Management of aggression and violence

Reviewed date: 16/01/2025 Emma Jenson

 

Next review: 16/01/2027 (or before if there is a change in practice or circumstances)

 

Amendments:

 

Introduction:

 

This policy provides guidance to Leuchie House staff who may be required to respond to violent or aggressive behaviour from guests.

 

Scope:

 

• To inform staff of the policies and guidelines for safe, effective and appropriate working practices.
• To minimise the risk of violence to staff and guests.
• To contribute to the promotion of a safe environment at Leuchie House for staff and guests.
• To ensure that all staff are aware of their responsibilities in the prevention and management of aggression and violence.
• To ensure effective mechanisms for reporting, recording and evaluation of aggressive and violent incidents.
• To ensure that the dignity of all guests remains a primary goal of support
• To ensure that staff or guests who may become victims of violence receive appropriate support.

 

1. Definitions

 

1.1 Aggression is a normal human emotional response and defence mechanism. It may take the form of an act or gesture, verbal or physical, which is precipitated by feelings of pressure, threat or stress. 

 

People who suffer from a mental illness or learning disability may experience relatively high levels of stress and/or a low stress threshold. They may also be more susceptible to perceptions of threat and pressure. 

 

People with impaired psychological resources may experience increased frustration due to unmet needs.

 

1.2 Violence can be defined as the use of physical force that inflicts pain, injury, and psychological distress. It may or may not involve the use of a weapon. 

 

Violence, like aggression, is a strategy that some people use in certain situations to express feelings of anger, fear, despair or frustration.

 

2. Standards

 

2.1 Leuchie House will ensure compliance with the following standards which will help to meet the objectives of this policy:

 

• Each guest will have a detailed care plan that identifies how that person will be supported to meet their basic human needs within the context of the personal profile

 

• A risk assessment will be completed for each guest identified as a risk prior to arriving at Leuchie House to commence their short stay respite break and also during the short break.

 

• For those guests for whom a specific risk has been identified
• the care plan will include guidance to prevent/minimise risk and this will be reviewed at the start of each of the guest’s short stay respite breaks.

 

• All care staff at Leuchie House will participate in training which addresses the causes, prevention and management of violence and aggression. Training will be repeated annually. 

 

• When a guest been identified as posing a significant risk of aggression and violence, all care staff involved in the care of that guest shall be appropriately trained to carry out the agreed responses.

 

• Leuchie House will provide general written guidance to staff

on the action to take in response to emergency situations. This guidance will include reference to any emergency alarm systems.

 

• Leuchie House, its Managers, Heads of Departments and staff will take all reasonable steps to prevent or manage violent and aggressive incidents.

 

• In exceptional circumstances, the safety of staff and guests may require the assistance of the police. In such circumstances the Chief Executive of Leuchie House will be informed without delay.

 

3. Guidelines for the prevention of aggression and violence

 

3.1 Recognition of causative factors:

 

• Aggression arises from many different causative factors and frequently from a combination of these factors. Effective prevention requires a comprehensive assessment of all possible contributory factors.

 

• Guest’s personal factors: low stress threshold, pain, sensory impairment; epilepsy, emotional states; fatigue; boredom confusion, delusional states.

 

• Impact of staff/others – excessive demands, high expressed emotion, low tolerance, criticism, poor communication, lack of interpersonal skill, fear/apprehension; excessive control; inappropriate values and beliefs.

 

• Environmental factors: space/crowding, light, noise, temperature; lack of structure or inflexible routines.

 

3.2 Effective assessment includes:

 

• Physical health status.
• Mental health status.
• Behavioural issues.

 

• The most sensitive predictor of aggression and violence is a previous and recent history of aggressive or violent behaviour.

.

3.3 A thorough understanding of each guest’s emotional/physical needs and preferences is an important part of any effective prevention strategy. 

 

Aggression can be seen simply as an inability to successfully meet a basic need. Therefore supporting a guest to meet their basic emotional and physical needs can help identify triggers for aggression as well as agreed responses to diffuse a situation.

 

3.4 The following list is intended to provide suggestions to staff in Leuchie House for responding to common causative factors of violence and aggression (see 3.1 above):

• Low stress threshold: avoid over-criticism, excessive demands and emotional over-involvement. Ensure that new staff at Leuchie House are made aware of potential triggers such as noise and crowding for individual guests. Managers and Heads of Departments should take prompt corrective action to address staff interventions that appear to potentially exacerbate aggression.

 

• Pain: Some guests may have difficulty communicating the presence of pain and discomfort. They may express their suffering through behaviours, which may be aggressive in nature. Staff need to observe and understand the way pain is experienced and expressed by individual guests users .Where this is appropriate, pain indicators and pain management plans should be identified.

