The management of challenging behaviour, violence and aggression in emergency departments (EDs), and increasingly in general hospital wards, is often traumatic for both patients and the staff involved (Hext et al, 2018). Guidelines from the Department of Health (2014) stipulate the use of the least restrictive practices and interventions when caring for people who exhibit behaviour that may challenge staff and others. This article explores the role of nurses in relation to the administration of contemporary rapid tranquillisation as a restrictive intervention to manage aggression and violence in acute care settings. It will review drugs used, routes of administration, dosing, potential adverse effects and their management, and offer practical guidelines for acute care settings.
Specific training and education surrounding the causes and management of challenging behaviour, aggression and violence is essential for nurses working in all fields. An understanding of the biological causes of challenging behaviour is crucial, especially regarding reactive psychiatric symptoms and behavioural responses to pain, fear, infection or chronic disease. Patients with intellectual impairments, mental health problems and those with dementia or acute confusional states may be particularly prone to exhibiting challenging behaviour as a result of biological aetiology (Clark and Clarke, 2014). Healthcare staff should have an awareness of groups where there are known higher risks of violence and aggression such as young males, those with a forensic history and or/social restlessness, street drug and alcohol misusers, those with antisocial personality disorders or traits and those involved in gang culture (Mason and Chandley, 1999; Dickinson et al, 2018)
Restrictive practices and interventions
It is important to differentiate between restrictive practices and restrictive interventions; however, the former may result in the latter. Restrictive practices involve restriction of a person's rights of choice, self-determination, privacy and liberty (Department of Health, 2014). They include the use of ward ‘rules’, limit setting and authoritarian staff attitudes, while restrictive interventions include the use of bed rails, mittens, rapid tranquillisation, restraint (physical, mechanical and chemical) and seclusion (Xyrichis et al, 2018). The use of restrictive practices and restrictive interventions is not only an issue for mental health and learning disability nurses, but also for nurses working across the adult nursing field including EDs, medical assessment units (MAUs), intensive care units (ICUs) and general medical or surgical wards.
The role of rapid tranquillisation
Rapid tranquillisation (RT) is defined as giving medicines to a person who is very agitated or displaying aggressive behaviour to help quickly calm them (National Institute for Health and Care Excellence (NICE), 2015). It is often considered a form of chemical restraint, therefore it should be administered with a clear rationale for its necessity, delivered in the least restrictive manner and documented in detail. Monitoring and observation of the patient is essential following administration of RT, using appropriate National Early Warning Score 2 (NEWS 2) scoring charts. The administration of RT should be humane, legal and evidence based, in addition to being justifiable and arising from clinical necessity (Dickinson et al, 2009; NICE, 2019). Patients in EDs or general acute wards may be administered RT in an emergency situation if it is considered to be in the patient's best interests and is administered as prescribed by medical staff. It should only ever be given when it is considered the least restrictive option, as part of an emergency treatment plan and in the patient's best interests. RT should never be given as a form of ‘punishment’ or as an automatic response following an episode of violence, aggression or restraint.
Oral medication for RT should always be offered initially where possible as the least restrictive option (Department of Health, 2014). This is often not possible in EDs, ICUs or on general wards as ingestion via an oral route may be contraindicated on medical grounds, or by refusal of the patient to take oral medication. Therefore, alternative routes of administration would need to be considered, which could include intramuscular injection and intravenous injection. Box 1 outlines the recommended drugs and dosage for each of these routes of administration.
Preferred injection sites
The use of prone (face down) restraint should be avoided wherever possible (Department of Health, 2014), including when administering RT. Mental health nurses in particular tend to use the dorsogluteal site for intramuscular injections of RT, especially when administration follows incidents where the patient has been physically restrained, thus increasing the use of prone restraint (Santos and Cutcliffe, 2018). Alternatively, use of the vastus lateralis may reduce the need to place a patient in the prone position.
The vastus lateralis is situated on the anterior aspect of the thigh in the quadriceps muscle, a hand's breadth above the knee and a hand's breadth below the greater trochanter of the femur (Ogston-Tuck, 2014). This site gives easy access to the muscle and there are few major blood vessels in that area (Ogston-Tuck, 2014). Intramuscular injections should be administered using a Z-track technique (Delves-Yates et al, 2018). Box 2 outlines fundamental principles that nurses should follow when administering RT.
