Child Hitting at Home: Why It Keeps Happening
What this article will help you do
If your child keeps hitting at home, this article will help you understand why the behaviour may be repeating, what to do in the moment, what to look for before and after it happens, and what to change first so you aren’t just reacting when things are already difficult.
Quick summary
A child hitting often keeps happening because it’s started to work in some way.
That doesn’t mean your child is bad, cruel, or deliberately trying to hurt people. It just means the hitting may be helping your child change the situation. It might help them get something, avoid something, delay something, gain adult attention, move a sibling away, or bring a parent closer.
The most useful first step is usually not a bigger punishment. It’s understanding the pattern.
Start by asking:
- What tends to happen before the hitting?
- What exactly does the hitting look like?
- What usually happens after?
- What might my child need to learn instead?
- What can I change before the hitting starts?
A calmer plan usually has three parts:
- Keep people safe.
- Teach a safer way for your child to communicate.
- Make sure the safer behaviour works better than hitting.
Need a calmer starting point? The Behaviour Pattern Starter Pack helps you focus on one main behaviour first instead of trying to solve everything at once.
What to do next time your child hits
When hitting happens, your first job isn’t teaching a full lesson. Your first job is to keep people safe and avoid making the pattern stronger.
Try this simple sequence.
1. Make the situation safer
Move yourself, siblings, or objects if needed.
Use as few words as possible.
You might say:
“I will not let you hit.”
“I am moving back.”
“Hands down.”
“I will help when hands are safe.”
If a younger child, sibling, baby, or vulnerable person is at risk, move them away first.
2. Avoid long explanations in the hardest moment
When a child is already very upset, long talking can add more attention, more demand, and more emotional intensity.
Save the teaching for later.
In the moment, keep your language short and predictable.
3. Keep the original boundary as consistent as safety allows
If hitting changes the answer, hitting may become part of the negotiation.
For example, if screen time has finished, avoid giving the screen back because hitting happened.
You might say:
“The tablet is still finished. You can be upset. I will help you choose what to do next.”
4. Prompt a safer behaviour
Give your child something else to do or say.
For example:
“Say, ‘help please’.”
“Say, ‘break please’.”
“Say, ‘move please’.”
“Show me safe hands.”
“Step back.”
The replacement needs to be simple enough for your child to use when emotions are high.
5. Respond quickly when your child uses the safer behaviour
If your child asks for help, gives space, uses words, or keeps hands safe, respond quickly.
For example:
“Good asking. I can help.”
“You moved back. That was safer.”
“You used words. I am listening.”
This teaches an important lesson:
Safe communication works better than hitting.
6. Practise later, when calm
After everyone is calm, briefly review and practise.
You might say:
“Earlier, you hit when tablet finished. Hitting hurts. Next time, you can say, ‘help me stop’, or ‘I am angry’. Let us practise.”
Keep it short. The goal is skill-building, not a long lecture.
When to get extra support sooner
Get extra support sooner if:
- hitting is causing injury
- siblings are frightened or unsafe
- younger children or vulnerable people are at risk
- your child is also hurting themselves
- behaviour has changed suddenly
- you feel unable to respond safely
- hitting is becoming more frequent or intense
- there are concerns about pain, sleep, anxiety, trauma, communication, development, or mental health
- the behaviour is happening across home, school, or childcare
- you cannot identify a pattern and things are escalating
This article can help you think more clearly about the pattern, but it doesn’t replace personalised professional support where risk is high or the situation is becoming unsafe.
Why hitting at home can become a pattern
It can feel deeply upsetting when your child hits you, a sibling, or another adult at home.
You may feel shocked, angry, embarrassed, worried, guilty, or completely drained. You may also find yourself wondering:
“Why do they keep doing this?”
“Do they understand that it hurts?”
“Am I making it worse?”
“Should I be stricter?”
“Why does it happen more with me than with other people?”
Those questions make sense.
Hitting is not something to ignore. It needs a clear response. But it’s also important not to jump straight to labels such as “naughty”, “manipulative”, or “out of control”.
A more useful question is:
What pattern has the hitting become part of?
Children don’t usually keep repeating behaviour for no reason. If hitting keeps happening, it’s often because something before the behaviour makes it more likely, and something after the behaviour helps it continue.
That’s not about blaming you as a parent. It’s about finding the part of the pattern that can be changed.