 

• Emotional reactions: Guests may have a similar difficulty coping with and communicating feelings such as sadness, frustration, anxiety, and loss. An inability to communicate an unmet need may lead to increasing frustration and aggression.

 

• Boredom: Guests may have difficulty engaging with everyday activities and with those around them. Periods of inactivity may result in frustration, irritation and aggression. Individual guest centred support will play an important part in reducing levels of boredom.

 

• Sensory impairment: Visual, hearing and tactile impairments may result in both frustration and confusion. Staff need to be fully aware of the both the presence of any impairment and the impact that impairment has on the individual guest.

 

• Epilepsy: Epilepsy has many hidden consequences over and above the visible seizure. These can include permanent headaches, sensory disturbances and emotional fluctuations. These may contribute to an aggressive episode.

 

• Mental Health: Confusion or misinterpretation of surroundings/events and the intentions of others are commonly associated with both aggression and violence. It is important that staff at Leuchie House develop relevant skills and knowledge necessary to identify and respond to mental health problems. Staff also need to know when to seek the support of the local mental health team.

 

• Communication: Staff need to be aware of the impact they may have on the behaviour of the individual guest. Aggressive episodes can relate directly to an interaction between that guest and a member of staff. Communication should always be appropriate to the individual guest’s capacity to understand and respond. Staff should be aware of their own body language, listening skills, voice tone, volume and the importance of personal space. All staff should be willing to learn from colleagues’ more appropriate styles of communication with particular guests.

 

• Values and attitude: Everyone in the care team at Leuchie House should subscribe to explicit positive values based on a belief in the intrinsic worth of each guest in their care. These values should be communicated verbally and in writing to all new staff joining the team. 

 

• Environmental factors: These factors can often interact with personal factors such as stress thresholds. The team should be sensitive to those environmental factors which may contribute to aggression and violence. These factors may include variations in temperature, noise (from radios, televisions, loud conversations for example) numbers of people in a room, corridor etc.)

 

• Staff responses: Incidents of aggression and violence in care services can sometimes arise from interactions between staff and guests. All care staff at Leuchie House have a responsibility to be aware of their own emotional reactions, both in general terms and in relation to specific guests. 

 

4. Observing warning signs

 

4.1 Changes in guests’ normal behaviour or appearance may serve to alert staff to the possibility that a guest may be escalating to physically violent behaviour, for example:

 

• tense or angry facial expression
• general signs of over-arousal, including increased/laboured breathing,
• pacing, erratic movements or changes to normal patterns of behaviour.
• increased speech volume
• prolonged eye-contact
• distress including a failure to communicate, withdrawal, fear.

 

Behaviour that preceded an earlier incident of aggressive/violent behaviour should be recorded in the service users risk-assessment and support plan.

 

5. Guidelines for the management of aggressive or violent incidents.

 

• Remain as calm as possible.
• Do not respond to hostility with hostility
• Avoid confrontation – you can be both firm and pacifying.
• Use positive calming body language.
• Do not invade a guest’s personal space if this is likely to inflame a difficult situation. Keep a reasonable distance – at least one arms length.
• Speak slowly with a soft calm voice.
• Avoid sudden movements or changes in tone of voice.
• Focus on achieving a positive outcome for everyone – little will be gained if you try to “win”.
• Give time to allow “verbal venting” of feelings
• Be prepared to listen to the guest and try to understand their
• perspective and feelings.
• Try to acknowledge the feelings that the guest is experiencing.
• Ignore personal insults and concentrate instead on resolving the problem.
• If you feel yourself becoming angry move away.
• Your first priority is to prevent injury – to yourself and others. Do not risk your own safety for the sake of property.
• If violence is threatened in a crowded area, encourage the guest into a quieter area, alternatively, move others away.
• Identify and keep clear an escape route.
• Do not allow yourself to become isolated.
• If withdrawal from the situation appears sensible, maintain face to face contact do not turn your back.
• If you call for help, state as clearly as possible, where you are and the nature of the problem.

 

6. Team working

 

6.1 Failure to work in a co-ordinated and consistent manner in accordance with a guest’s care plan can be a contributing factor to aggressive behaviour. 

 

The Head of Nursing Operations will make every reasonable effort to consider the views of all care staff during the design of a guest’s care plan. However, once a care plan has been approved, all staff are expected to comply with this.

 

6.2 Care plans will be reviewed regularly. Non-compliance by staff with a guest’s care plan may well result in disciplinary action – including the possibility of dismissal.

