Trends, Victims, and Injuries in Injurious Patient Assaults on Adult, Geriatric, and Child/Adolescent Psychiatric Units in US Hospitals, 2007-2013

American Psychiatric Nurses Association Position: Staffing Inpatient Psychiatric Units

OBJECTIVE

An American Psychiatric Nurses Association (APNA) task force reviewed current staffing research to revise and update the 2011 APNA "Staffing inpatient psychiatric units" position paper and provide recommendations to the APNA Board of Directors on how psychiatric mental health (PMH) nurses might champion the staffing needs of inpatient psychiatric units.

METHODS

Current research on staffing and nursing practice in inpatient psychiatric units was reviewed as well as variables believed to influence staffing and nursing practice, such as consumer needs and workplace culture. Since current nurse staffing principles emphasize nursing value and how that value is connected to outcomes, the literature search included a focus on staffing and related patient outcomes.

RESULTS

PMH nurses are critical to the safety and quality of care in inpatient psychiatric units. However, there are little existing data on the relationship between staffing levels and even common adverse events such as staff injury and restraint of patients. Furthermore, there is scant research conducted on inpatient psychiatric units that informs optimal staffing models or establishes links between staffing and patient outcomes.

CONCLUSIONS

Consistent with current evidence, the universal use of a single method or model of determining staffing needs (e.g., nursing hours per, case mix index, or mandatory ratios) is not recommended. PMH nurses should champion systematic evaluation of staffing on their inpatient units against select patient, nurse, and system outcomes. A data repository of PMH nurse-sensitive outcomes is necessary to benchmark unit performance and staffing.

Delineating Quality Indicators of Inpatient Psychiatric Hospitalization

BACKGROUND

Assuring quality care is critical to the well-being and recovery of individuals receiving inpatient psychiatric treatment, yet a comprehensive map of quality inpatient care does not exist.

AIMS

To isolate and describe quality elements of inpatient psychiatric treatment.

METHODS

A survey queried psychiatric inpatient nursing leaders on what they considered to be critical elements of quality. The survey was emailed to 40 American Psychiatric Nurses Association members, and 39 individuals responded. In the survey, participants were asked to comment on the importance of six dimensions of quality as well as quality indicators used on their units.

RESULTS

Data from this survey indicate how thought leaders conceptualized quality of inpatient care. A unifying philosophy of care was endorsed as a quality element as was structure that affords staff available time on the unit-engaging with patients. While staffing levels were viewed as important, the respondents commented on the nuances between staffing and quality. Participants endorsed the importance of involving individuals in their treatment planning as well as tapping into patients' perspectives on the treatment experience.

CONCLUSIONS

The participants' responses compliment the quality literature and reinforce the need to develop a comprehensive map of quality elements. These elements interact in complex way, for instance, staffing, engagement, and teamwork is tied to the organizational structure and philosophy of care, which in turn facilitates consumer involvement in care. Thus, gauging the impact of quality on outcomes will demand consideration of the interaction of factors not just the linear relationship of one element to an outcome.

Characteristics of Assaultive Patients Whom Inpatient Psychiatric Staff Report to Law Enforcement

OBJECTIVE

The authors sought to identify factors that affect hospital staff's decision to pursue criminal charges against patients who assault staff on inpatient psychiatric units.

METHODS

Data on assaults occurring on inpatient psychiatric units in one hospital system were collected over 32 months, from November 1, 2016, to July 1, 2019. The events were grouped by whether staff pursued criminal charges after the incident. Descriptive statistics and regression models were used to describe the data and identify predictive variables.

