Risk management by early recognition of warning signs in patients in forensic psychiatric care

Systematic Aggression Registration in Forensic Psychiatric Care: A Qualitative Study on Preconditions for Successful Implementation

Available research emphasizes the importance of getting a systematic overview of inpatient aggression in forensic psychiatric care. However, the same research does not focus on how systematic aggression registration should be introduced in clinical practice. To facilitate the use of systematic aggression registration instruments, it is very relevant to gain insight into the perspective of staff members on the introduction of these instruments in daily clinical practice. Additionally, preconditions for achieving a successful implementation can be considered. Therefore, this study aims to gain insight into the perspective of the staff members on the implementation of a systematic aggression registration instrument-that is, the MOAS-in a forensic psychiatric unit. Interviews (n = 8) and a focus group with staff members were carried out. Three main themes: (1) creating the most appropriate context for introduction, (2) choice for the MOAS as relevant instrument, and (3) perpetuating the use of the MOAS in clinical practice are scrutinized. The mentioned preconditions can be used as guidelines when implementing systematic aggression registration in clinical practice. We hope that this paper can inspire other forensic psychiatric facilities to introduce systematic registration of aggressive incidents.

Nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings: An integrative review

Rapid tranquillization is a restrictive practice that remains widely used in mental health inpatient settings worldwide. Nurses are the professionals most likely to administer rapid tranquillization in mental health settings. To improve mental health practices, an enhanced understanding of their clinical decision-making when using rapid tranquillization is, therefore, important. The aim was to synthesize and analyse the research literature on nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings. An integrative review was conducted using the methodological framework described by Whittemore and Knafl. A systematic search was conducted independently by two authors in APA PsycINFO, CINAHL Complete, Embase, PubMed and Scopus. Additional searches for grey literature were conducted in Google, OpenGrey and selected websites, and in the reference lists of included studies. Papers were critically appraised using the Mixed Methods Appraisal Tool, and the analysis was guided by manifest content analysis. Eleven studies were included in this review, of which nine were qualitative and two were quantitative. Based on the analysis, four categories were generated: (I) becoming aware of situational changes and considering alternatives, (II) negotiating voluntary medication, (III) administering rapid tranquillization and (IV) being on the other side. Evidence suggests that nurses' clinical decision-making in the use of rapid tranquillization involved a complex timeline with various impact points and embedded factors that continuously influenced and/or were associated with nurses' clinical decision-making. However, the topic has received scant scholarly attention, and further research may help to characterize the complexities involved and improve mental health practice.

Early recognition method for patients with schizophrenia or bipolar disorder in community mental health care: Illness insight, self-management and control

AIMS AND OBJECTIVE

To investigate how participating in the early recognition method treatment strategy affect illness insight and management, in patients with schizophrenia or bipolar disorder in community mental healthcare.

BACKGROUND

The current practice in mental healthcare focus on shared decision-making and self-managing capacity, but poor insight is a predictor of poor adherence and dropout. Engagement in illness management and recovery predict the treatment response.

DESIGN

Semi-structured interviews with a phenomenological-hermeneutic approach.

METHODS

We conducted 36 semi-structured interviews with 26 patients. The interviews were conducted before and after participating in the intervention using the early recognition method strategy. The analysis was based on Ricoeur's theory of interpretation: Naive reading, structural analysis, interpretation and discussion. The COREQ checklist was used as reporting guideline.

RESULTS

The experience of participating in treatment as usual and early recognition method revealed two main themes. The first theme 'patient care' describes how dialogue and collaboration increase awareness of the illness and how to gain control. The second theme 'insight and experience' describes how illness affects personality and self-image, and how insight entails control and self-confidence.

CONCLUSION

Managing life with severe mental illness is complex and challenging. However, the experience of guidance, support and collaboration between patient and nurse are essential to improve these circumstances.

RELEVANCE TO CLINICAL PRACTICE

A systematic approach to the patient' symptoms, as in the early recognition method strategy, enhances knowledge of the individual patient' symptoms, both for nurse and patient. A knowledge that is significant for meeting individual treatment needs. Therefore, applying this strategy is likely to enhance collaboration and improve treatment outcome.