The key question: what does hitting change?
A behaviour is more likely to keep happening when it changes the situation in a way that matters to your child.
That change might be obvious.
For example:
A child hits and gets the tablet back.
But the change can also be less obvious.
For example:
A child hits during homework. The homework stops for ten minutes while everyone calms down.
Or:
A child hits when a parent is busy. The parent immediately stops, turns around, talks, moves closer, and gives intense attention.
Or:
A child hits a sibling. The sibling moves away and the child gets the toy or space back.
The key question is not:
“Why is my child doing this to me?”
The more useful question is:
“What does hitting change for my child?”
That question helps you move from blame to problem-solving.
A quick pattern guide
Use this table as a starting point. It’s not a diagnosis or full assessment, but it can help you notice what may be happening.
| If hitting usually happens when… | Hitting may be helping your child… | Teach or strengthen instead… |
|---|---|---|
| You say no | Restart negotiation, gain access, or get a different answer | “Can I have another choice?” / “Can I ask later?” / “I am angry” |
| You ask them to do something | Delay, escape, or reduce the task | “Help please” / “Break please” / “Do it with me” |
| Screen time or play ends | Delay the transition or get the activity back | “Help me stop” / “One more minute?” / “What is next?” |
| You are busy | Get fast adult attention | “Look” / “Play with me” / gentle tap / “Help” |
| A sibling takes something | Get the item, space, or adult help | “My turn” / “Stop” / “Move please” / “Help” |
| Bedtime starts | Delay bedtime or bring the adult closer | “Stay with me for one minute” / “Help me settle” |
| They are corrected | Escape embarrassment, stop the correction, or regain control | “I need a minute” / “Say it again calmly” |
| A routine changes | Avoid uncertainty or regain predictability | “What is happening?” / visual routine / first-then language |
The exact reason will vary from child to child.
The point is to stop treating hitting as one big mystery and start looking for the repeated pattern around it.
Look at before, behaviour, and after
A useful way to understand hitting is to look at three parts.
1. What happens before?
This is the situation that makes hitting more likely.
It might include:
- being told no
- being asked to stop something enjoyable
- being asked to start something difficult
- waiting
- sibling conflict
- hunger or tiredness
- bedtime
- getting ready for school
- homework
- screens ending
- transitions
- being corrected
- losing a game
- adults talking to each other
- unclear instructions
- too many demands close together
These are not excuses. They are clues.
If hitting usually happens when your child is told to stop the tablet, that tells you something different from hitting that usually happens when a sibling touches their toys.
2. What exactly does the behaviour look like?
Use plain, observable words.
Instead of:
“My child becomes aggressive.”
Try:
“My child hits my arm with an open hand.”
Or:
“My child runs towards their sibling and pushes them with both hands.”
Or:
“My child swings their hand towards my face when I say no.”
Clear descriptions help you see whether the behaviour is changing over time. They also make it easier to explain what is happening if you later seek support.
3. What happens after?
This is often where the pattern becomes clearer.
After the hitting, does your child usually:
- get the item back?
- avoid the task?
- delay the instruction?
- receive lots of talking?
- get held close?
- get sent away from the demand?
- get a parent’s full attention?
- make a sibling move away?
- cause adults to argue about what to do?
- receive a different answer from a different adult?
This is not about blaming anyone for “rewarding bad behaviour”.
A better question is:
What did the hitting change?
That question gives you something practical to work with.
Three common hitting patterns at home
Every child is different, but these patterns are common.
Pattern 1: Hitting after being told no
A child asks for a snack, screen, toy, or activity.
The parent says no.
The child hits.
The parent explains, warns, argues, comforts, negotiates, or eventually gives a slightly different version of the answer.
The pattern may become:
Hitting changes “no” into more attention, more negotiation, or sometimes access.
That does not mean your child is bad. It means the “no” moment may have become hard for them to tolerate, and hitting has sometimes changed what happens next.
A helpful response might be:
“The answer is still no. You can be cross. I will not let you hit.”
Then later, when calm:
“Next time, you can say, ‘I am angry’, or ask, ‘Can I have something else?’”
The replacement behaviour does not need to give your child everything they want. It needs to give them a safer way to communicate and recover.
Pattern 2: Hitting when a demand is placed
A parent asks the child to get dressed, brush teeth, start homework, come to the table, or turn off a game.
