The UK’s mission to reduce violence in mental health care: What can be done?

Over the last decade, mental health has gone from being a topic of non-discussion to the word on everyone’s lips. Through the hard work of hundreds of charities and calls for attention from experts in the medical field, we’re finally starting to see the stigma on mental health fall away.

However, this spotlight on psychological well-being has unearthed disturbing revelations about the way that it’s handled in our healthcare system. 

Many aspects of current treatment and its consequences are under scrutiny — none more so than the problem of violence towards medical staff. In 2016-17, the number of assaults on NHS staff shot up by almost 10% compared with the previous year. 

Worse still, staff in mental health trusts were seven times more likely to be attacked than those in other trusts.

Online scenario training experts, Near Life, examine healthcare environments – past and present – to ask the question: what is being done to reduce the risks towards caregivers in mental health? And if further measures need to be taken, what can be done to protect staff in the future? 

Recent changes

The NHS has taken several measures in the last few years to improve the prospects of mental health patients. 

  1. Waiting times standards — In 2016, NHS England introduced waiting time standards for mental health services – these standards were based on guidance recommendations from the National Institute for Health and Care Excellence (NICE).
  2. Parity of Esteem — In the following year, the NHS also introduced ‘Parity of Esteem’. Parity of Esteem is a principle which mandates that mental and physical health services be treated equally. In 2017/18, 90% of clinical commissioning groups met this new target and it’s possible that this figure will reach 100% by the end of 2019 (Source: NHS England)
  3. Increased government spending — In 2018/19, the government planned to spend £12.2 billion on mental health services. That’s roughly one in every ten pounds spent by the Department of Health and Social Care. It’s an increase of £1.4 billion (13%) in less than three years, having spent only £10.8 billion in 2015/16.

Despite these changes, there are still 200 assaults on NHS staff every day (Source: The Guardian). So what else can be done to protect carers?

What can be done?

1. Proper risk assessment

One of the key reasons why incidents of violence are still occurring so regularly in mental health services is that staff often fail to carry out an in-depth risk assessment before engaging with a patient. 

A proper risk assessment can be defined as the systematic collection of information to determine how likely it is that harm — whether to others or the patient themselves — will occur in the future. Once this information is collected and all risks are identified, action can be taken to minimise them. 

In order to carry out an accurate risk assessment, staff need accurate information. Guidelines published by the American Psychological Association (APA) specify several risk factors that should be considered in a risk assessment.

  • Past history
  • Prior violence
  • Prior arrest
  • Young age at the time of first arrest
  • Drug or alcohol abuse
  • Cruelty to animals or people
  • Firesetting
  • Risk-taking
  • Behaviour suggesting loss of control or impulsivity
  • Present mental state
  • Male under 40
  • Noncompliance with treatment
  • Access to weapons
  • Neglect of caretaker (provocative towards patient or not protective)
  • Sees self as victim
  • Lack of empathy
  • Intention to harm
  • Lack of concern over the consequences of violent acts

(Source: APA)

It’s vital that trusts are using risk assessment outlines that account for all of these factors and not just a select few. They must ensure staff have access to all the information they need. That includes medical records, informants and police reports (if there are any). 

Staff should also be encouraged and empowered to ask colleagues to consult on the cases they work on. Peer review ensures key details aren’t missed so that all risks can be managed correctly.

2. Risk management

One a risk assessment has been conducted correctly, the next step is to implement steps that will manage those risks.

Unfortunately, this is a key failure in the performance of many mental health trusts. A study by Camilla Parker and Andrew McCulloch found that poor risk management was cited as the most important factor that led to violence in mental healthcare (Source: PMC).

The Department of Health and Home Office outlines that good risk management should involve: 

  • Developing flexible strategies aimed at preventing any negative event from occurring or, when preventing events is not possible, minimising the potential harm caused.
  • Take into account that risk can be both general and specific, and that good management can reduce and prevent harm.
  • Knowledge and understanding of mental health legislation
  • Include a written summary of all risks identified, as well as evaluations of the likelihood of crisis scenarios occurring and the actions that should be taken by staff to respond to it effectively
  • Be based on assessment using the structured clinical judgment approach if the right tools are available

3. Good communication

Parker and McCullcoch’s study found that communication problems were the second-most likely factor to lead to violence in mental healthcare. 

The importance of effective communication cannot be overstated. This applies not only to interactions between staff and patients but also to the way that staff inform one another. 