RESULTS

Data were reviewed from 9,654 admissions, of which 124 patient encounters involved assaults on staff. Overall, 27 (22%) of 124 assaults on staff resulted in staff pursuing criminal charges. Regression models indicated that criminal history (odds ratio [OR]=2.18, 95% CI=1.26-3.78, p=0.006), age (OR=0.92, 95% CI=0.91-0.94, p<0.001), and diagnosis of chronic mental illness with psychotic symptoms (OR=7.23, 95% CI=1.49-35.04, p=0.01) predicted patient assaults resulting in contact with law enforcement. Several variables were not statistically significantly associated with filing of criminal charges, including race, gender, degree of injury from the assault, number of instances of restraint, and number of as-needed medications.

CONCLUSIONS

This is the largest quantitative study to examine the demographic and clinical factors that may play a role in whether staff pursue criminal charges against patients on inpatient psychiatric units. The results suggest that certain patients are more likely to be reported to law enforcement. Institutions should monitor factors that increase the likelihood of assaults on staff resulting in criminal charges and create policies that mitigate discrepancies in criminal justice involvement.

Conceptual framework for a comprehensive competence in managing challenging behaviour: The views of trained instructors

WHAT IS KNOWN ON THE SUBJECT?: There is body of knowledge available about the harms associated with restrictive interventions used in behaviour management, service users' perceptions of the use of restraints, and staff competence in behaviour management. The staff perspective has been studied in terms of staff exposure, responses to and prevention of aggression, staff-related factors associated with service user aggression, and staff attitudes and perceptions towards violence. The definitions of competence in behaviour management provided in training interventions are fragmented and based on unilateral measurements. Training interventions with the purpose of enhancing staff competence in behaviour management are organized regularly, yet there is a lack of clarity on how effective these interventions are. Inadequate conceptual understanding of behaviour management can weaken the effectiveness of these interventions. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study produced new knowledge by providing a preliminary conceptual framework that can be used to comprehensively describe and assess competence in managing challenging behaviour and to cover safely the whole care process. Humane care and ethical sensitivity should be the premises of interaction with people in distress. We also pointed out the needs for conceptual clarification of the concepts of confidence, support and restraint. We provide important new insight into the leadership and cultural issues of behaviour management that is relevant for patients, staff members and healthcare organizations. We found that staff members do not consider service user safety and workplace safety as opposing issues. Further, we provide new perspectives for prevention, the risk assessment process and effective communication in the context of behaviour management. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A comprehensive understanding of the competences related to behaviour management will foster universal definitions for "support" and "restraint," which can then be used to ensure that the best practices are used for behaviour management. Organizational culture and participative leadership on behaviour management should be developed with a special focus on safety issues, common understanding of comprehensive competence, risk assessment and prevention, views regarding the use of restraints, and teamwork. ABSTRACT: Introduction Previous research concerning staff views of behaviour management has not considered instructors' views. The definitions of competence in behaviour management are fragmented, which can undermine the effectiveness of training interventions. Aim/Question This study aimed to describe Finnish and British Management of Actual or Potential Aggression instructors' perceptions of safety and behaviour management-related competences and create a conceptual framework for comprehensive competence. Method An explorative-descriptive qualitative approach with purposive sampling (N = 22), semi-structured interviews and abductive content analysis. Results Conceptual framework of comprehensive competence in managing challenging behaviour includes five categories-knowledge, skills, attitude, confidence and ethical sensitivity-and 21 subcategories. Competent staff and supportive leadership ensured safety, while inconsistent risk management culture, the health and behaviour of service users, and inadequate staff orientation endangered safety. Discussion The study produced new knowledge of safety issues and competences from the perspective of the instructors who deliver behaviour management training. Implications for practice Competence to manage challenging behaviour should be developed based on our conceptual framework to provide an effective and safe training. Prevention, the risk assessment process, alternative communication, and the definitions of "confidence," "support" and "restraint" should all be sufficiently addressed in future training.

Relationships between medical incidents, clinical competency, and clinical experience in child and adolescent psychiatric in-patient nursing: A structural equation modeling approach

PROBLEM

Psychiatric nurses experience medical incidents, including potential errors and adverse incidents. We aimed to identify the elements of clinical competency related to medical incidents and to test the hypothesized relationships between medical incidents, clinical competency, and clinical experience.

