Managing imminent violence in learning disability settings
Apr 6, 2005 - 6:31:38 PM

The evidence base for the management of imminent violence in disability settings (OP57) is the title of a new occasional Paper from the Royal College of Psychiatrists.

In 1998 the College produced guidelines (Occasional Paper OP41) for the management of imminent violence in mental health services. In 2001 the College Research Unit decided to develop a similar guideline for the management of imminent violence in learning disability settings, and also to carry out a multicentre national audit on this topic.

The evidence base for the subject was created with the help of the Department of Information Services in the University of Wales College of Medicine, for which the literature search was updated in 2003. Key findings are:


§ Environment plays a major role in the precipitation and perpetuation of violence
§ One suggested way of minimising the impact of environment on behaviour is to train both staff and the patients to make the best use of the environment, including reduction of excessive noise, heat and crowding, and providing proper facilities for disturbed patients

Staff-related factors

§ Training and support for staff to manage important staff-patient interaction factors, such as staff denials of patients requests and activity demands, lack of appropriate activities for the patient, confrontational social contacts and negative verbal statements
§ Regular refresher training for staff to increase their knowledge and confidence, and decrease burnout; and regular monitoring of effectiveness

Policy issues

§ The presence of a clear policy for dealing with violence, implementation of the policy, regular monitoring, communication between staff and management, training in the appropriate procedures, in-service training, and support and counselling for both staff and patients are proposed as the hallmarks of an effective organisational policy framework

Physical intervention

§ Most studies in the UK support the notion that physical intervention should cause no pain, or very little pain in the patient. This proposal is supported by the finding that a high proportion of people with learning disabilities have an altered pain threshold. Many also have physical conditions such as heart or respiratory disease, which contribute towards the potential hazards associated with physical restraint
§ It is important to carry out a physical examination of patients who are likely to be physically restrained, although it is not always easy to determine when and how often that should be done
§ If physical intervention is used early in the incident, it may prevent a potentially serious situation, but at the same time the patient may perceive this approach as punitive
§ Planned rather than unplanned physical intervention is preferred. The environment should be made safe, staff should work as a team under a team leader, and training should be given in non-confrontational methods and the reinforcement of alternative positive behaviour
§ As stated in the 1993 revision of the Mental Health Act 1983 Code of Practice, physical intervention should be used as a last resort, and must be the minimum necessary to deal with the harm that needs to be prevented

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