DEFINITION

Animosity or hostility shown towards another person or object as a response to opposition or frustration.

FEATURES

Aggression may be behavioural, verbal or physically violent to people or objects. It may also be direct to the person or object, or indirect – from another route: such as unsigned written abuse, anonymous telephone calls, calls to police, employer or media about an issue which may not warrant such action. It may also be unintended, due to drink, drugs or dementia where the person is not in control of their actions, and may not remember the incident afterwards.

CAUSES

There are many causes of aggression. Some are clear and stark, others are less clear.

FEELINGS

Feelings of frustration, being pressurised or humiliated, and being unable to cope with these feelings, as if being pushed to the limit of their endurance.

VALUES

Privacy, Dignity or Independence is threatened, being forced to accept the unacceptable, such as imprisonment or having intimate care such as washing or shaving, or going to the toilet.

EXTERNAL FACTORS

Feelings of others are being judgmental or unacceptable criticism of their actions. Mistaken or negligent behaviour may also be a factor.

FEARS

Being lost frightened confused or bewildered, a change of routine or too much noise, or the inability to cope.

ANXIETY

Anxiety or fear can be a cause, or being in a strange unfamiliar place, even if it is their own home.

ALCOHOL/MANIA A PORTU

ALIMENTARY

Constipation, discomfort, pain or boredom, or a desire for food or drink, yet not being able to communicate this.

COMMUNICATION PROBLEMS

Inability to communicate, either by verbal or by non-verbal means, people who do not pick up on the signs of need.

PHYSICAL OR MENTAL ILLNESS

In any Physical Illness, pain and underlying symptoms may be the underlying cause. In Mental Illness, any of the illnesses can cause aggression. Personality disorders can also have a predisposition to aggression.

CEREBRAL DISFUNCTION

A head injury causing changes in brain function may be a cause of Aggression, leaving an individual with uncontrolled anger, which may be vented without the individual being aware of their actions, or being aware but unable to prevent the aggressive act. Confusion, caused by Dementia, Drugs, Toxicity may provoke aggression. Epilepsy may be a trigger point.

PREVENTATIVE MEASURES

If the causes can be established then the preventative measures can be put into place preventing aggression. Where the situation is beyond an individuals capability then there should be an appropriate person with skills for defusing the situation, this could be family, friend, professional or an agency working on behalf of the individual. Other mechanisms used may be:

STRESS

Reduce the levels; allow for coping mechanisms to be put into place. It may be necessary to withdraw, or reduce input. Reduction of intervention and even a cup of tea or a cigarette may help.

COMMUNICATION

Be clear in how an issue is stated, use simple straightforward language, and avoid jargon. Keep sentences short. Allow time for the client to respond. Speak in a reassuring manner, do not show or enounce fear, frustration or anger. Keep the verbal input at a comfortable level.

TACT

Be sensitive about the individuals plight, think how an average person would feel in the same situation. Take a Step by Step approach to the problem; do not overload information or activity. Give the client the appropriate guidance and input as possible. Make them feel part of the solution.

IMPARTIALITY

Do not take sides, be an honest broker. Do not build up unreasonable hope, or negate a possibility where an outcome can be forecast. Use praise where praise is due and concern where dangers are seen. Allow optimum ability for the client to deal with each activity within their ability.

ENVIRONMENT

Where possible, minimise noise and unhelpful activity, minimise the threat, reduce the amount of people involved to the minimum, yet have enough in reserve to help if all goes wrong.

CONFRONTATION

Avoid a him/her or me situation. If the situation is becoming confrontational, then either withdraw and let someone else take over, or where there is a situation that requires firm and immediate action, ensure adequate staffing and or full professional agreement either contractually or through a care plan to protect against repercussions later. If required police may be needed.

ACTIVITIES

Diversional inputs such as a constructive activity, such as gardening, or games or even exercise. Many frustrations can be relieved by recreational pursuits and it is important to find an appropriate activity that can calm a client and be therapeutic at the same time.

HEALTH

As stated previously, any Mental or Physical Illness may cause aggression. Involve the medical services (GP, Psychiatrist, Health Visitor etc.) if it is believed that this may be a cause.

HANDLING AGGRESSION

Where aggression or aggressive tendencies are noted, it is essential to assess the level of danger from assault.

CALMNESS

Remain calm, non-judgmental and reassured. Think before talking, take a deep breath and count to ten.

SPACE

If there is a perceived danger of violence, ensure there is space for manoeuvre, and ensure that there is an available exit if things go wrong. If restraint is the only option, then the individual may become MORE violent. Ensure there is enough staff to cope with the situation.