METHODS

A self-administered survey was conducted among 406 nurses working in child and adolescent psychiatric wards at 29 Japanese hospitals.

FINDINGS

Medical incidents were significantly negatively correlated with two competencies-collecting client information and solving potential problems-and significantly positively correlated with the competency of collaboration with team members.

CONCLUSIONS

Our hypothesis was partially supported, suggesting that medical incidents involve various factors other than nurses' clinical competency.

Violence in Psychiatric Settings: Demographic and Clinical Characteristics of Patients Who Were Targets of Aggression

ABSTRACT

Violence is a serious concern in the psychiatric inpatient and emergency setting. Much of the research on victims of inpatient violence has focused on identifying and supporting staff who are at risk of being victimized when working in psychiatric settings. This article presents an analysis of 72 patients who were targeted during incidents of patient-on-patient physical aggression in hospital-based psychiatric settings (both inpatient and emergency) from 2014 to 2018. Results suggest that patients who are at risk of being targeted by another patient while in the hospital tend to be younger, are more likely to be male, and present with manic symptoms and recent cannabis use. These variables have all been identified as risk factors for perpetration of violence by patients with mental illness. This study adds to a literature demonstrating a consistent overlap between individuals with mental illness who are victimized and those who initiate violence.

Frequency of violence towards healthcare workers in the United States' inpatient psychiatric hospitals: A systematic review of literature

The purpose of this systematic review is to determine the frequency of violent or aggressive behaviour towards healthcare workers in inpatient psychiatric settings in the United States. To achieve this aim, five databases were searched to find English-language quantitative studies reporting prevalence or incidence data of violence or aggression directed towards staff members in inpatient psychiatric settings. No limitations were set based on publication date, and intervention studies were included only if baseline data were provided. Of 335 total studies found, 38 full-text articles were suitable for full-text analysis based on inclusion and exclusion criteria, and 14 were included in the final review. Years of data collection ranged from 1986 to 2018, and a range of psychiatric facilities were represented, from small, private hospital units to large forensic institutions. Researchers utilized surveys, real-time incident reporting tools, and government databases, or a combination of strategies, to collect data related to workers' experiences on the job. Included research indicates that workplace violence in the U.S. inpatient psychiatric setting is a widespread problem, with 25-85% of survey respondents reporting an incident of physical aggression within the year prior to survey, and statewide workers' compensation findings indicating 2-7 claims due to assault per 100 000 employee hours. There are substantial differences between findings based on measurement strategy, making it difficult to arrive at a single estimate of prevalence nationally. As management of this persistent problem receives continued attention from stakeholders, it becomes increasingly important to define and measure the problem with the most appropriate tools.

Incidents of aggression in German psychiatric hospitals: Is there an increase?

INTRODUCTION

In a meta-analysis of international studies, 17% of admitted patients in psychiatric hospitals had exhibited violent behavior toward others. Reported data from studies in Germany were considerably lower until recent years. However, studies examining only single hospitals, as well as the quality of the data itself, have raised questions as to the validity of these findings. Indeed, a debate currently exists as to whether there has, in fact, been an increase of violent incidents in German mental institutions.

METHODS

In a group of 10 hospitals serving about half the population of the Federal State of Baden-Wuerttemberg with 11 million inhabitants, the Staff Observation Aggression Scale-Revised (SOAS-R) was introduced into patients' electronic charts as part of routine documentation. Data recording was strongly supported by staff councils and unions. A completed data set is now available for the year 2019. For one hospital, data are available since 2006. Due to some doubts with respect to fully covering self-directed aggression, we restricted the analysis to aggression toward others and toward objects.

