Adults with ‘Learning Disabilities’ or ‘Mental Health Difficulties’ routinely pass through the ‘public’ domain, and in and out of both ‘health’ and ‘social care’ ones too. It follows then that any behavioural disturbances associated with their diagnosis could conceivably occur anywhere as they journey through the various places, spaces and systems. However the different ways in which the adjacent sectors define such behaviour can mean in practice staff respond in significantly different ways.

Understanding challenging behaviourWithin Social Care settings ‘Challenging Behaviour’ is accepted as something that comes in both verbal and physical forms. The most widely recognised definition, developed by Eric Emerson,3 describes it as “Culturally abnormal behaviour(s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities.” This definition highlights that the main consequences of behaviour are to the individual displaying it. This type of behaviour is therefore something to be analysed, understood, and prevented, and when it becomes manifest it is something to be carefully and sensitively managed.

In other settings comparable behaviours can be considered and managed under a wholly different system of categorisation. A major driver here is the Health and Safety Executive (HSE). It presides over a body of law that compels organisations to protect their staff from hazards and risks. It considers work-related violence as one such hazard and defines it as: “Any incident in which a person is abused, threatened or assaulted in circumstances relating to their work”. Within the health and safety framework there is no drive to understand the behaviour, rather just to recognise that it has consequences which are ‘adverse’ to staff, and that it is something to be controlled, preferably eliminated.

Within the NHS setting ‘physical’ and ‘non-physical’ forms of violence or ‘assault’ are differentiated further. ‘Non-physical assault’ is defined as “The use of inappropriate words or behaviour causing distress and/or constituting harassment”. Again it is something that staff are exposed to or suffer adverse consequences from. According to guidance published by the NHS Security Management Service1 (now NHS Protect) local procedures must recognise that taking action is appropriate when ‘non-physical assault’ or abusive behaviour is likely to prejudice any benefit the patient might receive from care or treatment, prejudice the safety of staff or other patients, or result in damage to property. The guidance goes on to say that a range of responses may be taken, depending on the severity of the behaviour. These include verbal warnings, written warnings, withholding treatment, civil injunctions and criminal prosecution.  The emphasis here is on corrective actions (the person is to become compliant with the wishes and/or will of the organisation and its representatives) or ultimately on some sort of punitive response (the person has done ‘wrong’ and should be ‘punished’).

NHS Protect2 define a ‘physical assault’ as “The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort” In their 2012 guidance they state: ‘All incidents of physical assault on staff, including those that may have been due to the patient’s mental or other clinical condition, should be reported to the NHS CFSMS [now, to NHS Protect]. Other than in exceptional cases, all occasions when a patient, service user or member of the public makes any unnecessary, unwarranted or uninvited physical contact with an NHS staff member should be regarded as an intentional act of assault.’ So physically assaultive behaviour is something to be reported, and evidence to be gathered as it will typically be treated as if it were criminal in nature. In practice this may mean the intervention of in-house security teams, the application of physical restraints and disposal of to the Police.

This highlights the longstanding dilemma that arises when a behavioural disturbance takes place, especially one where staff are exposed to physical aggression or assault: When is it right to accept the behaviour, and when should sanctions be applied? When a person lives with a ‘Learning Disability’, for example, punitive action is unlikely to produce positive changes and may only engender further hostility. When a person lives with a ‘Mental Health Difficulty’, punitive action is likely to increase alienation and paranoia. It also goes without saying that punishment is entirely wrong in terms of Adult Safeguarding. At the same time, health and social care workers cannot simply become targets for physical aggression. The answers to this dilemma lie in two key areas:

  • The Mental Capacity Act:  If a person is unable to use reason to foresee consequences of their actions due to a “disturbance in the functioning of the mind or brain,” then assaultive behaviour may be viewed as part of their condition.  At such times, staff may intervene in the person’s own best interests to prevent the person from injuring themselves or others.  Conversely, if the person does have the capacity to know what they are doing, then legal action may well be the appropriate course of action.
  •  Staff Training:  Staff awareness of preventative and de-escalating actions are of paramount importance, as well as the physical skills necessary to prevent actual violence.

SecuriCare offer a range of courses designed to enable support workers, carers and foster families to best respond to any ‘Challenging Behaviour’ that may occur. All programmes are finalised after full training needs analysis and delivered by experienced frontline practitioners. Click to see our ‘Preventing & Managing Challenging Behaviour’ Training Course which includes ‘Positive Behaviour Management’ techniques designed to minimise the need for any kind of restrictive intervention. You can also take a look at our person centred Behaviour Planning Service.

1Non-Physical Assault explanatory Notes – A framework for reporting and dealing with non-physical assaults against NHS staff and professionals – NHS Security Management Service (2004)

2Guidance on data requirements for the annual violence against staff (VAS) collection exercise Explanation of the exercise, counting rules and data submission guidelines NHS Protect (2012)

3Emerson, 1995, cited in Emerson, E (2001, 2nd edition): Challenging Behaviour: Analysis and intervention in people with learning disabilities. Cambridge University Press