Management of Violence in Services for People with Learning Disabilities

Summary

Forty-four psychiatric wards from 27 learning disability services participated in an audit of the management of violence in services for people with learning disabilities. The audit programme began in January 2001 and ended in September 2002. The standards were drawn from the Royal College of Psychiatrists' clinical practice guidelines, which identified the factors that reduce the frequency of violence and minimise injury to staff and service users. The audit data included questionnaire returns from 1249 people who worked on, used or visited psychiatric wards. Many aspects of the physical and environment of the wards, staffing and communication systems fell short of the audit standards. The audit provided a baseline against which improvements in services can be gauged.

Key National Findings

The physical environment

• Low staffing levels are cited repeatedly as a major problem by many of the trusts. Staff numbers are reported to be too low to effectively handle violent incidents when they occur, and staff can feel unsupported and low in morale. In addition, staff shortages make it difficult for staff to be released for effective and regular training. This means that training is not always considered to be adequate and appropriate to the needs of the unit.
• 70% of staff felt that the content of staff training and development was relevant to the need of the people living there with 20% saying it wasn't.

• Access to training: 43% of staff had not received more specialised training before working with people who may require physical interventions.
• Adequacy of training: 81% of staff had not, in the past 5 years had any training that would enable them to train others in the prevention or management of violence.
• Only 58% of staff felt that their training was adequate to minimise the risk of violence occurring, with 62% considering their training adequate to deal with violence when it occurs.

Institutional responses to violent incidents

• Team support with regard to violence, was often reported as sporadic and not formalised. Respondents from many trusts called for a more formal debriefing process after critical incidents.
• It was often reported that they were unclear about the procedure for involving the police and that action against service users should be taken more often than was currently the case.

The management of violence

• 62% of service users agreed that violence between patients was managed effectively.
• Comments indicated that nurses are both expected and perceived to take the lead role in managing violent incidents when the occur on the unit.
• Non-staff were asked about their experiences of violence during their stay. 76% of service users answered yes when asked if residents threatened or were violent to each other, and 77% said residents had threatened or were violent to staff.

• As part of the module three, critical review of violent incidents, teams were asked to compile action plans. Throughout all stages of the audit, staff, service users and visitors made recommendations for improvement. The findings below are the common themes that emerged from the returned action plans, questionnaires and environmental audits.
• Ensure new staff receive training prior to working on the unit
• Be aware of individual service users warning signs and triggers
• Increase staff awareness of self harm issues
• Regular training and updates for all staff on; seclusion, breakaway techniques, C&R or equivalent and defusion.
• Reflect on violent incidents in order to learn and make changes to improve safety and the management of such incidents.
• Involve individual service users in boundary setting and action planning around managing their own violent and potentially violent behaviours.
• Involve all professionals in discussions and decision making concerning individual service users.
• Establish, maintain and improve relationship with local police.
• Raise staff awareness of the serious effect of violent and verbal assaults and the need for support when such incidents occur.
• Increase staffing levels to decrease staff stress and allow service users individual time with staff when need, instead of running shifts therefore under staffed.
• Examine the unit environment and understand its impact and influence on precipitating violent incidents.
• Make changes to environment where possible, e.g. introduce convex mirrors at blind spots, ensure there is a quiet room for service users and staff, maintain acceptable room temperature.

The national audit aimed to: I) determine the extent to which good practice prevailed, II) to raise awareness of the amended clinical practice guidelines and III) provide national data from which benchmarks can be derived. The project itself was an ambitious and unique one.

The audit findings highlight the areas in which practice or provision can be improved. Key themes that emerge from the audit findings include:

• unsuitable units which were often too hot and noisy and had little personal space for the service users;
• poor communication systems between staff and other professionals;
• lack of support for staff following a violent incident; low staff morale and lack of communication to service users regarding their stay and treatment.

There are a number of issues that require addressing for service users and staff alike. It would be easy to suggest that the solution would be to build new units. This would not be sufficient. Firstly, mainly of the issues highlighted relate not to the units themselves but to the social environment and to the training, development and support of staff. There is a danger that organisations would be merely relocating these issues to a new environment. Secondly, many of the identified issues can be addressed now and with limited financial implications. For example, changing the use of space and involving service users in the care planning process does not cost money or require a new building.

As part of the audit process the participating units were encouraged to develop action plans to address the specific local problems that were identified. Several units identified similar issues and action plans. These recommendations are valuable to the wider learning disability services and have been listed below. The audit will have only been a success if these local action plans are put into effect and recommendations taken on board.