RESULTS

In 2019, 17,599 aggressive incidents were recorded in 64,367 admissions (1,660 staying forensic psychiatric inpatients included). 5,084 (7.90%) of the admitted cases showed aggressive behavior toward others. Variation between hospitals was low to modest (SD = 1.50). The mean SOAS-R score was 11.8 (SD between hospitals 1.20%). 23% of the incidents resulted in bodily harm. The percentage of patients showing violent behavior was highest among patients with organic disorders (ICD-10 F0) and lowest among patients with addictive or affective disorders (F1, F3, F4). Forensic psychiatry had the highest proportion of cases with aggressive behavior (20.54%), but the number of incidents per bed was lower than in general adult psychiatry and child and adolescent psychiatry (indicating a lower risk for staff). In the hospital with longer-term recordings available, an increase could be observed since 2010, with considerable variation between years.

CONCLUSIONS

This is the most robust estimate of the frequency of violent incidents in German psychiatric hospitals thus far. The incidence is about half of what has been reported internationally, probably due to sample selection bias in previous studies and a relatively high number of hospital beds in Germany. Available data suggest an increase of violent incidents over the last ten years; however, it is unclear to which extent this is due to increased reporting.

Applicability of two violence risk assessment tools in a psychiatric prison hospital population

The risk of violent behavior is known to be higher for patients who suffer from a severe mental disorder. However, specific prediction tools for clinical work in prison psychiatry are lacking. In this single-center study, two violence risk assessment tools (Forensic Psychiatry and Violence Tool, "FoVOx," and Mental Illness and Violence Tool, "OxMIV") were applied to a prison hospital population with a primary psychotic or bipolar disorder and subsequently compared. The required information on all items of both tools was obtained retrospectively for a total of 339 patients by evaluation of available patient files. We obtained the median and inter-quartile range for both FoVOx and OxMIV, and their rank correlation coefficient along with 95% confidence intervals (CIs)-for the full cohort, as well as for cohort subgroups. The two risk assessment tools were strongly positively correlated (Spearman correlation = 0.83; 95% CI = 0.80-0.86). Such a high correlation was independent of nationality, country of origin, type of detention, schizophrenia-spectrum disorder, previous violent crime and alcohol use disorder, where correlations were above 0.8. A lower correlation was seen with patients who were 30 years old or more, married, with affective disorder and with self-harm behavior, and also in patients without aggressive behavior and without drug use disorder. Both risk assessment tools are applicable as an adjunct to clinical decision making in prison psychiatry.

Effects of organizational commitment, job satisfaction and workplace violence on turnover intention of emergency nurses: A cross-sectional study

AIMS

To describe turnover intention of emergency nurses and clarify the effects of organizational commitment, job satisfaction and workplace violence on turnover intention.

BACKGROUND

Research has showed the predictors of turnover intention differed among nurses of different specialties. However, research on turnover intention has mostly focused on general nurses rather than emergency nurses.

DESIGN

A descriptive, cross-sectional study was conducted.

METHODS

A self-administered questionnaire was used to collect data from 415 emergency nurses in Beijing, China, using convenience sampling. Path analysis was used to test the relationships between organizational commitment, job satisfaction, workplace violence and turnover intention.

RESULTS

Most emergency nurses (90.2%) had a high level or very high level of turnover intention. Contrary to previous studies, organizational commitment had a significant direct positive effect on workplace violence. It also had a direct positive effect on job satisfaction and a negative effect on turnover intention. Workplace violence had a negative effect on job satisfaction and a positive effect on turnover intention. Job satisfaction had a direct negative effect on turnover intention.

CONCLUSION

To reduce turnover intention in the emergency department, measures should be taken to reduce workplace violence and increase nurses' job satisfaction, especially those with high organizational commitment.

Validation of the Assault (Violence) Response Scale: An Update

Background and Purpose

The Assault (Violence) Response Questionnaire has been used widely in the United States, Europe, Asia, and Africa since the 1980s. The purpose is to update the ARQ.

Method

Specifically the ARQ-R has been expanded to include verbal assault and withholding information, more extensively tested for reliability and validity, and shortened.

