4 Background to the guideline Background to commissioning of the guideline

In March 2002, the National Collaborating Centre for Nursing and Supportive Care (NCC-NSC) was commissioned by NICE to develop cost effective and clinically relevant guidelines on the short-term management of disturbed/violent behaviour in adult psychiatric in-patient settings and emergency departments. The remit from the Department of Health and Welsh Assembly Government was as follows: To prepare clinical guidelines for the NHS in England and Wales for the short-term management of disturbed/violent behaviour in in-patient psychiatric settings, including consideration of pharmacological, physical (including seclusion and restraint), preventative and psychosocial interventions.

Relationship to other key developments, such as National Service Frameworks (NSFs), other guidelines and policies
The short-term management of violence is a key Government target. This is outlined in the recently developed Mental Health National Service Framework (1999), which stipulates that staff should be competent to assess the risk of violence, manage individuals who may become disturbed/violent, and that staff should know how to assess and manage risk and ensure safety. The effective short-term management of disturbed/violent behaviour is a means of helping to minimise the risk of injury to the individual service user, other service users and staff involved in these types of incident. The short-term management of violence is also a key aim in the cross-Government NHS zero tolerance zone campaign, which was launched in 1999. The aim of this initiative is to combat violence against NHS staff, where violence is defined as: Any incident where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health. (www.nhs.uk/zerotolerance/definitions.htm) In the light of the serious nature of disturbed/violent behaviour in adult psychiatric inpatient settings and emergency departments, the interventions for the short-tem management of disturbed/violent behaviour in adult psychiatric in-patient settings and related topics were selected as the focus for this NICE guideline.

The Royal College of Psychiatrists produced a guideline (RCPsych guideline) on the short-term management of disturbed/violent behaviour, The management of imminent violence in 1998, which was due to be updated. All the archive material for this guideline was obtained, search strategies and critical appraisal sheets examined, and copies of the original evidence reviews were considered. The original appraisal of the guideline undertaken by St George's hospital was also obtained (see Appendix 12). The guideline and all archive material were then appraised using the agree tool (see Appendix 11). On this basis, it was decided that the RCPsych guideline should be used as a basis for the current guideline, meaning that this guideline would update and replace the RCPsych guideline, while also extending it into new areas. Searches for this guideline did not therefore go back further than 1995, unless otherwise stated, as this period was covered by the RCPsych searches. All studies included from RCPsych guideline can be found in the evidence tables of included studies for this guideline (Appendix 5). All evidence statements in this guideline take into account both the evidence base contained in the RCPsych guideline and that generated from any new studies included here. The NICE guideline on schizophrenia (2002) also reviewed rapid tranquillisation in relation to the treatment of schizophrenia. This current guideline builds on this work developed by the National Collaborating Centre for Mental Health (NCC-MH). The NICE guideline on bipolar disorder (forthcoming 2006) will also review the issue of rapid tranquillisation in relation to the treatment of mania. In addition to this guideline, several further initiatives are also currently underway which seek to improve the short-term management of disturbed/violent behaviour in adult psychiatric in-patient settings. These are: The collaborative work being undertaken by the National Institute for Mental Health in England (NIMHE) and the NHS Security Management Service (SMS) which are in the process of establishing a core training curriculum for the short-term management of disturbed/violent behaviour, and a national accreditation scheme for trainers. The core training curriculum is expected to be announced in 2005 and the accreditation scheme is expected to come into force in 2005. The NCC-NSC and the GDG have worked closely with these agencies in developing this guideline and the recommendations and good practice points within it. A national audit of the short-term management of disturbed/violent behaviour is being carried out by the Royal College of Psychiatrists on behalf of the Healthcare Commission. The first phase of the audit was scheduled to run concurrently with the development of this guideline. The NCC-NSC liaised closely with the Royal College of Psychiatrists and is grateful to them for helping develop the audit criteria listed in this guideline (see Section 9). The David Bennett Inquiry raised important concerns about the treatment of black service users within the NHS. While the inquiry examined the whole of Mr Bennett's care, many of the recommendations produced by the inquiry are relevant to the scope of

this guideline. Each of these recommendations has been carefully considered and reflected upon when developing the recommendations and good practice points in this guideline. Additional consultation work with black service users was also undertaken by the NCCNSC in the course of the development of this guideline. We are grateful to Black Orchid in Bristol and Footprints UK in Walthamstow for running focus groups for us. This work was used to inform the recommendations and good practice points see, in particular, the section on working with service users found in Section 8.4. The NCC-NSC also ran a focus group with health care professionals experienced in the area of black mental health (see Appendix 14).

Clinical need for the guideline

Disturbed/violent behaviour by an individual in an adult in-patient psychiatric setting poses a serious risk to the individual, other service users and staff. In 1998/99, an NHS Executive survey found that there were approximately 65,000 violent incidents against staff across the NHS. The scope of the guideline discusses the short-term management of disturbed/violent behaviour in adult psychiatric settings, excluding learning disabilities (72 hours). The guidance applies to all adult persons aged 16 or more.