Management Imminent Violence

The information contained here is based on the RCPsychiatrist Publication Management Imminent Violence - RCPsychiatry 2004 Quick Reference Guidance.

Risk assessment and action to anticipate and de-escalate violence

All staff should be trained to recognise the warning signs of violence and to monitor their own verbal and non-verbal behaviour.

Possible antecedents of violence:

Increased restlessness, bodily tension, pacing, arousal
Refusal to communicate, withdrawal
Verbal threats or gestures
Increased volume of speech, erratic movements

Thought processes unclear, poor concentration
Self-reporting angry or violent feelings
Facial expression tense and angry, discontented
Delusions or hallucinations with violent content
Carers reporting users’ imminent violence

Tactics for de-escalation

Maintain adequate distance
Move towards safe place, avoid corners
Explain intentions to patient and others
Appear calm, self-controlled, confident

Ensure own non-verbal communication is non-threatening
Engage in conversation, acknowledge concerns and feelings
Ask for facts of problems, encourage reasoning
Ask for weapon to be put down (not handed over)
Consider methods (e.g. medication).

Restraint

Protocol for rapid tranquillisation

Restraint should be used only after the failure of attempts to promote full participation in self care, e.g. by voluntary 'time out' and/or consent to take medication. It should not be used as a means of intimidation or punishment but only as a last resort, at the end of a hierarchy of interventions. If restraint is necessary, it should be used with thoughtful consideration for the self-respect, dignity, privacy, cultural values, and any special needs (e.g. physical illness or disability) that the patient may have. Mechanical restraints should not be used.

Reasons for using restraint Serious degree of urgency and danger

Significant physical attacks
Significant threats or attempts at self-injury
Seriously destructive of property
Prolonged and serious verbal abuse, threats, disruption of ED
Risk of serious accident to self and others
Attempts to abscond (if detained under Section)
Protocol for rapid tranquillisation

Staff must receive training in the use of restraint
The reasons for restraint should be explained to the patient
Team members should be allocated responsibilities
Miantain communication
Be appropriate to the age, size and gender of the patient. (not be dependent on the height or weight of staff members or patient)
Not involve neck compression
Use secure grips, Minimise pain, Maintain dignity
Protect the patient's head during descent
Protect the patient's air supply and use controlled descents
Avoid unnecessary pressure on the patient's back or chest

Debriefing

All staff and patients, involved with the incident should be considered. Facilitate discussion about:

What happened and any trigger factors
Their role in the incident
How they feel now
How they might feel in the next few days
What can be done about it