In the front line of risk from violence

Violence perpetrated by patients against nurses can have devastating effects, and leads to high staff sickness rates. Recent NICE guidance recommends staff training to spot the triggers of violence. Structured risk assessment can reduce the risks but must be supported by employers.

Training is essential to help staff anticipate triggers for aggression

Picture credit: Science Photo Library

Violence and the threat of it can have serious detrimental effects on nursing staff, leading to sickness and absenteeism, poor morale and even burnout.

According to figures collated by NHS Protect, there were 68,683 assaults reported against NHS staff in England in 2013/14, a rise of 8% over the previous 12 months. Almost seven out of ten reported assaults happened in mental health or learning disability settings.

In May, the National Institute for Health and Care Excellence published updated guidance on the short-term management of violence and aggression in mental health, health and community settings.

With a clear focus on preventing violent situations, the guidance includes detailed advice on managing any incidents safely.

Among the recommendations from NICE is comprehensive staff training, including skills to assess why behaviour might become violence or aggressive, with methods and techniques to reduce or avert imminent incidents. Physical restraint should be used only as a last resort once all other methods of preventing or calming the situation have failed, says NICE.

‘There are good things in this new guidance,’ says Ian Hulatt, the RCN’s professional lead for mental health.

The RCN is concerned about the welfare of its members, ‘who need the tools and techniques to be able to keep themselves safe’, says Mr Hulatt. But he adds: ‘There is also an issue about those in our care. It’s a fine balance between keeping individuals safe and not being excessively restrictive. We want what’s best for our patients, but recognise the challenges.’

Staff training should include:

An understanding of the relationship between mental health problems and the risk of violence or aggression.

The skills to assess why behaviour might become violent or aggressive, recognising the warning signs.

Methods and techniques to reduce or avert imminent incidents, including verbal de-escalation, distraction and relaxation.


In situations where restraint is necessary, NICE says the techniques and methods used should be the least restrictive option to meet the need. They should also be proportionate to the risk of harm, be used for no longer than necessary, and take the aggressor’s health and age into account.

There is a lack of accreditation and proper regulation for staff training in physical restraint, says Mr Hulatt. He points out that little has changed since restraint was debated at RCN congress in 2013, when a resolution was carried – almost unanimously – calling on RCN council to lobby UK governments to review, accredit and then regulate national guidelines for approved models.

‘Currently there are about 650 training providers, of whom around 35 are accredited,’ says Mr Hulatt. ‘For trusts, there’s a real difficulty in how they determine what they buy in. With so many different techniques, we need more research in this area’

Mark Haddad, senior lecturer in mental health and a senior tutor for research at City University London, says that even the potential threat of violence and aggression is a significant cause of sickness absence and distress among staff. Violence happens or is threatened in other professions as well, such as teaching and social work, but nursing staff are particularly exposed, says Dr Haddad. ‘Patients in states of stress and distress are more vulnerable to acting out their frustrations,’ he says.

‘For some mental health patients, aggression can be a feature of their illness, while others have reduced impulse control. Patients can be angry and agitated when they’re admitted because they are unhappy about being there or they feel threatened.’

To help nursing staff improve the way they manage the threat of violence, Dr Haddad set up a 12-month pilot study, working with RCN mental health forum colleague Norman Young. Funded by the Health Foundation, the project took place at an inpatient mental health unit in Cardiff.

Using a simple and structured risk assessment, nursing staff reviewed newly admitted patients twice a day for the first three days of their stay, looking for behaviours associated strongly with impending violence. These are: being confused, attacking objects, being verbally or physically threatening, irritable, or boisterous. These are measurements on the Broset Violence Checklist. The nursing team then determined the level of risk presented and took appropriate action from a list provided on the risk assessment tool, with scoring linked to suggested responses.

‘It’s a traffic-light system, with decisions made on whether someone was green, amber or red that day,’ explains Dr Haddad. ‘It was carried out every day in the staff handover meetings.’

Approaches to manage the threat of violence ranged from careful observation, walking and relaxation exercises, to ‘talking down’, preventive seclusion, injection of psychotropic drugs and, finally, physical restraint.

While some of the findings of the study were mixed, with no meaningful clinical changes in violence, says Dr Haddad, there were benefits for staff, including improvements in sickness rates and wellbeing. ‘While the project worked in some direct ways, there were some indirect benefits too,’ he says. ‘One was helping staff to make shared decisions and be more in control.’

He believes the tool offers a structured and sustainable way to communicate to staff at the start and end of a shift that a patient presents a risk, evaluate what happened in the previous shift, and plan what to do next. ‘Of course, it’s not the only way to manage violence or its threat,’ says Dr Haddad. ‘But it does fit well with NICE’s emphasis on providing support to staff about the precursors of violence and the warning signs to look out for.’

Mr Hulatt adds: ‘We know trusts are reviewing their policies and will be informed by the processes in the NICE guidance.

‘We hope they will have a closer look at their staff’s abilities to de-escalate situations, understanding the imperative to intervene early. Guidance can sit on a shelf or hold the door open – but it’s how employers buy into it that will make the difference’.

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