Early Recognition Method - Amplifying relapse management in community mental health care; a comprehensive study of the effects on relapse and readmission

This naturalistic multicenter study explored the relationship between participating in the Early Recognition Method (ERM) intervention and relapse, defined as spending at least one night at a psychiatric ward. The intervention was tailored to adult patients with schizophrenia or bipolar disorder in an outpatient mental health care setting. Before the intervention, the staff received training in application of the strategy. The ERM strategy is protocolized and includes identification and monitoring of individual early warning signs and development of a personal plan of action. The study showed a reduction in mean number and duration of readmissions during the period the patients participated in the intervention, compared to an equal pre-intervention period. For patients with bipolar disorder the reduction was statistical significant. The difference in outcome between the two diagnostic groups suggests that further tailoring of the application of the ERM strategy might improve the relapse prevention outcome.

Conflict management: A qualitative study of mental health staff's perceptions of factors that may influence conflicts with forensic mental health inpatients

Internationally, clinical services are under pressure to reduce their use of restrictive practices. The aim was to explore how mental health nurses and nursing assistants perceive conflict and their use of restrictive practices with mental health inpatients in forensic mental health care. A total of 24 semi-structured interviews with forensic mental health staff were conducted and analysed using thematic analysis. The findings propose a dynamic model that explains how tolerance of potential conflict situations changes depending on individual staff members' perceptions of patients and colleagues, and their relationships.

A Clinical Decision Support System to Prevent Aggression and Reduce Restrictive Practices in a Forensic Mental Health Service

OBJECTIVE

Preventing aggression and reducing restrictive practices in mental health units rely on routine, accurate risk assessment accompanied by appropriate and timely intervention. The authors studied the use of an electronic clinical decision support system that combines two elements, the Dynamic Appraisal of Situational Aggression instrument and an aggression prevention protocol (eDASA+APP), in acute forensic mental health units for men.

METHODS

The authors conducted a cluster-randomized controlled trial incorporating a crossover design with baseline, intervention, and washout periods in a statewide, secure forensic mental health service. The study included 36 mental health nurses (13 men and 23 women, ages 20-65 years) with direct patient care responsibility and 77 male patients (ages 21-77 years) admitted to one of two acute mental health units during the baseline and intervention periods.

RESULTS

eDASA+APP implementation was associated with a significant reduction in the odds of an aggressive incident (OR=0.56, 95% confidence interval [95% CI]=0.45-0.70, p<0.001) and a significant decrease in the odds of administration of as-needed medication (OR=0.64, 95% CI=0.50-0.83, p<0.001). Physical aggression was too infrequent for statistical significance of any effects of eDASA+APP to be determined; however, incidents of physical aggression tended to be fewer during the eDASA+APP phase.

CONCLUSIONS

These results support the use of the eDASA+APP to help reduce incidents of aggression and restrictive practices in mental health units.

Strong Associations Between Childhood Victimization and Community Violence in Male Forensic Mental Health Patients

Background: Childhood abuse and neglect increase the risk of both mental disorders and violent behavior. Associations between child relational adversities and violent behavior have not been extensively investigated in forensic mental health settings. We asked whether the extent of child adversities predicts the extent of violence in the community in forensic mental health patients. Methods: We included 52 male patients at a medium security forensic mental health ward, with diagnoses of predominantly paranoid schizophrenia and other schizophrenia and psychotic disorders. Seventy-five percent had comorbid substance abuse. We extracted information on six types of child adversities based on clinicians' administrations of the Historical Clinical Risk Management 20 version 3 (HCR 20) scale and summary notes in electronic patient journals. These same sources were used to extract information on war trauma and interpersonal violence in the community. We established cumulative scales for exposure to number of types of child adversities and number of incidents of community violence. Results: Physical and emotional abuse, emotional and physical neglect, and bullying were associated with higher levels of community violence. We observed a linear, significant increase in the frequency of community violence with cumulative numbers of child adversity types. Conclusions: Cumulative exposure to child adversities may be associated with higher degrees of violence in forensic mental health patients, with the most violent patients having the most extensive exposures to adversities. An enhanced focus on child adversities in risk assessment and management of violence may be considered in forensic inpatient settings.

