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Crichton JHM, Calgie J. Responding to inpatient violence at a psychiatric hospital of special security: a pilot project. MEDICINE, SCIENCE, AND THE LAW 2002; 42:30-33. [PMID: 11858208 DOI: 10.1177/002580240204200106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Within secure psychiatric hospitals, staff have to manage many difficult and challenging situations. Crichton (1997) suggested that when staff perceive a greater degree of responsibility on patients for their actions there is a particularly morally censorious response. The aim of this pilot study was to discover if this association, discovered using a hypothetical scenario, was also present in how nursing staff respond to real violent patient behaviour. Over a five week period all episodes of inter-personal violence in a hospital with special security were identified and those involved interviewed. Thirty-one episodes of inter-personal violence were identified. A disproportionate number were caused by female patients and patients detained under civil sections of mental health legislation. A personality disorder diagnosis and the staff belief that mental disorder did not reduce the individual patient's blame for the incident were associated with the response of a restrictive sanction (both cases p < 0.01).
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52
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MacPhail S, Beck-Sander A. A cost analysis of untoward incidents in a medium secure unit. MEDICINE, SCIENCE, AND THE LAW 1999; 39:302-312. [PMID: 10581909 DOI: 10.1177/002580249903900406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
All untoward incidents perpetrated by 36 patients--residents in a medium-secure hospital--over a period of six months were examined using a prospective design. Demographic and psychiatric details of patients involved in incidents were compared with those of patients not involved in incidents. Financial costs associated with incidents were calculated. A minority of patients were found to be responsible for the majority of incidents. Patients detained under criminal sections of the Mental Health Act 1983 were involved in disproportionately more incidents than their civil section counterparts. The female patients involved in untoward incidents all had a diagnosis of personality disorder and were over-represented in the number of incidents. However, most of the financial burden of untoward incidents was incurred by those incidents perpetrated by male patients. Likewise, although patients detained under the legal category of psychopathic disorder were involved in a higher number of incidents, higher costs were associated with incidents perpetrated by patients detained under the category of mental illness.
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Affiliation(s)
- S MacPhail
- Shaftesbury Clinic, Springfield Hospital, Tooting, London
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53
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Gudjonsson G, Rabe-hesketh S, Wilson C. Violent incidents on a medium secure unit over a 17-year period. ACTA ACUST UNITED AC 1999. [DOI: 10.1080/09585189908403679] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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54
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Gordon H, Hindley N, Marsden A, Shivayogi M. The use of mechanical restraint in the management of psychiatric patients: Is it ever appropriate? ACTA ACUST UNITED AC 1999. [DOI: 10.1080/09585189908402148] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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55
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Robinson D, Collins M. Risk assessment: a challenge to nurses and nurse managers. ACTA ACUST UNITED AC 1999. [DOI: 10.7748/mhp.2.6.8.s14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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56
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Abstract
In this paper, the literature on aggressive behaviour in the elderly is reviewed, with emphasis on: definition; study samples; patient groups; study designs and methodology; data collection; instruments used to measure aggressive behaviour; social, clinical, demographic and biological correlates; prevalence and rates; precipitants; outcome; site; timing; daily and seasonal variation; patterns of usage of hospitals and other institutions; stuffing levels, staff morale, staff attitudes, staff training and other staffing factors.
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Affiliation(s)
- A Shah
- Imperial College School of Medicine, London
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57
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58
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Raja M, Azzoni A, Lubich L. Aggressive and violent behavior in a population of psychiatric inpatients. Soc Psychiatry Psychiatr Epidemiol 1997; 32:428-34. [PMID: 9383975 DOI: 10.1007/bf00788184] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The aim of this observational study was to assess the rates of aggressive and violent behavior in patients admitted to an Italian emergency psychiatric unit and to explore possible risk factors for patient violence. In a population of 313 consecutive patients, we considered aggressive or violent behavior, rated according to a hierarchy from no aggressive behavior to serious physical violence. The results confirm that young age, psychotic symptoms, excitement, akathisia, and diagnosis of personality disorder are risk factors for violent behavior. The unique and major finding of the study is the low prevalence of aggressive and violent acts in this sample of patients, possibly related to their cultural background and to the system of psychiatric care. These data provide supportive evidence for the importance of sociocultural factors in the behavior of psychiatric patients and suggest the need to explore new strategies of prevention and treatment of patient aggression and violence. A non-restraint policy could be a critical factor in reducing violence among psychiatric inpatients.
