental Illness & Violence
• Important to remember the diverse nature of Mental Illness, and question how real generalisations are. • The majority of people experiencing mental health problems such as schizophrenia are not violent. • There is a much stronger link between drug/alcohol dependency or addiction and violence than between mental illness and violence. • People experiencing mental health problems are many times more likely to commit suicide rather than homicide. Public beliefs about the nature of the relationship can severely overestimate the extent of the relationship. • There are those who continue to deny an association between mental illness and violence. (Pilgrim and Rogers 2002)
Learning Disabilities & Violence
• Important to remember the diverse nature of Learning Disabilities and question how real generalisations are. • Challenging Behaviours (Emerson (1995:4) Culturally abnormal behaviours of such intensity frequency or duration that the physical safety of the person or others is likely to be placed in jeopardy or behaviour which is likely to seriously limit use of or result in the person being denied access to ordinary community facilities.
The individuals mental illness and/or learning disability somehow removes or inhibits an individual’s capacity for self control. By doing so ‘it’ removes the ‘barriers’, which prevent violence.
This is sometimes referred to as the ‘mad-bad’ characterisation and the divide finds its expression in explanations such as
‘Brian has a servere learning disability he can’t control himself’ ‘Simon has a borderline personality disorder you can never trust them’ ‘He’s always been like that he’s a right so and so’ ‘So does that just wind me up’ ‘He’s schizo what can you expect’
These point towards illness’ or people being the cause of violence as opposed to situations, interactions & relationships.
Proximal antecedents: things happening before, sometimes well before the incident.
15 Section 4 De-Escalation
To de-escalate a developing situation verbally is clinically ethically and legally preferable to using physical restraint. De-escalatory procedures should therefore be utilised in any arena that requires workers to come into contact with a potentially violent individual.
De-escalation: circles of influence This concept is relatively simple. There are certain things that we have significant control over notably our own non-verbal and verbal behavior. There are other factors that are role dependant, which we may have less control over such as the behavior of other members of staff (although there is a responsibility to report abuse).
De-escalation: circles of influence
Unit/team Alcohol prices culture Staffing levels
Your behaviour Behaviour of other members of staff
Masculine Skill mix Behaviour of other gender stereotypes Service users In wider society
Commonly reported reactions to violence and fear, frustration and anger. Unless all three are acknowledged and managed can
1. Diminish cognitive control 2. Evoke our own fight or flight reaction 3. Promote a desire to punish the service user for making us feel like this.
Counter aggression in a care setting is inappropriate. At times an assertive response may be necessary and warranted but not an aggressive one. Staff have a responsibility to recognize and manage their own emotions and a
16 responsibility to monitor the emotions of other staff involved in a situation to ensure safety of all. Managing your own emotions • Recognize and acknowledge signs of anxiety • Recognize danger signals of your own & others anger • Take one deeper than normal breath / exhale slowly • Use positive self statements e.g. ‘I can cope’ if you feel your anxiety levels are increasing • Focus on active listening • Avoid a defend-attack spiral • Choose what you are going to do Violent Incident Models: There are five possible incident models; the underlying idea is that each incident is a unique event. However, there may be common patterns amongst types of incidents. If staff can learn to recognize incident types then they can adapt their response accordingly.
The five possibilities are 1 AFFECTIVE 2 INSTRUMENTAL 3 MIXED 4 AVERSIVE 5 STIMULUS -RESPONSE- CONSEQUENCE
Non-verbal Aspects of De-escalation.
Verbal de-escalation is a skilled intervention that is specifically used to intervene when a patient's behaviour moves from being normal for that individual to a state that can be recognised as pre-aggressive. The technique particularly lends itself to use by health care workers who spend long periods of time with patients, have formed a relationship, and can note the early warning signs. It is important to appreciate and attend to ours and others non-verbal behaviours and the need for cultural sensitivity. For example, in Iranian communities thumbs up, which indicates good in many western societies is generally considered very rude.
Any response to a potential incident must be guided in the first instance with an awareness of the risk the situation presents. The options are to stay or to leave the situation.
Having decided that it is safe to stay it is suggested that the acronym PERFECT is used to summarize aspects of practice.
17 1. Proxemics – (stance/posture/space) Angry and aroused people have an increased need for personal space. Staff can therefore provoke incidents unwittingly by not respecting this need for increased distance or by adopting a confrontational posture. It is best to avoid standing directly in front of a service user who is angry. A stance that places the member of staff at an angle to the service user whether sitting or standing should be adopted.
2 Eye contact Eye contact should try to remain akin to that of a normal conversation. Prolonged direct eye contact where the service user is highly aroused should be avoided as it can be interpreted provocatively. Avoidance of eye contact may be interpreted as submissive or fearful.
3 Respect Touch boundaries The use of touch when someone is highly aroused requires extreme care. It must always be done in a way that respects dignity and individuality of service users. If the service user is angry touching should be avoided altogether or done very slowly so that the reaction can be observed and preferably with the service users explicit permission.
4 Facial expression Facial expression is important as it serves to convey and reinforce the context of speech. Facial expression should ideally remain neutral; smiling should be avoided as it can be interpreted as laughing at the person.
5 Environment The environment has both physical and social dimensions. Incidents can occur in front of an audience of other service users and staff. This influence must be judged; it could be a positive influence in this case the environment should remain unaltered. At other times it can exacerbate the situation making it harder for involved parties to negotiate. In this circumstance a change of environment should be considered.
6 Consider influence of your appearance Appearance forms part of the dynamic. A smart suit may convey one message whilst unshaven or chipped nail varnish another. Appearance is generally not right or wrong, however clothing that may be perceived as overly sexual is inappropriate in professional settings.
7. Think about your hand movements Palms should be open in view of the service user and not in pockets, arms folded, or hands on hips, which may be viewed as aggressive. This stance already described and posture demonstrates minimum treat to the service user but is not submissive. In addition it forms the basis for a defensive posture should violence occur.
In addition to the above active listening should also be utilized where appropriate. Active listening refers not just to being attentive to what the person is saying and picking up on all relevant topics, but also refers to appearing to be
18 paying attention. A client talking to someone who appears disinterested may very quickly become frustrated.
Nodding, having your face directed towards to the client, yes, right etc are all useful responses to the client. Another useful skill utilised in active listening, is where some of what the client has said is rephrased or repeated.
Verbal Skills
Verbal communication is of equal importance to non-verbal. There are five aspects to consider that form the acronym LOADS
1. Learn to manage pitch / tone / volume Pitch tone and volume are integral to communication and close attention is warranted. The aim of speech is to convey an empathic response and avoid escalating the situation further.
Do not rush into a situation imaging that you know what is going on. Getting it wrong may cause further upset. Much better to ask the client what is bothering him/her, so that they can tell you what the issues are.
Asking questions such as: Are you okay? What is upsetting you? What can I do to help/sort this out?
Not only does this provide you with information, so that you can work on info provided. It also gives the client the chance to ventilate, verbally what otherwise they may only release through physical means.
2. Overload with agreement Where the service user is extremely angry/distressed suggestions are that staff should consider agreeing with everything they say. The goal of this is to avoid giving the person a reason to escalate from verbal to physical violence. Where anger is less extreme consider the idea of partial agreement.
3. Acknowledge and check feelings Acknowledging feelings is an important dimension of practice. In the context of de-escalation where the incident appears affective, the person is visibly aroused red or white in the face then an acknowledgment might be helpful.
In situations where affective arousal appears missing it can be helpful to acknowledge your own feelings to prompt the service user to reflect on their own behavior.
Empathy can be an affective tool, try to imagine
How you would feel in their situation, What you would want, feel you need, How you would want to be treated.
19 These considerations should not only assist us in choosing our approach, but if the client sees that you’re trying to see things how he/she sees them, then this may build a better rapport based on mutual respect.
E.g. “Mmmm, yes I get what you’re saying, if I’d had to wait for 2 hours to have my appointment, I’d be annoyed. So what are we going to do to get this sorted out?” The we, implying that you are going to work together
4. Distraction If the source of the anger is something that is outside your control then a suitable strategy may be to move from the irresolvable conflict to a different compromise that can be attained.
Temporary distraction can sometimes be managed by offer to phone, write or make tea. When the person is very angry asking detailed questions, which requires the person to think engages recall, which can prompt the re- engagement of cognitive control. It is sometimes tempting to make promises but caution should be exercised if they cannot be fulfilled.
5. Start negotiations Negotiation has a series of discreet stages starting with establishing and agreement to negotiate. Certain things may not be negotiable so it is helpful to clarify what is and what is not negotiable. Ground rules for negotiation can include no shouting or swearing exemplified by limit setting e.g. ‘I am here to listen to you but I need you to sit down and stop swearing before we do that’.
Accepting when we are in the wrong.