Violence after discharge from forensic units in the safe pilot study: a prospective study with matched pair design

Objective

This paper reports on a prospective naturalistic study of violent recidivism after discharge from forensic mental health. Main aims were to find predictors of violence and to test the feasibility of a matched pair design for this purpose.

Methods

Patients from the Safe pilot project (n=18) and a group of controls (n=18) were matched on 10 variables, such as diagnosis, seriousness of violence, setting after discharge, and risk management plans. All the Safe pilot patients had been through repeated measurement of dynamic risk factors of violence the year before discharge to develop efficient risk management plans for use after discharge. We wanted to test whether violent recidivism during follow-up would be lower and less serious in the Safe pilot group.

Results

We found no significant between-group difference concerning number of patients with violent recidivism. However, the Safe pilot patients had significantly lower rates of violence and fewer severe violent episodes. In the control group, there was a significant association between a high number of risk management plans and high rates of violence. There was a statistical trend for the opposite association in the Safe pilot group.

Conclusion

We discuss this in terms of a possible gap between the development and implementation of plans.

Promoting positive and safe care in forensic mental health inpatient settings: Evaluating critical factors that assist nurses to reduce the use of restrictive practices

Reducing and eliminating the use of restrictive practices, such as seclusion and restraint, is a national priority for Australia's mental health services. Whilst legislation, organization and practice changes have all contributed to a reduction in these practices, forensic mental health services continue to report high rates. This paper details the findings of research that examined the experiences of nurses working in the inpatient forensic mental health setting. The research aimed to (i) document the experiences of nurses working in the forensic mental health setting, (ii) articulate their perceived unique skill set to manage challenging patient behaviours, and (iii) determine how their experiences and skill set can inform practice changes to reduce the use of restrictive practices. Thirty-two nurses were recruited from one Australian forensic mental health service. Data were collected using semi-structured interviews and analysed using inductive content analysis. Four categories were identified that influenced practice experiences: (i) working in a challenging but interesting environment, (ii) specialty expertize, (iii) exposure to aggression and resilience as a protective factor, and (iv) the importance of effective teamwork and leadership. Forensic mental health care is complex, highly specialized, and often delivered in an unpredictable environment. Whilst high rates of restrictive practices may be linked to the unique characteristics of forensic patients, training, teamwork, and leadership are critical factors influencing their use in this setting. Nurses working in this area need to be educated and supported to work confidently and safely with this high-risk patient cohort.

The role of emotion regulation, coping, self-reflection and insight in staff interaction with patients with a diagnosis of personality disorder in forensic settings

WHAT IS KNOWN ON THE SUBJECT?: Interaction between staff and patients with a diagnosis of personality disorder in forensic settings is important for quality of care, but research is lacking on what determines this interaction. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Insight, emotion-focused coping and emotion regulation of staff influence the interaction between staff and these patients. Staff who understand their own thoughts, feelings and behaviour better (more insight) needed less support, encouragement or back-up from their patients. Staff who cope by getting upset, blaming themselves or fantasizing about solutions (emotion-focused coping) on the contrary needed more support from their patients. Emotion regulation had an impact on the relation between coping and hostile staff behaviour. When staff get upset (emotion-focused coping) and try to think differently about the situation (reappraisal), this makes them behave in a more hostile manner towards their patients. When staff suppress their emotions and also distract themselves or engage in social activities (avoidance-focused coping), they behave in a less hostile manner towards their patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: In order to provide compassionate care for their patients, staff ought to be trained in self-compassion. This may help them not to get upset, blame themselves or fantasize about solutions and to understand their own thoughts, feelings and behaviour better. As a result, staff may need less support, encouragement or back-up from their patients. Context is important: Staff ought to suppress their emotions when emotions run high, but only when they also care for themselves by distracting themselves or engaging in social activities. Facing and regulating their emotions by changing what they think about the situation (reappraisal) may be more appropriate once emotions have settled down. This may help staff to remain compassionate towards their patients in the long run and avoid burn-out or compassion fatigue due to ignoring their own needs and boundaries. ABSTRACT: Introduction Research is lacking on what determines interaction between staff and patients with a diagnosis of personality disorder in forensic settings. Aim To test whether coping, self-reflection, insight and emotion regulation are related to the behaviour of staff towards these patients, and to test the possible moderating and mediating effect of emotion regulation. Method Using a cross-sectional design, 76 direct care staff of a forensic clinic completed questionnaires on all variables. Relations were tested using simple linear regression, mediation and moderation analyses. Results Insight and emotion-focused coping of staff were related to seeking less and more support from patients, respectively. Emotion regulation by reappraisal combined with emotion-focused coping was associated with more hostile behaviour by staff, and suppression combined with avoidance-focused coping with less hostile behaviour. Conclusion Insight, emotion-focused coping and emotion regulation of staff influence the quality of care of patients with a diagnosis of personality disorder in forensic settings. Future research ought to include contextual factors. Implications for practice Enhancing self-compassion may improve insight and reduce emotion-focused coping. Context is important: Taking the needs of staff into account may involve suppressing emotions combined with avoidance in a highly emotional situation while facing and reappraising the situation when emotions are low.

