A GUIDE
TO GOOD PRACTICE In the last issue of 'Mental Health' David Boorer examined the need for a code of practice for staff working in psychiatric hospitals and assessed the consultative and preparatory work to be done, if such a code were to be of practical value. The code, renamed guidelines', has now been drawn up and is printed here in the form in which it has been submitted to the organisations involved in its drafting.*
Many adult patients who the mentally handicapped
in hospitals for the mentally ill and for have behaviour problems which make caring for them very difficult. In the past, for want of clearly defined procedures, hospital staff have come in for heavy criticism over their handling of difficult patients in crisis situations. are
the product of a working party convened by the National Association for Mental Health are intended to start discussion of the principles involved in the standardisation of procedure in these very difficult circumstances.
These
guidelines
*The draft has been sent, with a request for comments, to: the Royal Medico-Psychological Association; the Royal College of Nursing; the Confederation of Health Service Employees; the Society of Mental Nurses; the General Nursing Council; the Association of Hospital Matrons; the Society of Principal Nursing Officers; and the Department of Health and Social Security. The Association welcomes comments from any reader. They should be addressed to: Social Services Dept. (GGP), NAMH, 39 Queen Anne St., London, WIM OAJ. 32
Guidelines for the
of patients who
care
exhibit violent behaviour in mental and mental subnormality hospitals Incidents
violence are not a frequent Nevertheless there are occasions when they occur?sometimes in the most unexpected situations. It is therefore necessary that those who are involved in the care and treatment of mentally ill and handicapped patients should be aware of the factors which can precipitate violence, of how it can be prevented and of the action to be taken when an incident occurs : 1. The essential process in the care of the potentially violent patient, as of all patients, is to establish and nurture a good relationship with him, to gain his trust and confidence. Violence expresses the patient's feelings?anger, fear or despair?about a situation as he perceives it. It should not be regarded as wholly, or even largely, a symptom of his disease. It will be forestalled if steps are taken to relieve the patient's feelings by removing what he perceives as threatening.
involving
occurrence.
?
of physical methods of control, such as segregation, is only necessary when other methods have failed. Physical methods of control should then only be used with gentleness and kindness, exerting the minimum of force compatible with the security of the patient, the protection of the staff and the avoidance of damage to property. Segregation should never be for a pre-determined period The restraint
2.
use or
as a sentence, but only for may be necessary to calm the patient. In all emergencies the use of restraint must be
which could be understood as
long
4.
Each
hospital must design a system whereby senior officers, nursing, medical or administrative, or to the Management Committee is clearly available and understood. Every member of staff must be made aware of the system and of his responsibility to work within it. access
to
for receiving complaints from relatives and the methods to be followed for their investigation shall be those laid down in 5.
The
patients HM
procedure
or
66/15.
6. All staff have a right to expect that they will receive the support of the Hospital Management Committee where action has beer taken in good faith for the benefit and safety of a patient.
as
therapeutic, only
Each member of staff in contact with potentially violent patients should be given the opportunity of discussing his feelings and experiences with senior nursing and medical staff. Every occasion on which physical restraint has been required must be reviewed in order that all staff may learn from the experience and similar incidents avoided in future. Resort to physical methods of control is seldom necessary if the morale of the staff is high. If staff have the sympathy and support of their colleagues they will be able to do their work with confidence and pride in their professional skills.
never
punitive. Drugs
or
ECT should
be used to relieve disorders of the
mind,
not
subdue excitement or rebellion. The test lies in the nurse's intention: did he act in good faith for the benefit of the patient.
primarily
to
3. The potentially violent patient requires the close attention of the staff. The higher the level and the better the quality of staffing, the less will be the need for physical restraint. Whatever rules governing physical methods of control are adopted, they should conform to a clearly stated policy discussed and approved at all levels of management. All patients and staff should be aware of this policy.
hospital is asked to admit a patient who may require a high level of security because of his violent or unpredictable behaviour,, the question of admission should be discussed with the Nursing 7.
