Implementing clinical practice guidelines on the management of imminent violence on two acute psychiatric in-patient units

There is evidence of a significant risk of violent incidents within in-patient psychiatric settings. The Royal College of Psychiatrists published Clinical Practice Guidelines on the 'Management of Imminent Violence'. This paper discusses the impact of implementing these guidelines on two psychiatric in-patient units. The intention was to implement routine risk assessments. Although resources limited risk assessment completion, staff reported some selective risk assessments where they considered violence risks to require detailed appraisal. The organisational training programme and risk assessment implementation strategy were begun after the first of four audit periods. We found that the total number of incidents in each audit period did not decrease, but violent incidents among those admitted in each consecutive audit period, did decrease. However, these findings were explained by a cohort effect. There appeared to be no actual reduction in violent incidents, partly as violence was unexpectedly uncommon on these wards (11.4%) such that the study did not have adequate power to detect a significant reduction. The limitations of an audit rather than a cohort study or a randomised trial are discussed, alongside the strengths of an organisational training programme. Users' views about violence on wards urged that staff take greater account of contextual precipitating factors, as well as staff attitudes to users who break ward rules. The findings are discussed in light of recent developments in clinical governance, resource limitations and the implementation of guidelines to improve practice.