ABUSE

Some aggressive behaviour may be cause by abuse by another person, which may be taking place, and no actions are taken to prevent such abuse. If a person makes racist abuse, and no action is taken to curtail it then aggressive actions may follow. Once a situation is known, the Carer must take steps to prevent the abuse. This may mean initial separation, followed up by Counselling about the abuse being used and where required, sanctions are introduced in order to ensure the abuse does not reoccur. This may be written into a contract specifying what actions that will take place if a reoccurrence takes place.

ENVIRONMENT

A great deal can be done to prevent aggression by altering the environment in which the individual may live. Wide-open spaces can be relaxing, whilst busy streets stressful. Accommodation has a role to play, if someone spends their time in a Home with all double rooms with one lounge, and cannot get any personal space for themselves, then they are more likely to feel tensions than an individual in a Home where there is all single rooms, a variety of lounges, with non smoking as well as smoking areas, quiet rooms as well as TV rooms. Inappropriate placement into a Home, which has older people when someone is considerably younger, can cause aggression to take place.

RISK POLICY.

Mental Health Aftercare involves decision-making that requires a certain amount of risk. In order to minimise the danger of inappropriate actions or omissions, the following points should be noted: –

RIGHTS

Where an individual is admitted informally he or she may decide to take actions regarding his/her life which may be contrary with the care needs of that individual.

RESTRICTIONS

Where the individual has legal sanctions imposed on him/her as a care order, the staff must take action to ensure those care order conditions are met. Appropriate Authorities must be informed.

DUTY OF CARE

The Person-in-Charge has a ‘ Duty of Care ‘ towards the individual in which he/she must act in the best interests of that person. Any failure to act or any omission caused, which affects their best interests may be regarded as negligent by the Home, families, Agents, Mental Health Professionals, Registration Authorities, Tribunals and / or Courts of Law.

Any decision involving risk may put the good name of the Home in disrepute.

MULTI-AGENCY INPUT

The express wishes of the individual, Multi-Disciplinary Team, Family, Home or other interested parties may well be of concern in the decision making.

PROFESSIONAL RESPONSIBILTY

The actions of the Person-in-Charge if inappropriate in advising the may in exceptional circumstances affect the professional viability of that professional.

EXCEPTIONAL REQUESTS

Where a individual requests activities or situations outside of the care needs, then the Person-in-Charge must find out the rationale for such actions, and advise accordingly.

ADVICE REFUSAL

Where the individual fails to accept the advice of the Person-in-Charge and proceeds with his actions then the Person-in-Charge should:

Advise the individual with regard to the dangers of their actions and/or of its consequences.

Document in full the situation and the impact at the time, or as soon as possible.

Inform all relevant authorities of what has happened, and the possible impact of the actions.

In serious cases bring it to the notice of the Manager, or designated deputy.

CONCLUSION

DISCHARGING RESPONSIBILITIES

Where all aspects of the risk have been covered which relate to the individual and has been documented and further information given to appropriate agencies then the Person-in-Charge has discharged their responsibilities, and have given the right level of advice for the care and well-being of the individual

EVALUATION OF RISK

Where decisions have been made of a sensitive nature and complications have arisen because of the level of risk involved, a full discussion of the events should be conducted, as soon after the event as possible to ascertain if the decisions that were taken were correct and to establish if other mechanisms would have enhanced the processes and could have been more effective.

PLACEMENT OUTCOME

If the situation has been assessed and it is found that the actions of the individual were incompatible with his/her care needs, it may be evident that the placement of that individual is inappropriate, and that alternative placement needs to be found.

GUIDELINES for VIOLENT/UNTOWARD INCIDENTS

This document is an outline of the elements exposed and needed in dealing with Violent / Untoward Incidents.

TRAINING

Training can and does help reduce the threat of Violence / Untoward Incidents. Staff Training in the Home, plus the Training Courses available should be maximised. All staff should be aware of the following.

PREVENTION

Most incidents are preventable. Some incidents not preventable can be at least minimised by observing the build up of volatile situations. Many incidents do not take place due to this activity; therefore many violent incident situations do not take place.

SITUATIONS

Some incidents are slow to come to the surface, but can be seen if the signals are assessed and acted on. Borrowing of cigarette, and not repaying debts are problems, as are the confused who constantly trip over others feet. Some incidents are fulminating and decisive action is needed. Separating combatants and removing them from one vicinity may be required.

ATTITUDES

Staff and residents attitudes can play a major role in both contributing to violence. An inadequate response for requests for counselling, medical help or passing unhelpful remarks may cause a threat. Medical and Paramedical causes, such as Doctors, Social Workers, C.P.N.s failure to respond adequately or quickly enough to care needs can rebound into violence.