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Affiliation(s)
- M Raja
- Department of Mental Health, Santo Spirito Hospital, Rome, Italy
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59
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Affiliation(s)
- B Rogers
- Occupational Health Nursing Program, School of Public Health, University of North Carolina, Chapel Hill 27514, USA
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60
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61
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Rangecroft ME, Tyrer SP, Berney TP. The use of seclusion and emergency medication in a hospital for people with learning disability. Br J Psychiatry 1997; 170:273-7. [PMID: 9229036 DOI: 10.1192/bjp.170.3.273] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The management of disturbed behaviour in facilities for those with learning disabilities involves a spectrum of approaches including the prescription of emergency medication, restraint and seclusion. The use of these techniques has recently come under close scrutiny. METHOD All incidents requiring emergency medication or seclusion that occurred in a large hospital for those with learning disabilities were studied over a six-months period. The precipitating factors, course and outcome of those who had received emergency medication or seclusion were then examined. RESULTS In all, 286 incidents involving 72 individuals occurred during the study period. The episodes requiring seclusion comprised 19% of all incidents. Two-thirds of the patients involved were male but six female patients accounted for 36% of all incidents. During the second part of the study, when the staff knew that the treatments used were being monitored, there was a significant reduction in use of restraint and emergency drugs given intramuscularly. Patients receiving seclusion were judged to have a better outcome one hour after the onset of the incident compared with those who received medication. CONCLUSIONS Despite concerns about the use of seclusion, the results of this survey suggest that procedures that remove the patient from the environment contributing to the disturbance may have certain advantages in this population.
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Affiliation(s)
- M E Rangecroft
- Regional Department of Psychotherapy, Royal Victoria Infirmary, Newcastle upon Tyne
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62
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Cheung P, Schweitzer I, Tuckwell V, Crowley KC. A prospective study of assaults on staff by psychiatric in-patients. MEDICINE, SCIENCE, AND THE LAW 1997; 37:46-52. [PMID: 9029921 DOI: 10.1177/002580249703700112] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
This study determined the prevalence and features of assaults on staff, compared them with other aggressive incidents by psychiatric in-patients, and studied their relationship with the ward atmosphere. There were 181 physical assaults among 279 staff in two months, i.e. 389 assaults per 100 staff per year. A few patients were responsible for the majority of the assaults. Most assaults were triggered off by staff-patient interaction. About one-third of the staff were significantly psychologically shaken by the incidents. Patients were more likely to be provoked and used more severe means of aggression against staff than against other targets of aggression. There were no significant differences between the characteristics of patients who assaulted staff and those who had other targets of aggression.
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Affiliation(s)
- P Cheung
- University of Melbourne, Australia
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63
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Parkes J. Control and restraint training: A study of its effectiveness in a medium secure psychiatric unit. ACTA ACUST UNITED AC 1996. [DOI: 10.1080/09585189608415035] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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64
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Agarwal M, Roberts M. Violence among psychiatric in-patients at an Interim Secure Unit: changes in pattern over a two-year period. MEDICINE, SCIENCE, AND THE LAW 1996; 36:31-36. [PMID: 8907855 DOI: 10.1177/002580249603600107] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
A retrospective study of recordings of all violent episodes among in-patients requiring restraint was undertaken over a two-year period during which the nature of admissions to the unit changed to an increase in mentally abnormal offenders (those admitted through the criminal justice system and detained under criminal sections of the Mental Health Act). It was found that those detained under criminal sections were less likely to be aggressive, were of relatively older age and less likely to repeat the violence than their mentally ill counterparts detained under civil sections. In addition to the past history of violence, verbally abusive behaviour was the best predictor of subsequent physical aggression though only a minority of patients displaying serious physical assault showed verbally abusive behaviour. Deterioration in mental health and staff-patient interaction were seen as major contributory factors to aggression which will also explain a greater degree of aggression directed towards the staff. Further comparative analysis of aggressive behaviour of mentally ill patients detained under civil sections and mentally abnormal offenders is warranted.