Sometimes we accept that the client is right, and for whatever reason, they have been treated badly or wronged. Though some will still bear a grudge, most people will accept to some extent, an apology. It is easy if you are a person in a position of authority to wield your power proudly. Sometimes all that is required in an aggressive situation is to admit you or your service, were wrong or failed the client.
E.g. “I’m sorry, sometimes I talk without thinking, I didn’t mean that the way it came out,” or “I’m sorry I know you’ve been told just five minutes too many times, you should have been seen by now, and I apologise.”
De-escalation caveats
20 De-escalation is not treatment Where aggressive or violent behavior can be foreseen, planned de-escalation strategies must be part of a behavior management plan which in turn must be part of behavioral change strategies
Section 5 Restraint Safety and Legal aspects
What is RESTRAINT? The positive application of force to overcome a subject’s resistance.
This may be required to: • Prevent the actual or imminent physical assault to self or others. • Effect lawful detention. • To stop/prevent serious damage to property.
RESTRAINT INVOLVES THE USE OF FORCE.
Risks, Rights and Responsibilities
Is it legal to use force? Section 3(1) of the Criminal Law Act 1967 provides a statutory defence it states that any person can use such force as is reasonable in the prevention of a crime.
What is Section 3 of the Criminal Law Act 1967? It is an Act of Parliament and therefore provides, in its interpretation, the right of all citizens to use force in the defence of themselves or others or in the prevention of a crime.
However, the use of force against another person may amount to assault against that person and as such be a crime.
This will be judged upon the fact that the person had only done what was honestly and instinctively believed at the required time.
Self-defence and Criminal Law. What the criminal law rules of defence do is try to establish equilibrium between the 2 extremes of not allowing the victim to use any force at all or using force that is excessive.
21 Lawful Excuse The Law Commission draft criminal code states that force may be used in the following circumstances- • To prevent or terminate a crime. • To effect or assist in the lawful arrest of an offender, suspected offender or person unlawfully at large. • To protect self or others from unlawful force or unlawful personal harm. (This is self defence broadened to cover defensive support of another person.) • To prevent or terminate unlawful detention of self or other. • To protect property (whether belonging to self or other) from unlawful appropriation, destruction or damage. • To prevent or terminate trespass.
Reasonable Force. The law states that the use of force must be reasonable.
What does reasonable mean? For force to be considered reasonable it must Be: NECESSARY PROPORTIONATE
What is NECCESITTY? This is outlined by Common Law. • Was the force used NECESSARY (or believed to be necessary) to prevent the crime or affect the arrest? E.g. was the aggressor presenting a direct threat? Was the threat imminent? Defensive force will only be considered necessary if the attack is immediate or perceived to be imminent.
We have a duty to avoid conflict. This addresses the question, is the person acting in self-defence or acting in revenge or retaliation?
Evidence of an attempt to withdraw or retreat will negate a suggestion of revenge. It would not be considered reasonable to utilise force if the initial aggressor has started to retreat and poses no further threat.
Protection of home- a person protecting his/her home is exempt from a duty to retreat. However, the use of force used to protect property and assets may be challenged if excessive to the threat posed.)
Pre-emptive strike -This allows individuals to utilise force pre-emptively if an attack is imminent. The rationale suggests that citizens can protect their vital interests (life, physical security) without waiting until a blow is struck if they genuinely believe their life is in danger.
Freedom of movement- English law recognises an exception to a duty to avoid conflict in certain circumstances. An individual is acting lawfully by remaining at
22 or going to a place where violent confrontation may occur e.g. a nurse on a ward, a social worker carrying out an assessment is entitled to go to or remain in a place knowing there is a risk of violence in pursuit of their occupational role.
What is PROPORTIONATE? Was the force used proportionate to the harm to be avoided?
This standard is best defined in terms of what is reasonably proportionate to the amount of harm likely to be suffered if no forcible intervention was made. Proportionate response will be considered with reference to the degree, duration and nature of force used. ‘The force used should be no more than is necessary to accomplish the object for which it is allowed (so retaliation and punishment are not permitted) and secondly, the reaction must be in proportion to the harm which is threatened’. Diamond 1995 Assessing reasonableness. Crown Prosecution Service-Offences against the Person-Charging standards (1996) state that offences will be considered in the context in which they are allegedly committed. In all cases, surrounding circumstances will aid the decision with regard to pursuit of criminal proceedings. A number of factors will be considered e.g. the assailant-height, build, gender, level of threat, use of weapon, intent to harm. The victim-height, build, gender, alternative courses of action available.Location. Circumstances e.g. action deemed suitable in response to a threat in a pub may not be considered appropriate in a care home.
Consideration will also be given to situations where the ‘victim’ was at the time engaged in a criminal activity. E.g. a burglar assaulted by the occupier of the premises.
ALWAYS CONSIDER- Was the force used justified in the circumstances? (Was there any need to use force at all?)Was the force excessive in the circumstances? Practice Implications. Application of the principles of necessity and proportionality reinforces safe and therapeutic practice and the need to always utilise the least restrictive intervention. Accurate reporting of circumstances in which force is used is essential, local procedures must be in place. Honestly Held Belief. The courts indicate that questions of necessity and proportionality are answered on the basis of the facts as the accused honestly held them to be. To this extent it is a subjective test. The objective aspect is applied, as courts will ask whether, on the basis of the facts, a reasonable person would consider the force used reasonable or excessive. If a jury thought that in a moment of unexpected anguish a person had done what they believed was required this would provide potent evidence that reasonable defensive action had occurred. Human Rights Legislation. The Human Rights Act came into effect on 2nd October 2000. It is the most significant statement on human rights since the
23 1689 Bill of Rights. The UK participated in drafting the 1998 European Convention on Human Rights hence the convention is part of UK law.
Section 6 states that it is now unlawful for any public authority to act in a way that is incompatible with such rights.
Article 2-Right to life (limited right) This states a positive obligation to preserve life. ‘Everyone's right to life shall be protected by law. No one shall be deprived of life intentionally save in the execution of a sentence of a court following conviction of a crime for which the penalty is provided by law.’
The positive obligation to preserve life. Article2 (1) This states that authorities must not only refrain from taking life intentionally, but also take appropriate action to safeguard life.
24 Article 2 has been described as one of the most fundamental provisions of the convention.
Article 2(2)-Exceptions to the right to life. The use of no more force than is absolutely necessary is the crucial test applied for exceptions to article 2(2). This application has been examined in case law and refers to – NECESSITY. PROPORTIONALITY. HONESTLY HELD BELIEF.
Article 2 –Vulnerable persons. Article 2 refers to the positive obligation to preserve the life of those vulnerable by nature - Young children. Elderly. Mentally disordered persons. Those who may be at risk during Restraint. (RESTRAINT RELATED DEATH.)
Article 5 - Right and Liberty and security of person Article 5 states that no one shall be detained if detention is not authorised by law. Care staff have a duty of care legally, morally and ethically to protect vulnerable persons. E.g. an elderly person wishes to leave the care home to see her family and staff honestly believe she will be killed crossing the road, she is not detained by law but is prevented from leaving by means of a locked door. Do this and many similar scenarios breach article 5?
Article 8 – The right to respect for private and family life. Within a clinical context consideration must be given to privacy and dignity. Access to family must be actively facilitated as part of the care planning process. Cultural needs e.g. access to space to pray, must be addressed.
Legal Aspects Human Rights Act
Ethical Principles. Autonomy- moral obligation to act in accordance with the decisions/choices of clients. Beneficence-to do good, promote clients best interests. Non maleficence-to do/cause no harm. Justice-to treat people fairly and justly, to treat equals equally and unequal’s unequally. Do the ethical principles of beneficence; non-malficence and justice justify detention under duty of care?
25 Human Rights Legislation in the Workplace. The protection of rights in any organisation requires a balance of economic and business interests of the employer and the employee’s right to be protected from unreasonable demands imposed by an employer in pursuit of that business.
The purpose of Article 2 is to ensure employers do not rest on an assumption that their employees will always do the obvious.
In any environment where an employee is expected to use force in an occupational role, the use of force must be strictly controlled and competently managed by the organisation. Risk assessments must be carried out and appropriate training provided.
Health and Safety at Work Act (1974) The Health and Safety at Work Act states that –
‘The employer has a responsibility to ensure, as far as is reasonably practical, the health, safety and welfare of their employees.’
Employees are also tasked with a responsibility to maintain a safe working environment by complying with measures put in place by the employer.
‘It is the employer’s responsibility to ensure that employees receive such information, instruction, training and supervision, as is necessary, to ensure the health, safety and welfare of staff by ensuring that staff are competent.’
Management of Health and Safety Regulations (1999) ‘Every employer shall make and give effect to such arrangements as are appropriate, having regard for the nature of his activities and the size of his undertaking, for the effective planning, organisation, control, monitoring and review of the preventative and protective measures.’