When
a
full
made of facilities for Senior nursing staff should be aware of the level of skill and experience available in their staff and admission policy should be related to these resources. Any limiting factors in nursing and medical facilities to deal with such cases must be made known to the Management Committee.
Services,
and
a
assessment
the treatment of the
patient.
8. A clear medical and nursing policy for each patient should be formulated by discussion. All staff responsible for the care of patients should be aware
33
of the policy, which should allow the nurses a degree of flexibility to exercise professional judgement in the management of incidents. All incidents
9.
involving
the
use
of restraint
must
fully reported and examined by the medical and nursing staff, not primarily to apportion blame but
be
problems and learn from experience. investigation suggests that a staff member has other than in good faith or has applied undue
to
evaluate the
If
an
acted
force, that incident must be reported to the person or body of persons responsible for initiating disciplinary
procedures. 10.
Senior Nurses have
a
duty
to:
(a) Establish good working conditions for staff. (b) Counsel staff who handle situations in any way unwisely. (c) Ensure that where staff tolerance levels have been stretched by manipulative behaviour, staff are enabled to evaluate and learn by experience and are given opportunities to express their views on their own
difficulties.
11.
Every
member of staff must
:
(a) Report patient behaviour, or changes in behaviour which may indicate potential violence. Extensive use should be made of nursing notes by all staff involved in the care of patients. (b) Report any incident, indicating the cause and the action taken. A form of written reporting procedure must be adopted. The report must be conveyed to the responsible medical officer for effective action. (c) Report to a senior nurse any situation in which a nurse is seen to be unprepared or poorly adjusted to the needs of any patient. By this means more adequate training can be arranged, especially for those grades of staff for whom no formal training currently exists. (d) Report action by interpreted as cruelty. 12.
any person which
All staff must be made
(a) Their legal
might
be
aware of : in any incident where
position alleged. (b) The function of the representative organisations, and the point at which these official bodies are
violence
or
assault is
able to advise and represent their members. 13. Trained nurses and nurses in training must know the function of the General Nursing Council,
investigating professional conduct and responsibility of the Management Committee in notifying incidents to the general Nursing Council. its methods of
the
TO GOOD PRACTICE In the last issue of 'Mental Health' David Boorer examined the need for a code of practice for staff working in psychiatric hospitals and assessed the consultative and preparatory work to be done, if such a code were to be of practical value. The code, renamed guidelines', has now been drawn up and is printed here in the form in which it has been submitted to the organisations involved in its drafting.*
Many adult patients who the mentally handicapped
in hospitals for the mentally ill and for have behaviour problems which make caring for them very difficult. In the past, for want of clearly defined procedures, hospital staff have come in for heavy criticism over their handling of difficult patients in crisis situations. are
the product of a working party convened by the National Association for Mental Health are intended to start discussion of the principles involved in the standardisation of procedure in these very difficult circumstances.
These
guidelines
*The draft has been sent, with a request for comments, to: the Royal Medico-Psychological Association; the Royal College of Nursing; the Confederation of Health Service Employees; the Society of Mental Nurses; the General Nursing Council; the Association of Hospital Matrons; the Society of Principal Nursing Officers; and the Department of Health and Social Security. The Association welcomes comments from any reader. They should be addressed to: Social Services Dept. (GGP), NAMH, 39 Queen Anne St., London, WIM OAJ. 32
Guidelines for the
of patients who
care
exhibit violent behaviour in mental and mental subnormality hospitals Incidents
violence are not a frequent Nevertheless there are occasions when they occur?sometimes in the most unexpected situations. It is therefore necessary that those who are involved in the care and treatment of mentally ill and handicapped patients should be aware of the factors which can precipitate violence, of how it can be prevented and of the action to be taken when an incident occurs : 1. The essential process in the care of the potentially violent patient, as of all patients, is to establish and nurture a good relationship with him, to gain his trust and confidence. Violence expresses the patient's feelings?anger, fear or despair?about a situation as he perceives it. It should not be regarded as wholly, or even largely, a symptom of his disease. It will be forestalled if steps are taken to relieve the patient's feelings by removing what he perceives as threatening.
involving
occurrence.
