Psychiatric Bulletin (2006) 30: 196. doi: 10.1192/pb.30.5.196
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 196
© 2006 The Royal College of Psychiatrists
Safety for Psychiatrists
Council Report CR134, January 2006, Royal College of Psychiatrists,
£7.50, 32 pp
Despite many investigations and inquiries into violent incidents in mental
health settings, safety considerations for mental health staff continue to be
an issue of serious concern.
Aggression and violence are often preventable. Prevention relies heavily on
the awareness and skills of mental health clinicians working in organisations
that are supportive and that help professionals to develop practical skills in
a safe physical environment. However, there are still serious gaps.
This report replaces Safety for Trainees in Psychiatry (CR78),
published in 1999. The scope of the report has been broadened to include all
practising psychiatrists. The working party has reviewed the safety literature
published since the last report, and consulted widely with other organisations
which have similar concerns.
The report focuses on those measures which can reduce the chances of
assaults taking place, or of serious injury being sustained should they occur.
Trusts and other employing organisations already have statutory obligations to
ensure that the environment in which mental health professionals work is safe
and secure, and this report does not dwell on this area, other than to point
out where psychiatrists still notice deficiencies.
Brief vignettes exemplify situations which are likely to give rise to
safety considerations in various settings, and advice is given on prevention
and ways to reduce escalation of risk.
Recommendations:
- Although junior psychiatrists are now more likely to receive training in
the recognition and prevention of violence, and in using de-escalation
strategies and breakaway techniques, there is less evidence to suggest this is
happening with senior psychiatrists. This should take place early on in the
post, with regular refreshers.
- Senior clinicians have a central role in preventing seriously aggressive
behaviour in their patients. They not only have experience of assessing the
risks posed by patients, but they can also advise their colleagues on how to
manage such risks. Early detection of possible eruption of violence in an
in-patient setting can be enhanced by a close working relationship with
nurses, ability to read and take action when difficult atmospheres exist, and
more active participation of psychiatrists in therapeutic activities.
- Psychiatrists need to be aware of the potential for aggressive behaviour
which might emanate as a direct result of their intervention, particularly
where there exists an atmosphere of perceived confrontation, such as
assessments under the Mental Health Act 1983, meetings with advocates,
tribunal hearings, or where they are unrealistically expected to resolve
problems outside their brief, skills or capacity.
- Recognition of issues that require sensitive handling, in particular
regarding racial or gender issues, and the careful use of language in heated
interchange, can help prevent violent outbursts. The judicious use of
interpreters can also calm distressed patients who are unable to communicate
in English.
- In out-patient settings, accident and emergency departments and prison
environments robust safety measures need to be in place, such as adequate and
well functioning alarm systems, clear exit facilities, and arrangements for
support by other staff in cases of emergency. This procedure should be checked
regularly. Recognition of the anxiety experienced by patients when coming to
see a psychiatrist, or waiting to be seen, can do much to reduce tension and
enhance the quality of the interview.
- For psychiatrists working in the community it is important to gather as
much information as possible before the visit about the patient, the family,
and the environment where the visit will take place in order to take adequate
preventative measures. In particular psychiatrists should carry a means of
communication and ensure that the base is aware of the time of the
appointment, and what to do if the psychiatrist fails to return to base within
an agreed time. It is recommended that psychiatrists should not visit private
dwellings alone if they are not sure about the circumstances, and never at
night.
- As far as Mental Health Act Assessments in the community are concerned, a
pre-visit conference with all parties concerned, including the family, police
and social workers, is strongly recommended in order to plan the intervention
and take appropriate measures.
- For those working with families and carers, in particular in old age and
child and adolescent psychiatry, it is important to bear in mind that members
of the family can also become highly agitated, aggressive and violent on
behalf of their ill relative.
- Psychiatrists should receive specific training on the assessment,
management and risk assessments of patients with dual diagnoses.
- The working party has endorsed the recommendations of the earlier College
report on Safety for Trainees (CR78), many of which apply to all
psychiatrists. In particular it wishes to highlight the importance of
induction courses which take into account local safety considerations, matters
of personal privacy, behaviour and appearance, and clear guidelines on what
must be done following a violent incident.
- A jointly agreed and understood protocol for the reporting of untoward
incidents should be in place in each workplace. This will only work if the
culture allows staff to feel comfortable about reporting incidents without
prejudice. Reporting incidents should be linked to a structure that allows
learning to take place, and adaptation of practices as a result of incidents.
Clinical governance principles should be followed, with regular audits of
violent incidents, and effective measures introduced resulting from their
recommendations.
- In cases of serious assault, the matter should be reported to the police,
who jointly with the trust should consider pressing charges against the
perpetrator. In less serious incidents, a judgement needs to be made on
clinical grounds whether this is the best form of action to prevent
recurrences. This may need to be discussed with the legal advisor of the
trust, as well as the medical defence society.