Human Rights in the Workplace. A violation of Article 2 can result not only from those who committed the act but also from the fact that training and preparation is inadequate. If authorities know there are problems and fail to address them, and such a failure leads to a subsequent death that could have been prevented a violation of Article 2 will occur. The Health and Safety at Work Act also carries a corporate (organisational) responsibility.
Implications for Practice. • Organisational planning around the use of force must occur to eradicate as much as possible the chances of loss of life. • Training for staff to recognise and deal with life threatening situations must be adequate. • Training for staff in methods of restraining violent individuals must be safe and compliant with the convention standards and Health and Safety Legislation.
26 Article 3 –Prohibition of Torture (absolute right) This prohibits torture and inhumane or degrading treatment. The provision aims to protect individuals from physical and mental ill treatment.*Everyone is entitled to the protection of Article 3 regardless of their own conduct. * What is Torture? • Torture-Deliberate, inhumane treatment causing very serious and cruel suffering. • Inhumane Treatment- Treatment that causes intense physical and mental suffering. • Degrading Treatment- Treatment that arouses in a victim a feeling of fear and inferiority capable of humiliating and de basing the victim and possibly breaking his/her physical or moral resistance. Does the use of pain compliance constitute torture? • Does this breach article 3? • If used to positively protect life is pain compliance acceptable? • ‘The use of pain compliance is justified legally by reference to the concept of reasonable force, and ethically by reference to utilitarianism' Aggression and Violence-Approaches to effective Management-John Turnbull and Brodie Paterson-1999. Pain Compliance-Legal and Ethical Aspects. • Techniques that cause pain or discomfort pose major legal, ethical and moral difficulties. • Pain compliance techniques should not be used if an alternative pain free method can safely achieve a similar desired outcome. • Pain based techniques serve no therapeutic value and must only be used in extreme circumstances to ensure safety of self/others.
MENTAL CAPACITY ACT (MCA)
The Mental Capacity Act 2005 (MCA 2005), covering England and Wales, provides a statutory framework for acting and making decisions on behalf of people who lack the capacity to make those decisions for themselves. These can be small decisions, such as what clothes to wear, or major decisions, such as where to live or accepting medical treatment. The MCA 2005 sets out some core principles and methods for making decisions and carrying out actions in relation to personal welfare, healthcare and financial matters affecting people who may lack capacity to make specific decisions about these issues themselves. In some cases, people lack the capacity to consent to particular treatment or care that is recognised by others as being in their best interest, or which will protect them from harm. Where this care might involve depriving vulnerable people of their liberty in either a hospital or care home, extra safeguards have been introduced, in law, to protect their rights and ensure that the care or treatment they receive is in their best interest. These safeguards are called the
27 Deprivation of Liberty Safeguards (DOLS) and were implemented on 1st April 2009 Professional responsibility and accountability
Use of force in professional practice • Professionally healthcare staff are trusted to always act in the best interests of the service user, to protect the public and do no harm. • Such ethical principles are reflected in professional codes of conduct and in service contracts. • It is therefore essential to balance rights with responsibilities. • As citizens certain rights cannot be challenged, as professionals these rights must be applied responsibly. • The consequences of the use of unreasonable force within a care environment are extensive. • A legitimate reason to use force must exist – must be a reason considered legitimate by law. • A forceful intervention may be justified in the following circumstances – • Statutory Authority e.g. Mental Health Act. • Compulsory care or treatment orders. • Prevention of a crime e.g. assault. • Necessity –common law principle applied in best interests. • Physical force must never be used for –
REVENGE. RETRIBUTION. RETALIATION. TO TEACH PEOPLE A LESSON.
Potential consequences of UNREASONABLE use of force – Disciplinary action. Professional misconduct hearing. Dismissal. Personal moral accountability.
Legal consequences of UNREASONABLE use of force – Criminal offence – e.g. assault. Breach of Mental Health Act. Breach of Human Rights Act. Civil offence – e.g. assault, wrongful detention, negligence. The consequences of inaction i.e. failure to intervene can also have consequences. Failure in moral, ethical and legal duty of care. Civil offence - Negligence. Criminal offence – Omission amounting to negligence
28 Mental Health act and Restraint- Code of Practice
The original Mental Health Act (1983) was updated in 2007 to ensure it keeps pace with the changes in the way that mental health services are – and need to be – delivered.
There is also a Code of Practice that provides guidance to registered medical practitioners (“doctors”), approved clinicians, managers and staff of hospitals, and approved mental health professionals on how they should proceed when undertaking duties under the Act.
Since then Code of Practice for the Mental Health Act 1983 was last revised in 1999, the revised Code of Practice (“the Code”) was prepared in accordance with section 118 the Mental Health Act 1983 (“the Act”). The Code came into force on 3 November 2008.
In terms of use of restraint whist supporting service users who are subject to conditions in the Mental Health Act 1983 (amended 2007) we need to focus on chapter 15 of “the code”.
Assessment and management of disturbed behaviour
15.3 On admission, all patients should be assessed for immediate and potential risks. (Including potential risks of violence and aggression to self or others)
15.6 All hospitals should have a policy on the recognition and prevention of disturbed or violent behaviour, as well as risk assessment and management, including the use of de-escalation techniques, enhanced observation, physical intervention, rapid tranquilisation and seclusion.
15.8 Interventions such as physical restraint, rapid tranquilisation, seclusion and observation should be used only where de-escalation alone proves insufficient, and should always be used as a last resort in conjunction with further efforts at de-escalation; they must never be used as punishment or in a punitive manner.
15.9 Any such intervention must be used in a way that minimises any risk to the patient’s health and safety and that causes the minimum interference to their privacy and dignity, while being consistent with the need to protect the patient and other people.
15.12 Services and their staff should demonstrate and encourage respect for racial and cultural diversity and recognise the need for privacy and dignity. These are essential values that must be engendered and asserted in all policy, educational material, training, and practice initiatives related to the safe and therapeutic management of patients.
29 Interventions where de-escalation is insufficient
15.17 Interventions such as physical restraint, seclusion or rapid tranquillisation should be considered only if de-escalation and other strategies have failed
15.18 The most common reasons for needing to consider such interventions are: Physical assault; dangerous, threatening or destructive behaviour; self-harm or risk of physical injury by accident; extreme and prolonged over-activity that is likely to lead to physical exhaustion; and attempts to abscond (where the patient is detained under the Act).
15.19 The method must be a reasonable, proportionate, necessary and justifiable response to the risk posed by the patient
Physical Restraint
15.22 Any physical restraint used should: • be reasonable, justifiable and proportionate and necessary to the risk posed by the patient; • be used for only as long as is absolutely necessary, while maintaining the Health and Safety of all involved • involve a recognised technique that does not depend on the deliberate application of pain (the application of pain should be used only for the immediate relief or rescue of staff where nothing else will suffice); and • be carried out by those who have received appropriate training in the use of restraint techniques.
15.23 Managing aggressive behaviour by using physical restraint should be done only as a last resort and never as a matter of course. It should be used in an emergency when there seems to be a real possibility that harm would occur if no intervention is made.
15.24 Any initial attempt to restrain aggressive behaviour should, as far as the situation allows, be non-physical – for example, assistance should be sought by the call system or by verbally summoning help. A single member of staff should assume control of the incident. The patient should be approached, where possible, and agreement sought to stop the behaviour. The special needs of patients with sensory impairments should be taken into consideration – approaches to deaf or hearing-impaired patients should be made within their visual field. Where possible, an explanation should be given to the patient of the consequences of refusing the request from staff to desist.
Restraint in order to administer medication
15.33 The use of restraint to administer treatment in non-emergency circumstances should be avoided wherever possible. The decision to use
30 restraint should first be discussed with the clinical team and should be properly documented, along with the justification for it.
Restraint as an indicator of the need for detention under the Act
15.34 If a patient is not detained, but restraint in any form has been deemed necessary (whether as an emergency or as part of the patient’s treatment plan), consideration should be given to whether formal detention under the Act is appropriate (subject to the criteria being met).
Training
15.36 All hospitals should have a policy on training of staff who work in areas where they may be exposed to aggression or violence, or who may need to become involved in the restraint of patients. And undertake periodic refresher training (15.38)
15.37 All staff should also be competent in physical monitoring and emergency resuscitation techniques.
Seclusion
15.45 Seclusion should be used only as a last resort and for the shortest possible time. Seclusion should not be used as a punishment or a threat, or because of a shortage of staff. It should not form part of a treatment programme. (See trust Seclusion Policy (CLP41)
The guidance in chapter 15 covers a range of interventions which may be considered for the safe and therapeutic management of hospital patients, whose behaviour may present a particular risk to themselves or to others, including those charged with their care. Except where otherwise stated, this guidance applies to all patients presenting such behaviour, whether or not they are detained under the Act. “the code” reflects Nationally recognised guidelines, such as those of the National Institute for Health and Clinical Excellence (NICE)
Positional Asphyxia
Definition: Death resulting from a body position that interferes with the ability to breathe.