 

7. Training

 

7.1 Leuchie House has a responsibility to ensure that staff are adequately prepared to comply with each guest’s care plan. The training implications of each care plan must be clearly understood by individual staff and the Head of Nursing Operations. 

 

7.2 Training needs can be identified through discussion at shift hand-over meetings, monthly staff meetings, supervision sessions and annual staff reviews. Training needs that cannot be met or resourced by Leuchie House should be identified.

 

7.3 All staff will receive regular violence and aggression training which will enable staff to:

 

• Identify and recognise early signs of aggression and violence.
• Use techniques for physically breaking free from specific and identified forms of aggressive situations 
• Display an awareness of, and the need for, good de-escalation skills.
• Demonstrate how to adapt skills for use in different types of
• situations.

 

Training updates will be at least annual. 

 

7.5 When it has been identified that a specific guest may require an intervention that involves some degree of restraint, all team members must receive sufficient training and guidance to enable them to apply the restraint technique safely and appropriately.

 

7.6 Access to additional forms of training in relation to violence and aggression will be available on request.

 

8. Recording and reporting

 

8.1 Effective prevention and understanding of aggression is dependent on robust and comprehensive documentation. Any violent incident as well as significant or unexpected aggression from a guest, should be clearly recorded in the guest’s health records. 

 

8.2 If any member of staff is unclear as to the need to report a specific incident they should discuss this with the Head of Nursing Operations.

 

8.3 A quarterly analysis of all incidents, as well as accidents, will be presented to the Leuchie House Trustee Board together with any specific recommendations for action. 

 

8.4 Violent incidents should always be reported to the Care Inspectorate.

 

9. After care and support

 

9.1 In the event of a violent or aggressive incident occurring in Leuchie House, immediate support should be available, including first aid and medical attention, if required. The person in charge should determine whether an injured guest or member of staff should attend the nearest Accident and Emergency department and, if necessary, make the necessary arrangements.

 

9.2 If the victim of a violent assault is a member of staff, they should also be offered additional help including the emotional support of the Chief Executive, Head of Nursing Operations, colleagues, and the assistance of an Occupational Health department/ counselling services.

 

9.3 When safe to do so, staff must check the physical and emotional well being of all guests involved.

 

10. Post incident review

 

10.1 A review of any significant incident in Leuchie House involving violence and aggression should be held as soon as possible. The review should seek to identify any lessons, which would help to prevent any similar incident recurring. A review should consider the following questions:

 

What was happening immediately before the incident?

• what was the guest doing?

• what demands were made of the guest?
• how were other people interacting with the guest?

 

What factors might have contributed to this incident ?

• noise, crowding, room temperature?

• unmet need or expectations?
• misunderstanding or misinterpretation?

 

How was this incident dealt with?

• did the member of staff remain calm?
• did staff feel supported?
• were staff happy with the way the incident was handled?

 

What lessons can be learnt for the future?

• are there issues for training or supervision?
• are there issues about the physical environment?
• are there any resource issues?
• is there a need for more detailed guidance in the guest’s care plan?

 

An action plan incorporating the lessons of each review should be recorded together with agreed completion dates. Any violent incident should be immediately reported to the Care Inspectorate by the Head of Nursing Operations or deputy.

 

11. Post incident staff review

 

11.1 Following any significant aggressive incident the staff involved should meet to discuss the events. It may be helpful to separate the technical from the emotional aspects of debriefing. Emotional debriefing aims to identify potential stress reactions and to provide a supportive and structured setting to allow people to cope more effectively.

 

If a member of staff is unable to work as a result of a violent incident, the Manager or Head of Department should ensure that contact is maintained and that the person is adequately supported.

 

Where appropriate the victim of a violent incident may be referred to the Occupational Health Department for counselling.

 

12. Responsibilities of Managers/Heads of Departments 

 

12.1 Managers/Heads of Departments have a duty to:

 

• Establish safe systems of work including appropriate assessment of risk.
• Ensure that detailed strategies are available and understood for any service user where a risk of violence has been identified.
• To ensure that risk management strategies and guidelines are implemented
• To ensure that all staff comply with mandatory training requirements
• Ensure that training needs are identified and that appropriate steps are taken to meet these needs.
• Ensure that incidents of aggression and/or violence are satisfactorily documented and reported
• Ensure that staff who are victims of an aggressive and/or violent incident are properly supported.

 

13. Guidance and further reading

 

Royal College of Nursing (2008) Work related violence. An RCN tool to manage risk and promote safer working practices in health care.

 

HSE (2006) Violence at work. A guide for employers.

 

HSE (1997 – Updated 2010) Violence and aggression to staff in health services. Guidance on assessment and management.