Conflict Resolution Refresher Training.

1. Conflict Resolution Refresher Training. December 2013

2. December 2013 • Learning outcomes: • Reflect upon incidents of elective aggression / violence & how to approach this. • Understand what is meant by clinically related challenging behavior & apply a core care plan. • Be aware of reporting process (Datix) and subsequent ARA’s / alerts. • Understand reasonable / proportionate response, in terms of keeping self safe.

3. Elective /Intentional Behaviour What causes it? (discussion) Waiting, lack of communication, external circumstances, personality, car parking, expectations/perception. Remember, State of mind=mood=behaviour What to look for? (Psychological / thought or speech content and Physiological / observable) (discussion) Psychological Emotional thinking/irrational dialogue, change in voice, increase expletives, inflexibility. Physiological Adrenalin release, increased breathing, complexion change, pacing, abnormal eye contact, aggressive body language, arm splaying, finger pointing.

4. Approaches - What works & what doesn’t? (Identify examples and group discussion / feedback) Betaris Box My attitude My behaviour Affects Your behaviour Your attitude

5. Core Care Plan - Clinically Related Challenging Behaviours

6. Assess and document all underlying causes of clinically related challenging behaviour, for example: • Infection • Head injury • Pain • Medication • Anxiety • Acute Confusional State • Manic episode • Document if these are short term and reversible or established longer term challenges. • Consider the need for Safe and Supportive Observations as per Trust Policy. • Psychosis • Hallucinations • Dementia • Sleep deprivation • Alcohol and/or drug misuse • High stimulus environment • Disempowerment • Recent altercation or receipt of bad news

7. RESTRAINT Assessment of Mental Capacity should be demonstrated as per Trust Policy when restraint is required - document the assessment and outcome in the evaluation sheet. Persons implementing restraint must reasonably believe that restraint is necessary to prevent harm and the level of restraint used is proportionate in response to the likelihood and seriousness of harm - document the identified risks and how many staff are required in the evaluation sheet. Staff applying restraint should be made aware of physical and emotional risks to the person being restrained, in particular including risk of positional asphyxia – document how this has happened in the evaluation sheet. The effectiveness of the practice in meeting its aims should be continually reviewed and the practice should continue only for as long as it remains both effective and necessary - document the review and outcome in the evaluation sheet.

8. ACTIONS Offer the person support and reassurance – document how this has happened in the evaluation sheet. Promote privacy and dignity at all times – document how this has happened in the evaluation sheet. Ensure all staff are aware of any risks and how to call for help when required – document how this has happened in the evaluation sheet. All incidents must be reported on DATIX and documented in the medical notes, including: A Mental Capacity assessment where appropriate Steps that were taken to de-escalate the situation prior to the use of restraint The duration of the restraint How many staff were involved The outcome of the situation On-going assessment and management of the patient with regards to violence, aggression and restraint

9. Ray70 yr old gentleman from Newlyn.Fisherman all his working life.Married for 40 yrs (wife died 5 yrs ago).Son & daughter both in their thirties, living locallyOver past few years Ray supported in the community with a carers package, living in his own home. Increasingly unable to care for self at home, showing onset symptoms of dementia. Often confused, finding it difficult to put sentences together and increasingly forgetful.Son & daughter visit regularly (but too busy to provide continual care, as have own families).Admitted to hospital after another fall in his home – found by daily carer.Treated for acute chest infection.Whilst in hospital became increasingly confused. Often wandering up and down the ward.Repeatedly asking when going home and when children were visiting.On occassions seemingly unable to remember his name or where he lived – displaying frustration and anger, when this happens.Appears a little unsteady on his feet & requires assistance washing and dressing.Over the past fortnight, continually approaching staff, visitors and other patients, asking where his wife is, or when his children were visiting. (Son & daughter take it in turns visiting most evenings).When staff or others explain family will be in later, he becomes aggressive, shouting at them and on occasions trying to hit out at staff.Lately has been entering other peoples bed spaces and trying to urinate there. He also is often incontinent in bed at night. Again, when staff attend to Ray, he becomes hostile towards them.He also seems to struggle finding his way back to his bedroom when wandering around the ward.Staff have assessed that Ray does have capacity some of the time around some activities, however this is inconsistent.Ray is not ready for discharge yet, as family insisting on a suitable discharge & care package are in place prior to this.

10. DATIX, ARAs (acknowledgement of agreements) & Alerts ARA Issued Demographic Screen in the Patient Administration System Alerts recorded here are fed into Maxims and Oceano automatically

11. Maxims Demographic Screen A red triangle appears for anyone with an alert

12. Maxims Alert Screen Alert Details

13. Red triangle appears Oceano Demographic Screen

14. Expanded to see alert detail Expanded details of alert

15. Definition of the law of Self Defence, Defence of another, Defence of property “A person may use such force as is reasonable in the circumstances, in the prevention of crime or effecting or assisting in the lawful arrest of offenders or suspected offenders or persons unlawfully at large.” Sec. 3 Criminal Law Act 1967

16. Common Law • “A defendant is entitled to use reasonable force to protect himself, others for whom he is responsible and his property. It must be reasonable” - Beckford v R AC 130, 1988 (Lord Griffin)

17. Contacts Jon Wiggans – Management of Aggression & Violence – Lead, Learning & Development, Royal Cornwall Hospitals NHS Trusts Ian Davies – Management of Aggression & Violence – Specialist Trainer. Jon.Wiggans@rcht.cornwall.nhs.uk Ian.Davies@rcht.cornwall.nhs.uk Learning & Development Dept – 01872 255148 Training@cornwall.nhs.uk