31 This occurs when compression of the trunk limits chest movement, preventing the diaphragm from moving up and down between the chest and the abdomen and impairing breathing.
Positional asphyxia is a recognised cause of death.
Risk Factors in Restraint. Physical complications may more readily occur where: A clear airway is not maintained throughout the restraint process. Pressure is placed on, the neck, face, shoulders, chest, back, or stomach. A grip is maintained around the neck, stomach, or chest. Patient is bent over at waist when sitting. Struggle is prolonged. Prone position is prolonged. Respiratory syndromes (asthma, bronchitis) are present. Cardiovascular disorders are present. Drug &/or alcohol intoxification, or C.S. gas use is a factor. Mania is present. The patient is obese.
Excited Delirium This is a rare form of severe mania, sometimes part of the spectrum of manic depressive or schizophrenic illnesses.
Excited delirium is also known as: Acute behavioural disturbance Agitated delirium Cocaine-induced psychosis Acute exhaustive mania.
Causes Drug intoxication (notably cocaine) Alcohol intoxication Psychiatric illness Combination of the above
Excited delirium increases the risk of death if restrained. The person may be dangerous They will potentially struggle beyond the point of exhaustion It may be impossible to avoid going to the ground and using prone positions Pain compliance techniques will have little effect due to diminished sense of pain.
Any person who is exhibiting, or has exhibited, such symptoms should be considered a medical emergency and be examined by a doctor, regardless of any subsequent recovery.
Additional risks
32 These appear to occur with Substance use Prescribed medication Sickle cell disease Compartment syndrome
Golden Rules of restraint safety .
1. All clients will where possible, have a thorough medical assessment upon admission. Should abnormalities be detected, these will be communicated to all staff, and considered if restraint becomes necessary. 2. Medical advice may be sought from a member of medical staff as to what equates to the safest means by which to manage an individuals aggression, medication, restraint or where necessary seclusion etc. This must then be placed in the care plan. 3. All physical interventions carry a level of risk and hence should be used as a last resort, prioritising therapeutic relationship building, de- escalation, and other options as initial approaches to conflict management. 4. Never place pressure on the back, chest, stomach, face, neck, or shoulders. 5. One member of the restraint team (the person on the head), takes responsibility for observing safe airway, facial colouring and state of consciousness. Unless the role of the head person is passed on to another member of the team. 6. One member of the team (the person on the head), takes responsibility for the co-ordination of the restraint team. 7. All episodes of restraint must be for the shortest time possible. 8. Prone restraint (face down) should where possible be avoided, and where someone is in a prone position they should be moved to a supine (face up) position, sitting, kneeling, as soon as it is safe to do. 9. Care must be taken that the face remains free from soft materials such as blankets, pillows etc., which could hinder breathing. Only the flat of the lead persons hand can be placed between the clients head and the floor to prevent injury. 10.No holds will ever be used which will compress the chest, i.e. bear hugs or basket holds. 11.Where rapid tranquillisation is to be used, where possible this should take place after any struggle, and it must follow the trusts rapid tranquillisation policy. 12.Where a restraint has taken place, staff must make a judgement as to whether a medical examination or other actions may be required. The end of physical interventions may not be the end of the emergency. Where any of the issues mentioned Risk Factors are present, medical review is advised.
At all times, throughout restraint procedures, one member of staff (Head Person) will take responsibility for the head. This person will be found to have the best overall view of the client, and thus, is the team member most suited to maintaining the client’s safety, as well as coordinating the restraint process. This
33 member of the team will most usually be the one to note any physical problems that may be occurring and hence advice action as appropriate to any given situation.
It may be helpful at this stage to point out how dreadfully wrong things can go during restraint. Below are some excerpts from the Inquiry into the death of David Bennett who died during/following the use of restraint in the prone position.
Excerpts from The Bennett Inquiry
“David Bennett did not suffer from sickle cell disease, which can increase the chances of death as a result of restraint.”
“Dr Cary, a Consultant Forensic Pathologist who carried out a post mortem on David Bennett at the request of the Bennett family said: Prone restraint is an area that we know from cases around the world is a position in which people appear to die suddenly when they are restrained for long periods. And that I think is a matter of fact. There is some debate however, as regards what sort of mechanisms may be involved in causing those deaths. But we do know that the deaths occur, firstly when people have been restrained in the prone position in particular. And just to clarify that means that they are laying face downwards. And secondly, that the deaths seem to occur when the restraint and the struggling against the restraint goes on for a long period and those, as I say, are two quite well established facts.”
“The actual trainer, Mr Loudon, was a Charge Nurse (CN) at the Norvic Clinic.”…. “He was unaware of the term “positional asphyxia” prior to David Bennett’s death.”
“After he went quiet, SN Fixter took David Bennett’s blood pressure, which was 120/60. He said it was not possible on that night for a nurse to have hold of David Bennett’s head so there was no nurse in that position. He said that that was the correct thing to do in role play, but in a live situation, when you were dealing with somebody who was extremely psychotic, it did not work.”
The report in criticizing one member of staff who was apparently in overall control of the incident, stated, “The training that he had received clearly indicated that the nurse at the head is the No1 nurse in charge.”
“While appreciating that there is always a difference between an actual incident involving violence and a demonstration at a training session, we are of the view that it was negligent not to have a nurse taking proper control of David Bennett’s head throughout the incident.”
34 One patient present during the restraint, reported hearing David Bennett shout, “Get off me, get off me, I can’t breathe. Get off my throat.”
“We conclude that the restraint was mishandled by the nursing staff. There were nurses pressing on to David Bennett’s body when they should not have done so. His capacity to breath adequately was restricted so that he was unable to inhale sufficient oxygen.”
“It should have been appreciated earlier than it was that David Bennett had not simply stopped struggling, but was in a state of collapse. If there had been a nurse at his head observing the situation we consider that the delay was less likely to have occurred.”
“Dr Harrison said in evidence to us that the most important factor leading to death was restraint in the prone position for a length of time. He said:
“I understand that restraint in that position can be carried out relatively safely, although some people say you should never restrain in the prone position; but the time interval is critical. In this case I understand it was fifteen to twenty minutes which I think was far too long.””
This report, together with its findings and recommendations, was presented by the Inquiry to the Secretary of State for Health and the Norfolk, Suffolk and Cambridge Strategic Health Authority on Wednesday, 17 December 2003.
35 Section 6 Managing Clinical Risk
Effective risk management relies on planning to avoid a crisis occurring by using primary and secondary interventions.
Can violence be predicted?
By understanding the variables that contribute to violent situations an assessment of risk can be carried out and proactive rather than reactive management plans can be developed for individual service users.
What factors can help predict the risk of violence? Historical / Static Variables - remain constant throughout time and such static factors may indicate an increased risk of aggressive or violent conduct. Clinical / Dynamic Variables – can be altered through circumstantial changes and / or treatment intervention. The presence of one or many dynamic variables at a point in time can influence the risk of aggression or violence. Situational – Situational variables should also be considered and include social support, availability of a weapon, access to potential victim and staff attitudes.
Examples of Static and Dynamic Variables Historical / Static • Current young age. • Young age at first ‘offence’. • History of violent behaviour. • Early social maladjustment. • History of substance misuse. • History of mental illness. • Diagnosis of Personality Disorder. • Previous unstable relationships. • Employment difficulties. • Psychopathy.
Clinical / Dynamic Variables. • Lack of impulse control. • Anti social attitudes and beliefs. • Anger and hostility. • Suicidal / self harm intent. • Sadistic fantasies. • Homicidal ideation. • Active symptoms of mental illness. • Substance misuse. • Unwillingness to engage in treatment/.
36 Risk and Dangerousness
Risk factors alone will not make someone dangerous.
A ‘risky’ individual may be managed in a situation that reduces dangerousness.
Example – A sex offender may present a risk to children but will not necessarily be dangerous if serving a custodial sentence without access to victims.
Clinical example – A patient with schizophrenia has paranoid ideas regarding his neighbours and the threat they present to him, and he has challenged them previously. When compliant with treatment such beliefs are not present. He may therefore present a risk to his neighbours but will not be dangerous provided the risk is managed, i.e. his treatment compliance is monitored.
Application in Practice. • The following ‘preventative model’ suggests an approach to risk assessment and management utilising the evidence based good practice principles from the structured clinical judgement approach. • 1.Know the service user (identify clinical variables) – communication, respect and formation of therapeutic relationships. • 2.Obtain appropriate information – establish historical variables. • 3.Involve relevant others – care for the whole person.
