The Spinney Psychiatric Services
1 Day De-escalation
Programme
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Introduction
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Facilitators
Facilities
Fire exits
Toilets
Refreshments
Breaks
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Ice Breaker
To start the course proper we will start
with an exercise.
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Aims
• Management of aggression in health
care settings
• Permissible forms of control
• Organisational issues
• Increase confidence
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Objectives
• Raise knowledge concerning
aggressive/violent behaviours
• Examine own feelings and attitudes towards
people who exhibit such behaviours
• Recognise triggers which cause aggression
• Identify ways to reduce aggression
• Learn strategies for dealing with aggression
and violence
• Understand the main laws, policies and
guidelines in respect to work setting
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Violence
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Extreme end of spectrum
Causes damage, destruction or injury
Abuse, threats or assaults at work
Who is at risk?
Is it MY concern?
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Legal Requirement
• Section 2(1) of the Health and Safety at Work
Act 1974
• Management of Health and Safety at Work
Regulations 1999
• UKCC (1996)
• The Spinney Policy Manual
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What the Law Requires
• The Management of Health and Safety at
Work Regulations 1999
• The Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations 1995
(RIDDOR)
• Safety Representative and Safety Committees
Regulations 1977
• Health and Safety (consultation with
employees) Regulations 1996
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Violence to Staff in Health Care
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Health service advisory committee
1987 survey
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Major injuries
Minor injuries
No physical injury due to threats
Verbal abuse
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Mezey & Shepherd (1997)
• Primary health care and A & E increased
assaults
• Increased injuries to nursing staff
• Increased injuries to junior doctors,
support workers and student nurses
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Health Service Advisory Committee
1997
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Training
Causes of violence
Warning signs
Interpersonal skills
Incident reporting
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Violence in Mental Health Care UKCC
2001
• Violence directed towards anyone is
unacceptable.
• Recognition, prevention and
management of violence
• A need for appropriate training
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Break
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Reasonable Force (Definition)
“ Reasonableness means, firstly, that the force
should be no more than is necessary to
accomplish the object for which it is allowed
(so retaliation and punishment are not
permitted) secondly, the reaction must be in
proportion to the harm that it is threatened…
obviously, the greater the severity of the
threatened anger, the more reasonable it is to
take tougher action”
Dimond (1995)
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Reasonable Force (Principles)
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Assessment
Assessing reasonable force
Rule of engagement
There must always be a resolution
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Use of Force
• Lord Griffiths ………
• Section 3 criminal law act 1967
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Scenario 1
• Exercise on the use of force and what is
reasonable
• Justification of actions
• Correct documentation
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Review scenario 1
• Discussions on the scenario on the use
of force.
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Body`s Autonomic Response
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Outward non-verbal cues
Indication of person aroused
Bodily responses to threat and stress
These come in a variety of forms
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Responses
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Clenched fists, teeth and muscles
Wrinkled brow, frowning
Lack of eye contact
Invading personal space
Hands on hips, provocative movements
Square on, confrontational
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Responses
• Flushed, pale or blotchy complexion
• Pacing, foot tapping, page flicking
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Group work
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Divide into three groups and
brainstorm to find definitions of the
following
1. Anger
2. Aggression
3. Violence
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Lunch Break
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Anger
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Emotional response
Disrupts thinking
Disrupts problem solving
Intense irritation
Motivation
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Aggression
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Outward act
Acceptable
Physical, verbal, mental and passive
Difficult to define barrier
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Violence
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Extreme end
Great force
Damaging
Physical and mental
Two kinds
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Manifestations
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Thoughts
Feelings
Actions
Bodily functions
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Aggression in Healthcare
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Triggers
Personal factors
• Genetic/constitutional/physiological
• Personality
• Attitude
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Triggers
External factors
• Frustration
• Powerlessness
• Threat
• Fear
• Provocation/abuse
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Assault Cycle
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Trigger
Escalation
Crisis
Plateau
Post crisis
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Assault Cycle Chart
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Baseline Behaviour
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Normal behaviour
Settled
Feeling in control
Different from person to person
Maslow`s(1970) hierarchy of needs
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Trigger
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A shift from baseline
Enforced socialisation
Lack of choice
Lack of privacy
Lack of autonomy
Trigger reduction
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Escalation
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Deviates more from baseline
Over focused
Early intervention
Non verbal cues
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Crisis
• Physically, emotionally and
psychologically more aroused
• Direct assault likely
• Focus on own safety
• Intervention of physical restraint (preemptive)
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Plateau
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High arousal slowly returns to baseline
Adrenaline and glucose levels remain
Possible further risk of assault
Interventions similar to escalation phase
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Post Crisis
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Fall below the base line
Physically and mentally exhausted
Remorseful
Need support
Time to explore
Comprehensive documentation
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Role Plays
• There will be a series of role plays to be
presented with your participation to
illustrate the interventions at various
stages of the cycle.
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Break
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Assault Cycle Chart
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Self positioning
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Clear exits
Angled sitting position
Ready for departure
Hand gestures
Distance
Not standing over person
Tone of voice
Peripheral vision
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Questions and Answers
• A little question and answer sheet for
you to participate in
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Feedback and Evaluation
• Verbal
• Written
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References
• Department of health and welsh office
(1993). Code of practice: mental health
act 1983. London HMSO
• Department of Health Guidelines
HC(72)11 : Dealing with violence in the
hospital setting
• Dimond, B. (1990). Legal aspects of
nursing. London: prentice-hall.
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References
• Health and safety at work act (1974).
London HMSO.
• Kaplan, S. G., & Wheeler, E. G. (1983).
Survival skills for working with
potentially violent clients. Social
casework: the journal of contemporary
social work.
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References
• Farrell,G.A. & Gray,C.(1992).
Aggression, A Nurses guide to
Therapeutic Management, London,
Scutari Press
• Health and Safety at Work Act 1974
Section 2(1)
• Hogan, G (1995) Care and
Responsibility the Legal Framework,
Ashworth Hospital handout.
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References
• Maslow, A (1970) The farther reaches
of human nature, New York: The Viking
press.
• The Spinney Policy Manual 2002
• UKCC (2001) The recognition,
prevention and therapeutic
management of violence in mental
health care.
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Home time
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Zero Tolerance
The NHS zero tolerance statement has
two principal targets. They are:
• Public
• Staff
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Zero Tolerance – Public
To get over to the public that violence
against staff working for the NHS is
unacceptable. The government and the
NHS are determined to stamp it out.
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Zero Tolerance - Staff
To get over to all staff that violence and
intimidation is unacceptable and is
being tackled.
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Zero Tolerance – Survey 1998
• 3/1000 incidents every month in acute
hospitals
• 7/1000 incidents every month in
ambulance services
• 14/1000 incidents every month in
community settings
• 24/1000 incidents every month in
learning difficulties/mental health units
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Zero Tolerance Targets
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Record
Publish
Reduction
Police
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European Human Rights Act 1998
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Article 2 - A right to life
Para 3.14
Para 3.15
Para 3.16
Article 3 - freedom form torture or
inhumane or degrading treatment
1. Para 3.24
2. Para 3.25
• Article 5 – personal freedom
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