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Affiliation(s)
- M Agarwal
- Registrar in Child Psychiatry, Blackburn
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65
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Whittington R, Patterson P. Verbal and non-verbal behavior immediately prior to aggression by mentally disordered people: enhancing the assessment of risk. J Psychiatr Ment Health Nurs 1996; 3:47-54. [PMID: 8696797 DOI: 10.1111/j.1365-2850.1996.tb00191.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In this study we seek to enhance the assessment of imminent violence risk by providing empirical data on the types of verbal and non-verbal behaviour exhibited by 31 psychiatric inpatients immediately prior to assaulting a staff member, and 31 non-aggressive controls. Verbal abuse, high overall activity level and standing uncomfortably close to the intended victim were the most common behaviours immediately prior to the assault, but most preassault behaviours were also exhibited when patients were not assaulting staff. In the 3 days prior to the assault, aggressive patients differed from non-aggressors in terms of verbal abuse, abnormal activity level (P < 0.05), threatening gestures and threatening stance (P < 0.01). Only one patient was aggressive in the absence of any predictive behaviours. We conclude that most patients exhibit easily identifiable signs of imminent aggression, but that many of these signs occur in the absence of aggression.
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66
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Crichton JH. Is it time for a formal disciplinary code for psychiatric in-patients in England and Wales? MEDICINE, SCIENCE, AND THE LAW 1996; 36:65-68. [PMID: 8907860 DOI: 10.1177/002580249603600112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Within psychiatric hospitals it is not legal for staff to formally punish a patient for any misdemeanour. The staff response to such an incident is cloaked in therapeutic terms even if it is in effect a disciplinary punishment. To avoid injustice and introduce safeguards into this process Professor Genevra Richardson (1993, 1995) suggests the need for the introduction of a disciplinary code for psychiatric in-patients. This paper discusses the need for better guidance for psychiatric staff and the problems of punitive sanctions on patients.
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67
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Abstract
Behavior and symptoms seen in 48 24-h periods preceding violent episodes and 93 control observations were studied. Six behaviors were more common before violence: confusion, irritability, boisterousness, physical threats, verbal threats and attacks on objects. A logistic regression equation based on these behaviors in a randomized half of the observations predicted the occurrence of subsequent violence in 92.1% of the other half of the sample without any false positives, giving a sensitivity of 81.3% and a specificity of 100%. It is concluded that mentally ill people display the same behaviour before violent acts as we would expect in people without such disorder. The potential for short-term prediction of violence seems good.
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Affiliation(s)
- O M Linaker
- Department of Psychiatry and Behavioural Medicine, Faculty of Medicine, University of Trondheim, Norway
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68
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Whittington R, Mason T. A new look at seclusion: Stress, coping and the perception of threat. ACTA ACUST UNITED AC 1995. [DOI: 10.1080/09585189508409896] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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69
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Kennedy J, Harrison J, Hillis T, Bluglass R. Analysis of violent incidents in a regional secure unit. MEDICINE, SCIENCE, AND THE LAW 1995; 35:255-260. [PMID: 7651106 DOI: 10.1177/002580249503500314] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
This study examined violent incidents occurring over a four-year period in a Regional Secure Unit. Data were collected from incident reports and case notes. Patients referred from district general psychiatric hospitals because of unmanageable behaviour were over-represented among the small number of patients who were responsible for the majority of incidents. Most patients exhibited little or no aggression. Seclusion was found unnecessary in the management of such patients. Suggestions for further research in this area are made.