Serious Incident – prevention planning. Identifying Needs and Planning Individual Care.
Advantages of a structured approach. Moray 1994 suggested – • ‘Many adverse events can be a result of faulty ‘systems’ rather than human error i.e. poorly designed processes that put people in situations where errors are more likely to be made, practitioners are therefore ‘set up’ to make errors for which they cannot and should not be held truly responsible.’ • By adopting safer practices the systems can support practitioners, aid decision-making and most importantly help patients by meeting their needs to aid recovery.
37 Section 7 Post Incident Procedures –Closing the loop
Incidents of violence and aggression are frightening for everyone involved and are best managed by preventing occurrence. However, primary and secondary interventions may not always be successful and crisis situations can occur in clinical environments. It is essential that any incident occurring is subject to post incident review to identify cause and plan for future prevention. Effective post incident review can only occur if all parties are involved- including the service user. The outcomes must be factually based to ensure positive outcomes. It can easily be assumed that someone is violent because of a learning disability or a mental illness. This may well contribute but often is not the case – the violence may be due to an emotional response simulated by external sources e.g. needs not being met.
There are various different means by which staff may receive support, which may avoid, not only the serious psychological effects of aggression, but also the stress which some people presume must go alongside healthcare posts.
If a member of staff has a bruise on their face or arms, people will naturally show concern and empathise or sympathise. When a member of staff cannot sleep at night however, or is suffering from flashbacks or nightmares following a violent incident, there may be no obvious outward signs that they are in distress.
The emotional and psychological effects can be seriously traumatising, ranging from short-term sleep disturbance right through to Post Traumatic Stress Disorder.
Some of the support offered is outlined below SEPT`s Occupational Health Provider ASP Serco contact number 01733 316519
Employee Support Helpline The Employee Support Helpline available for various issues, including advice on Finances, Legal matters, harassment, bullying, and emotional trauma resulting from violent incidents. Support can be gained through this free confidential service. The Helpline is available 24hrs a day, 365 days a year. Free phone: 0800 282 193
Managing Incidents Incidents of aggression and violence are frightening for everyone involved and are best managed by preventing occurrence. However primary and secondary interventions may not always be successful and crisis situations can occur in clinical environments.
38 It is essential that any incident occurring be subject to post incident review to identify cause and plan for future prevention. • Effective post incident review can only occur if all parties are involved – including the service user. • Outcomes must be factually based to ensure positive outcomes. • The efficacy of de briefing following an incident has been the subject of conflicting opinions. • Psychological de briefing, if done badly can potentially be more damaging to the victim. • Good practice does however indicate that an opportunity to discuss, understand and reflect on an incident is favoured by clinicians and service users. • Debriefing should not direct blame. • It should allow an opportunity to discuss and reflect upon the incident and enhance understanding. • The objective is to minimise the risk of psychological harm and re establish positive relationships.
Staff perspectives. • Staff members who have been the victim of aggression or violence need to be listened to. • They need to feel that their safety and well-being matters. • They need to know action will be taken to reduce the risk of recurrence. • They need to know how and where to access on-going support if it is required.
Service user perspectives. • Service users are at risk of being the victims of violent assault whilst in care. • Service users who experience (or witness) physical restraint can experience trauma. • Service user safety must be a priority both legally and ethically. • Service users must be provided with post incident de briefing. • If a service user is the victim of assault it must be addressed and action to ensure safe future management agreed. • If a service user is restrained this must be discussed and the reasons why this was deemed necessary shared. • Collaborative planning to prevent recurrence is essential.
Debrief Debrief is sometimes provided so that staff involved in traumatic events may be supported through the emotions which sometimes result.
“The aims of debriefing are to review in detail the facts, thoughts, impressions and reactions following a traumatic incident as well as providing information on typical reactions to critical events (Dyregrov 1997). Bisson et al. (2000) describe
39 the purpose of psychological debriefing as providing survivors of a traumatic experience with an opportunity to review their impressions and reactions to the trauma in an atmosphere where psychiatric ‘labelling’ is avoided. During the debriefing, the debriefer will also provide assurances that the participants are normal people who have experienced an abnormal event.” Tehrani Noreen (2004) Workplace Trauma, Concepts, Assessment and Interventions, Brunner-Routledge Hove and New York De-brief should not direct blame but should allow an opportunity to discuss and reflect upon the incident and enhance understanding. The objective is to minimise the risk of psychological harm and re-establish positive relationships.
The efficacy of de-briefing following an incident has been the subject of conflicting opinions. If psychological de-briefing is done badly it can be damaging to the victim. However, good practice does indicate that an opportunity to discuss understand and reflect on an incident is favoured by clinicians and service users.
Reviewing incidents
An ABC approach can be used to reflect on incident.
Antecedent – What was happening prior to the incident, were any triggers evident? Behaviour – What happened –what did the patient do? Consequence – what actions occurred in response to the incident – what did the staff do? - What did the patients do –why?
This process aims to encourage reflective practice, to gather facts from all involved and to learn from the events in order to reduce the risk of re-occurrence. The approach also prompts the need for accurate reporting and information sharing with relevant sources. The consequence element addresses de-briefing to ensure emotional support is provided for all involved. It is a separate issue to the fact-finding in order to ensure time and resources are dedicated to the person orientated need. Post incident review should identify factors for future prevention by indicating triggers and actions – this should inform active changes to the risk management process. Failure to review incidents and learning lessons will result in future incidents.
Service user support. • Organisations must ensure support structures are available and accessible for service users involved in incidents. • This may include support from the care team, advocacy, external counselling and, in some cases access to the criminal justice system. • A robust reporting and complaints procedure for service users is essential to ensure incidents are reported and action is taken.
40 Section 8 Documentation and incident reporting
Client Case Notes / Records.
The recording of accurate information regarding client behaviours is, as previously discussed, of paramount importance when it comes to care planning and risk assessment, in order to ensure good communication within a team. Accurate recording of information at times of high stress, e.g. following aggressive incidents, is something that cannot be praised too highly, especially as health care staff at times are expected to record, highly charged, emotional situations in which they find themselves.
The sheer volume of paperwork expected following a violent incident can at times be daunting, and therefore requires a methodical approach.
Before examining what forms etc, are relevant, let us look at the principles of good record keeping.
Nursing & Midwifery Council Guidelines for records and record keeping. NMC London, August 2004.
Good record keeping helps to protect the welfare of patients and clients by promoting: • High standards of clinical care • Continuity of care • Better communication and dissemination of information between members of the inter-professional health care team • An accurate account of treatment and care planning and delivery • The ability to detect problems, such as changes in the patient’s or client’s condition, at an early stage
The Nursing & Midwifery Council also laid out guidance on:
Content and Style There are a number of factors that contribute to effective record keeping. Patient and client records should: • Be factual, consistent and accurate • Be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient or client
41 • Be written clearly and in such a manner that the text cannot be erased • Be written in such a manner that any alterations or additions are dated, Timed and signed in such a manner that any alterations or additions are Dated, timed and signed in such a way that the original entry can still be read clearly • Be accurately dated, timed and signed, with the signature printed alongside The first entry • Not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements • Be readable on any photocopies
In addition, records should: • Be written, wherever possible, with the involvement of the patient, client or their carer • Be written in terms that patient or client can understand • Be consecutive • Identify problems that have arisen and the action taken to rectify them • Provide clear evidence of the care planned, the decisions made, the care delivered and the information shared.”
And
Legal matters and complaints Patient and client records are sometimes called in evidence before a court of law, by the Health Service Commissioner or in order to investigate a complaint at a local level. They may also be used in evidence by the NMC’s Fitness to Practice committees, which consider complaints about registered nurses, midwives and specialist community public health nurses. Care plans, diaries, birth plans and anything that makes reference to the care of the patient or client may be required as evidence.
42 Accident / Incident Datix Reporting
The approved methods for incident reporting are as follows: A Trust on-line DATIX web incident reporting form, the web form can be accessed through the SEPT Intranet site and is located under the forms section of the intranet. If the DATIX web on-line reporting system is unavailable or not working properly, the Trust Contact centre should be contacted on 0300 1230808 and the incident reported over the phone.
The online incident reporting form has been designed so that it is simple to use and suitable for both clinical and non-clinical incident reporting. The user interface can be personalised and adapted for ease of use. Incidents can be submitted by anyone in the organisation with access to a computer on the network.
The Datix Incident form includes a section for Control & Restraint where applicable, Attempted assault and assault All reported incidents make a valuable contribution to patient and staff safety. As an Organisation we are fully committed to ensuring our patients receive the highest standard of care and treatment; incidents assist us in acknowledging and sharing good practice and also identifying and learning from adverse events.
It does not matter whether you are reporting an accident, incident, serious incident, patient safety incident or near miss they must all be reported.