?
of physical methods of control, such as segregation, is only necessary when other methods have failed. Physical methods of control should then only be used with gentleness and kindness, exerting the minimum of force compatible with the security of the patient, the protection of the staff and the avoidance of damage to property. Segregation should never be for a pre-determined period The restraint
2.
use or
as a sentence, but only for may be necessary to calm the patient. In all emergencies the use of restraint must be
which could be understood as
long
4.
Each
hospital must design a system whereby senior officers, nursing, medical or administrative, or to the Management Committee is clearly available and understood. Every member of staff must be made aware of the system and of his responsibility to work within it. access
to
for receiving complaints from relatives and the methods to be followed for their investigation shall be those laid down in 5.
The
patients HM
procedure
or
66/15.
6. All staff have a right to expect that they will receive the support of the Hospital Management Committee where action has beer taken in good faith for the benefit and safety of a patient.
as
therapeutic, only
Each member of staff in contact with potentially violent patients should be given the opportunity of discussing his feelings and experiences with senior nursing and medical staff. Every occasion on which physical restraint has been required must be reviewed in order that all staff may learn from the experience and similar incidents avoided in future. Resort to physical methods of control is seldom necessary if the morale of the staff is high. If staff have the sympathy and support of their colleagues they will be able to do their work with confidence and pride in their professional skills.
never
punitive. Drugs
or
ECT should
be used to relieve disorders of the
mind,
not
subdue excitement or rebellion. The test lies in the nurse's intention: did he act in good faith for the benefit of the patient.
primarily
to
3. The potentially violent patient requires the close attention of the staff. The higher the level and the better the quality of staffing, the less will be the need for physical restraint. Whatever rules governing physical methods of control are adopted, they should conform to a clearly stated policy discussed and approved at all levels of management. All patients and staff should be aware of this policy.
hospital is asked to admit a patient who may require a high level of security because of his violent or unpredictable behaviour,, the question of admission should be discussed with the Nursing 7.
When
a
full
made of facilities for Senior nursing staff should be aware of the level of skill and experience available in their staff and admission policy should be related to these resources. Any limiting factors in nursing and medical facilities to deal with such cases must be made known to the Management Committee.
Services,
and
a
assessment
the treatment of the
patient.
8. A clear medical and nursing policy for each patient should be formulated by discussion. All staff responsible for the care of patients should be aware
33
of the policy, which should allow the nurses a degree of flexibility to exercise professional judgement in the management of incidents. All incidents
9.
involving
the
use
of restraint
must
fully reported and examined by the medical and nursing staff, not primarily to apportion blame but
be
problems and learn from experience. investigation suggests that a staff member has other than in good faith or has applied undue
to
evaluate the
If
an
acted
force, that incident must be reported to the person or body of persons responsible for initiating disciplinary
procedures. 10.
Senior Nurses have
a
duty
to:
(a) Establish good working conditions for staff. (b) Counsel staff who handle situations in any way unwisely. (c) Ensure that where staff tolerance levels have been stretched by manipulative behaviour, staff are enabled to evaluate and learn by experience and are given opportunities to express their views on their own
difficulties.
11.
Every
member of staff must
:
(a) Report patient behaviour, or changes in behaviour which may indicate potential violence. Extensive use should be made of nursing notes by all staff involved in the care of patients. (b) Report any incident, indicating the cause and the action taken. A form of written reporting procedure must be adopted. The report must be conveyed to the responsible medical officer for effective action. (c) Report to a senior nurse any situation in which a nurse is seen to be unprepared or poorly adjusted to the needs of any patient. By this means more adequate training can be arranged, especially for those grades of staff for whom no formal training currently exists. (d) Report action by interpreted as cruelty. 12.
any person which
All staff must be made
(a) Their legal
might
be
aware of : in any incident where
position alleged. (b) The function of the representative organisations, and the point at which these official bodies are
violence
or
assault is
able to advise and represent their members. 13. Trained nurses and nurses in training must know the function of the General Nursing Council,
investigating professional conduct and responsibility of the Management Committee in notifying incidents to the general Nursing Council. its methods of
the