The child hits.
The adult stops the demand to manage the hitting.
The task is delayed.
The pattern may become:
Hitting delays or removes a difficult demand.
The answer is not to force the task through at any cost. That can make things worse and increase risk.
The better question is:
How can I make this demand easier to start, and teach my child a safer way to ask for help or a break?
For example:
- give a short warning before the transition
- break the task into smaller steps
- reduce language
- offer two acceptable choices
- reinforce the first small step
- teach “help please”
- teach “break please”
- return to the task after a short break so hitting does not become the only way out
Useful lines might be:
“You can ask for help. Say, ‘help please’. Then we will do the first bit together.”
Or:
“You can ask for a two-minute break. After the break, we will do shoes.”
The important part is that the safer communication works, and the hitting does not work better.
Pattern 3: Hitting for attention or connection
This one can be hard for parents to hear, because “attention” can sound like blame.
It should not.
Children need attention, connection, and adult response. Sometimes hitting becomes part of the pattern because it reliably brings the adult close, especially when calmer bids for attention are missed.
For example:
A parent is cooking, working, caring for another child, or trying to rest.
The child makes small bids for attention.
The adult is busy.
The child hits a sibling or parent.
The adult immediately turns, speaks, moves closer, and gives intense attention.
The pattern may become:
Hitting brings adult attention faster than asking calmly.
This doesn’t mean “ignore your child”. It means you may need to strengthen the safer ways your child can get attention before hitting starts.
That might include:
- noticing early bids for attention
- giving short planned attention before busy periods
- teaching “play with me”, “look”, “help”, or “your turn”
- praising calm requests
- giving attention quickly when the child uses the safer behaviour
- keeping the response to hitting brief and low-drama while still protecting safety
A useful line might be:
“I want to listen. Hands need to be safe first. Say, ‘Mum, look’.”
Then when they use the safer phrase:
“You asked with safe hands. I can look now.”
What often makes hitting harder without meaning to
Parents are usually trying to help. But some very understandable responses can accidentally make hitting more likely next time.
1. Long explanations during the hardest moment
When your child is already very upset, a long explanation can become more attention, more demand, and more conflict.
Try shorter language:
“I will not let you hit.”
“Hands down.”
“Move back.”
“We will talk when everyone is safe.”
2. Changing the answer after hitting
If the answer changes after hitting, the child may learn that hitting is part of negotiation.
You can still be kind and flexible. But avoid making hitting the reason the boundary changes.
For example:
“The tablet is still finished. You can choose drawing or Lego.”
3. Removing every demand completely
Sometimes you need to pause for safety. That is fine.
But if hitting always removes the demand completely, the behaviour may become a reliable escape route.
A better plan is:
Pause, calm, then return to a smaller version of the task.
For example:
“Shoes felt too hard. We will do one shoe together.”
4. Hitting back or using physical punishment
Hitting back is not a safe or recommended response. It can hurt your child, frighten them, and increase safeguarding or legal concerns. It also teaches the opposite of what you are trying to build: safe hands, safer communication, and calmer problem-solving.
If you feel so overwhelmed that you might hit back, the priority is to create distance, keep everyone safe, and get support. Step back if it is safe to do so, use fewer words, move other children away, and return to teaching once everyone is calmer.
5. Trying to solve every behaviour at once
If you try to fix hitting, shouting, refusal, bedtime, screen time, sibling conflict, and mealtimes all in one week, the plan usually becomes too big to follow.
Start with one main behaviour in one repeated situation.
That is where you will see the pattern most clearly.
A practical first plan for child hitting at home
This is a starting framework, not a personalised assessment. Use it to organise your thinking.
Step 1: Choose one hitting pattern
Do not start with “hitting in general”.
Start with one repeated pattern, such as:
- hitting when told no to screen time
- hitting during bedtime
- hitting when asked to get dressed
- hitting when a sibling touches toys
- hitting when parent attention is divided
Write it down clearly:
“We are starting with hitting during the evening tablet transition.”
This reduces overwhelm and makes progress easier to see.
Step 2: Track five examples
For each example, write:
- What happened just before?
- What did the hitting look like?
- What happened after?
- How intense was it?
- How long did it take to settle?
- What helped?
- What may have made it harder?
You are not trying to write a perfect report. You are looking for clues.