Incident - An unplanned event which resulted in harm or could have. Harm is to people or the organisation (see later)
Accident - An unplanned event which causes injury to persons, damage to property or a combination of both.
Patient Safety Incident – An incident that harmed or could have harmed a patient
A near miss, where harm could have resulted but was avoided, in relation to any of the categories will be reported
Serious incident: likely to produce significant legal, media or other interest and could result in loss of the Trusts reputation or assets.
SEPT ensures that appropriate reporting and investigation procedures are applied and enable the Trust to learn from incidents and thereby minimise the risk of similar incidents occurring in the future. This supports the Trusts philosophy and helps to achieve and maintain a safe culture within the organisation for its service users, staff, carers and visitors.
43 Any individual can report an incident and the Trust encourages that all staff who witness an incident participate in the reporting of that incident, whether they result in harm to patients or not.
Adverse Incident Policy CP3 / Adverse Incident Procedure CPG3 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR)
RIDDOR reporting is a statutory requirement to comply with the law. Failure to comply can result in prosecution.
For incidents which may fall under the RIDDOR requirements a report must be completed on DATIX and include the specifics of any injuries involving any person – i.e. client, visitor, and staff - if the incident has occurred on Trust premises (including Trust vehicles or vehicles used in the course of trust business).
The DATIX report must be completed as-soon-as-possible, but within 24 hours of the time of the incident. A Telephone call must also be made to the Risk Department to notify them of the RIDDOR on 01268-739-731.
Injuries which must immediately be reported include: Death of any person, which occurs as a result of work activity. The death of any employee if this occurs as a result of a reportable injury, but not more than one year afterwards. Any staff member being incapacitated from his/her normal duties for 4 days or more. Fracture, dislocation, amputation, or loss of sight. Hospitalisation of a person for 24 hours or more.
Various other specific injuries, diseases, dangerous occurrences and conditions are described in RIDDOR Policy, which also require reporting.
See Corporate Policy CP03, Adverse Incident Policy, Guidelines, and Appendix 14
44 Section 9 Rapid Tranquillisation
Rapid Tranquillisation is covered in the Medicine Management training for qualified Nurses.
All staff that is involved in the administration or monitoring of RT should ensure that they are familiar with the Rapid Tranquilisation (RT) Policy CLP52 and Procedural Guidelines CLPG52.
The RT policy should be read in conjunction with Policy CLP25 Prevention and Management of Violence and Aggression.
Actions to be taken prior to drug Administration
Talking Strategies De-escalation Rarely-Seclusion
Aims of Rapid Tranquillisation
To Calm the Patient To Reduce the Risk of Violence
Principles of Rapid Tranquillisation
At the earliest opportunity the MDT should fully assess the situation. This should include medical and psychiatric differential diagnosis Staff should be aware of the risks associated with RT and be able to assess these risks. Particular caution should be taken if a service user is highly aroused and/or may have been misusing drugs or alcohol, be dehydrated or possibly be physically ill.
Drugs should be used with caution because of the following risks: Loss of consciousness Over-sedation with loss of alertness Cardiovascular and respiratory complications and collapse Akathisia which can worsen aggression Damage to the therapeutic partnership between patient and clinician Specific issues in relation to diagnosis
45 Seizures
Remember: Patients who are heavily sedated or under the influence of alcohol or illicit substances should not be secluded. There may however be exceptional circumstances where seclusion is necessary. In this rare circumstance an increased level of observation will be necessary and must be obtained. The service user must be observed within eyesight by a qualified nurse (level 3 observations) as per trust policy CLP8 engagement and formal observation policy). This is due to a high risk of sudden collapse/death. If a service user is secluded, staff should be aware of the possible complications of R.T. Level 3 observations must be maintained by a qualified nurse at least until clinical monitoring of patients vital signs are possible. Absorbsion from intramuscular administration can occur far more rapidly when a service user is agitated, excited, or physically overactive. When benzodiazepines e.g. are given in high doses or when used in combination with other hypnosedatives, including alcohol and some illicit drugs. Staff should be aware that there is a higher risk of respiratory depression and ensure observations are monitored in these circumstances. Resuscitation equipment including flumazenil must be available Minimum effective doses of medicines should be used. Be aware of BNF maximum doses Oral route should be used where possible Intra muscular route is the preferred parenteral route. If IV administration is required the consultant should be involved in the decision.
Monitoring Patients should not be left unattended Vital signs must be monitored after parenteral administration (every 5-10mins for 1hour then every 30mins) BP Pulse Temperature Respiratory Rate Skin Colour (Cyanosis) Level of hydration
More intensive monitoring is required if: The patient is asleep IV administration has taken place BNF limits have been exceeded Where patients are under the influence of alcohol or illicit substances.
46 Monitoring of vital signs must be recorded on a standardized recording form that can be found as Appendix 1 at CLPG52 Procedure for Rapid Tranquillisation (RT)
Pharmacological Agents used If disturbance is behavioural and non-psychotic use lorazepam orally Intramuscular if necessary
Where there is behaviour disturbance in the context of psychosis Consider oral haloperidol, olanzapine or risperidone. Risperidone and olanzapine not for behavioural disturbance in the elderly. Single agents preferred to combinations where possible
NOTE - IM chlorpromazine and IM Diazepam are not recommended for the pharmacological control of behavioural disturbances in people with schizophrenia
Where RT is urgently needed a combination of IM haloperidol and lorazepam may be considered. Sufficient time for response should be allowed before doses are repeated If im haloperidol used consider use of an anticholinergic agent
Staff should use the opportunity to discuss any issues related to RT within clinical supervision.
Once an episode of restraint and rapid tranquillisation is over, the patient should be allowed to discuss their experience at the earliest opportunity. This should include a discussion on their views of the medication administered and an opportunity for them to prepare an advance directive that can be used in future episodes. The outcome of these discussions should be written in the service users notes, The service user should have the opportunity to document this themselves where appropriate.
47 48 Section 10 Gender
Gender-specific provision Developments in gender-specific service provision remain patchy, variable and vulnerable, although some significant advances have been made in recognising women’s special needs. The third sector remains the main provider of women-only day services. There are concerns about the sustainability of this financially vulnerable provision. Reports from some areas suggest that the restructuring of mental health day service provision has included consideration of appropriate gender-specific services. However, there is no clear evidence that this has occurred routinely. Local voluntary sector women’s centres have a clear and important role in engaging women and fostering well-being, particularly women who are marginalised. There has not been widespread development of crisis houses for women. It seems likely that commissioners and providers have been focusing on the development of Crisis Resolution Home Treatment (CRHT) services to meet national requirements. These will have benefited women, but there is a need to research whether these teams are applying gendered understandings of crisis to their work. Single-sex inpatient accommodation remains a focus for service development. Progress appears to have been slow.
There are some excellent examples where Trusts have adopted a whole-system approach to create a therapeutic environment that is physically and emotionally safe for women so that healing from mental trauma and distress can take place. Joint work combining improvements to acute care with a gender equality perspective will provide the most effective way to achieve high quality, appropriate services. Secure services for women have been rationalised since Into the Mainstream, with the concentration of women’s high secure services at Rampton and development of new gender-specific services in medium and low secure provision. However, women remain a minority within the secure services, meaning their specialised needs may be overlooked. Further work is needed as a matter of urgency to move towards the provision of genuinely personalised, tailored secure services for women as close to home as possible, and greater availability of ‘step down’ services.
Gender-sensitive provision is also variable. Welcome developments have occurred in policy and practice since Into the Mainstream, but there remains considerable scope for improvement to ensure women’s needs are not overlooked
National Mental Health Development Unit (NMHDU)
Funded by the department of Health
49 Female Male
Life Sexual, physical abuse, Domestic violence Caring and domestic responsibilities Experiences Pressure to adhere to ‘traditional’ male values, eg. not express emotion Single parents Fighting Live alone in old age Expectations of strength/protect others Bullying Institutional care Social – Poverty/state benefit or pension only Greater risk of being distant from economic children Unequal pay/part-time employment/low paid jobs realities Stress in workplace Unemployment (education, caring duties) Full-time employment Lack of mobility/non car driver or owner Burden of responsibility Fewer achievements in further education Unemployment Less likely to be in leadership position Retirement Competing, often unsupported multiple roles Low societal status and values placed on women’s roles Depression (loss and bereavement) Suicide Anxiety/Phobias (threat) Expressions Early onset psychosis of mental Obsessive compulsive disorder distress Drug and alcohol related problems Self-harm/low self-esteem Anti-social behaviour /Anger attacks Eating disorders Acting out generally Perinatal mental health problems Go missing, Rough sleepers Pathways in Primary care A&E to services Community services Criminal justice system Maternity services Substance misuse services Treatment Physical and relational safety Mental health promotion focused on needs and physical health, eg. nutrition, exercise Tackling underlying issue responses Language – ‘well-being’ rather than Talking therapies mental health Expertise in responding to history of sexual abuse Dedicated advice (not help) lines Role of voluntary sector/informal settings Proactive outreach via generic Flexible access to recognise caring responsibilities community rather than NHS services Holistic approach Work-friendly primary care hours Women-only facilities, community and inpatient Men-only group therapy Assertive outreach/early intervention National Mental Health Development Unit (NMHDU) Funded by the department of Health
50 3.1.1 Delivering gender equality The National Service Framework for Mental Health35 first drew attention to the importance of developing gender sensitive services and to address experiences e.g. violence and abuse and expressions of mental distress e.g. self harm that are more prevalent in women.