Factors impacting perceived safety among staff working on mental health wards

BACKGROUND

Safety at work is a core issue for mental health staff working on in-patient units. At present, there is a limited theoretical base regarding which factors may affect staff perceptions of safety.

AIMS

This study attempted to identify which factors affect perceived staff safety working on in-patient mental health wards.

METHOD

A cross-sectional design was employed across 101 forensic and non-forensic mental health wards, over seven National Health Service trusts nationally. Measures included an online staff survey, Ward Features Checklist and recorded incident data. Data were analysed using categorical principal components analysis and ordinal regression.

RESULTS

Perceptions of staff safety were increased by ward brightness, higher number of patient beds, lower staff to patient ratios, less dayroom space and more urban views.

CONCLUSIONS

The findings from this study do not represent common-sense assumptions. Results are discussed in the context of the literature and may have implications for current initiatives aimed at managing in-patient violence and aggression.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) license.

Identification and Analysis of Factors Contributing to the Reduction in Seclusion and Restraint for a Population with Intellectual Disability

BACKGROUND

A cohort of 11 patients with an intellectual disability and a psychiatric diagnosis present severe behavioural disorders in psychiatric hospital of Quebec in 2009. Control-measure use for this clientele has now been reduced. How do management personnel, families and care teams explain the changes? What clinical interventions did management and care providers implement that contributed to the reduction?

METHOD

A retrospective case study was conducted. Five focus groups were held with people involved in their care, and the patient files were examined.

RESULTS

The factors contributing to this change were the cohesion of the care providers, the involvement of the families and the efforts to determine the function of the behaviour.

IMPLICATIONS

This study may inspire other care teams to try new approaches in dealing with patients with severe behavioural disorders. Also, the model of factors and interventions supporting a reduction in seclusion and restraint measures may inspire future studies.

Mental Health Nurses' Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression: A Cross-Sectional Study of Associations With Nurse-Related Characteristics

PURPOSE

To explore mental health nurses' attitude and self-efficacy to adult inpatient aggression, and to explore the association with nurse-related characteristics.

DESIGN AND METHOD

Cross-sectional study in a sample of 219 mental health nurses in nine psychiatric hospitals, with stepwise linear regression analysis to detect predictive models.

FINDINGS

Female and less experienced nurses were less likely to blame patients for their behavior. Gender, burnout, secondary traumatic stress, and compassion satisfaction accounted for 26.2% of the variability in mental health nurses' self-efficacy toward aggression.

PRACTICE IMPLICATIONS

There needs to be attention to professional quality of life for mental health nurses, to provide them with of self-efficacy and a positive attitude toward coping with aggression.

Predictive validity of the START for unauthorised leave and substance abuse in a secure mental health setting: a pseudo-prospective cohort study

BACKGROUND

Risk assessment and management is central to the nursing role in forensic mental health settings. The Short Term Assessment of Risk and Treatability (START) aims to support assessment through identification of risk and protective factors. It has demonstrated predictive validity for aggression; it also aims to aid risk assessment for unauthorised leave and substance abuse where its performance is relatively untested.

OBJECTIVES

To test the predictive validity of the START for unauthorised leave and substance abuse.

DESIGN

A naturalistic, pseudo-prospective cohort study.

SETTINGS

Four centres of a large UK provider of secure inpatient mental health services.