Even three to five examples can show whether the behaviour is mostly linked to access, escape, attention, transitions, sibling conflict, tiredness, unclear expectations, or a mix of factors.
Step 3: Change what happens before
This is often the most underused part of behaviour support.
Parents are often told what to do after hitting. But the biggest improvements often come from changing the setup before hitting starts.
Depending on the pattern, this might include:
- giving a clear warning before ending an activity
- using “first, then” language
- reducing the number of instructions
- making the first step smaller
- offering two acceptable choices
- giving planned attention before a difficult transition
- moving siblings further apart during high-risk moments
- keeping routines more predictable
- removing unnecessary audience or crowding
- preparing your child for what will happen next
- reinforcing calm transitions before behaviour builds
For example, instead of:
“Right, turn it off now, we are going upstairs.”
Try:
“Two minutes, then tablet finished. First tablet away, then story.”
Then after two minutes:
“Tablet finished. You can carry it to the shelf or I can.”
The aim is not to avoid all frustration. The aim is to make the situation clearer and easier to handle.
Step 4: Teach what to do instead
A child who hits often needs a replacement behaviour that is easier, faster, and safer.
The replacement depends on what the hitting seems to achieve.
If hitting gets attention, teach:
- “Look”
- “Play with me”
- “Help”
- tapping your arm gently
- bringing a card or object
- saying the parent’s name once
If hitting delays a demand, teach:
- “Help please”
- “Break please”
- “One minute”
- “Can you do it with me?”
- “I need it smaller”
If hitting happens after no, teach:
- “I am angry”
- “Can I have another choice?”
- “Can I ask again later?”
- “I need space”
- “Can I squeeze a cushion?”
If hitting happens with siblings, teach:
- “My turn”
- “Stop”
- “Move please”
- “Can I have it when you are finished?”
- “Parent help”
The replacement must be practised when calm.
Do not wait for the hardest moment and expect a new skill to appear.
Practise briefly, often, and positively.
For example:
Parent: “Pretend I said tablet is finished. What can you say?”
Child: “One more minute?”
Parent: “Good asking. Sometimes I can say yes, sometimes I will say no, but asking is the right way.”
Then practise the no version too:
Parent: “This time I say no. What can you do with your hands?”
Child: “Safe hands.”
Parent: “Yes. Safe hands even when it is no.”
Step 5: Make the safer behaviour work
This is crucial.
If the child says “help please” and nothing changes, but hitting brings everyone running, hitting is still the stronger behaviour.
The safer behaviour needs to work.
That does not mean your child gets everything they ask for. It means the safer behaviour produces a useful response.
Examples:
If the child asks for help:
“Yes, I can help with the first one.”
If the child asks for a break:
“Yes, two-minute break, then we come back.”
If the child says “I am angry”:
“I hear you. You can be angry. The answer is still no, and I can help you choose what to do next.”
If the child asks for attention safely:
“You asked with safe hands. I can look for one minute.”
This teaches:
Safe communication works better than hitting.
Step 6: Make hitting less useful without making things harsher
The goal is not to punish harder.
The goal is to stop hitting from being the most effective strategy.
If hitting gets the tablet back, the tablet should not come back because of hitting.
If hitting delays shoes, you may pause for safety, but return to a smaller shoe step once calm.
If hitting gets intense adult attention, keep the safety response brief and give more attention to safe communication.
If hitting makes adults argue, agree the plan in advance so your child does not experience two different responses.
A simple after-hitting plan might be:
- Block or move for safety.
- Use one short line.
- Keep the original boundary as consistent as possible.
- Prompt the safer replacement.
- Reinforce the replacement as soon as it happens.
- Return to the routine in a smaller, calmer way.
For example:
“I will not let you hit. Tablet is still finished. You can say, ‘help me stop’. Good asking. I will help you put it on the shelf.”
That is very different from:
“Stop it. Why do you always do this? Fine, just have five more minutes.”
The first teaches a better pattern. The second may accidentally strengthen the old one.
What if hitting gets worse when you change the plan?
Sometimes behaviour increases when a familiar pattern stops working.
For example, if hitting has often delayed bedtime, and bedtime now continues calmly after a pause, your child may try the old behaviour more strongly at first.
That doesn’t mean the new plan is wrong. It may mean the old behaviour is being tested because it used to work.