The consultation document for the national women’s mental health strategy Into the Mainstream36 was developed in recognition that the needs of women service users had been hitherto neglected. Into the Mainstream is an important strand of the Department of Health’s approach to tackling inequalities. The key message is that, in order to provide equity of service to all, specific gender differences in women and men, and their interrelationship, need to be addressed: in childhood and adult life experiences;
the day-to-day family, social and economic realities of their lives today; their expression and experience of mental distress; pathways into services; treatment needs and responses. The subsequent Implementation Guidance outlines a series of aims, recommended actions and expected outcomes to develop a gendered context for mental health and social care and to ensure that, in future, commissioners and providers of mental health services consistently: Listen to what women say they want and need. Assess their needs taking full account of the causes and context of their mental distress in addition to addressing their symptoms. Acknowledge and address the high prevalence and impact of violence and abuse: childhood sexual abuse, domestic violence and sexual violence (Outside the home). Maintain women’s safety – physical, sexual and psychological – particularly in inpatient settings. Increase the number and range of women-only services including Community day services. Improve services for specific groups of women: those from black and minority ethnic communities, mothers, women offenders, women who self-harm, have a diagnosis of personality disorder, have a dual diagnosis with substance misuse, have perinatal mental ill-health and those who experience eating disorders, with violence And abuse as an underlying theme. The Implementation Guidance also included a detailed service specification for women-only community day services and secures
51 mental health services. The Gender Public Sector Duty, that took effect in April 2007, will legally charge all public sector bodies, including NHS organisations, to demonstrate equity of outcome for women and men in all aspects of policy, workforce issues and service delivery.
See: Department of Health. (2003). Implementation Guidance: Mainstreaming Gender and Women’s Mental Health. London: Department of Health. http://nimhe.csip.org.uk Department of Trade and Industry (2005). Public sector duty to promote gender equality. Consultation document. http://www.dti.gov.uk/consultations/ consultation-1540.html
“THE GENDERED EXPERIENCE OF MENTAL ILLNESS
Pathways into Services Pilgrim and Rodgers (1993) argue that violent men are perceived as ‘bad’ whereas violent women are perceived as ‘mad’. This is clearly an oversimplification. However, they suggest that this differentiation is based on social judgement concerning rule breaking and is influential in determining that females and males enter psychiatric and criminal justice systems respectively.” Stuart & Sundeen’s (1997) Mental Health Nursing Principles and Practice Thomas Ben, Hardy Sally & Cutting Penny. Mosby, London.
Service Delivery Care & Treatment “In the prescribing of medication, the following are taken into account: - That women may require lower doses of drugs than men;
- Some side effects are of particular concern for women e.g. weight gain, loss/restart of menstruation, hair loss; some drugs have a damaging effect on foetal development, others are required at lower doses in pregnancy and some are excreted in breast milk;”
Some of the above mentioned side effects are also of concern for men along with sexual dysfunction, lactation. These are not quoted but whether male or female, when clients become hostile or lose trust in Mental Health Services this must be considered as a possible cause, which may lead to aggression.
Specialist mental health services: Extending women-only provision. Women only inpatient services
52 “A significant number of women express the wish to be cared for in a women-only ward as it makes them feel safer, comfortable at a time when they are acutely distressed and they feel that their needs are more appropriately met in an all-women environment. Some women advocate the need for choice of either a mixed-sex or women-only setting which reinforces the need to consult with women service users at the planning stage on the option of retaining a proportion of mixed-sex wards or changing to solely single-sex wards.”
“Aims: To provide a self-contained women-only ward/unit* in every acute inpatient service by reconfiguring existing services (or provision of a new-build if one is planned). To address the wish of many women service users to be cared for in a women-only inpatient environment.”
Key Actions Address staffing issues e.g. staff preference for working with women and/or men, desired ratio of women to men staff/women-only staff;
Meeting the needs of specific groups of women Women who have experienced violence and abuse Research has consistently shown that between 20-30% of women have been sexually abused as a child (and up to 10% of male children). Domestic violence accounts for 25% of all violent crime, two out of five murders of women in England and Wales are by partners/ex-partners and around 30% of domestic violence begins during pregnancy or after childbirth; existing violence often escalates at this time. Figures indicate that one in ten women have experienced some form of sexual victimisation including rape, and that ‘strangers’ are only responsible for 8% of rapes. Research has also consistently shown a link between domestic violence and the physical and/or sexual abuse of children by the same male perpetrator, in addition to the majority of children witnessing the violent and abusive behaviour to their mothers.
Moreover, some women abused as children, can be vulnerable to re-victimisation and find themselves in violent or abusive situations and relationships subsequently.
Studies indicate that 50% or more of women within the mental health system are survivors of violence and abuse; in secure settings the figure is much higher.
Department of Health Mainstreaming Gender and Women’s Mental Health Implementation Guidance September 2003 Crown Copyright 2003
53 Section 11 Equality and Diversity
Definitions • Discrimination is the unfair treatment of a person or group on the basis of prejudice; • Diversity is about the recognition and valuing of difference, in the broadest sense. It recognises respect, value and harnesses difference; • Equality is about creating a fairer society, so that everyone can fulfil their potential; • Equal opportunities ensures that people have an equal chance, and are not disadvantaged; • Prejudice is a pre-conceived opinion of a person or a group of people, often with little or no justification; • Stereotype is a widely held belief towards a group of people. These perceptions can lead people to blame or criticise a specific group of people unfairly
Equality & Diversity Awareness Without respect for equality and diversity, bullying and harassment can be allowed to take place. Examples of bullying and harassment include: • Insults; • Malicious rumours; • Ridiculing or demeaning someone; • Exclusion or victimisation; • Misuse of power or position; • Deliberately undermining people and blocking promotion or training opportunities.
The Equality Act 2010 which replaced the Disability Discrimination Act (DDA) 1995 aims to end the discrimination that many disabled people face. It now gives disabled people rights in the areas of employment, education, access to goods, facilities and services.
The Act defines a disabled person as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. A mental illness no longer has to fulfil the criterion of 'clinically well-recognised'; Long term means that the effect of the impairment has lasted or is likely to last for at least 12 months; People with HIV, cancer and multiple sclerosis will be deemed to be covered by the Act from the point of diagnosis, rather than from the time when the condition has some adverse effect on their ability to carry out normal day-to-day activities.
Discrimination Why does discrimination happen? People adopt attitudes, perceptions, prejudices and stereotypical views during early life that are then hard to shift. This can be further compounded by experiences in later life. For example, a person may become prejudiced by witnessing discriminatory behaviour by their peers
54 Discrimination Actions Discriminatory actions include bullying, harassment and victimisation. 1. Bullying - A misuse of power or position which criticises, condemns or humiliates people, undermining their ability and confidence. 2. Harassment - Conduct or comment which is unreasonable, unwelcome or offensive and causes the recipient to feel threatened, humiliated or embarrassed. 3. Victimisation -Treating an individual less favourably because they have complained about discrimination or supported someone else who has
Discrimination Types The new Equality Act extended the types of discrimination to seven. These are: 1. Direct discrimination - where someone is treated less favourably than another person because of a protected characteristic. 2. Associative discrimination - this is direct discrimination against someone because they are associated with another person who possesses a protected characteristic. 3. Discrimination by perception - this is direct discrimination against someone because others think that they possess a particular protected characteristic. They do not necessarily have to possess the characteristic, just be perceived to. 4. Indirect discrimination - this can occur when you have a rule or policy that applies to everyone but disadvantages a person with a particular protected characteristic. 5. Harassment - this is behaviour that is deemed offensive by the recipient. People can now complain of the behaviour they find offensive even if it is not directed at them. 6. Harassment by a third party - employers are potentially liable for the harassment of their staff or customers by people they don't themselves employ, i.e. a contractor. 7. Victimisation - this occurs when someone is treated badly or less favourably because they have made or supported someone else who has made a complaint or raised a grievance
Trust Policies To support the Equality and Diversity agenda the Trust has developed a range of policies. • Dignity at Work • Disability in Employment • Time off for Trade Union Duties • Whistle-blowing • Equal Opportunities • Flexible Working These policies are in place to support all staff, throughout their working lives here at SEPT. They demonstrate that our Trust is committed to providing support and will continue to develop workable and effective solutions
55 Section 12 Culture, Race and Ethnicity
Culture and ethnicity
Culture What does it mean?