Results

The scale was reduced from 88 to 33 items and yet had the same high reliability and validity as did the larger scale.

Conclusions

The reduction in size makes it much less time consuming to complete, making it an instrument that very busy nurses can more easily use. The ARQ-R can be used for nurses measuring assault in both hospital and community settings.

User violence in mental health services: Adaptation of an instrument. Healthcare-workers' Aggressive Behavior Scale-Users-Mental Health Version (HABS-U-MH)

Background/Objetive

According to the World Health Organization, one out of every four violent workplace acts takes place in the health setting. The aims of the study are to adapt the Healthcare-workers’ Aggressive Behavior Scale-Users (HABS-U) to mental health professionals, to establish the frequency of exposure to hostile indicators and to determine which professional group is most exposed.

Method

Study through qualitative and quantitative methodology in MH professionals of the Region of Murcia (Spain). In the qualitative phase, 12 in-depth interviews were conducted, and during the quantitative phase, the instrument was applied to 359 professionals of Mental Health Services (MHS).

Results

Non-medical and nursing staff were found to be the professional group most exposed, as well as Brief Psychiatric Inpatient and Medium-Stay Inpatient Services.

Conclusion

The resulting scale shows excellent psychometric properties. The distribution of user violence is not homogeneous among the different professional groups of MHS. The adaptation of the scale may be useful to detect user violence, as well as to evaluate the efficacy of intervention programs.

Violent Behavior During Psychiatric Inpatient Treatment in a German Prison Hospital

Violent behavior in correctional facilities is common and differs substantially in type, target, implication, and trigger. Research on frequency and characteristics of violent behavior in correctional facilities and psychiatric hospitals is limited. Results from recent research suggest that comorbidity of severe mental disorder, personality disorder, and diagnosis of substance abuse is related to a higher risk of violent behavior. In the Berlin prison hospital, a database was created to collect data from all violent incidences (n=210) between 1997 and 2006 and between 2010 and 2016. In a retrospective, case-control study, we analyzed specific socioeconomic data and psychiatric diagnosis and compared the group of prisoners with violent behavior with randomly selected prisoners of the same department without violent behavior (n = 210). Diagnosis of schizophrenia, non-German nationality, no use of an interpreter, no children, and no previous sentence remained significantly associated with the dependent variable violent behavior. There were no significant differences regarding age and legal statuses. Practical implications for clinical work are discussed.

Characteristics of International Assaultive Psychiatric Patients: Review of Published Findings, 2013-2017

Since the 1960s, empirical research has worked toward a better understanding of the characteristics of assaultive psychiatric patients. International research through 2012 indicated that male and female patients with schizophrenia and other diagnoses presented the greatest risk for assault. This present review of studies that presented raw assault sought to assess the latest research findings on assaultive patients for the most recent 5 year period, 2013-2017. It was hypothesized that male patients with schizophrenia would present the greatest risk. The findings indicated a sharp increase in the total number of reported assault incidents over the proceeding decade. These assaults were committed largely by male patients with a diagnosis of schizophrenia. Explanations for these findings and an updated methodological inquiry are presented.

A quantitative systematic review of the effects of training interventions on enhancing the competence of nursing staff in managing challenging patient behaviour

AIMS

This systematic quantitative review identifies and summarizes the current knowledge and effects of training interventions for managing patients' challenging behaviour.

BACKGROUND

Challenging behaviour is an acknowledged worldwide healthcare problem and its management can have a huge impact on quality of care. Evidence-based training interventions that focus on managing challenging behaviour are needed, but few tools for the systematic evaluation of these interventions are currently offered.

DESIGN

A quantitative systematic review following the 2008 Centre for Reviews and Dissemination guidelines.

DATA SOURCES

CINAHL, Scopus, PsycInfo, PubMed and Cochrane were searched using the same terms for papers published in English from 2005-2015.