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70
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Homicide in Psychiatric In-Patient Facilities: A Review, a Six-Year Study, and a Case Report. J Forensic Sci 1995. [DOI: 10.1520/jfs13799j] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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71
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Kelsall M, Dolan M, Bailey S. Violent incidents in an adolescent forensic unit. MEDICINE, SCIENCE, AND THE LAW 1995; 35:150-158. [PMID: 7776865 DOI: 10.1177/002580249503500209] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Violent incidents in psychiatric institutions have been the focus of much study over the past few decades. But there has been little work looking at similar incidents in child and adolescent units. The authors set out to examine whether some of the patterns observed in adult populations are true of adolescent groups. The Gardener Unit was considered appropriate in light of reports of a higher frequency of assaultative behaviour among younger clients and because of the nature of problems presented by clients needing a secure environment. All violent incidents are automatically recorded. The violent incident register was examined between 1 June 1991 and 1 June 1992 and the information cross-checked with case notes and nursing reports. Demographic details, etc. were obtained from case notes. The results indicated a slightly higher daily incident rate than adult studies. At least half of the population were involved in some form of violent episode over the 12-month period. The majority of incidents were minor in nature. Nursing staff were the most frequent targets, although females showed an excess of inwardly directed aggression (self harm). A prior history of violent behaviour did not serve as a realistic predictor of frequency of violent incidents in this study. With increasing concern regarding the care of this disturbed group of young people, it was felt important to look closely at the nature of and handling of violent incidents on this unit. A second paper will consider in detail how these incidents were dealt with.
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Affiliation(s)
- M Kelsall
- Gardener Unit, Adolescent Forensic Mental Health Services, Prestwich Hospital, Manchester
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72
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Crichton JH. Psychiatric in-patient violence: issues of English law and discipline within hospitals. MEDICINE, SCIENCE, AND THE LAW 1995; 35:53-56. [PMID: 7877475 DOI: 10.1177/002580249503500111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
There has been a considerable increase in the number of publications about psychiatric patient violence, perhaps indicating an increase in violence or an increase in staff anxiety about assault. Missing from the debate are issues of law and ward discipline and these are discussed here.
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Affiliation(s)
- J H Crichton
- University of Cambridge, Institute of Criminology
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73
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74
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Abstract
A prospective study was undertaken of physical assaults over six months in a newly opened psychiatric intensive care unit. There were 58 admissions of 48 patients, and 37 assaults, three against other patients, and 34 against nursing and medical staff. Features which correlated with committing assault were a criminal record and previous drug abuse. Assaults occurred most frequently during the week, at times when staff were actively involved with the patients.
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75
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Abstract
Regional secure units provide one of the main routes of release for special hospital patients; a route that in many cases is unsuccessful as the patient is subsequently readmitted to the special hospital. Processes underlying this were investigated in this UK study using a grounded theory approach. The interview data obtained in 1993 from a sample of 14 readmitted special hospital patients were analysed and five explanatory categories were generated. This paper concentrates on descriptive data from two categories. One describes negative experiences of a group of patients in regional secure units; an experience often considered a 'backward step'. The second data category identifies four principal reasons for readmission; one reason, inappropriate sexual behaviour, was of particular concern due to its frequency and the possibility that it resulted from the special hospital practice of gender segregation.
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Affiliation(s)
- C Skelly
- Ashworth Hospital, Liverpool, England
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76
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Walker WD, Caplan RP. Assault behaviour in acute psychiatric wards and its relationship to violence in the community: a comparison of two health districts. MEDICINE, SCIENCE, AND THE LAW 1993; 33:300-304. [PMID: 8264361 DOI: 10.1177/002580249303300405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Evidence suggests that the level of violence in psychiatric institutions reflects that of society at large. This study investigates this by comparing the psychiatric hospital assault rates and the violent crime rates of two District Health Authorities. The differences between the two districts on each of these parameters were found to be of a very similar order, which would tend to support the hypothesis.