ETHNICITY Culture forms the fundamental basis for Denoting or people’s lives and behaviours. deriving It is vital that we have an awareness of from the cultural the various cultures that form the traditions of a societies that we live in. group of people Some behaviours and attitudes result from cultural backgrounds.
R. Kanyuaghu 2004
An awareness of the different cultures that we deal with in health services helps: To appreciate peoples differences Beliefs and attitudes Religious and spiritual values Dietary preferences Behaviours
When assessing the risk of violence, care needs to be taken not to make negative assumptions based on ethnicity. Staff members should be aware that cultural mores might manifest as unfamiliar behaviours that could be misinterpreted as being aggressive. The assessment of risk should be objective, with consideration given to the degree to which the perceived risk can be verified (NICE 2005).
Staff should take time to listen to service users, including those from diverse backgrounds (taking into account that this may take longer using an interpreter), so that the therapeutic relationships can be established. (NICE 2005)
56 Non - Verbal Communication Signals of non – verbal communication vary across cultures in terms of posture, gesture, distance, spacing, eye contact and volume and tone of speech. D’Ardenne and Mahtani (1989) cite the example of high levels of eye contact found in some Arabic and Latin American cultures that Europeans may find uncomfortable. Cross – culturally, notions of ‘comfortable distance’ between individuals vary widely and point to the need for our awareness of how we frequently interpret the non – verbal conventions of other cultures by our own norms.
Staff Should Acknowledge and learn from the many and varied cultures experienced through the profession Always check cultural needs as part of the assessment process Work collaboratively with the patient and their family to meet the needs of the individual. If Language proves a barrier to understand request an interpreter is required to help alleviate fears and anxieties.
Lack of awareness could cause the following Feelings of disrespect from the patient Anger Perceive behaviour as an insult Feelings of neglect Purposeful infringement of ones human rights (R.Kanyanghu 2004).
Comments on racism from the Bennett Enquiry (2004)
“This is a subject of great importance in our multi – ethnic society. The views of our witnesses were virtually unanimous. Institutional racism is present throughout the National Health Service (NHS).”
“The confidence of the black and minority ethnic communities, as far as the mental health services are concerned, has been lost.”
“ We have adopted the definition of “Institutional Racism” as set out by Sir William Macpherson in the Stephen Lawrence inquiry (1999):”
“Institutional Racism is the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping, which disadvantage minority ethnic people”.
“ African cultures are different from Caribbean cultures and people from different African Cultures are also diverse. Statistics show that the black patient group from these backgrounds is more likely to be restrained, more likely to be secluded and more likely to be prescribed medication than any other group. These patients are also less likely to be given psychological treatment rather than physical treatment.” The Bennett Enquiry (2004).
57 Section 13 Key messages and action planning
Key Messages The most effective way to manage violence is to prevent it occurring. If a crisis situation occurs reflect and learn and plan for future prevention.
Safer and more therapeutic services can be achieved by working collaboratively.
Preventing and managing violence is everyone’s responsibility. – Are patients violent?
Key Messages-How would you rather manage violence?
With this? Think people……
• Empathy • Listening • Understanding • Compassion • Patience • Caring • Hearing • Helping • Talking • Sharing • Empowering
Or this? Think problems…Stop/think….
• Restrain • Prosecute • Medicate • Seclude • Contain • Inject
Not all incidents can be prevented and some may result in a high level intervention being necessary…….but question how many can?
58 Key messages – what would describe a mental health problem – STOP/THINK?
• Challenge the language…
• She went crazy • He is playing up • She is acting up • She is a typical P.D • It is just attention seeking • It is just behavioural • He is bad not mad • He kicked off
• Change the culture….
• Frightened • Distressed • Angry • Tormented • Agitated • Unwell • Upset
Is the young lady with a manic illness who keeps interrupting the staff handover meeting attention seeking or ill…..
Is the elderly man asking for the 10th time to go home annoying or confused and disorientated….
Is the child with learning disability who is banging his head on the floor acting up of frustrated at being unable to articulate his needs…..
59 Promoting Safe and Therapeutic Services
In order to ensure a change in culture a number of initiatives are required as demonstrated by the safer services model.
The model demonstrates the importance of communication to enhance trust and confidence for people working in and using mental health and learning disability services. Safer Services Model
Clinical support Post incident & supervision support & review Staff training Recruitment & & education Retention
COMMUNICATION Services users & carer involvement Therapeutic environment
SAFER SERVICES TRUST Criminal justice liaison Robust complaints process with follow up •prosecution actions CONFIDENCE •police intervention
Organisation Collaborative boundaries Joint policy risk management & clear development documentation Information •search sharing •exclusion •violence prevention •sedation •seclusion
60 Action plan.
What additional training do I need? What can I do differently? What can my team do differently? What does my organisation have to do to help?
Appendix 1 Translation and Interpreting Services
Some Guidance Minority Languages The Trust has a contract with Essex Interpreting to provide interpreters for assessments and meetings, with people who cannot understand English well enough to fully participate. British Sign Language is also included. As a principle of good practice it is not appropriate for a service user's family member to provide interpretation in professional meetings. Please see the Trust leaflet on the Translation and Interpreting Service.
When using interpreters, efforts should be made to avoid the use of medical terminology, as this may easily be misunderstood in translation.
Please call Essex Interpreting : 01206 822080
8.2 Women from black and minority ethnic communities “Services who are working with women whose first language is not English must ensure that, wherever possible, women translators are made available. This will enable them to discuss confidentially any issues that they may be more reluctant to disclose if their partner or male community representative is translating on their behalf. The use of independent translator would also eliminate the potential for the ‘known’ translator to convey their own interpretation or ‘view of the events’ rather than strictly conveying the woman’s expressed feelings or needs.”
Department of Health Mainstreaming Gender and Women’s Mental Health Implementation Guidance September 2003 Crown Copyright 2003
61 Appendix 2 SAFE CLIENT ESCORTS
Within Hospital Grounds
Where clients are to be taken on ground leave / escorted on walks with staff, from any clinical area, the safety of the client, staff and also members of the public must be considered.
As a general precaution ground leave is best avoided in hours of darkness
Nursing Action Prior to patient going on leave
Just because leave has been granted in notes, or in current risk assessment/care plan this does not always mean that leave has to be given
A few pertinent questions would be:
Has there been any contra indication, since leave was last granted? Is the same level of supervision still appropriate or may this need to be increased? Consider risk to escorting staff. Brief mental state examination Confirm current leave status – i.e. Duration of leave Number of escorts Any other restrictions
Nurse in charge and other members of staff on duty especially security nurse (where appropriate) to be made aware of leave taking place.
Escorting nurse/s to maintain radio contact (where available) with ward.
Patients name, clothing description, time of going on leave and time due back to be indicated in security book (where available).
Patients name and time of departure/arrival is to be indicated on security board (where available).
It may at times be necessary for clients to hand over keys, credits cards etc, as part of their agreed leave status.
Whilst patient on leave Nurse escorts never to walk in front of patient, to be either a step behind or on the side of patient. Particular care to be taken around stairs, stay at least three paces above or below client .If radios are available, radio check with ward once out of ward area
62 If patient absconds, do not attempt to physically stop them on your own, contact ward for assistance
What may be done, is to follow the client at a safe distance and maintain radio contact as this may lead to support and hence the opportunity to safely detain the client
If patient attempts to be physically aggressive towards you, running away is perfectly acceptable, breakaway if necessary and seeks assistance via radio or move to safe area.
Terminate leave if there are any concerns about you and/or patients safety contacting the ward area immediately
Monitor patient’s general behaviour/interaction with others whilst on leave, handover to other staff and enter in client notes upon return
Upon return to ward
Indicate time that patient returned to ward in security book.
Make your colleagues aware of your return
Give verbal and written feedback (Phonecalls, Cardex, Incident Form, Untoward Incident Form etc)
Review of patient leave status if patient presented problems.
Escorts Involving Vehicles
Where escorts to other hospitals, appointments, courts etc, are to be arranged involving the use of vehicles, the safety of staff, clients, taxi drivers, and other road / transport users must be considered.
Taxis and public transport should only be used where risks are generally low, and even then appropriate use of staff escort should usually be considered when dealing with inpatient clients.
Always remember that taxi drivers etc are not responsible for assessing the safety of a client. That is a multi-disciplinary team decision.
Risk assessment processes should be used when considering means of transportation.
63 Ground Rules
64