REVIEW METHODS

Studies were assessed for quality and risk of bias, according to the Cochrane Effective Practice and Organisation of Care Group criteria. A narrative summary was conducted.

RESULTS

We included 17 studies and evaluated 16 training interventions. Interventions were classified into four key themes: disengagements, communication, controlling behavioural symptoms and restrictive measures. Our review showed that interventions were more likely to decrease violent incident rates and increase staff confidence than change staff attitudes or increase knowledge. The elements of competence used to manage challenging behaviour were measured unilaterally. The evidence provided by studies was largely weak.

CONCLUSION

The variety of measurements used in the studies made comparing the effectiveness of the training interventions difficult. An individual's competence to manage challenging behaviour needs to be defined and a comprehensive scale for evaluating competence is also needed. Patient safety should be included in future evaluations.

Workplace Violence in Mental Health: A Victorian Mental Health Workforce Survey

The international literature suggests workplace violence in mental health settings is a significant issue, yet little is known about the frequency, nature, severity and health consequences of staff exposure to violence in Australian mental health services. To address this gap, we examined these aspects of workplace violence as reported by mental health services employees in Victoria, Australia. The project used a cross-sectional, exploratory descriptive design. A random sample of 1600 Health and Community Services Union members were invited to complete a survey investigating exposure to violence in the workplace, and related psychological health outcomes. Participants comprised employees from multiple disciplines including nursing, social work, occupational therapy, psychology and administration staff. A total of 411 members responded to the survey (26% response rate). Of the total sample, 83% reported exposure to at least one form of violence in the previous 12 months. The most frequently reported form of violence was verbal abuse (80%) followed by physical violence (34%) and then bullying/mobbing (30%). Almost one in three victims of violence (33%) rated themselves as being in psychological distress, 54% of whom reported being in severe psychological distress. The more forms of violence to which victims were exposed, the greater the frequency of reports of psychological distress. Workplace violence is prevalent in mental health facilities in Victoria. The nature, severity and health impact of this violence represents a serious safety concern for mental health employees. Strategies must be considered and implemented by healthcare management and policy makers to reduce and prevent violence.

Patient Aggression in Real Time on Geriatric Inpatient Units

This study focused on verbal and physical aggression against nursing staff, in real time, by elderly patients. The aggressive incidents were recorded at the end of each shift when they were more likely to be accurately remembered. Before beginning the study, nursing staff were taught how to use the Modified Overt Aggression Scale (MOAS) to identify aggressive acts. High rates of verbal and physical aggression among the elderly were observed by nurses, and data show that 75% of nursing staff experienced aggression on their shift. They either experienced aggression themselves or observed aggression on every single shift; that is at least five violent incidents in a work-week. Even if one is not the target of aggression, such observation is associated with elevated levels of stress.

[Violence by and against people with mental illnesses]

There is robust evidence for an increased risk of violence through people with psychotic disorders. Until recently this was frequently denied to prevent stigmatization. Alcohol and drug abuse equally increases the risk, while appropriate treatment reduces it drastically. Staff in psychiatric hospitals is exposed to an elevated risk of aggressive assaults. A limited number of severely ill and socially disintegrated patients accounts for these incidents, which are often recurrent. Besides patient characteristics, factors such as ward climate, staffing levels, education and attitudes of staff, and physical environment play a major role in aggressive escalations. On the other hand, mentally ill people, particularly women, are themselves at a higher risk of becoming victims of violent and non-violent crime. This also applies after correction for variables such as social status and living environment. Additionally mentally ill people are confronted with violence in the form of coercive interventions legitimised by the state (involuntary admission, involuntary treatment, freedom-restrictive measures such as seclusion or manual/physical restraint). In contrast to other countries in Central and Western Europe, involuntary outpatient treatment has never been legalized in Germany. Efforts to reduce violence and coercion in psychiatric facilities by evidence-based interventions are widespread nowadays, treatment guidelines are available.