This chapter explores the evolving use of rapid tranquillisation (RT) through the years, examining the complexities surrounding its definition and the factors that need consideration before, during and after its administration. Every acute disturbance experienced by a patient is different and a multidisciplinary approach with good communication is key. The chapter discusses the use of covert medication in

RT, the SafeWards approach to creating engaging and meaningful ward programmes for patients, laws for governing the use of restrictive procedures, and the medications used for RT and their routes of administration along with their potential side effects.

This chapter describes two principles for supporting trainees. The Scaffolding Principle describes how support should be adapted to accommodate a trainee’s current skill to keep them in a “high challenge/high support” learning mode. The Reflection Principle describes ways in which training should encourage active reflection in trainees so they can learn how to constantly reflect on their own performance and apply new insights to future situations. The chapter provides examples of intelligent tutoring systems that employ adaptive scaffolding techniques, along with other types of learning applications. The chapter also discusses strategies for encouraging learners to reflect on their training experiences.

Incidents involving violence and aggression are unfortunately common on mental health wards and in community settings. These incidents can lead to emotional distress, mental health issues and, in certain circumstances, moral injury. Serious incidents of aggression are, however, critical learning junctures from which improvements in clinical care should be driven. Yet if staff feel under threat or unsupported by leaders, they may not engage in the process. Clinical leaders should therefore create clinical teams which are psychologically safe, so that learning can take place as a core component of team activity. How to create such cultures is described, wherein leaders play a critical role. Staff support, after an incident, must be part of the learning process, for no traumatised team can learn effectively. Post-incident reviews should form a key component in this learning process. A team-based seven-step process of incident review is outlined, which does require skillful delivery. In some instances, a formal investigatory review might be needed, as well as prosecution of perpetrators, and brief guidance is given on this.

Key Learning Points

1. 1. All busy hospitals receive violent patients. Staff should be trained in appropriate reduction and response practices. Make the environment as safe as possible, and plan for a ‘worst case scenario’.

2. 2. For patients who understand their behaviours, set limits to expressions of anger. Aggression must not compromise others’ care.

3. 3. Identify specific groups at risk of ‘unpredictable aggression’.

4. 4. Reducing aggression requires: (1) coordinated, multi-level action; (2) treatment of pain, review of medication and safe prescription of sedatives; (3) consistent nursing staff, extra staffing and a multidisciplinary team approach; (4) family involvement; and (5) psychiatric liaison.

5. 5. After violent events, document and report events accurately, and debrief all staff involved.