J R Coll Physicians edinb 2017; 47: 176–82 | doi: 10.4997/JrCPE.2017.218 SYMPOSIUM REPORT How to deal with violent and aggressive patients in acute medical settings RH Harwood1 EducationDealing with violence and aggression is an area where health professionals Correspondence to: often feel uncertain. Standing at the interface between medicine, psychiatry RH Harwood Abstract and law, the best actions may not be clear, and guidelines neither consistently Health Care of Older People applicable nor explicit. An aggressive, violent or abusive patient may be Nottingham University behaving anti-socially or criminally. But in acute medical settings it is Hospitals NHS Trust more likely that a medical, mental health or emotional problem, or some Queen’s Medical Centre combination thereof, is the explanation and usually we will not know the relative contribution Nottingham NG7 2UH of each element. We must assume that dif cult behaviour represents the communication UK of distress or unmet need. We can prevent and de-escalate situations by understanding why they have arisen, identifying the need, and trying to anticipate or meet it. In these situations ‘challenging behaviour’ is much like any other presenting problem: the medical approach is Email: to diagnose and treat, while trying to maintain safety and function. In addition, the person- [email protected] centred approach of trying to understand and address psychological and emotional distress is required. Skilled communication, non-confrontation, relationship-building and negotiation Based on a lecture given represent the best way to manage situations and avoid harm. If an incident is becoming at the St Andrews Day dangerous, doctors need to know how to act to defuse the situation, or make it safe. Doctors Symposium, Royal College must know about de-escalation and non-drug approaches, but also be con dent about when of Physicians of Edinburgh, physical restraint and drug treatment are necessary, and how to go about using appropriate November 2016 drugs, doses, monitoring and aftercare. There are necessary safeguards around using these approaches, from the perspectives of physical health, mental wellbeing, and human rights. Keywords: acute hospitals, challenging behaviour, de-escalation, distress, rapid tranquilisation, violence Declaration of interests: no confl ict of interests declared Introduction Sometimes this is the case; intentional or wilful aggression or Violence is the use of physical force, verbal abuse, threat negligent harm committed by someone with mental capacity or intimidation, which can result in harm, hurt or injury to is a crime. But there are other possibilities. For doctors and another person. Aggression is a hostile behaviour or threat other staff in acute medical settings there is uncertainty, of attack. Both are part of a larger group of challenging about why it is happening, or what you can do to stop it. behaviours: non-verbal, verbal or physical actions which make Healthcare staff are called upon to make decisions about how it diffi cult to deliver good care safely.1,2 to respond, including whether to involve psychiatrists, security staff, or the police, or using physical restraint or medication Unfortunately, aggression in acute hospital settings is to try to reduce the behaviour or regain control. Decisions common, especially low-level resistance, hitting out or must be made on the basis of limited information, often in other physical assault, or verbal abuse. Many healthcare a hurry. This can result in unease, indecision and stress. professionals, especially nurses, feel it is part of the job, and simply tolerate it. But it can result in serious injury to In general hospital settings, aggression is commonly the patient, staff, other patients or visitors, and contributes assumed to be most prevalent in Emergency Departments, to staff stress and work absence.3 where dealing with aggression is a signifi cant concern. But NHS incident reports indicate that events are numerically Interpreting aggression and violence is complex and can be more common on medical, geriatric and psychiatric wards.4 misunderstood. Politicians and the press often assume it has The most likely demographic involved in incidents is men a moral basis; aggression is due to lack of control or respect, aged between 75–95, with their female peers not far behind or is associated with intoxication with drugs or alcohol. (Figure 1), strongly suggesting that delirium and dementia lie 1Consultant Geriatrician and Professor of Geriatric Medicine, Health Care of Older People, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK 176 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH VOLUME 47 ISSUE 2 JUNE 2017 Violent and aggressive patients in acute medical settings Figure 1 Population pyramid for occurrence of violent incidents in acute hospitals by age range and gender of alleged perpetrator (2010– 2015). Source NHS Protect4 Figure 2 Population pyramid for occurrence of violent incidents in acute hospitals by age range and gender of victim (2010–2015). source nhs Protect4 behind much of the problem. Female nurses are most often understanding the reasons for distress, then anticipating the victims (Figure 2). These data take no account of cause, and meeting needs. Dealing with violent situations when they severity or likely under-reporting. occur is a last report. Understanding challenging behaviours Since the 1990s the NHS has had a policy of zero- tolerance to violence against staff. This calls for setting There is always a cause for aggression. The cause will be and communicating explicit boundaries of acceptable a combination of factors intrinsic to the patient, such as behaviour, warning or confrontation if they are breached, personality, physical symptoms or intense mental distress, followed by resorting to coercive enforcement (security and extrinsic factors, including attitudes and behaviours staff or the police), and possible exclusion from services shown by staff and other people, the physical environment, or judicial sanction if transgression is serious or repeated. and restrictions that limit the patient’s movement or actions.1 The underlying assumption is that acts of aggression are, or should be, under voluntary control. If they are, individual A good starting point is to assume that any aggression patients should exercise that control, and violence is a crime. indicates a patient’s distress, or an attempt to communicate But in practice determining degrees of control and culpability unmet needs, in someone whose coping abilities have are not so simple. Conditions associated with aggression been exceeded. The person wants something, wants to include delirium, dementia, psychosis, intellectual (learning) do something or is afraid of something. Prevention means disability, personality disorder, grief, anxiety, frustration, and JUNE 2017 VOLUME 47 ISSUE 2 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 177 RH Harwood Table 1 Mental state examination Domain Comments Appearance and Describe what you see objectively and dispassionately. Alertness, vigilance, attentiveness or behaviour distraction, motor activity, involuntary movements, calling out, mood, emotions, response to interaction and care giving, evidence of reaction to delusions or hallucinations Communication Assess and record understanding and expression, as in a neurological examination, and content of speech. Note sensory impairments Mood and emotions Ask about mood. Consider elation, enjoyment, hopelessness, guilt, self-harm or suicidal ideation. Biological features of depression, including sleep and appetite. Emotions such as anxiety, fear or anger Perceptions Hallucinations are perceptions not explained by sensory stimulation – visions, voices, sometimes other modalities Thoughts Delusions are strongly held false beliefs, not culturally or religiously appropriate. Often paranoid (involving threat of harm), but may be grandiose, or nihilistic (‘mood congruent’). Ask about worries, or if the person is being treated well by others Cognition Orientation, memory, attention (days of week or months or year backwards), reasoning and logical thought; use a brief screen such as the Abbreviated Mental Test score, and a delirium screen such as 4AT or Confusion Assessment Method. Insight To what extent does the patient realise there is a problem? Risk Of harm to self or others, suicide, absconding, self-neglect, exploitation Mental capacity Ability to make a specifi c decision, for example about remaining in hospital or receiving medical tests or treatments unpleasant symptoms. In an acute medical setting most lack control over events. Hospitals can also be boring, with instances of aggression will not be culpable. In this context an long periods of inactivity, long waits, lack of information, approach advocating ‘zero tolerance’ is insuffi cient. It may be or restricted movement, and little access to fresh air (or that under suffi ciently extreme circumstances and provocation cigarettes). Hospitals concentrate people who are vulnerable, any of us could become aggressive. who cannot understand, cannot communicate, who misinterpret, or who have a different perception of reality or Some groups of patients represent a higher risk than others, different priorities. Provocation though illness, environment or including those with cognitive or mental health problems, drug relationship problems with staff or the organisation may lead or alcohol misuse, or a history of crime or aggression, but