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Affiliation(s)
- W D Walker
- Peter Hodgkinson Centre, County Hospital, Lincoln
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77
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Abstract
A considerable body of evidence suggests increasing levels of violence among psychiatric inpatients. The literature on the subject is reviewed, highlighting correlates of violence among psychiatric patients and methodological flaws in the published literature. Improvement in the definition of violence and the methodology as well as future areas of research are discussed.
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Affiliation(s)
- A K Shah
- St Mary's Hospital Medical School, London, United Kingdom
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78
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Cooper AJ, Mendonca JD. A prospective study of patient assaults on nurses in a provincial psychiatric hospital in Canada. Acta Psychiatr Scand 1991; 84:163-6. [PMID: 1950611 DOI: 10.1111/j.1600-0447.1991.tb03122.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A 27-month prospective study was conducted of patient assaults on nurses in a Canadian psychiatric hospital. Rates were low (4% of the patients committing an assault) and the injuries mostly trivial. Schizophrenics accounted for 43% of attacks, but when allowance was made for the disproportionate number of patients in the hospital with this diagnosis, individuals with mental retardation or dementia were approximately twice as likely to be assaultive as schizophrenics. Repeat assaulters (greater than 4 attacks) were more likely to be suffering from paranoid schizophrenia.
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Affiliation(s)
- A J Cooper
- Department of Research, St. Thomas Psychiatric Hospital, Ontario, Canada
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79
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Schipperheijn JA, Dunne FJ. Managing violence in psychiatric hospitals. BMJ (CLINICAL RESEARCH ED.) 1991; 303:71-2. [PMID: 1860004 PMCID: PMC1670627 DOI: 10.1136/bmj.303.6794.71-a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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80
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Phillips MS, Dickie B. Patients who reoffend while on warrants of the Lieutenant-Governor. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1991; 36:176-81. [PMID: 2059935 DOI: 10.1177/070674379103600304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Occasionally, psychiatric patients detained in institutions against their will or residing in the community under legal restraints elope and commit serious offenses. The authors looked at the frequency with which this occurred with patients on warrants of the Lieutenant-Governor in Ontario. Using the files of the Ontario Lieutenant-Governor's Board of Review, they examined the records and isolated such recorded incidents over a 16 year period. In spite of the limitations identified by the authors, their findings indicate a lower than expected occurrence. As well, they point to the risk management implications of certain diagnostic groups being treated in a less than secure setting.
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Affiliation(s)
- M S Phillips
- Forensic Division, METFORS/Clarke Institute of Psychiatry, Toronto, Ontario
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81
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82
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Palmstierna T, Wistedt B. Risk factors for aggressive behaviour are of limited value in predicting the violent behaviour of acute involuntarily admitted patients. Acta Psychiatr Scand 1990; 81:152-5. [PMID: 2327279 DOI: 10.1111/j.1600-0447.1990.tb06470.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Violent behaviour within 8 and 28 days respectively was related by a multivariate statistical procedure to risk factors for aggressive behaviour in an epidemiologically representative sample of 105 acute involuntarily admitted patients. Previous violent behaviour by the patient was found to correlate significantly with aggressive behaviour during the first 8 days of admission, and abuse of drugs other than alcohol was found to correlate significantly with aggressive behaviour during the first 28 days of admission. Determination coefficients were very low, and it is concluded that risk factors associated with aggressive behaviour are of limited value in predicting aggressive behaviour among acute involuntarily admitted inpatients.
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Affiliation(s)
- T Palmstierna
- Department of Psychiatry, Västerås Central Hospital, Sweden
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83
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