Restraint should be last resort for violent behaviour
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《英国医生杂志》
Rapid tranquillisation and physical restraint should be considered for use in patients with disturbed or violent behaviour only when other strategies have failed, say guidelines published this week for the NHS in England and Wales.
The guidance recommends that short term measures for managing disturbed or violent behaviour in psychiatric inpatient settings and accident and emergency departments should be based on comprehensive risk assessment and risk management. All mental health service providers should ensure that their services have a full risk management strategy for assessing risk and preventing violence. This should include measures to calm down a potentially violent situation and intervene safely when violence occurs.
Rapid tranquillisation, physical restraint, and seclusion should be considered only after these measures have failed to calm the service user, the guidance warns. The intervention selected must be a reasonable and proportionate response to the risk posed by the service user. The guidelines point out that failure to act in accordance with its recommendations would "not only be a failure to act in accordance with best practice, but in some circumstances may have legal consequences."
The guidelines were developed for the National Institute for Clinical Excellence (NICE) by the National Collaborating Centre for Nursing and Supportive Care, a professionally led group based at the Royal College of Nursing; they also included input from service user groups. The recommendations state that all staff who might have to manage patients with disturbed or violent behaviour should receive ongoing competency training to recognise anger, potential aggression, antecedents, and risk factors of disturbed and violent behaviour and to monitor their own verbal and non-verbal behaviour. This training should include methods of anticipating, calming, or coping with disturbed or violent behaviour.
Professor Kevin Gournay from the health services research department at the Institute of Psychiatry, London, who is chairman of the guideline development group, said: "This guidance has taken into account all the available evidence and has been compiled taking into account the views of staff, patients, service users, patient抯 families, and all who are involved in the area of mental health. I hope this guideline will lead to better awareness of the triggers of violent behaviour and better management of incidents when they occur."
The guidelines stipulate that staff who may need to use physical intervention such as restraint or seclusion and those involved in administering rapid tranquillisation must be trained to an appropriate level in life support techniques, including the use of defibrillators. They specify that during physical restraint, one team member should be responsible for protecting and supporting the patient抯 head and neck, where required. The team member who is responsible for supporting the head and neck should take responsibility for leading the team through the physical intervention process, and for ensuring that the airway and breathing are not compromised and that vital signs are monitored.
To try to work more effectively with service users, the guidelines suggest that those identified to be at risk of disturbed or violent behaviour should be given the opportunity to have their needs and wishes recorded in the form of an advance directive.
Donna-Maria Fraher, representing service users on the guideline development group, said: "This guideline is good news for service users because it emphasises the importance of actively involving service users in the decision making process by, for example, an advance directive requirement and involvement in the risk assessment interview process. The focus on relationships and on alternatives to drugs and restraint in this guideline are important indicators of a shift to a more humane and respectful service."
Joan Field-Thorn, manager of Black Orchid, a support group for black and ethnic minority users of mental health services based in Bristol, said: "The guideline stresses the importance of ensuring everyone has care that is appropriate for their needs and redresses the imbalance of power that people with mental illness may suffer. It is suggesting ways of mental health service users and health workers building better relationships. This will make violence less likely to occur." Ms Field-Thorn chaired a focus group of Afro-Caribbean service users that provided input to the guideline, including a chapter focusing specifically on the needs of black and ethnic minority mental health service users. The guideline will set a standard against which service users can now assess the care they receive, she concluded.(London Susan Mayor)
The guidance recommends that short term measures for managing disturbed or violent behaviour in psychiatric inpatient settings and accident and emergency departments should be based on comprehensive risk assessment and risk management. All mental health service providers should ensure that their services have a full risk management strategy for assessing risk and preventing violence. This should include measures to calm down a potentially violent situation and intervene safely when violence occurs.
Rapid tranquillisation, physical restraint, and seclusion should be considered only after these measures have failed to calm the service user, the guidance warns. The intervention selected must be a reasonable and proportionate response to the risk posed by the service user. The guidelines point out that failure to act in accordance with its recommendations would "not only be a failure to act in accordance with best practice, but in some circumstances may have legal consequences."
The guidelines were developed for the National Institute for Clinical Excellence (NICE) by the National Collaborating Centre for Nursing and Supportive Care, a professionally led group based at the Royal College of Nursing; they also included input from service user groups. The recommendations state that all staff who might have to manage patients with disturbed or violent behaviour should receive ongoing competency training to recognise anger, potential aggression, antecedents, and risk factors of disturbed and violent behaviour and to monitor their own verbal and non-verbal behaviour. This training should include methods of anticipating, calming, or coping with disturbed or violent behaviour.
Professor Kevin Gournay from the health services research department at the Institute of Psychiatry, London, who is chairman of the guideline development group, said: "This guidance has taken into account all the available evidence and has been compiled taking into account the views of staff, patients, service users, patient抯 families, and all who are involved in the area of mental health. I hope this guideline will lead to better awareness of the triggers of violent behaviour and better management of incidents when they occur."
The guidelines stipulate that staff who may need to use physical intervention such as restraint or seclusion and those involved in administering rapid tranquillisation must be trained to an appropriate level in life support techniques, including the use of defibrillators. They specify that during physical restraint, one team member should be responsible for protecting and supporting the patient抯 head and neck, where required. The team member who is responsible for supporting the head and neck should take responsibility for leading the team through the physical intervention process, and for ensuring that the airway and breathing are not compromised and that vital signs are monitored.
To try to work more effectively with service users, the guidelines suggest that those identified to be at risk of disturbed or violent behaviour should be given the opportunity to have their needs and wishes recorded in the form of an advance directive.
Donna-Maria Fraher, representing service users on the guideline development group, said: "This guideline is good news for service users because it emphasises the importance of actively involving service users in the decision making process by, for example, an advance directive requirement and involvement in the risk assessment interview process. The focus on relationships and on alternatives to drugs and restraint in this guideline are important indicators of a shift to a more humane and respectful service."
Joan Field-Thorn, manager of Black Orchid, a support group for black and ethnic minority users of mental health services based in Bristol, said: "The guideline stresses the importance of ensuring everyone has care that is appropriate for their needs and redresses the imbalance of power that people with mental illness may suffer. It is suggesting ways of mental health service users and health workers building better relationships. This will make violence less likely to occur." Ms Field-Thorn chaired a focus group of Afro-Caribbean service users that provided input to the guideline, including a chapter focusing specifically on the needs of black and ethnic minority mental health service users. The guideline will set a standard against which service users can now assess the care they receive, she concluded.(London Susan Mayor)