PARTICIPANTS

Inpatients resident between May 2011 and October 2013 who remained in the service for 3-months following assessment with the START by their clinical team. Exclusion criteria were missing assessment data in excess of prorating guidelines. Of 900 eligible patients 73 were excluded leaving a final sample size of n=827 (response rate 91.9%). Mean age was 38.5 years (SD=16.7); most participants (72.2%) were male; common diagnoses were schizophrenia-type disorders, personality disorders, organic disorders, developmental disorders and intellectual disability.

METHODS

Routinely conducted START assessments were gathered. Subsequent incidents of substance abuse and unauthorised leave were coded independently. Positive and negative predictive values of low and elevated risk were calculated. Receiver Operating Characteristic analysis was conducted to ascertain the predictive accuracy of the assessments based on their sensitivity and specificity.

RESULTS

Patient-based rates of unauthorised leave (2.4%) and substance abuse (1.6%) were low. The positive and negative predictive values for unauthorised leave were 5.9% and 98.4%; and for substance abuse 8.1% and 99.0%. The START specific risk estimate for unauthorised leave predicted its associated outcome (Area under the curve=.659, p<.05, 95% CI .531, .786); the substance abuse risk estimate predicted its outcome with a large effect size (Area under the curve=.723, p<.01, 95% CI .568, .879).

CONCLUSIONS

The study provides limited support for the START by demonstrating the predictive validity of its specific risk estimates for substance abuse and unauthorised leave. High negative predictive values suggest the tool may be of most utility in screening out low risk individuals from unnecessary restrictive interventions; very low positive predictive values suggest caution before implementing restrictive interventions in those rated at elevated risk. Researchers should investigate how multidisciplinary teams formulate risk assessments for these outcomes since they outperform the quantitative element of this tool.

User involvement in structured violence risk management within forensic mental health facilities -- a systematic literature review

AIMS AND OBJECTIVES

To examine empirical literature on user involvement in collaboration between patients and nurses. The scope of the review was limited to structured violence risk management interventions in forensic mental health settings.

BACKGROUND

Violence in forensic mental health settings represents a significant problem for patients and staff. Structured violence risk management interventions in forensic mental health have been reported to ignore patient participation, despite the growing attention on user involvement in clinical practice.

DESIGN

A systematic review.

METHOD

Searches were conducted in six databases: the Cochrane Systematic Reviews, MEDLINE, CINAHL, ProQuest, ScienceDirect and PsycINFO. Papers were assessed according to a predetermined set of inclusion and exclusion criteria.

RESULTS

After searches of the reference lists of retrieved articles were conducted, only three papers met the inclusion criteria.

CONCLUSIONS

This review has shown that empirical research on the topic of risk management interventions in which patients are involved is scarce.

RELEVANCE TO CLINICAL PRACTICE

There is barely any research evidence of the clinical effect of user involvement approaches on violence risk management in forensic mental health practice. Therefore, we suggest that clinicians may learn from positive experiences concerning user involvement in general psychiatry and carefully adapt and test them out in the forensic treatment context.

Kennedy Axis V: Clinimetric properties assessed by mental health nurses

The Kennedy Axis V is a routine outcome measurement instrument which can assist the assessment of the short-term risk for violence and other adverse patient outcomes. The purpose of this study was to evaluate the interrater reliability and clinical utility of the instrument when used by mental health nurses in daily care of patients with mental illness. This cross-sectional study was conducted in inpatient and outpatient adult psychiatric care units and in one adolescent inpatient unit at a university hospital in the Netherlands. Interrater reliability was measured based on the independent scores of two different nurses for the same patients. The clinical utility of the instrument was evaluated by means of a clinical utility questionnaire. To gain a deeper understanding of rating difficulties at the adolescent unit, additional data were collected in two focus group interviews. The overall results revealed a substantial level of agreement between nurses (intraclass correlation coefficient and Pearson 0.79). Some rating challenges were identified, including difficulties with scoring the instrument and using tailor-made interventions related to the scores. These challenges can be resolved using refined training and implementation strategies. When the Kennedy Axis V is accompanied by a solid implementation strategy in adult mental health care, the instrument can be used for short-term risk assessment and thereby contribute in efforts to reduce violence, suicide, self-harm, severe self-neglect, and enhanced objectivity in clinical decision-making.