For example, it’s vital that carers provide detailed information in the handover of patient care to other staff. It should include observations of indicators of future aggression, whether or not those acts are in themselves violent. Behaviour-based indicators from the APA guidelines (referenced above) are particularly important to record, such as the patient seeing themselves as a victim and a lack of empathy.

A risk assessment, no matter how detailed, is rendered ineffective if it isn’t communicated properly to all parties involved. 

However, the way trust staff communicate shouldn’t just preserve the physical safety of carers; it should also serve to build healthy relationships with those who are in their care.

For example, professionals are encouraged to demonstrate sensitivity in relation to the individual circumstances of each patient. They should be able to interact correctly based on factors like race, age, gender, faith, disability and sexual orientation. When staff can successfully communicate with clarity and respect around these topics, they’re protected from violence that can come about when a patient misunderstands incorrect language as a provocation.

Carers can further ensure their safety by avoiding contradictions of the patient’s point of view. Contradication can be perceived as conflict, which could lead to distress, increasing the risk of violence. Peer monitoring is crucial in ensuring that all patients are treated with respect at all times. 

4. Reduce restrictive interventions

In crisis situations, those struggling with their mental health may require restrictive intervention — whether it’s physical restraint, sedation or seclusion — to keep others and themselves from harm. 

In less dangerous scenarios, though, there are significant benefits to avoiding the use of physical restraint. Research shows that wards displaying a decline in the use of restrictive interventions are also better at anticipating and de-escalating dangerous behaviours before they lead to harm. 

For this reason, reducing the use of restrictive measures should be a priority for all mental health trusts.

However, reports indicate restrictive interventions are frequently overused in mental health trusts. For example, in 2017, around 1 in 5 women (6 393 female patients) admitted to mental health facilities were physically restrained, despite guidance it should be used as a last resort (Source: Royal College of Psychiatrists). That being the case, intervention is a problem that many trusts still struggle to mitigate.

To reduce restrictive interventions, trusts first need to monitor incidents to understand where they currently stand. Staff need to routinely measure: 

  • Total number of restrictive interventions
  • Frequency of each type of intervention
  • Duration of restrictive intervention (mean and range)
  • Trends in time of day, week, month, year
  • Comparison against national benchmark

Once this information being collected consistently, wards can identify and manage environmental factors that are likely to increase the need for restrictive interventions

Additional factors that should be considered include:

  • Staffing — Are more interventions occurring at times when staffing is low? Are particular members of staff more likely to take restrictive measures?
  • Procedures — When interventions occur, are they escalated through the correct safeguarding procedures? 
  • Injuries — Regulators need access to data on the number of patient injuries sustained during restrictive interventions to keep wards accountable. Was the harm that came to the patient justified by the level of harm that was prevented?

5. Staff training

Perhaps most importantly of all is ensuring that all mental health trust staff are getting the right training. The problem is that on-the-job training can vary from person to person, and if the trainers aren’t properly equipped, they themselves can miseducate trainees on the correct ways to deal with dangerous situations. 

Staff training needs to be consistent and replicable. It should develop a person-centred, values-based approach to mental health that’s built on personal relationships and prizes continuity of care. It should also cultivate a clear understanding of the link between mental health and the risk of violence.

An effective educational programme should train delegates to spot factors that can indicate whether a patient’s behaviour could turn violent. These factors include: 

  • Personal
  • Constitutional
  • Physical
  • Mental
  • Environmental
  • Social
  • Communicational
  • Behavioural

Health and social care organisations should give staff training in de-escalation that enables them to:

  • recognise the early signs of agitation, irritation, anger and aggression
  • understand the likely causes of aggression or violence, both generally and for each service user
  • use techniques for distraction and calming, and ways to encourage relaxation
  • recognise the importance of personal space
  • respond to a service user’s anger in an appropriate, measured and
  • reasonable way and avoid provocation. 

A better training solution

Near Life is helping to improve safety in mental health services by partnering with the Lancashire Care NHS Foundation to create a unique online training programme.

Mike Todd from Near Life said: “It’s been a real privilege to work with some of the talented and dedicated people who are delivering on the frontline for the NHS. 

“Violence reduction is an incredibly important topic – and effective learning clearly has a critical role to play. 

“Allowing people to experience realistic situations where they can experience the consequences of their decisions in a controlled way,” he added, “can help train large numbers of people in a more immersive and engaging way.”

See the trailer for Near Life’s new online training programme here.

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