COMMUNICATION

Full communication between staff, through ongoing observation, Handover periods, staff meetings are essential in evaluating the potential of any incident. Staff conversations with residents, formal and informal, residents meeting can pick up on problems that can get out of hand. Communication between the Home and the Mental Health Team is important if decisions are taken outside the Home, which affect the resident, which may potentiate incidents. Effective written notes are essential for ongoing continuity, especially where new; part time or bank staff are employed

THE INCIDENT

Staff should be calm, effective and positive. All attempts should be made to limit violence. In law minimum force required to control situation must be used. The Person in Charge will have to gauge that level. The incident should be dealt with in such a way that all involved should not be put at an unacceptable risk. If danger exists call the police. Medical and professional help should be sought if necessary. Remove any object that can be used as a weapon or could cause damage if people fell against it. Draw the incident to a close within an appropriate timescale. Where medication is indicated, prescribed medication and dose may be given, at times this may be agreed with the Doctor over the telephone. The situation may have stabilised by the time the medication is prescribed, at times it may be sensible and important to allow medical practitioners see the psychological state of the resident. Often when medicated, the resident does not exhibit symptoms that may need medical supervision and hospital treatment.

POST INCIDENT

Continue observation, writing up all notes in detail is important, including any Violent Incident / Untoward Incident form, and where required, an Accident form and / or a Missing Persons form if required. A resident (not just the combatant), relative or Agency may wish to complain therefore a complaints form should be issued. Discussion of the incident with colleagues and possibly others may be required, which may pinpoint areas of potential conflict and timing relating to the incident (often violence happens at mealtimes) which gives clues to what happened and assess preventability, with a view to preventing future incidents. Assess any damage, and whether damage is repayable by resident, probation service or other agency, or whether it is to be written off. The intervention of the police if an assault takes place may be valuable if the resident is felt to have enough insight to understand what was happening. It may be that agreement from professionals need to be elicited, or that even if they do not wish action to take place, the Person in Charge carries out a Risk Assessment which indicates that serious actions should be taken.

STAFFING LEVELS

The Person in Charge should consider whether when admitting a Resident, that there known potential violence or their level of difficulty could be managed on the Homes regime and Staffing Levels. If not, it is not wise to admit, unless the Home seeks from the Admission Authority an appropriate fee structure in order to not put others at risk. Admissions should be in line with the Homes Aims and Objectives.

PERIODIC REVIEWS

Resident needs change, it is important to be aware of this, as a passive resident may change into a more aggressive or intolerant person. Familiarity breeds contempt. Medication needs change. Ongoing assessments are important, Periodic Reviews with the resident, the Multi Disciplinary Team, with professionals individually and with relatives build a network of both care and confidence of each others judgement and abilities that can improve the care of the resident and act as a prevention of incidents, where there is division it can be destructive.

CONTRACTS

Whilst all Residents should have a contract, specific contracts may be required to control Violent behaviour. There should be an agreement of what is acceptable in behaviour and what is not. It may or may not be time limited, depending on each individual situation.

COUNSELLING

Counselling of both staff and residents on an ongoing basis is important in dealing with incidents.

REMEMBER

The more assured the individual is, the safer the Home is.

CONTROL AND RESTRAINT

There are times, though this should be rarely, when restraint of an individual is used as a last resort, where after analysis any other course of action would be likely to fail. Physical Restraint is only permissible where the safety of the resident, others or serious damage to property is apparent. Wherever possible, strategies for coping with a resident will be agreed in advance as part of their plan of care. All staff should be aware that Physical Restraint would only occur as an act of care compassion and concern. The term ‘Those involved’ primarily means those in charge of others and has the Authority to take action.

Where Physical restraint is deemed necessary, these underlying principles will apply.

GROUNDS FOR RESTRAINT

Those involved will believe that restraint is necessary and have good grounds for applying it. Physical Restraint will never be used where there is no immediate danger to the resident, others or property. The line between restraint and assault may be a very thin one in the eyed of some, therefore all avenues of persuasion and professional intervention should be contemplated before any control and restraint is decided on.

ENSURING ADEQUATE FORCE AND BACKUP

Unless a situation explodes without warning, any requirement for Control and Restraint will need adequate staff to control the outcome and minimise the danger of injury to the person to be controlled, or those involved with Control and restraint, further there may be a necessity to have further backup such as the Police, GP, Community Nurse or others in order to gain advise, or physical presence which may in itself reduce the tension and prevent the need for any actions.

VERBAL WARNING

Before applying Physical Restraint those involved will verbally warn the resident that the stated course of action will be taken unless behaviour ceases. In cases where this is inappropriate, i.e. there is apparent danger. Those involved will take the appropriate course of action following this policy. The skill of those involved must be to be able to give authority to the possible actions, without mounting a threat that will be matched by the individual who is to be restrained.