Assessing aggressive behavior in forensic psychiatric patients: validity and clinical utility of combining two instruments

OBJECTIVES

Accurate observation of aggressive behavior among forensic psychiatric patients requires valid instruments. This study examines the validity and clinical utility of combining the social dysfunction and aggression scale (SDAS) and staff observation aggression scale revised (SOAS-R).

METHODS

Nurses weekly obtained SDAS scores of 127 patients, resulting in 6.124 assessments. Aggressive incidents were documented by the SOAS-R. Internal consistency, subscale structure, interobserver reliability of the SDAS, and convergent validity with SOAS-R were analyzed.

CONCLUSION

A three-factor solution was found. Interobserver reliability was moderate, and good convergent validity was found. The SDAS, in conjunction with the SOAS-R, monitors changes in aggressiveness and may contribute to the prevention of aggressive behavior.

Collaborative Care for patients with severe borderline and NOS personality disorders: a comparative multiple case study on processes and outcomes

BACKGROUND

Structured psychotherapy is recommended as the preferred treatment of personality disorders. A substantial group of patients, however, has no access to these therapies or does not benefit. For those patients who have no (longer) access to psychotherapy a Collaborative Care Program (CCP) is developed. Collaborative Care originated in somatic health care to increase shared decision making and to enhance self management skills of chronic patients. Nurses have a prominent position in CCP's as they are responsible for optimal continuity and coordination of care. The aim of the CCP is to improve quality of life and self management skills, and reduce destructive behaviour and other manifestations of the personality disorder.

METHODS/DESIGN

Quantitative and qualitative data are combined in a comparative multiple case study. This makes it possible to test the feasibility of the CCP, and also provides insight into the preliminary outcomes of CCP. Two treatment conditions will be compared, one in which the CCP is provided, the other in which Care as Usual is offered. In both conditions 16 patients will be included. The perspectives of patients, their informal carers and nurses are integrated in this study. Data (questionnaires, documents, and interviews) will be collected among these three groups of participants. The process of treatment and care within both research conditions is described with qualitative research methods. Additional quantitative data provide insight in the preliminary results of the CCP compared to CAU. With a stepped analysis plan the 'black box' of the application of the program will be revealed in order to understand which characteristics and influencing factors are indicative for positive or negative outcomes.

DISCUSSION

The present study is, as to the best of our knowledge, the first to examine Collaborative Care for patients with severe personality disorders receiving outpatient mental health care. With the chosen design we want to examine how and which elements of the CC Program could contribute to a better quality of life for the patients.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR2763.

The development of the Forensic Early Warning Signs of Aggression Inventory: preliminary findings toward a better management of inpatient aggression

OBJECTIVE

"Early warning signs of aggression" refers to recurring changes in behaviors, thoughts, perceptions, and feelings of the patient that are considered to be precursors of aggressive behavior. The early recognition of these signs offers possibilities for early intervention and prevention of aggressive behaviors in forensic patients. The Forensic Early warning Signs of Aggression Inventory (FESAI) was developed to assist nurses and patients in identifying and monitoring these early warning signs of aggression.

METHODS

The FESAI was developed by means of qualitative and quantitative strategies. One hundred seventy six early detection plans were studied to construct a list of early warning signs of aggression. Inventory drafting was done by merging and categorizing early warning signs. Forensic nursing professionals assessed face validity, and interrater agreement was tested.

RESULTS

The investigation of early detection plans resulted in the FESAI, which contains 44 early warning signs of aggression subdivided into 15 main categories. The face validity of the form was very good, and the interrater agreement was satisfactory.

CONCLUSIONS

Preliminary findings indicate that the FESAI provides a useful listing of early warning signs of aggression in forensic patients. It may facilitate the construction of early detection plans for the prevention of aggressive behaviors in forensic psychiatry.

Detached concern of forensic mental health nurses in therapeutic relationships with patients the application of the early recognition method related to detached concern

OBJECTIVE

Improvement of the interaction between forensic mental health nurses and patients may lead to a reduction of inpatient violence. The concept under study is detached concern, which refers to nurses' skills to neutralize the emotional appeal of patients by a balanced attitude between objectivity and emotional involvement. The Patient Contact Questionnaire (PCQ) aims at measuring the degree of concern of nurses for their patients.