Maintaining competence
Specific guidelines should be consulted when administering RT, including individual hospital policies. Many EDs now have their own specific guidelines and policies to cover the management of challenging behaviour, violence and aggression; this usually includes a policy surrounding the use of RT. Other useful guidelines include the Maudsley Prescribing Guidelines in Psychiatry (Taylor et al, 2018) and NICE (2015) guidelines on managing violence and aggression.
Nurses who are responsible for the administration of RT must be confident that they have exhausted verbal de-escalation skills. Therefore, it is essential that training and education on this be provided during nurses' pre-registration education, with regular updates following registration (Mencap, 2012; Hext et al, 2018).
Guidance from the Royal Pharmaceutical Society and Royal College of Nursing (2019) on the administration of medicines in healthcare settings should be adhered to at all times and nurses must be proficient and up to date in basic life support techniques (BLS) (Resuscitation Council UK, 2015). All patients should be assessed by the multidisciplinary team from a bio-psycho-pharmaco-social perspective (Clark and Clarke, 2014) to avoid diagnostic overshadowing. Diagnostic overshadowing occurs when health professionals ignore the signs and symptoms of a secondary diagnosis and attribute certain ‘behaviours’ to the primary condition (Clark and Clarke, 2014). This is more likely to occur in people where communication may be problematic such as those with dementia, intellectual disability or a mental health problem (Parish, 1987). In circumstances such as these, vital warning signs of a medical emergency or disease may be overlooked and an accurate and timely diagnosis delayed. Often the patient is subsequently stigmatised as exhibiting ‘challenging behaviour’ (While and Clark, 2009).
Documentation
Incident and circumstances leading to the administration of RT should be recorded in the patient's clinical notes, along with the rationale for administration. The date, time, nurse administering, and nurse witnessing checking and administration of the drug (including injection site) should be recorded in addition to related physical restraint. This should appear on the patient's medication chart, individual clinical notes and the relevant incident reporting systems.
Patient monitoring following rapid tranquillisation
Patient monitoring is paramount after administration of RT. Vital signs must be monitored and charted using the NEWS 2 system. This must include temperature, pulse, respiration rate, oxygen saturation levels and blood pressure. This should be initially recorded every 5–10 minutes for the first hour, then every half hour until the patient becomes ambulatory and stable (Dickinson et al, 2009). The patient should also be placed on one-to-one constant observation for the first 2 hours, which should also be recorded. Patient monitoring after RT needs to be increased if:
Where the patient's vital signs cannot be recorded because, for example, the patient refuses or it may add to their distress or potential for aggression or violence, medical staff must be informed in a timely manner. Local policy regarding recording should also be adhered to regarding RT, monitoring of vital signs and restraint. Nurses should always seek medical advice if in doubt about a clinical situation. Box 3 discusses actions that RNs should take if a patient has an adverse reaction to RT. Early detection and appropriate management of such complications is vital, as failure to rescue could lead to avoidable death (Simmonds, 2019).
An episode of restraint can be distressing for both the patient and staff involved. Therefore, staff and patients involved in such incidents should be offered debriefing and support (Wilder and Sorensen, 2001). The patient should be offered an explanation of the decision to use RT, the medication and its effects, and a discussion of his or her experiences. The nurse should ensure that the use of RT is discussed at the earliest opportunity with the multidisciplinary team, and any lessons learned should be incorporated into future practice (NICE, 2015).
Conclusions
The administration of RT is often a traumatic event for both the patient and those involved. Nurses should always exhaust verbal de-escalation techniques before administering RT and it must then be considered by the multidisciplinary team to be in the patient's best interests. The least restrictive options should always be adopted throughout the procedure, with oral forms of RT being offered, where appropriate, in the first instance. Mechanical and physical restraint (especially in the prone position) should be avoided where possible and the vastus lateralis site considered in order to enable this. Nurses need to maintain clinical competency in administration of RT, including standards for medication management, accurate documentation and record keeping.