WITNESSING

Those involved will make every effort to ensure other staff are present to act as a witness to the Physical Restraint. There may be situation where someone is on their own, however, where physical intervention is being applied, there is a danger of the individual stating an assault took place, and seek criminal and or legal redress against those involved. If it is a one on one issue, doubt may be shed on the staff member, even if they have applied the appropriate actions.

FORCE USED

Only minimum force to control the situation and to prevent injury and damage will be used. The degree of restraint used is important as any act of touching another person’s body may be technically assault if there is no consent so, there must always be ‘good cause’ to use Physical Restraint.

VERBAL REASSURANCE

Those involved will ensure that, during the intervention, every effort will be made to verbally pacify and calm the resident. There should be no anger or affront to the individual, and all efforts should be made to ensure the individual is aware that despite the situation, those involved are acting in their best interests

MINIMAL FORCE TIME

Physical Restraint will be released as soon as it is safe thus allowing the resident to gain self-control. There is no need or necessity to hold an individual longer than necessary, as the longer they are held, the increased danger of injury is apparent, plus those involved may give grievance reasons to the individual and ultimately may lead to resentment, or a legal redress.

HAZARD MINIMISING

Those involved will ensure that all potential hazards are removed immediately. This will include resident’s property considered to be dangerous. Those involved will be aware of and inform the resident of their right to the return of their property when circumstances prevail.

PHYSICAL EXAMINATION

Immediately following the incident, Those involved will check the resident / others for any signs of injury and, where appropriate, will complete an Accident Form following The Home’s written procedure for dealing with accidents. Any signs of injury will necessitate immediate medical attention, either with GP input or admission to the Accident and Emergency Department

RECORDING OF INCIDENT

Those involved will enter the circumstances and justification for Physical Restraint in the individuals personal file, the Handover Report and will complete a Violent Incident Form. Accident Forms and Complaints Forms may be required to complete the process.

AGENCY INFORMING

The Nurse Administrator and / or Director will be informed at the earliest opportunity, as will other agencies as appropriate. Other agencies could be the resident’s Psychiatrist, G.P, Social Worker, Community Psychiatric Nurse and Police (where relevant). The earlier the incident is reported to the appropriate agency, it will diminish negative feedback and/or concerns of improper actions used by those involved by those agencies.

POST-INCIDENT EVALUATION

Those involved will evaluate the circumstances which led to the incident to find out if the incident could have been avoided and whether there were signs of change that were not noted, and whether anything can be learned for the future which will prevent the same problem reoccurring.

PREVENTION OF ABUSE

Care and Nursing Homes are committed to ensuring that they are an ‘abuse free environment’. Staff should be aware that abuse can be Physical, Sexual, Financial, Emotional, Spiritual or Psychological violation or a neglect of a person unable to protect themselves, to prevent the abuse from happening or to remove themselves from the situation.

RIGHTS

It is appreciated that individuals have the right to express their wishes and priorities and their right to live as independently as possible without the risk of abuse. They have the right to live in a home-like atmosphere without fear and free from abuse from their carers, fellow residents or visitors. Residents will have the right to move freely in the Home without fear of violence or harassment and to have their money, goods and possessions treated with respect.

STAFF KNOWLEDGE

All staff will be aware of their abuse policy and will be aware that they have a duty to report any concerns about abuse in the interest of protecting people within the home.

MINIMISING ABUSE

Steps to minimise the risk of abuse and has written procedures on: Staff Selection and Recruitment, Training, Complaints, and Disciplinary Procedure, Dealing with Residents’ Cash and Valuables. All of the Home’s staff undertake the comprehensive In-Service Training Programme and receive three monthly appraisals. Staff also have regular teaching sessions, staff and management meetings.

DEALING WITH ABUSE

CHALLENGING ABUSE

Where possible actions should be taken without first confronting the perpetrator or alerting them to what has been alleged. If the situation is urgent, the person witnessing the abuse should immediately challenge the person who is abusing the resident and try and persuade him/her to stop. The Person-in-Charge must be informed immediately as the alleged perpetrators may need to be removed from the residents or Care Duties.

PERSON IN CHARGE RESPONSIBILITY

The Person-in-Charge will take immediate action where there is concern that a resident is in immediate danger or that they need urgent medical attention. The residents’ safety will be maintained at all times and emergency services will be called where required.

ESTABLISHING THE FACTS

In all cases of abuse, whether alleged or witnessed, all facts will be established and a written statement taken. The Person-in-Charge will investigate and decide if there are grounds for action by talking to and collecting written statements from all those concerned. The Manager will also be informed.

DISCIPLINARY PROCEDURES

Where staff have been accused, the Manager will decide whether Disciplinary or Instant Dismissal Procedures will be used. All persons will be made aware of the Complaints Procedure if they are unhappy about the way in which the matter has been dealt with.

MEDICAL INTERVENTION

The resident will be given support through all stages of an investigation and / or medical examination