METHODS

The PCQ was applied in a pretest-posttest design, evaluating the effects of the Early Recognition Method (ERM). This method aims at the prevention of inpatient violence in forensic psychiatry. Subjects were 116 forensic mental heath nurses working on 16 wards of a large Dutch forensic hospital. First, the baseline scores were compared to scores reported in an earlier study conducted in general psychiatry. Second, pretest-posttest comparisons were carried out for all nurses, and for subgroups of nurses with regard to gender, educational level, years of working experience, and patient population. Third, pretest-posttest comparisons were made on the PCQ item level.

RESULTS

The baseline scores of male nurses indicated significantly higher levels of concern than those of female nurses. In addition, more experienced nurses scored significantly higher with regard to concern than less experienced nurses. When comparing the scores before and after applying ERM, no significant differences were found. However, the sores of female nurses showed a tendency toward more concern after implementation of ERM.

CONCLUSIONS

Detached concern may be a meaningful concept in forensic mental health nursing in measuring nurses' concern for their patients. Levels of detached concern did not change significantly after application of ERM. However, the application of the PCQ could contribute to a better understanding of the interaction between nurses and their patients.

Preventing aggressive incidents and seclusions in forensic care by means of the 'Early Recognition Method'

OBJECTIVE

The Early Recognition Method aims at improving collaboration between nurses and patients to prevent aggression in forensic psychiatric care. To achieve this goal, Early Recognition Method strongly focuses on early signs of aggression. In the current study, we investigated whether application of Early Recognition Method led to a significant decrease in inpatient incidents.

BACKGROUND

Nurses in forensic settings are often confronted with patients' aggression. Better collaboration between nursing staff and patients may improve patients' ability to self manage aggression and contribute to a decrease in inpatient aggression.

DESIGN

Naturalistic one-way case-crossover design.

METHODS

The Early Recognition Method was introduced on 16 wards of a maximum security forensic hospital. Using a one-way case-crossover design, where cases were their own controls, the effects of Early Recognition Method were assessed by comparing the number of incidents of 189 patients during 'Treatment As Usual' with the period after Early Recognition Method was implemented. The Early Recognition Method intervention involved weekly evaluations of signs of aggression between staff and patients. The outcome measures were the number of seclusions and the severity of inpatient incidents.

RESULTS

A significant decline in the number of seclusions was observed after Early Recognition Method was introduced. Apart from this decrease, the mean severity of inpatient incidents was also found to be lower during the post intervention period. The effect size was most pronounced for patients with substance abuse and personality disorders. Patients with schizophrenia, however, showed modest, yet significant, effect sizes.

CONCLUSIONS

The results suggest that Early Recognition Method may be an innovative and effective risk management method for forensic psychiatric patients, in particular for patients with personality disorders.

RELEVANCE TO CLINICAL PRACTICE

This article aims to contribute to evidence-based risk management for nurses in collaboration with their patients, resulting in a decrease in inpatient aggression.

Patient-related violence at triage: A qualitative descriptive study

AIM

The aim of the study was to describe the experiences of a group of triage nurses with patient-related workplace violence during the previous month.

BACKGROUND

Globally and within the Australian health industry, nurses have been reported to be the occupation at most risk of patient-related violence, with triage nurses identified as a high risk group for both verbal and physical violence.

METHOD

The study took place in the Emergency Department of a tertiary referral and teaching hospital in regional New South Wales, Australia. Data were collected from August to September 2008, and a qualitative descriptive methodology was employed.

FINDINGS

The participants all reported experiencing episodes of patient related violence that were perceived as inevitable and increasing in intensity and frequency. Themes included identification of precipitating factors such as long waiting times and alcohol and substance misuse. Organisational issues included lack of aggression minimisation training; lack of formal debriefing following episodes of violence and frustration at lengthy reporting processes.

CONCLUSION

In the context of the Emergency Department where patients present with a range of diagnoses and behaviours, it is unlikely that the issue of patient-related violence can be totally eliminated. However it can be prevented or managed more effectively on many occasions. Strategies to support staff and prevent and manage violence effectively should be a priority to provide a safe working environment and occupational health and safety for staff.