However, safety still matters. If hitting becomes unsafe, intense, or unmanageable, seek support rather than trying to push through alone.
A good plan should be:
- safe
- realistic
- consistent
- focused on one pattern
- built around teaching
- adjusted based on what the pattern shows
If a plan depends on everyone staying perfectly calm forever, it isn’t a strong plan.
Real homes need plans that can survive tiredness, siblings, work pressure, and ordinary family stress.
What if your child laughs after hitting?
Parents often find this especially upsetting.
Laughter after hitting doesn’t always mean your child thinks hurting someone is funny. It can happen for different reasons.
It might be:
- nervous laughter
- excitement
- attention seeking
- uncertainty
- a response to the adult’s big reaction
- difficulty knowing what to do next
- a way to avoid discomfort
The best response is usually not to debate the laughter in the moment.
Keep the boundary clear:
“I will not let you hit. Move back.”
Then later, teach repair and replacement:
“When you hit, it hurt. Next time you can say, ‘move please’. Now we need to check they are okay.”
Repair matters, but it should not become a long shame-based lecture.
The aim is responsibility plus skill-building.
What if your child says sorry but keeps hitting?
An apology is not the same as a replacement skill.
A child may genuinely feel sorry and still not know what to do the next time the same trigger appears.
If the pattern is:
Trigger → hitting → apology → same trigger tomorrow → hitting again
Then the missing piece is not more apology. The missing piece is practice before the trigger happens again.
Ask:
- What should my child do instead of hitting?
- Have we practised that when calm?
- Does the safer behaviour actually work?
- Do adults respond consistently?
- Have we made the trigger easier to manage?
You can still accept the apology:
“Thank you for saying sorry. Now we need to practise what to do next time.”
Then practise the exact moment:
“If your brother takes the toy, say, ‘stop, my turn’, and come to me.”
What if hitting mostly happens with one parent?
This is common.
It does not automatically mean one parent is doing everything wrong. It may mean the pattern is different with each adult.
For example:
- one parent may be more available
- one parent may give more explanation
- one parent may change the answer more often
- one parent may be involved in more difficult routines
- one parent may be the “safe person” for emotional release
- one parent may handle most boundaries
- adults may respond differently after hitting
Instead of blaming the parent, compare the pattern.
Ask:
- What happens before hitting with Parent A?
- What happens after hitting with Parent A?
- What happens differently with Parent B?
- Are expectations the same?
- Are responses the same?
- Does one adult give more negotiation or more delay?
- Does one adult ask more difficult demands?
This can reveal practical changes.
The goal isn’t for both adults to become identical. The goal is for your child to experience a clearer, more predictable response.
A simple home script for hitting
Use this as a starting point and adapt it to your child’s age, language, and understanding.
In the moment
“I will not let you hit.”
“I am moving back.”
“Hands down.”
“You can say, ‘help please’.”
When your child uses the safer behaviour
“Good asking. I can help.”
“You used words. I am listening.”
“Safe hands. Now we can sort it out.”
When the original boundary still needs to hold
“The answer is still no. You can be upset. I will help you choose what to do next.”
After everyone is calm
“Earlier, you hit when tablet finished. Hitting hurts. Next time, you can say, ‘one more minute?’ or ‘help me stop’. Let us practise.”
For sibling hitting
“I will not let you hit your sister. Move back.”
“You can say, ‘my turn’, or come and get help.”
“Now we need to check she is okay.”
Get the Starter Pack for repeated hitting, shouting, or escalation at home
If this article sounds familiar, the next useful step is usually to track one main behaviour for a few days and look for the pattern around it.
The Behaviour Pattern Starter Pack™ is a calm, practical way to track one main behaviour for 5 days and spot what may be making it more likely.
Inside, you will find:
- a simple start-here guide
- a 5-day Behaviour Pattern Tracker
- pattern-review pages to help you notice triggers, early signs, and what may be keeping the behaviour going
- a clear explanation of when a more structured behaviour-mapping process may help
FAQ
Is hitting normal in young children?
Some hitting can happen as children learn to manage frustration, communicate, wait, share, and cope with limits.
But repeated hitting still deserves a clear response.
The aim is not to panic or shame your child. The aim is to understand the pattern and teach safer behaviour.
Should I punish my child for hitting?
A clear boundary is important. But punishment alone often misses the reason the behaviour is happening.
If hitting is helping your child escape, gain attention, access something, delay a demand, or move someone away, the plan needs to address that pattern and teach a safer alternative.
Should I make my child say sorry?
Repair can be helpful, but it should not be the whole plan.
A child can say sorry and still hit again if they have not learned what to do instead.
Focus on repair plus practice: check the other person is okay, then practise the safer response for next time.
What if my child hits during screen-time limits?
Screen-time transitions are a common trigger because they involve stopping something enjoyable.
Use warnings, predictable routines, a clear ending, and a replacement activity.
Avoid giving the screen back because of hitting.
If your child needs help stopping, teach a phrase such as “help me stop” and respond quickly when they use it.
What if my child hits their sibling?
Separate the children calmly, check safety, and avoid turning the whole moment into a long lecture.
Later, look for the pattern.
Is it about toys, space, adult attention, turn-taking, being copied, or being interrupted?
Then teach the sibling-specific skill:
“My turn.”
“Stop.”
“Move please.”
“Help.”
“Can I have it when you are finished?”
What if my child is autistic, has ADHD, or has communication difficulties?
The same pattern-based thinking can still help, but the support may need to be adapted.
Communication, sensory needs, predictability, processing time, sleep, anxiety, and demands may all matter.
The key is not to assume the diagnosis explains everything. Look at the specific behaviour, situation, and response pattern.
What if I lose my temper?
That happens in real families.
The repair matters.
When calm, you can say:
“I shouted earlier. I am sorry. I am going to practise using fewer words too.”
Then return to the plan.
A realistic plan should support both the child and the adult.
What if nothing seems to work?
If nothing seems to work, do not keep adding more consequences at random.
Step back and look at the pattern.
Ask:
- Are we focusing on one behaviour, or everything at once?
- Do we know what usually happens before the hitting?
- Do we know what hitting changes?
- Have we taught a safer replacement?
- Does the safer replacement actually work?
- Are adults responding consistently?
- Is there a safety, communication, sensory, sleep, pain, or anxiety factor we need to understand better?
If the pattern is still unclear or risk is increasing, it is sensible to seek support.
What to try first this week
Do not try to fix every behaviour at once.
Choose one repeated hitting pattern.
Track it for a few days.
Look at what happens before and after.
Choose one safer behaviour to teach.
Practise it when calm.
Respond quickly when your child uses it.
Keep your hitting response brief, safe, and consistent.
The goal is not to “win” the moment. The goal is to build a better pattern.
When the pattern becomes clearer, support becomes less reactive. You can stop guessing, start teaching, and give your child a safer way to handle the moments that currently end in hitting.
References
American Academy of Pediatrics. (2018). Effective discipline to raise healthy children. Pediatrics, 142(6), e20183112.
Baumel, A., Brandes, O., Brendryen, H., Muench, F., Kane, J. M., & Saar, C. (2023). The impact of therapeutic persuasiveness on engagement and outcomes in unguided interventions: A randomized pilot trial of a digital parent training program for child behavior problems. Internet Interventions, 34, 100680.
Gerow, S., Davis, T. N., Radhakrishnan, S., Gregori, E., & Rivera, G. (2018). A systematic review of parent-implemented functional communication training for children with developmental disabilities. Behavior Modification, 42(3), 335–363.
Hanley, G. P. (2012). Functional assessment of problem behavior: Dispelling myths, overcoming implementation obstacles, and developing new lore. Behavior Analysis in Practice, 5(1), 54–72.
Heilmann, A., Mehay, A., Watt, R. G., Kelly, Y., Durrant, J. E., van Turnhout, J., & Gershoff, E. T. (2021). Physical punishment and child outcomes: A narrative review of prospective studies. The Lancet, 398(10297), 355–364.
Mingebach, T., Kamp-Becker, I., Christiansen, H., & Weber, L. (2018). Meta-meta-analysis on the effectiveness of parent-based interventions for the treatment of child externalizing behavior problems. PLoS ONE, 13(9), e0202855.
National Institute for Health and Care Excellence. (2013). Antisocial behaviour and conduct disorders in children and young people: Recognition and management. NICE guideline CG158.
National Institute for Health and Care Excellence. (2014). Quality statement 4: Parent or carer training. NICE quality standard QS59.